Rotator Cuff Tears
The rotator cuff consists of muscles and tendons in the shoulders which connect the upper arm to the shoulder blade and hold the ball of the upper arm into the shoulder socket allowing for smooth and rotational movement of the arms.
These tendons can be damaged as a result of an injury or also get inflamed and torn as a result of wear and tear, as is more common in older individuals. In younger individuals, inflammation can also occur as a result of overuse or repeated overhead activities such as swimming, painting or playing tennis. Depending on the damage to these tendons and muscles, arm movement is impaired. Damage to any of these muscles and tendons is termed rotator cuff tears.
The main feature of a rotator cuff tear is weakness. Only certain movements of the shoulder may be weak depending on which tendon is torn. The supraspinatus tendon (the muscular tendon that runs over the shoulder bones) is the most common tendon to sustain tears and leads to weakness of lateral elevation. In certain individuals, there may be complete loss of lateral elevation of the arm and gives the appearance of a pseudo paralysis. Here, passive elevation is possible although the patient is not able to perform the movement on his/her own. Certain people with a tear of the rotator cuff may compensate for the loss of a particular tendon with other surrounding muscles and tendons, thereby allowing a normal range of movement.
- X-rays are helpful if the tear is a chronic one whereby there is upward migration of the humeral head. Sometime degenerative changes may also be seen which can also lead to pain eventually if left alone.
- Ultrasound scan by an experienced musculoskeletal radiologist can provide useful information about the tear.
- An MRI scan is very useful is diagnosing tears of the rotator cuff and to determine the extent of the tear.
Treatment depends on the age of the patient and the mode of injury. Younger patients are generally given the choice of surgery straightaway if the rotator cuff is torn. Older individuals can be given a trial of nonsurgical treatment.
Nonsurgical treatment includes pain-killer medications with physical therapy to improve shoulder movements and strengthen the shoulder muscles. An injection into the subacromial space or the space between the roof of the shoulder joint and the ball joint of the arm may also be recommended to patients who find it difficult to cope with the pain.
If nonsurgical treatment is unsuccessful, patients are recommended to undergo surgery to shave some bone spurs off from the under surface of the roof of the shoulder joint to make space for the rotator cuff repair. The rotator cuff can then be repaired by a minimal open surgery.
Following repair, the shoulder is usually immobilized for a few weeks in a sling to be followed by light movements for about 6 weeks. Active movements are started after this. Strength training of the muscle is usually started after about 2-3 months. Patients are advised to keep minimal movement for proper healing.
Massive cuff tears may sometimes require transfer of another tendon from elsewhere to cover the defect if the tear cannot be repaired. The results of this surgery are not always satisfactory and only recommended in exceptional cases.
Certain elderly individuals with rotator cuff tears may surprisingly have good movement of the shoulder and may only complain of pain. In these patients, the rest of the shoulder muscles have compensated for the torn tendon to provide normal shoulder movements. Repairing the cuff tear in these patients may possibly make their post-operative function worse. Depending on several factors, your surgeon may only recommend a subacromial decompression, a process to shave off the upper part of the shoulder socket, to help you take care of the pain. Following this procedure, the shoulder movements can be started immediately to prevent stiffness.
Chronic rotator cuff tears in elderly individuals can cause the humeral head (the upper end of the arm bone) to rub against the acromion (the roof of the shoulder socket) causing arthritis called as rotator cuff arthropathy. Treatment for this is usually surgical and replacement of the humeral head only (hemiarthroplasty) may be considered. In fairly active individuals a reverse shoulder replacement may be recommended which is a fairly recent procedure. Here, the traditional ball and socket joint are 'reversed' and parts of the shoulder joints are replaced to control pain and allow limited movements. Results of this treatment vary and long term results are awaited.