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Rotator Cuff MusclesA rotator cuff is a group of 4 muscles (see image) in the shoulder that is important in shoulder function. Each muscle has a tendon at its end that inserts into bone (the head of the humerus). It is at these tendon insertions that tears normally occur. A rotator cuff tendon can tear acutely during an injury when a normal healthy tendon is overloaded.

More often a tear develops gradually due to a “wear and tear” process in a weakened tendon. These “degenerate tears” are very common in the older population and may be completely painless. Studies have shown that painless full-thickness tears can be present in over 30% of patients older than 60 years and they certainly don’t all require surgical treatment.

However, a painless tear can gradually become painful due to an ongoing “wear and tear” process, or suddenly after an injury. The tear can become larger, become painful and/or start causing shoulder weakness. When a large tear is left untreated, the chances of a successful repair diminish over time due to weakening of the tendon as well as changes in the corresponding muscle (fatty atrophy). As the tear becomes bigger the tendon pulls further away from the bone, thereby also reducing the chances of a successful repair. Ultimately, large rotator cuff tears can lead to arthritis in the shoulder joint (cuff tear arthritis/arthropathy) due to altered shoulder mechanics.

Diagnosis and work-up

A rotator cuff tear may be suspected when lifting of the arm or other shoulder movements are painful and/or weak. The shoulder pain can be severe at night and often radiates to the side of the shoulder or upper arm. After a thorough examination of the shoulder, an ultrasound examination is performed to confirm a rotator cuff tear and to assess the location and size of the tear. An X-ray of the shoulder may also be needed to assess the surrounding bony anatomy and shoulder joint. In certain scenarios a MRI scan may be beneficial to assess the rotator cuff muscle quality and the reparability of the tear.

Conservative treatment

Small chronic degenerate tears may be considered for conservative treatment, especially in the older population. Although a full thickness rotator cuff tear will not heal by itself, the pain can subside and the shoulder can adapt. Simple pain-killers and anti-inflammatory medication can help to alleviate the pain. Physiotherapy is recommended to maintain shoulder range of motion and to improve the strength of the rest of the rotator cuff and deltoid muscles. A cortisone injection may be considered for pain relief initially, but repeated injections should be avoided as they can weaken the tendon further.

Surgical treatment of Rotator Cuff Tears

Acute traumatic rotator cuff tears in young patients should be repaired as soon as possible to give it the best chance to heal. Surgery is also considered for chronic degenerate tears causing pain and/or loss of function after failed conservative management. It is usually performed arthroscopically (key-hole surgery) under general anaesthesia (you are asleep). A few small holes are made to insert a small camera (arthroscope) and instruments into the shoulder without damaging the overlying deltoid muscle. Water is pumped into the shoulder to facilitate surgery and by keeping the water pressure regulated, bleeding is minimal.

Each rotator cuff tendon is examined and repaired if needed using suture anchors (small screws with suture threads or tape attached to it). Some of the overlying bone (acromion) may be shaved away (acromioplasty) if it was rubbing on the tendon (impingement). If you have painful arthritis of the acromio-clavicular (AC) joint, you may require an AC joint excision. A few millimetres are shaved away from the end of the collar bone to open up the AC joint. This normally relieves the pain and grinding that are usually associated with AC joint arthritis.

At the end of the operation, the small skin holes are sutured and a dressing applied to the shoulder. Your arm is placed in a sling which, depending on the size of the tear, may include a special cushion that keeps your arm slightly away from your body. The sling will normally be worn for 6 weeks. You may choose to
stay in hospital overnight to ensure maximum care and comfort. Ice packs are applied to control the swelling for up to 20 minutes at a time, three times daily. Before leaving hospital, the pads on your shoulder will be removed and waterproof dressings applied. These dressings should be left on until the 2-week follow-up visit.

The post-operative rehab protocol is available in the rehab protocols section.

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