Rotator cuff tear
Rotator cuff tear is a common cause of shoulder pain, especially for the patients with the age of 50 or above. Supraspinatus tendon is the most common affected rotator cuff tendon. Pain and weakness is the typical symptom. Conservative treatment can be adopted for patients with minimal symptom. Arthroscopic rotator cuff repair is the main stream of current treatment of rotator cuff tear. It provides good to excellent results for most of the patients with rotator cuff tear, especially in term of pain relief and improvement of function.
Anatomy
The rotator cuff is a network of tendon of four of the muscles that provide shoulder movement, namely the subscapularis, supraspinatus, infraspinatus and teres minor. While most of the strength is supplied by the bigger muscles (deltoid, pectoralis major and lattissimus dorsi), the rotator cuff muscles are responsible for the stability and coordinated movement of the shoulder joint. A rotator cuff tear is simply a tear of one or more of the rotator cuff tendons of the shoulder. The severity of tears can vary immensely, ranging from small partial thickness tears that may not cause any problems, to extensive full thickness tears that are complicated to treat. Massive tear is tear involved two or more rotator cuff tendons. The longer a tear exists, the weaker the shoulder, and the larger the tear, the poorer the prognosis.
Symptoms
Pain and weakness are classic symptoms of rotator cuff tears. The pain is usually diffuse and worsens when the arm is being lifted above the shoulder. The presence of night pain is also common. Weakness can range from mild to severe in which the arm is unable to lift at all.
Natural history of asymptomatic rotator cuff tears
A study on asymptomatic tears by ultrasound revealed that half of the patients became symptomatic over 3 years, and half of those who became symptomatic, the tear became larger and no tears became smaller1. Another study showed about half of patients with rotator cuff tear will have the tear enlarged in 5 years period, and 80% of them will develop symptoms2. Untreated massive tears will eventually cause arthritis of the shoulder known as ‘cuff tear arthropathy’. Therefore, rotator cuff tears are at risk of progression and are likely to become symptomatic, whereby symptomatic tears usually worsens over time.
Treatment
There are two types of treatment – conservative, non-surgical treatments and surgery. Small partial thickness tears can initially be treated with non-surgical treatments, and if there is no improvement then surgery may be considered. However, non-surgical treatment may be more suitable for elderly patients who are medically unfit to undergo surgery.
All symptomatic complete rotator cuff tears should better be repaired by surgery as large and massive tears can be very difficult to repair over time. A deep partial thickness tear behaves almost like a complete tear.
Non-surgical/conservative treatment
The main purpose of using anti-inflammatory drugs is to reduce pain. Physiotherapy, consisting of stretching and strengthening exercises of the remaining rotator cuff muscles, helps to stretch out any capsule tightness in order to prevent development of frozen shoulder. Physiotherapy also helps to reduce impingement by stabilising the shoulder joint during movement. Steroid injection can also be used to reduce inflammation in the rotator cuff tendons for temporary pain relief. However, it is not recommended if operative repair is the plan of treatment.
Surgical treatment
Arthroscopic shoulder surgery is the primary surgical treatment for rotator cuff injuries. It has been shown to provide results comparable with open surgery but without its associated morbidity. Unlike an open surgery, it is not necessary to injure the deltoid muscle, which may cause denervation and weakening of the shoulder. There is also less risk of scar and adhesion formation, which may compromise the rehabilitation. Other advantages include less post-operative pain, shorter hospitalisaton (most need just an overnight stay in hospital) and rehabilitation.
Arthroscopic shoulder surgery
It is a surgical procedure done at the hospital under general anaesthesia, in which the joint is examined through an arthroscope that is connected to a video camera. Small instruments are placed through the incision sights to remove bone and soft tissue, or to repair torn structures inside the joint. Arthroscopic shoulder surgeries offer a superior view of the inside of the shoulder joint that is merely possible with open surgeries.
Arthroscopic subacromial decompression
This surgery aims to increase the size of the subacromial space and reduce the pressure on the tendon. It involves release the thickened ligament and shaving away the bone spur on the acromion bone.
Post-operative rehabilitation
It is vital to follow the rehabilitation program post-surgery with the aim to protect the repair whilst allowing some movement to prevent development of stiffness.
A special arm sling for support and comfort after the procedure is necessary for 4 to 6 weeks. Depending on the size of the tear, passive mobilisation may also be allowed. The physiotherapist will provide a range of motion exercises followed by strengthening exercises.
It can be expected that work can be resumed in one to two weeks’ time, and resume normal daily activities involving the arm after 2 months, and full recovery by 3 – 6 months, depending on the size of the tear.
Prognosis
Arthroscopic rotator cuff repair has been shown in numerous studies to yield 90% to 95% excellent to good results in terms of pain relief, patient satisfaction and improvement in function3-5. Based on my experience with patients, I also found that arthroscopic repair gave significant improvement in pain relief and functional outcome8.
It is interesting to note that complete healing of the cuff repair is not always possible and, indeed, is not necessary to give good pain relief and patient satisfaction. This correlated well with the concept of “partial cuff closure” in massive rotator cuff tears as advocated by Dr. Stephen Burkhart. Re-tear rates up to 30% have been reported following open repairs and arthroscopic repairs of a single tendon, but 85% of them still satisfied after the surgery6.
However, for recovery of strength, the integrity of the cuff repair is more important. Study had shown a correlation between a poor result and preoperative strength and active range of motion7. If patients had marked weakness or were unable to lift their shoulder beyond 100 degrees, there was an increased risk of a poor result. This is because patients who had poorer preoperative strength usually had larger cuff tears, which are harder to repair and to keep intact after surgery.
Potential complication
Arthroscopic rotator cuff repair involves a very small risk of wound infection and nerve injury. Stiffness can be an issue, but it is less common and easier managed than that of an open surgery. Additionally, there may be some residual pain but the effect of pain relief is usually better when compared with pre-surgery. Residual weakness may also be present, especially in large and massive rotator cuff tear. Re-tear can happen as well, but it does not guarantee poor result or poor function. It is more common when the tear was large and more than 3 cm.
References
- Yamaguchi K, Tetro AM, Blam O, Evanoff BA, Teefey SA, Middleton WD. Natural history of asymptomatic rotator cuff tears: a longitudinal analysis of asymptomatic tears detected sonographically. J Shoulder Elbow Surg. May-Jun 2001;10(3):199-203.
- Tempelhof S, Rupp S, Seil R: Age-related prevalence of rotator cuff tears in asymptomatic shoulders. J Shoulder Elbow Surg 1999;8:296-299. 10471998
- Burkhart SS, Danaceau SM, Pearce CE, Jr. Arthroscopic rotator cuff repair: Analysis of results by tear size and by repair technique-margin convergence versus direct tendon-to-bone repair. Arthroscopy. Nov-Dec 2001;17(9):905-912.
- Murray TF, Jr., Lajtai G, Mileski RM, Snyder SJ. Arthroscopic repair of medium to large full-thickness rotator cuff tears: outcome at 2- to 6-year follow-up. J Shoulder Elbow Surg. Jan-Feb 2002;11(1):19-24.
- Wolf EM, Pennington WT, Agrawal V. Arthroscopic rotator cuff repair: 4- to 10-year results. Arthroscopy. Jan 2004;20(1):5-12.
- Jost B, Pfirrmann CW, Gerber C, Switzerland Z. Clinical outcome after structural failure of rotator cuff repairs. J Bone Joint Surg Am. Mar 2000;82(3):304-314.
- Ellman H, Hanker G, Bayer M. Repair of the rotator cuff. End-result study of factors influencing reconstruction. J Bone Joint Surg Am. Oct 1986;68(8):1136-1144
- Chow KPB, LI W. Arthroscopic rotator cuff repair – Our experience and results. The 27th Hong Kong Orthopaedic Association Annual Congress, 2007.
Written by Dr. Benjamin Chow
