The rotator cuff tear and the arthroscopic repair

What is the rotator cuff and how it functions?

The rotator cuff connects the humerus to the scapula. The rotator cuff is formed by the tendons of four muscles: the supraspinatus, infraspinatus, teres minor, and subscapularis. Tendons attach muscles to bones. Muscles move the bones by pulling on the tendons. The rotator cuff helps raise and rotate the arm.





Rotator Cuff function

How the rotator cuff tears?
The rotator cuff has areas of low blood supply. The areas of poor blood supply in the rotator cuff make these tendons predisposed to degeneration from aging.

ρήξη υπερακανθίου
Supraspinatus tear

This degeneration of aging explains why rotator cuff tear is such a common lesion in later life. This problem of degeneration may be accelerated by repeating the same types of shoulder motions. This can happen with overhead athletes, such as pitchers. Also, labors doing overhead routine work may cause rotator cuff fatigue from overuse.

Overhead athlete

Massive force can tear weak rotator cuff tendons. This can happen from trying to catch a heavy falling object or lifting a heavy object with the arm extended. There may be also a fall directly to the shoulder. The typical patient with a rotator cuff tear is in late middle age and has had problems with the shoulder for some time. This patient then lifts a load or suffers an injury that tears the tendon. After the injury, the patient is unable to raise the arm. However, these injuries also occur in young people.

Which are the symptoms when the rotator cuff tears?
Usually there is pain and weakness in the affected shoulder. In some cases, a rotator cuff may tear only partially. The larger the tear, the more weakness it causes.

No function in abduction

Supraspinatus tear in full thickness

In some cases the tendons are torn completely. A complete tear makes it impossible to move the arm in a normal range of motion. It is usually impossible to raise the arm away from the side in abduction. Some people say they can't sleep on the affected side due to the pain.

How is it diagnosed?
The physician asks about the history, the injury and the pain. He proceeds to a physical examination of the shoulder. The physical exam is most helpful in diagnosing a rotator cuff tear. A complete tear is usually obvious.

X-rays will not show tears in the rotator cuff. However, in some cases a down-sloping (hooked) acromion may predispose to rupture. Also, X-Rays may show an upward migration of the humerus, that denotes a massive tear.

Massive Tear. Superior migration of the humeral head

The magnetic resonance imaging (MRI) scan may give a complete information about the lesion type.

The MR Imaging in cuff tear

What treatment options are available?

Non-surgical Treatment
Initial treatment is usually rest and anti-inflammatory medication. Drugs are used mainly to control pain.
The physical therapist may proceed to a rehabilitation program. Manipulation and exercises are used to improve the range of shoulder motion.

Strengthening exercises improve the strength and control the rotator cuff muscles. The rehabilitation program may last six to eight weeks. Most patients are able to get back to their activities with full use of their arm within 8 weeks

Surgical treatment
Full thickness rotator cuff tear does not heal. Complete ruptures usually require surgery if the goal is full return shoulder function. The exception is elderly patients or patients who have other diseases that increase the risks of surgery.

Partial thickness rotator cuff tears may not require surgical repair. If you have a partial tear, your surgeon will most likely want to give your rotator cuff a chance to heal on its own. But if you can't stand the pain, or if you can't use your arm, you may consider surgery.

Degeneration of the supraspinatus fibers

Arthroscopic Debridement
Small tears sometimes may need a smaller operation. The surgeon via the arthroscope  debrides the torn fibers and sutures retension the tendon.

For partial tears on the undersurface of the rotator cuff tendon, surgery may include arthroscopic lavage and acromioplasty. In acromioplasty, the anterior end of the acromion is cut and shaped to take pressure off the rotator cuff beneath the acromion. This is a simple method than suture of the tear.

Osteophyte excision

Arthroscopic Repair
The surgeon via tiny tools, removes any degenerated tissue. The tendon is then sewn together and stitched. The tendon heals to the bone over time, reattaching itself.

Suture repair

Suture Anchor Repair
Surgeons also use  the anchor devices to fix the rotator cuff to the humerus. The surgeon arthroscopist makes small drill holes into the humerus. A suture anchor is implanted via a drill hole. By tugging on the suture, the fastener becomes anchored to the bone. The tendon is then sewn together and stitched to the humerus by looping sutures over the edge of the rotator cuff.

μεταλλική άγκυρα
Metallic anchor

Τοποθέτηση της ‘αγκυρας
Suture anchors implantation and tendon repair

σταθεροποίηση της ρήξης με 2 άγκυρες
In a simple row anchor fixation tendon repair

αρθροσκοπική  εικόνα της ρήξης μετά την νεαρροποίηση της βλάβηςεικόνα αρθροσκοπικής συρραφής
Supraspinatus tear and repair via arthroscopy

Open Repair
In some cases, open surgery is a necessity. These cases are mostly massive tears where a tendon transplantation is needed or when the skills of the surgeon on arthroscopic technique are inadequate.

Massive rotator cuff tear

Incision in open repair

Salvage Procedure
In some cases, the tendon tissue has simply worn away, and the remaining tendon is not strong enough, or is infiltrated by fat tissue in chronic ruptures. In these cases, simply removing scar tissue and fixing any other problems in the shoulder may reduce pain.

What about the Rehabilitation Programm?

Nonsurgical Rehabilitation
Even if the decision is conservative treatment, a program of rehabilitation exercises is a necessity. The doctor recommends the workout with a physical therapist. He will individualize the program to the lesion, in order that the shoulder functions again. This includes tips and exercise for improving posture and shoulder proper function.

After Surgery
Rehabilitation after rotator cuff surgery can be a slow process. Even if an arthroscoping technique is chosen, the healing biology of tendon to bone contact is the same as in open surgery. You will probably need to attend therapy sessions for two to three months, and you should expect full recovery to take up to six months. Getting the shoulder moving as soon as possible is important. However, this must be balanced with the need to protect the healing tissues.

The patient may have to wear a sling to support and protect the shoulder for a few days after surgery. Ice and electrical stimulation treatments may be used during your first few therapy sessions to help control pain and swelling from the surgery. Therapy can progress quickly after arthroscopic procedures. Treatments start out with range-of-motion exercises and gradually work into active stretching and strengthening. You just need to be careful about doing too much, too quickly.