ARTHROSCOPIC ROTATOR CUFF

“Rotator Cuff Tears” is a very common cause of severe shoulder pain which causes weakening of the shoulder such that daily life activities such as combing and getting dressed are compromised.

The arm is kept in the shoulder socket (glenoid cavity) by the tendons of four muscles (namely Supraspinatus, Infraspinatus, Subscapularis, and Teres minor) which collectively form the rotator cuff and help to lift and rotate the arm. Between the bone and the rotator cuff, a lubricating sac is present there on the top of the shoulder called bursa. It allows the rotator cuff to glide freely during the movement and gets inflamed and painful whenever the rotator cuff is damaged.

Most rotator cuff injuries are related to the supraspinatus tendon, however other parts can definitely be involved. The damage may worsen and can tear the tendon completely by further stress such as with lifting a heavy object.

The doctor carefully examines the shoulder so as to confirm the diagnosis and rule out other possibilities of shoulder pain such as Pinched nerve or arthritis.

The doctor may ask for an imaging test such as

• Shoulder X-ray
• MRI
• Ultrasound

• Partial Tear or Incomplete Tear in which the tendon is just damaged but not torn.
• Full-Thickness Tear or Complex Tear in which tendon(s) get separated from the bone.

Rotator cuff injury can be caused by an injury or degeneration

• INJURIES such as falling on an outstretched arm or lifting heavyweight with a jerk can cause rotator cuff injuries as well as other shoulder damages.
• AGING is a common factor of rotator cuff injury due to bone spur (bone overgrowth), shoulder impingement, and lack of blood supply.
• REPETITIVE STRESS ON SHOULDER as in various sports activities or job-related overhead works, overuse tears may occur.

Hence, athletes and people aged above 40 are more prone to get these injuries.

The choice of non-surgical treatments is made depending on age, activity level, and type of tear and is helpful in around 80% of chronic shoulder pain patients but may take a longer recovery time.

However, during this period of time

• Size of tear may increase overtime
• Routine activities are limited

The commonly used non-surgical treatments are as follows:

• Rest
• NSAIDs
• Activity Modification
• Physiotherapy
• Steroid Injection
• PRP Injection

Another non-surgical intervention that has a very effective role in decreasing pain and inflammation is the “Platelet-rich Plasma (PRP) Therapy” which potentially stimulates healing and provides a feasible alternative to surgery as well as steroid injection. For more details of PRP Therapy

Signs such as the following may suggest Rotator Cuff Repair by surgery

• Continued pain for more than 6 months
• Larger tear
• Significant Weakness
• Tear due to an acute injury

The choice of these surgical options depends on the need of the patient, size of the tear, quality of tendon tissue and bone, and the experience and familiarity of the surgeon with a particular procedure.

The generally used surgical options include:

• Open Repair: This is generally done for the large and complex tears or when an additional reconstruction such as tendon transfer is indicated. It is a traditional surgical method employing large incision, acromioplasty (removal of bone spurs underside the acromion). Nowadays, less invasive procedures such as Arthroscopic Repairs are generally preferred as with the development of techniques and experienced surgeons.
• Mini-open Repair: This is a slightly invasive procedure for rotator cuff repair which involves arthroscopy (to treat and investigate damage in the joint and avoids removal of deltoid muscle as happens in Open-Repair) followed by tendon repair through the small incision while directly viewing shoulder structures (and not on the monitor, as in Arthroscopic Repair).
• Arthroscopic Repair: This is a minimally invasive procedure, generally done as an out-patient procedure, in which an arthroscope (small camera) is entered into the joint through one small incision (called a portal) and surgical instruments from the others, usually under local anesthesia. Sutures are made to rejoin the torn muscles and bone. The patient is guided with rehabilitation therapies after the surgery. There are multiple techniques for doing this arthroscopic repair which the surgeon may discuss with the patient, before an operation.

Pain Management: As a part of the recovery process, patient does feel pain after the operation which is managed by NSAIDs, opioids or local anesthetics till the pain becomes tolerable.

Sling: A sling is used for few weeks to immobilise the arm until healing of the tendon.

Assisted Exercises: Passive exercises assisted by a physical therapist are done for few weeks as soon as the doctor finds the arm enough stable to be moved.

Unassisted Exercises: After around 4-6 weeks of assisted movement  the patient is guided by the therapist for strengthening active exercises. A complete recovery and full-range motion requires around 4-6 months and depends on patient’s commitment to the rehabilitation process.

• Nerve injury
• Infection
• Deltoid Detachment
• Stiffness
• Re-tear (might require Repeat Surgery)

Following factors may cause surgery results not to be as good as expected:

• Age above 65 years
• Smoking or use of other nicotine products
• Larger or complex tears
• Poor Compliance of patient with post- operative rehabilitation therapies.