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Rotator cuff tear is a common cause of shoulder pain and disability among adults and the elderly. Many daily activities, like combing your hair or getting dressed, may become painful and difficult to do and the patient may have severe pain at night affecting sleep.

The Shoulder Joint

The shoulder complex is made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle). The shoulder joint is a ball-and-socket type of joint: The ball, or head, of your upper arm bone, fits into a shallow socket in your shoulder blade made of scapula bone.

The Head of the Humerus (Arm Bone) is kept in your shoulder socket by your rotator cuff. The rotator cuff of the shoulder joint is a group of four muscles that come together as tendons to form a covering around the head of the humerus. The rotator cuff attaches the humerus to the shoulder blade and helps to lift and rotate your arm around the joint.

There is a sac called a bursa between the rotator cuff and the bone on top of your shoulder (acromion) that provide lubrication in the joint. The bursa is the Subacromial bursa, which allows the rotator cuff tendons to glide freely when you move your arm. When the rotator cuff tendons are injured or torn, this bursa can also become inflamed and painful.

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The four muscles rotator cuff tendons are:

• Supraspinatus: It is there at the top of the shoulder.  Initiates abduction i.e. moving the arm out sideways, and stabilises the shoulder during this movement.  Most commonly injured tendon.
• Infraspinatus: It is at the back of the shoulder.  It rotates the arm outwards.
• Teres Minor: It is at the back of the shoulder below the infraspinatus. It also turns it outwards.
• Subscapularis: This runs across to the front of the shoulder.  It medially rotates the arm i.e. turns it inwards

Rotator cuff tears

Most tears occur in the supraspinatus tendon, but other parts of the rotator cuff may also be damaged.

In most cases, tears in tendons begin by fraying. As the injury progresses, the tendon can completely tear.

There are different types of tears.

• Partial tear. this is also called an incomplete tear. It damages the tendon but does not completely damage it.
• Full-thickness tear. also called a complete tear. It separates all of the tendons completely from the bone.

Cause of Rotator cuff tears
There are two main causes of rotator cuff tears: injury and degeneration.

• Acute Tear
  If fall down on your outstretched arm at home or road traffic accident or lift something too heavy with a jerking motion, your rotator cuff might be torn.
• Degenerative Tear
  These types of tears are the result of age-related wearing down of the tendon that occurs slowly over time. These are more common in the dominant shoulder. If you are having a degenerative tear in one of the shoulders, there is a more chance of a rotator cuff tear in the opposite shoulder — even if you do not have pain in that shoulder.

These are factors that contribute to degenerative, or chronic, tears.

• Repetitive stress. Repeating the same shoulder motions, again and again, lead to stress on your rotator cuff muscles and tendons. Example Baseball, tennis, rowing, and weightlifting. These sports activities can put you at risk for overuse tears.
• Lack of blood supply. With increasing age, the blood supply in our rotator cuff tendons lessens. This can ultimately lead to a rotator cuff tendon tear.
• Bone spurs. With ageing bone overgrowth often develop on the underside of the acromion bone. When you lift your shoulder, this bony outgrowth rub on the rotator cuff tendon.

Risk Factors

Most rotator cuff tears are caused by the normal wear and tear that goes with ageing, people over 45 are at greater risk.

People who do repetitive overhead activities or lifting are also at risk for tears. Overhead Athletes are likely to overuse tears, particularly tennis players and baseball pitchers.

Most tears in young adults are caused by a traumatic injury, like a fall.

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Torn Rotator Cuff Symptoms

Degenerative torn rotator cuff tear symptoms at the start are fairly mild and get progressively increase over time.

Acute rotator cuff tears more typically cause instant, intense pain.

Torn rotator cuff symptoms commonly are:

• Pain: around the shoulder, often is as a dull ache deep inside. Pain tends to get worse when lifting or rotating your arm, with activities such as brushing your hair. Pain is worse when lying on that side in bed, which often leads to disturbed sleep at night.  As the condition gets worse, you may experience pain even on rest.
• Weakness: Difficulty lifting or twisting the arm is common which can lead to decreased range of active movement.

Symptoms will depend on the severity of the injury. Three grades for tendon strains are:

• Grade 1 Strain:  No fibres are torn,  but overstretching of the tendon
• Grade 2 Strain: a partial rotator cuff tear – only some of the fibres are torn
• Grade 3 Strain: a complete/full-thickness rotator cuff tear – the tendon completely detaches from the bone itself. Due to this, you may not be able to lift your arm.

Diagnosing Rotator Cuff Tears

After taking your history doctor will examine you for your problems. It is always advisable to visit a shoulder specialist arthroscopy orthopedic surgeon.

Depending on your symptoms, he may send you for further investigations, like x-rays, to look for any bone spurs or arthritis or an MRI or ultrasound scan to look at the soft tissues as rotator cuff and identify the presence, location and size of a tear.

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Rotator Cuff Tear Treatment
Treatment will depend on the severity of the injury, as well as the age and activity level of that patient.  Treatment should be directed not just to your symptoms, but also the underlying cause of the problem, such as any areas of weakness or postural issues.

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In most cases, conservative treatment that is non-surgical is sufficient, but in more severe cases such as grade 3 tears, or if symptoms have failed to settle, surgery may be advocated.

Surgical Repair Options

Advancements in surgical techniques for rotator cuff repair include minimally invasive procedures. While every method available has its own advantages and disadvantages, all have the same goal: getting the tendon to heal.

The type of repair performed depends on your surgeon’s experience and familiarity with a particular procedure, the size of your tear, your anatomy, and the quality of the tendon tissue and bone.

FULL RECOVERY AFTER ARTHROSCOPIC ROTATOR CUFF REPAIR SURGERY

Your orthopedic surgeon will discuss with you the best procedure to meet your individual health needs and demand.

In addition to a rotator cuff tear, other problems might be there such as biceps tendon tears, osteoarthritis, bone spurs, or other soft tissue tears. During the surgery, your surgeon may be able to take care of these problems, as well.

Three techniques most commonly used are –

• Open Repair
  An open surgical incision (several centimetres long) is often required if the tear is large or complex. During an open repair, the surgeon removes bone spurs from the underside of the acromion (this procedure is called an acromioplasty). This was the first technique used for torn rotator cuffs. Over the years, new technology and improved surgeon experience and skills have led to the least invasive procedures.
• All-Arthroscopic Repair
  During shoulder arthroscopy, your surgeon inserts a small camera, called an arthroscope, into your shoulder joint. The camera displays inside pictures of your joint on a television screen, and your surgeon uses these images to guide miniature surgical instruments in the joint to do the surgery.

Because the arthroscope and surgical instruments are very thin that is 5 to 6 mm, your surgeon can use very small incisions (cuts), rather than the larger incision needed for open surgery.

RECOVERY AFTER MASSIVE ROTATOR CUFF REPAIR

• Mini-Open Repair
  The mini-open repair uses newer technology and instruments to perform a repair through a small incision around the shoulder. The incision is typically 4 to 5 cm long.

This technique uses arthroscopy to assess and treat damage to other structures within the shoulder joint as bone spurs. Once the arthroscopic portion of the procedure is done, the surgeon repairs the rotator cuff through the mini-open incision. In this technique of tendon repair, the surgeon views the shoulder structures directly, rather than through the video monitor.

After rotator cuff repair surgery, physical therapy is vital to regaining the strength and movement in the shoulder. Recovery from rotator cuff tear surgery usually takes 8 to 12 weeks.

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The author is a reputed shoulder surgeon in Jaipur India with expertise in shoulder arthroscopy and joint replacement surgeries.

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