||ROTATOR CUFF TEARS
The rotator cuff is formed of 4 muscles
- Teres Minor
They form a cuff over the top of the humerus.
They have two roles a) to rotate the humerus on the glenoid. b)
To provide stability by compressing the humerus into the glenoid
socket. They contract as a unit before any other muscle in the shoulder,
anchoring the joint to allow the larger muscles around the joint,
such as the deltoid, to create movement of the arm. In effect they
are needed to counteract the forces developed by the large external
muscles ( e.g deltoid and pectoralis major)
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The most common site of a tear is within the supraspinatus muscle,
but any or all of the muscles can be affected.
Tears cause a problem because the joint looses its stability and
other problems arise as a result of this, such as impingement and
lesions of the biceps. Ultimately, large, untreated tears can lead
to severe,early secondary osteoarthrosis.
A tear is most common in people over the age of 40 due to degeneration
of the tendon structure or lack of specific exercise , but can also
occur in younger people as a result of an injury.
Common examples of when an injury is likely to occour :-
a) A fall onto an outstretched arm
b) Lifting a heavy object – especially from overhead to the
c) A sudden reach behind (eg reaching for something on the back
seat of a car), especially when forced.
d) In association with a fracture or repetitive motions ie workers
with overhead activities such as painting, plastering,construction
or athletes such as swimmers, tennis players etc.
Signs and Symptoms
• Pain at the front or side of the shoulder which radiates
down the side of the arm.
• Pain increases with overhead activities and during the movement
of lowering the arm to the side.
• Night pain, especially when lying on the affected side.
• Weakness of the arm.
• Cracking or grinding.
• Wasting of the muscles around the joint.
• Physical examination
• X- ray
• Arthrogram- this is when a local anaesthetic and dye is
injected into the joint guided with x ray to detect the size and
location of the tear.
• Ultrasound scan
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RC: Rotator cuff, B: biceps HH: humeral head
Arthroscopic view of a rotator cuff tear. A large space can be
seen between the humeral head and the edge of the rotator cuff
- Rest and limit overhead activity.
- Anti-inflammatory medication.
- Steroid injection.
- Physiotherapy to strengthen the muscles unaffected.
Managed conservatively, without surgery, it will take several months
of exercise to regain the strength necessary to stabilise the joint.
Surgery – Rotator Cuff Repair - The type of surgery depends
on the size, shape and location of the tear. A partial tear may
require only a trimming or smoothing, a procedure known as debridement.
A larger tear in the substance of the tendon is repaired by suturing
the two sides of the tendon. If the tendon is torn from its insertion
onto the greater tuberosity of the humerus it can be repaired directly
onto the bone.
ROTATOR CUFF REPAIR
To relieve pain and improve rotator cuff function
Patients with pain or difficulty elevating the arm against gravity
or lifting ,from repairable rotator cuff tears, either degenerate
or tears resulting from an injury e.g sudden, heavy lifting.
Sagittal, superior/lateral aspect of the shoulder. This is designed
to give the best cosmetic results.
The deltoid is divided between its fibers and detached from the
front of the acromium to provide access to the torn rotator cuff.
An acromioplasty is usually also required(link). This increases
the sub acromial space and reduces the possibility of impingement
and recurrent tear.
The rotator cuff tear is located (most commonly in the supraspinatus
tendon). The tendon is carefully released of all adhesions and bought
back to its original position. It is then repaired, without tension
directly to the bone utilizing small anchors secured within the
bone. The bone surface has to be carefully prepared.
Possible Associated Procedures
Excision of the acromioclavicular joint
Sub Acromial Decompression
Manipulation Under Anaesthetic
Main Possible Complications
Impingement of the repair
Recurrence of the tear
Temporary or permanent nerve damage ( to the nerve supplying the
rotator cuff muscles)
Detachment of the repaired deltoid muscle
Development of pain from pre-existing degenerative gleno-humeral
joint arthritis. Severe arthritis can develop as a result of a bad,
neglected rotator cuff tear.
After the operation
An abduction brace (either 15 or 30 degrees ) is applied in theatre.
Avoid all active movements
Seen by physiotherapist to be shown how to safely remove and re-apply
brace and to perform passive, controlled shoulder movements.
2 Weeks Post Op
Wound and sutures are reviewed by the hospital or practice nurse.
Pain levels discussed to keep under control
Physiotherapist assesses active and passive range of motion
4 Weeks Post Op
Surgeon reviews deltoid and rotator cuff function, pain levels,
active and passive range of motion and neurological function.
Physiotherapist progresses to active assisted exercises.
6 Weeks Post Op
Physiotherapy session to progress to full active exercise and discard
12 Weeks Post Op
Surgeon assesses active and passive range of motion, anterior deltoid
function and rotator cuff function.
6 Months Post Op
Assess active and passive range of motion
Discharge with continuation of physiotherapy or review in a further
Continue home strengthening exercise programme and plan return to
chosen sports/manual work/heavy lifting.