Rotator Cuff Tear
A rotator cuff tear might affect most of your normal everyday activities such as brushing your hair, carrying shopping bags or putting on your coat. The consultant orthopaedic surgeons at Schoen Clinic are specialist in treating shoulder disorders and injuries. Through our experience, we’ll help you get your normal life back as quickly as possible.
What is a rotator cuff tear?
The shoulder joint is the most flexible joint in the body. It’s made up of the humerus head and the joint socket. A special group of four tendons provide the joint with strength and stability and, most importantly, ensure that it’s centered. This group of tendons is called the rotator cuff because they lie on the humerus head like a cuff. The rotator cuff muscles that run from the shoulder blade to the humerus bone (the subscapularis muscle, the supraspinatus muscle, the infraspinatus muscle and the teres minor muscle) move the arm up and to the side, turn it outwards and inwards and stabilise the arm on the torso.
The tendon of the rotator cuff passes through a narrow space between the top of the arm bone and a prominent bone on the shoulder blade (the acromion). The tendon is very vulnerable to being pinched here when the arm is moved, especially above the head. Over time this pinching can lead to tears of the tendon; the chance of this increases as we get older.
Rotator Cuff Tear Symptoms
How does a rotator cuff tear occur?
From falls to sports injuries and even heavy lifting, there are many causes behind a rupture of the rotator cuff. While around just 5% of tendon tears in the shoulder joint occur as a result of an accident in younger patients, rotator cuff ruptures due to degeneration are much more common, making up approximately 95% of cases. In this instance, the tendons have already been damaged due to wear processes and have thereby lost some of their stability. Just a minor fall or forceful ordinary movement is enough to finally injure the already damaged tendons.
Symptoms that are signs of this injury
Many patients with a rotator cuff tear report a dragging or stabbing pain in the shoulder region that can radiate to the neck area or even the hand. This pain is typically even more severe at night, restricting the ability to have a good night’s sleep. Losing tension in these muscles and the ability to automatically maintain posture leads to significantly reduced mobility. In particular, moving the arm forwards or to the side will no longer be possible. This has far-reaching consequences. Those affected are severely limited in their everyday life, so their quality of life is reduced. They can no longer handle everyday activities that seemed normal before, such as brushing their hair or carrying shopping bags, or they can only complete them with great effort.
Rotator Cuff Tear Treatment
Diagnosis: how we determine a rotator cuff rupture
A functions test provides us with the first signs of a tendon tear. In this test, our specialists examine and assess the mobility and strength of your shoulder. In the case of a rotator cuff rupture, you’ll normally no longer be able to move your arm forwards or to the side or you’ll have decreased strength in these movements.
Imaging procedures for examining the shoulder
We can only accurately assess the bony structures using x-ray. But, because a rotator cuff tear involves an injury to the muscles and tendons, other imaging procedures are often used as well. X-ray images are still very important when diagnosing a rotator cuff tear – only x-ray images can be reliably used to determine whether the rotator cuff still directs or centers the humerus head stably in the joint. MRI performed with patients lying down cannot provide this information.
Ultrasounds and MRI show destroyed structures
Using ultrasound examination (sonography) and magnetic resonance imaging (MRI), we can analyse the status of the soft tissue inside your shoulder. Ultrasounds allow for clear images of the tear in your muscle and tendon apparatus. Changes to the tendons and any effusions inside your shoulder joint are also visible. An ultrasound examination allows a dynamic check which sometimes is the most valuable tool to detect dislocating tendons or imbalance of the muscular structures.
MRI examination offers the most accurate view of the affected joint. This presents the joint in high resolution, allowing us to reliably establish which structures are damaged.
Rotator Cuff Tear Treatment
Different factors determine treatment
If a tear in the rotator cuff has been diagnosed, there will be, of course, different therapeutic approaches to consider based on the severity of the damage and extent of the shoulder injury. Selecting the right type of treatment will depend on how the injury occurred, how much this restricts you and how much independence you want, among other things. Your age also plays an important role. For younger patients or more recent tendon tears, the function of the shoulder is typically restored through surgery. But because wear-related rotator cuff defects often occur in older people and sometimes only cause mild symptoms, extensive reconstruction will need to be carefully considered, along with your individual life circumstances, everyday requirements and sports activities.
Conservative treatment methods
Conservative treatment through immobilisation and medication
With conservative treatment, the focus is on temporary protection, decongestant and painkilling medication, localised applications of ice and special physiotherapy exercises. Through this, we can achieve a situation where you might become pain-free or have reduced pain, with as much shoulder functionality as possible. You can preserve the mobility of your shoulder in the early stages using arm pendulum exercises. If any swelling occurs, our therapists can help relieve this using manual lymph drainage. In addition, some physical applications such as massages or electrotherapy can support the healing process.
Surgical treatment methods
Rotator cuff tear surgery: making your shoulder pain-free again
If conservative treatments fail to improve the shoulder symptoms and function, we’ll need to repair the damaged structures in your shoulder through surgery. This is the only way we can prevent further damage in the joint.
Our joint specialists proceed with the operation using minimally invasive methods where possible. With arthroscopy, for example, only very small skin incisions are required. This way, we can treat the injury to your joint while also continuing to preserve your tissue reducing risk and complications.
Before deciding on rotator cuff tear surgery, we will always have a careful conversation with you as often surgical restoration of the rotator cuff involves lengthy aftercare. It typically takes several months before the operated tendon tissue heals again. Surgery therefore will create restrictions in your working life.
Arthroscopy and open surgery of the shoulder – both are possible
We can treat a rotator cuff tear using either the keyhole technique (which is most commonly used) or with open surgery. Both procedures can also be combined. This way, we can protect the torn tendon parts and safely reattach them as part of a quick surgical procedure.
With arthroscopy, we operate on your injury using several small (minimally invasive) skin incisions, protecting the tissue as much as possible. Because the surgical wounds are so small, less scarring forms and the healing process is much quicker. Furthermore, we can precisely assess the extent of the damage in your shoulder joint during this procedure and carry out additional treatment steps as needed.
The arthroscopic operation is carried out under a general anaesthetic. It is performed as a day surgery procedure in most patients. The tendon is repaired by stitching it to the bone using tiny suture anchors. The suture anchors can absorbable or non-absorbable (metallic). The arm is then placed in a sling to allow for healing.
Artificial tendon replacement (SCR): patching the tendon defect
If the rotator cuff defect is too large, the tendon pulled back too far and the muscles too fatty and degraded, the tendon tear won’t be able to close up successfully. This creates the risk of no longer having a centering function and having the humerus head sticking out of the shoulder joint, limiting the function of the shoulder.
In such cases, up until the last few years, the only option was to implant a reverse shoulder replacement. But, because the lifetime of this replacement is limited, this procedure was postponed, especially for younger patients under 60 years who were still very active physically.
In the last few years, however, some techniques have been developed that have demonstrated very good mid-term results. This involves closing the tendon defect and adding reinforcement with a type of patch. Artificial patches or foreign skin from the tissue bank can be used as well as one of the body’s own surface tendons from the thigh.
Muscle-tendon transfer as a mechanical replacement
Another option for closing tendon defects that can no longer be repaired is a muscle-tendon transfer. Here a back muscle tendon (latissimus dorsi transfer) is placed from the front-inner part of the upper arm to the top-outer part. This technique can be done arthroscopically assisted with minimally invasive approach and has shown excellent midterm results for active patients.
Implantation of a total reverse shoulder replacement: reduction of pain and restoration of active movement
If the joint shows damages on the surface alongside the rotator cuff tear, the humeral head under the shoulder cap will have the same lack of function as the shoulder joint. In this case, implantation of a reverse shoulder replacement is a good alternative, especially for patients aged over 65 years. Modern reverse shoulder replacements can often be anchored to the humerus while preserving the bone structure without the use of cement or a shaft, and are inserted through a 7-8cm long incision that protects the soft tissue. 85% of these implants currently have a lifetime of 15 years or more. The benefit of these implants is the relatively short aftercare duration. Because no tendons need to grow back, you’ll be able to have good mobility in your shoulder joint again three to six weeks after surgery.
The hospital stay lasts three to five days. You’ll start passive movement exercises to quickly regain joint mobility straight after the procedure. Inpatient or outpatient rehabilitation treatment is recommended after the immobilization period.
As with all surgery there is a risk of complications. These are rare, but you should be aware of them before your operation.
• Complications relating to the anaesthetic
• Failure to achieve a successful result.
• A need to redo the surgery
• Injury to the nerves or blood vessels around the shoulder
• Prolonged stiffness and or pain
• Implant failure
• Re-tear of the tendo
A nerve block is usually used during the surgery. This means that immediately after the operation the shoulder and arm often feel completely numb and weak. This may last for a few hours. After this the shoulder may well be sore and you will be given painkillers to help this whilst in hospital. These can be continued after you are discharged home. Ice packs may also help reduce pain. Wrap crushed ice or frozen peas in a damp, cold cloth and place on the shoulder for up to 20 minutes.
Wearing a sling
You will return from theatre wearing a sling. Your surgeon/physiotherapist will advise you on how long you are to continue wearing the sling but usually this is for around four weeks. Depending upon the size of the tear you will commence physiotherapy immediately, at three weeks or sometimes after six weeks. You will be expected to remove the sling for exercises only. Your physiotherapist will advise you of these.
Open repair: there is an incision at the top of the shoulder. The stitch is dissolvable but is usually removed at three weeks. Keep the wound dry until it is well healed.
Arthroscopic (keyhole) repair: This keyhole operation is usually done through three to five 4mm puncture wounds. Often there will be no stitches; only small sticking plaster strips over the wounds or resorbable stitches. These should be kept dry until healed. This usually takes five to seven days.
You will not be able to drive for a minimum of 4-6 weeks. Your surgeon will confirm when you may begin.
Returning to work
This will depend upon the size of your tear and your occupation. You will need to discuss this with your surgeon.
This will depend upon the size of the tear. Your physiotherapist and surgeon will advise you when it is safe to resume your leisure activities.
Follow up appointments
An appointment will be made for you to see a physiotherapist after your discharge and you will be seen by your consultant two to four weeks after surgery.