Tears in the rotator cuff

Introduction
In the advanced stages of impingement (see section 3), first small, and then later larger tears or defects appear in the rotator cuff. The rotator cuff can also be torn away from the bone by an accident. For example, this commonly occurs in combination with a dislocation of the shoulder.

Often the cause is found to be wear and tear combined with an accident. Astonishingly, several older patients exhibit large tears in the rotator cuff, which have apparently developed over the course of several years and cause hardly any symptoms. Other patients, on the other hand, have massive chro-nic pain, which is uncontrollable by a nonoperative treatment.

The diagnosis of a tear in the rotator cuff is usually made by a physical examination. To judge the size of the tear and quality of the tissue, an MRI scan is of proven benefit. When the diagnosis of a torn tendon is established, you need to decide together with your doctor whether the tendon should be repaired surgically.

Factors in favour of surgery include younger age, tear due to an accident (=traumatic tear), physical activity, overhead use of the shoulder and considerable pain. Cuff repair also makes sense in view of the future of your shoulder joint: Based on several studies we now know, that an untreated tear inevitably leads to slow degeneration and fatty infiltration of the muscle unit.

Surgical procedure
This intervention is also carried out in the beach-chair position, mostly with a combination of nerve block and general anaesthetic. To start with, a diagnostic arthroscopy allows precise planning of the best surgical procedure. Depending on the situation, either 1, 2 or 3 tendons of the rotator cuff may be affected by the tear (see section 2). Frequently the biceps tendon, which passes through the joint, is also damaged. Each pattern of damage has its own characteristics and the selection of the best surgical procedure requires great experience. Defects of over 5 cm diameter are judged beyond reconstruction by many shoulder surgeons; however a partial reconstruction is often beneficial.

In principle, it is possible to repair the rotator cuff in the framework of either open or arthroscopic surgery. Although this is still traditionally the domain of open shoulder surgery, arthroscopy is on the rise these days and can rightly be called an “emerging gold standard”.

Personally, I changed my technique at the beginning of 2000 and since then have dealt with all rotator cuffs arthroscopically with excellent success. My experience to date covers about 1000 cases. The most striking factor is the immediate reduction in postoperative pain. Healing occurs somewhat faster with the arthroscopic method, mobility is better, and a study of ours has verified that patient satisfaction after one year is higher, in comparison to open surgery (Arthroscopy, May 2005: 597).

The main steps of the operation include:

  1. Detailed diagnosis and establishment of the surgical strategy
  2. Debridement of the bone surface and tendon stump
  3. Re-attachment of the tendon to the bone surface by means of titanium anchors and permanent sutures
  4. Enlargement of the subacromial space as described in section 3.

The advantage of arthroscopy, in addition to the small and hardly visible scars, is that the deltoid muscle, which is very important for the shoulder, does not have to be detached.

Follow-up
Post-operatively the arm should be kept in a comfortable position. For this purpose you will receive a shoulder bandage (Ultrasling) with a small cushion, which keeps the arm slightly away from the body. In the first few weeks, the tendon sutures must be carefully protected, as the healing of the tendon to the bone can only be relied upon after 6 to 8 weeks. During this time, the strength of the reconstruction depends exclusively on the suture material. Resting the shoulder for several weeks results in stiffening of the joint, therefore, the maxim in the first few weeks is assisted, i.e. supported mobilisation of the shoulder.

The controlled, supported external ro-tation with a stick is the most important exercise in the first phase after the operation and reliably inhibits stiffening of the shoulder. The duration of phase I is 4 to 8 weeks, depending on the size of the tear. In the following phase II, the shoulder can be moved actively without loading, and stretched, including above the head. About 4 weeks later, strengthening exercises are started (phase III).

The surgeon and therapist will provide you with the details and give you appropriate instruction sheets. Please persist with the post-operative treatment programme which is appropriate to the operation carried out. You will receive a Shoulder-Rehabilitation Kit containing the necessary aids, including a stick, an overhead pulley and rubber bands of various strengths.

Prognosis
Following reconstruction of the rotator cuff, about 95 % of patients can expect a good result. A lengthy healing period of 3 to 4 months has to be accepted; further improvement of the shoulder function will be achieved over the course of a year. Large tears affec-ting several tendons cannot be fixed in all cases, all the more because the tendon tissues are often quite fragile. Despite this, even patients whose tears could not be completely closed up fortunately have, for the most part, considerably fewer complaints than before the operation.