ROTATOR CUFF DISORDERS
The rotator cuff muscles are a group of four muscles that pass from the shoulder blade (scapula) and attach to the top of the ball joint (humerus). These muscles are responsible for rotation and elevation of the arm.
Rotator cuff tears are very common, especially as we get older. They frequently cause pain over the upper arm that is made worse by overhead activities, reaching behind your back and lifting. They often ache at night and people find that they are unable to lie on the injured shoulder. They also cause weakness.
Rotator cuff tears most frequently occur with general wear and tear, and most people usually don’t remember injuring their shoulder. These “degenerative tears”, if not associated with arm weakness, may be successfully treated without surgery. This involves avoiding overhead activities, regular simple pain relief and gentle physiotherapy. Anti-inflammatory steroid injections can be very helpful in these situations to help manage pain and discomfort. When symptoms fail to improve despite these measures, surgical repair of the tear is indicated.
The less common group of rotator cuff tears occur following an injury, and are called “traumatic tears”. People usually remember the exact incident, and often have significant weakness after the injury. Early surgical repair is often indicated.
SUMMARY OF TREATMENT OPTIONS
• Simple pain relief e.g. regular paracetamol, ibuprofen.
• Physiotherapy: to maintain range of movement and strength.
• Anti-inflammatory steroid injections: to assist with pain relief. Note that excessive use of cortisone may cause more harm than good.
• Surgical repair is indicated in certain circumstances including but not limited to:
• Acute tears resulting in weakness of the shoulder.
• Tears that continue to be painful despite regular analgesia, physiotherapy and steroid injections
ROTATOR CUFF REPAIR
As a rule of thumb, rotator cuff tears will not heal on their own, and can only do so if a surgical repair is performed. A repair involves re-attaching the torn tendon to bone (humerus) using sutures and anchors. This operation is usually done under general anaesthesia, and may be performed as an open technique or arthroscopically (keyhole surgery).
Arthroscopic repair is more technically demanding than open surgery, but this method has advantages including less pain, smaller wounds and lower risk of post-operative infection. Not all tears can be repaired.
Risks of surgery include infection, stiffness, ongoing pain and weakness, re-tear of the tendon repair, and very rarely, nerve injury. The risk of the repair tearing again is much greater with large tears and with increasing age (over 70 years of age). Even if the repair does tear again, most people experience an improvement in their pain. The risk of ongoing pain at 12 months following the surgery is approximately 10 to 15%.
Antibiotics are given at the time of surgery to minimize the risk of infection. Despite this, infection of the wounds can occur. This is usually easily treated with antibiotics. However, sometimes the infection gets into the joint which is a serious complication and requires re-admission to hospital, additional surgery and intravenous antibiotics.
Most patients experience improved shoulder strength and less pain following rotator cuff repair, and each technique has similar medium to long-term results. Factors that decrease the likelihood of a satisfactory result include:
• Large / massive tears.
• Patient age (older than 70 years).
• Poor compliance with restrictions and rehabilitation following surgery.
• Smoking.
• Poor tissue quality.
Recovery following surgery usually involves being in a sling for 6 weeks. Most people can drive a car after 6 to 8 weeks. Rehabilitation guidelines to share with your physiotherapist are provided following the surgery, and vary according to the type and size of tear that is repaired. Recovery may take 6 to 12 months, depending on the severity of the tear.