In orthopaedics, it seems as if the most technological advances these days come in the smallest of devices and techniques. Repairing a tear in the rotator cuff is no exception.
What is a rotator cuff tear?
The rotator cuff is a group of muscles (the infraspinatus, subscapularis, supraspinatus, and, teres minor, muscles) and tendons (tissue connecting muscle to bone) that surrounds the shoulder joint (Fig. 1). The rotator cuff holds the joint in place and helps stabilize your shoulder while you lift your arm over your head and during movement such as swinging your arms from side to side. You can injure your rotator cuff by falling on an outstretched arm or develop an injury over time doing repetitive activities at work or while playing a sport. Muscle and tendon degeneration due to aging can also be a factor in a rotator cuff tear, especially if you are over 40 years of age.1,2 Additionally, the acromion process (the bone above the rotator cuff) can develop bone spurs that can rub on the rotator cuff tendons, causing impingement, or weakening and tearing at the tendons.3 A rotator cuff tear can range from small to large in size, it can be a partial tear in one of the muscles or it can be a partial or complete tear in the tendon. Tear sizes can be described as small (less than 1 cm), moderate (1 to 3 cm), or a large tear (3 to 5 cm).4
What are the symptoms of a rotator cuff tear?
People who have a rotator cuff tear often complain of pain and weakness in the shoulder. With a rotator cuff tear, you can experience intense pain during activity or at rest and you may have difficulty sleeping at night.1,2 You can experience trouble lifting your arm or moving it because of the pain and weakness in the affected muscle or tendon. The size, shape, and location of the tear often determine the extent of the discomfort you experience. You can also hear a crackling noise or have a crackling sensation in your shoulder while moving your arm.1,2
How is a rotator cuff tear diagnosed?
Your physician will examine your shoulder to see if it is tender to touch or if there is any sign of deformity caused by a tear. The doctor will ask you if a traumatic event occurred, such as a fall, or if the pain you feel has progressed over time in severity. Your physician can order an x-ray or magnetic resonance imaging (MRI, a scan that shows the bones, muscles, tendons, and ligaments) to help diagnose the source of your pain. X-rays are often taken first to eliminate other possible injuries causing the pain, such as a fracture. The MRI is often used because it will show the tear and its size. The details an MRI provides are usually excellent; however, sometimes arthroscopy (surgery through small incisions in the skin) of the shoulder is necessary to make a definitive diagnosis.1,2,3,5,6
Nonsurgical treatment can be effective in reducing pain and improving function of the shoulder.,2,3 Rest, using a sling, and taking anti-inflammatory medications can be effective; but, if you continue to experience pain and weakness in the shoulder your physician can prescribe physical therapy or cortisone injections.2 Often, rehabilitation is prescribed to strengthen the shoulder and non-steroidal medications are prescribed for pain. Cortisone injections can also be used to control inflammation and alleviate the pain and weakness.1,2
There are a number of treatment options for rotator cuff tears. Depending upon the size, shape, and location of the tear, your physician can start with nonsurgical treatments, which is often successful for many patients. However, for some tears, surgery is the first option and the best one to relieve your pain and shoulder weakness. Again, depending on your type of tear, your physician will determine whether an open, mini-open, or arthroscopic technique is best for you.1,2,3,6
Mini-Open Rotator Cuff Tear
If nonsurgical treatments are not successful in relieving the pain, then the doctor can recommend surgery. During the mini-open repair, the deltoid muscle is split to allow access to the torn tendon. By not fully detaching the deltoid (which is done in an open repair) the patient avoids possible complications with the deltoid muscle. The mini-open repair is often done in conjunction with an arthroscopic component so additional pathology, such as bone spurs, can be quickly assessed and remedied. During rotator tear surgery the torn tendon is reattached back down to the bone (for a complete tear) or the tear in the tendon (for a partial tear) is sutured back together. Often, during the surgery, the acromion bone is filed down smoothly (acromioplasty) to prevent future tears.4,5
After surgery, you will use a sling for about 6 weeks and will begin a rehabilitation program. The physical therapist will start with safe, easy shoulder exercises and will progress them depending on your response to treatment.3 Rehabilitation will take some time; however, with the less invasive mini-open technique, patients can begin rehabilitation sooner and they often experience a faster return to normal daily activities.4
Author: John C. Balbas
Reprinted with permission from the Hughston Health Alert, Volume 20, Number 1.
1) Operative Shoulder Surgery. Stephen Copeland. Churchill Livingston: New York, NY;1995:70-85.
2) American Academy of Orthopaedic Surgeons. Rotator Cuff Tears. http://orthoinfo.aaos.org/. Accessed May 1, 2008.
3) American Academy of Orthopaedic Surgeons. Rotator Cuff Tears and Treatment Options. http://orthoinfo.aaos.org/. Accessed May 1, 2008.
4) Hata Y, Saitoh S, Murakami N, et al. A less invasive surgery
for rotator cuff tear: Mini-open repair. J Shoulder Elbow Surg.
5) The Shoulder: Operative Technique. Melvin Post, Louis Biglinia, Evan Flatow, Roger Pollock. Williams and Wilkins: Baltimore, MD; 1998:142-151.
6) Throckmorton T and Albright J. Case Report: Concurrent Anterior Shoulder dislocation and Rotator Cuff Tear in a Young Athlete. Iowa Orthop J. 2001;21:76-79.