What is the rotator cuff?
The rotator cuff is a group of four muscles in the shoulder. These muscles originate at various points around the shoulder blade (scapula) and the tendons of these muscles are attached close to the ball of the upper arm bone (humerus). The rotator cuff is important in producing movement at the shoulder joint, particularly lifting and rotating the arm.
Although problems can arise in any of the tendons of the rotator cuff, the supraspinatus is the most commonly affected. The tendon has a relatively poor blood supply and passes through a narrow arch under the tip of the shoulder blade (acromion). Normally there is a lubricating membrane called the subacromial bursa, which allows the tendon to glide smoothly under the acromion as the arm moves.
What is a rotator cuff tear?
The tendons of the rotator cuff can become worn or torn much like a piece of cloth. The degree of damage may vary from just slight fraying of the tendon to a complete tear where the tendon is completely detached from the bone.
What causes a rotator cuff tear?
Despite many years of scientific study, the precise answer to this question is not known. Rotator cuff tears can occur following an injury to the shoulder although this is relatively uncommon. It has been suggested that repetitive strenuous activity can cause the accumulation of multiple tiny tears in the tendon. Instead of these small tears healing, the tendon becomes inflamed and weakened, causing a larger tear to develop. It has been established that rotator cuff tears are increasingly common with advancing age. In a study of asymptomatic patients (people without shoulder pain or stiffness) 13% of people aged between 50 and 59 had a rotator cuff tear and 51% of people over 80 had a rotator cuff tear.
What problems does a rotator cuff tear cause?
The symptoms from a rotator cuff problem vary widely between individuals and are not always proportional to the severity of tendon damage. As mentioned above, asymptomatic rotator cuff tears are very common. If symptoms occur they may include:
Pain is most commonly felt over the top and front of the shoulder joint and often in the upper part of the arm below the shoulder. Pain is often particularly severe when attempting to lift the arm overhead. Pain may be present at night, particularly if lying on the affected shoulder.
Limitation of movement
In some individuals there is no stiffness but movements are painful, in others there can be almost complete loss of movement at the shoulder (pseudoparalysis).
There may be popping, clicking, crunching or grinding felt when moving the shoulder. Despite having a full range of movement there may be varying degrees of weakness.
Will I need any further investigations?
An X-ray is the first investigation to help rule out other causes of pain and restriction in the movement of your arm. Following this an ultrasound scan of the shoulder is used to view the tendons and assess if they are torn and how retracted these tendons are.
What can be done to treat rotator cuff tears?
Every patient with a rotator cuff tear is different and responses to treatments vary between individuals. No single intervention works every time in every patient. Your surgeon will help you decide which treatment is likely to be most effective.
Treatments can be divided into those involving surgery and those not involving surgery:
A skilled physiotherapist advises with a variety of exercises to improve range of movement and strengthen the shoulder muscles.
Painkilling tablets, especially anti-inflammatory medication, often improve pain around the shoulder.
Injections of cortisone around the rotator cuff tendons often improve symptoms. These are most effective when combined with a course of physiotherapy. In many cases symptoms are permanently alleviated. If the effects of the injection wear off it can be repeated, although if injections only have a very brief effect, an alternative treatment may be more appropriate.
Most commonly performed through a keyhole (arthroscopy) under a general anaesthetic (with or without a nerve block) this procedure involves removing inflamed tissue from around the rotator cuff tendons (bursectomy) and shaving away bone from above the tendons (acromioplasty) increasing the space through which the tendons pass. In patients who have rotator cuff tears and on-going shoulder pain despite appropriate non-surgical treatment this treatment improves symptoms in up to 80%. Pain relief is seldom immediate and it is normal to have some degree of discomfort for six to nine months after surgery.
Rotator cuff repair
In cases where there is a rotator cuff tear, it may be appropriate to repair the tendon. This is done through a keyhole approach. Small metal/plastic screws attached to sutures (suture anchors) are inserted into the bone and the sutures passed through the tendon to secure the tendon to the bone. Usually subacromial decompression is performed at the same time.
On occasion, the tendons are too badly damaged to be repaired. In these cases removing scar tissue and inflamed tissue, along with performing a subacromial decompression can improve pain.
What is the recovery after surgery?
You will have a sling to wear for a period of four weeks to allow the tendons to heal to the bone. Physiotherapy is essential after the operation, to encourage good movement, rehabilitate the muscles back to normal function and ensure you are making good progress. You will see a therapist prior to discharge from the hospital and physiotherapy will commence from four weeks. You will be given painkillers to take home after surgery. You will be seen in clinic two weeks after surgery to check the wounds. There are no sutures to be removed. The pain will gradually settle and you will regain the movement in the shoulder over the next few months although it can take up to 12 months before you fully recover from the surgery.