Rotator Cuff Repair

Arthroscopy

Rotator Cuff Repair

The shoulder comprises three bones: the upper arm bone (humerus), the shoulder blade (scapula), and the collarbone (clavicle). It functions as a ball-and-socket joint, with the ball (head of the humerus) fitting into a shallow socket in the shoulder blade. The arm remains in place within the shoulder socket due to the rotator cuff, which is a set of four muscles (supraspinatus, infraspinatus, teres minor, and subscapularis) forming tendons covering the head of the humerus. These muscles attach the humerus to the shoulder blade and facilitate arm movement.

A bursa, a lubricating sac, exists between the rotator cuff and the shoulder’s top bone (acromion), enabling smooth tendon movement during arm motion. However, if the rotator cuff tendons suffer injury or damage, this bursa can become inflamed, causing pain.

When one or more rotator cuff tendons tear, they no longer fully attach to the head of the humerus. While tears most commonly occur in the supraspinatus tendon, other parts of the rotator cuff may also be affected. Tendon tears often initiate with fraying, progressing to complete tears, especially when subjected to heavy lifting.

Based on Extend of tear

Partial Tear : Sometimes referred to as an incomplete tear, this kind of tear results in damage to the tendon but does not entirely sever it.

Full-Thickness Tear : Also known as a complete tear, this type of tear involves the separation of all tendons from the bone. In a full-thickness tear, there is a noticeable hole in the tendon.

Based on the location of tear

Articular side tear

Bursal side tear

There are two primary reasons behind rotator cuff tears:

Injury: An acute tear can happen if you fall on your outstretched arm or lift something too heavy with a sudden jerk. Such tears may also accompany other shoulder injuries like a broken collarbone or a dislocated shoulder.
Degeneration: Most tears result from the gradual wearing down of the tendon over time, which naturally occurs with aging. These tears are more prevalent in the dominant arm. Interestingly, if one shoulder has a degenerative tear, there’s a higher chance of a tear in the opposite shoulder, even if there’s no pain present.

Several factors contribute to degenerative rotator cuff tears:

Repetitive stress: Engaging in activities that involve repetitive shoulder motions, such as baseball, tennis, rowing, and weightlifting, can strain the rotator cuff muscles and tendons. Similarly, certain jobs and routine tasks can also lead to overuse tears.
Lack of blood supply: With age, the blood supply to the rotator cuff tendons decreases. This diminished blood flow impairs the body’s ability to naturally repair tendon damage, ultimately increasing the risk of tears.
Bone spurs: As we age, bone spurs, or overgrowths, may develop on the underside of the acromion bone. When the arms are lifted, these spurs can rub against the rotator cuff tendon, leading to a condition known as shoulder impingement. Over time, this can weaken the tendon, making it more susceptible to tearing.

Symptoms

The typical signs of a rotator cuff tear are: Pain during rest, especially at night, particularly when lying on the affected shoulder. Pain while raising or lowering your arm, or during specific movements. Weakness when lifting or rotating your arm. A crackling sensation (crepitus) when moving your shoulder in certain ways. Sudden tears, such as those from a fall, causing intense pain, sometimes accompanied by a snapping feeling and immediate weakness in the upper arm. Slow-developing tears due to overuse also result in pain and arm weakness. You might experience shoulder pain when lifting your arm or pain radiating down your arm. Initially, the pain may be mild and only occur when lifting your arm above your head, like reaching into a cupboard. Over-the-counter medications like aspirin or ibuprofen may initially alleviate the pain. However, with time, the pain may worsen, persist even during rest, and no longer respond to medication. Sleeping on the affected side might become uncomfortable due to pain, and routine tasks like combing your hair or reaching behind your back may become challenging due to shoulder pain and weakness.

If you continue to use a shoulder with a rotator cuff tear despite increasing pain, you risk exacerbating the damage. Over time, the tear can worsen, potentially leading to conditions like wear and tear or arthritis in the shoulder joint, known as "cuff tear arthropathy." In such cases, cuff repair may no longer be effective, and joint replacement surgery may be necessary to restore function. Seeking early treatment can prevent symptoms from worsening and expedite your return to normal activities. The primary aim of any treatment is to alleviate pain and regain functionality. Treatment options for a rotator cuff tear vary from person to person, depending on factors such as age, activity level, overall health, and the specific nature of the tear. Your doctor will take these factors into account when planning your treatment.

Non-Surgical

Alternative treatments that don't involve surgery could encompass:

Rest: Limiting overhead activities and utilizing a sling for immobilization.

Modifying activities: Steering clear of actions that exacerbate shoulder discomfort.

Nonsteroidal anti-inflammatory drugs (NSAIDs): Medications such as ibuprofen and naproxen can alleviate pain and reduce swelling.

Physical therapy and strength-building exercises: Tailored exercises can enhance shoulder movement and bolster its muscles. Your regimen might also incorporate stretches to enhance flexibility and range of motion, potentially mitigating pain and preventing future injuries.

Steroid injections.

Platelet-Rich Plasma (PRP) injections.

Surgical

Criteria for Surgical Intervention

Duration of Symptoms: Your symptoms have persisted for a period ranging from 6 to 12 months.

Tear Size and Tissue Quality: A tear exceeding 3 cm in size, with surrounding tissue exhibiting good quality.

Impaired Shoulder Function: Significant weakness and diminished functionality in your shoulder are evident.

Recent Acute Injury: The tear was precipitated by a recent acute injury.

Surgical Procedures for Rotator Cuff Repair

Rotator cuff repair surgery typically involves reattaching the tendon to the head of the humerus (upper arm bone). Several options are available for addressing rotator cuff tears:

Arthroscopic Tendon Repair: Surgeons employ a minimally invasive approach, utilizing a small camera (arthroscope) and specialized tools inserted through minor incisions to reconnect the torn tendon to the bone.

Open Tendon Repair: In certain cases, an open tendon repair may be preferred, involving a larger incision through which the surgeon directly reattaches the damaged tendon to the bone.

Tendon Transfer: When the torn tendon cannot be feasibly reattached to the arm bone due to extensive damage, surgeons may opt for tendon transfer, utilizing a nearby tendon as a substitute.

Shoulder Replacement: Extensive rotator cuff injuries may necessitate shoulder replacement surgery. A cutting-edge technique, known as reverse shoulder arthroplasty, involves affixing the ball component of an artificial joint to the shoulder blade and the socket component to the arm bone, thereby enhancing the stability of the artificial joint.