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Rotator Cuff Tears

Rotator cuff tear is a common cause of shoulder pain in middle-aged and old people. However, it can occur at any age. A rotator cuff tear can occur due to injury such as forward fall on an outstretched hand, or on lifting a very heavy object with a jerk. Repetitive actions especially involving overhead hand movements such as swimming, playing tennis and games involving throwing a ball (cricket, baseball), and keeping things on overhead shelves can cause a rotator cuff tear. The condition makes even simple tasks like brushing the hair or reaching your own back very difficult. Pain can be felt even in the night while resting.

Rotator cuff is a group of four tendons that join the head of the upper arm bone (humerus) to the shoulder muscles. Tendons are the muscle extensions, which join muscle to bone and allow the muscle to control the movement of the bone. Thus by pulling on the tendons the shoulder muscle can move the arm.

The cartilage structure of the tendons accumulates changes with age and overuse (degenerative changes) of shoulder. With age, blood supply to the rotator cuff tendons decreases and also the ability to repair the changes in its cartilage structure, which over the time may lead to a tear. Bone spur or overgrowth of a shoulder bone may also occur with ageing and put mechanical pressure on the rotator cuff tendons below it, causing shoulder impingement. If not treated, impingement may finally cause the tendon to tear below the bone overgrowth. Repetitive actions of the arm also cause change in the cartilage structure making the tendons weak and more prone to rupture or tear. Tear of the tendons of the rotator cuff is known as rotator cuff tear. The tear is mostly noticed in the arm, which is most often in use. Thus, for a right-handed person, the tear is mostly in the right hand and for left-handers, in the left hand. It may be partial or complete. A complete tear leads to complete detachment of the tendon from the head of the humerus, whereas, a partial tear is the rupture of the tendon at a place where the tendon is still attached to the shoulder muscle.

Symptoms
Tear due to injury causes sharp strong pain with swelling and tenderness in front of the shoulder. In case of partial tears, there will be pain in the shoulder, but you can still move the arm. Whereas, in complete tears you cannot move the arm, especially raise the arm from your side, on your own.

Degenerative changes in the rotator cuff initially lead to mild pain in the shoulder with activities involving raising the arm. Pain is even felt in the affected shoulder when resting on that side at night. Initially, taking pain killer medications may provide relief, but slowly over time, the intensity of the pain increases and medications will no longer be effective in reducing the pain.

Diagnosis
The doctor will ask you about your symptoms and medical history. He will then examine the strength of the arms and the shoulder movements that are possible in the current situation. He will ask for an X-ray in case he suspects bone spur to be the cause of the rotator cuff tear. The X-ray cannot show soft tissues like tendon, so to further visualize the amount of tear and the position of the tear he may ask for an MRI or an ultrasound. Sometimes, shoulder arthroscopy is used to access the tear.

Treatment
Chronic shoulder and arm pain, even though mild, should not be neglected. If it is due to the tear of the rotator cuff, the tear will increase with use and so will the pain. To treat partial tears the doctor will ask you to rest the affected arm and may put it in a sling. Pain medications will be prescribed to reduce the pain and some physical exercises of the shoulder will be advised to increase the mobility and strength of the shoulder muscle. If rest, medication and exercises do not provide any pain relief, corticosteroid, a strong anti-inflammatory drug, along with a local anesthetic may be given as an injection in the shoulder in the space below the bone spur and above the rotator cuff. Surgery will be advised if:

  • Nonsurgical treatment for a year or so is ineffective
  • The tear is large or complete
  • The tear restricts activities, especially for a professional sports player
  • The tear is due to a severe injury

Surgery
To plan the surgery, the doctor may ask for an MRI or arthroscopy. Arthroscopy is a minimally invasive surgical procedure done under local or general anesthesia using an arthroscope. An arthroscope is a pen-thick instrument. It consists of a lens, a light system and a camera. A button-sized hole is made in the shoulder and the arthroscope is inserted through the hole. Fluid flows through the arthroscope and provides the surgeon with a clear view of the inside of the shoulder joint. It also minimizes bleeding. The surgeon can see the images from the arthroscope on the monitor. If necessary, surgical instruments are introduced in the joint through separate holes – one or three – depending on the type of repair need to be done in the joint. After surgery, the incisions are closed by stitching or with small sterile bandage strips. You will be kept in the hospital for few hours after the surgery for observation, and will be discharged on the same day.

  • If the damage is partial, the degenerative tissue of the tendon is removed using surgical tools. The tear is left to heal on its own.
  • If the bone spur is causing the tear and the tear is small, the front edge of the bone is removed to prevent pressing of the rotator cuff, and the torn tendon is sutured (acromioplasty).
  • If the tear is complete, the degenerative tissue of the torn tendon is removed; front edge of the bone spur (acromion) is removed along with some of the bursal tissue. Bursal tissue is present below the bony process to prevent friction between the bony process and the rotator cuff. Four to five millimeter of the clavicle, a bony process is also removed to increase the space for the rotator cuff muscle. The humerus bone head where the tendon was attached is cleaned and all the soft tissue is removed. The raw bone surface is exposed and holes are drilled into the humerus bone to accommodate the suture anchors. Suture anchors, nowadays, are made up of bio absorbable material that dissolves in the body on its own with time. Occasionally, metal anchors are used and they stay there in the bone permanently. The tendons are then sewn to the anchors on the bone. The incisions are closed by suturing or by the tape. It is much safer and less painful than open surgery.
  • If the tear is severe or old, open surgery is performed. In this, a long incision is made on the front side of the shoulder. The outer muscles are cut to reach the rotator cuff. The same procedure is done through open surgery as done in arthroscopy.
  • If the tear is long and the tendon cannot be stretched to the bone, tendon grafting may be done to extend it and then it is reattached to the bone. The procedure is complex and is rarely used.

After the surgery, pain medications are given to reduce pain and shoulder exercises are advised to regain mobility and strength of the shoulder. Over the period of time, healing occurs, and the tendons reattaches to the bone naturally.

Summary
Rotator cuff tear is a common cause of shoulder pain in middle and old people. It may occur due to injury or degenerative changes. Treatment depends on the degree of tear. Rest, pain medication, and shoulder strengthening exercises provide relief in partial tears but more severe tears require surgery. Surgery provides relief from pain in most of the cases, but the functional mobility of the shoulder joint may vary from individual to individual after the surgery.

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Houston Shoulder Specialists

Advanced Orthopedics and sports medicine has numerous Board Certified/Eligible physicians who are thoroughly educated in the latest treatment techniques both surgical and conservative. They are well versed in advances in shoulder treatments including arthroscopic rotator cuff and Bankart repairs, shoulder stabilization procedures, total shoulder replacement and reverse shoulder replacement.

Drs Elbaz and Brooks now perform Platelet-Rich Plasma (PRP) injections for the treatment of rotator cuff tendinitis, and biciptal tendonitis. PRP stimulates a more rapid healing of tendon, ligament, muscle and bone.

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