Dr Graeme MacDougal

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SYDNEY ORTHOPAEDIC SHOULDER AND ELBOW SURGEON

SYDNEY ORTHOPAEDIC SHOULDER AND ELBOW SURGEON

Rotator Cuff

The shoulder joint is a complex joint and its biomechanics allows circular movements through 360° in addition to movements across the body, out to the side and behind the back, i.e. rotation.

The shoulder and the elbow are essential in enabling a person to place the hand in the desired position to perform different functions.

Essential to the functioning of the shoulder joint is the rotator cuff, which is a group of four tendons which link muscles arising from the scapula to the humerus. It has a broad tendon insertion.

These tendons act together to produce movements of rotation of the shoulder and elevation of the shoulder. The common problems affecting the rotator cuff are age related degeneration and tearing. The tearing can be acute traumatic or an extension of pre-existing tears. The tears do not always present symptoms if chronic (long standing).
Supraspinatus tear

Full thickness supraspinatus tear

Supraspinatus tear and spur

Supraspinatus tear and spur

The patient’s history of the injury is important to decide whether the problem is an acute, traumatic disruption of the tendon from the bone, or if there is a chronic component to the tendon injury.

Rotator cuff tears are more common in the older age group, greater than 60 years of age.

Clinical examination aims to identify areas of wasting of muscle, points of tenderness and evidence of rotator cuff impingement or catching of the rotator cuff tendon with arm elevation. Weakness is commonly present and associated with pain when resisted testing of the affected tendon occurs. Night pain is a common complaint.

Appropriate investigations include a plain x-ray to look for bony abnormalities and a good screening test is ultrasound, which picks up full thickness tendon tears well.

MRI is a valuable tool in the assessment of rotator cuff tearing, quantifying retraction, atrophy and other changes which may be present in the tendon pathology.

Tendon tear sizes vary from small to massive and the treatment options available range from non-operative management to surgery.

SURGICAL TREATMENT OF ROTATOR CUFF PATHOLOGY


The surgical treatment should be tailored to each individual patient and take into consideration age, activity level, symptomatic level and functional requirements.

Typically rotator cuff repair can achieve good results in the order of 85 to 90%, whether the technique is done through open surgery, mini open arthroscopic assisted surgery or purely arthroscopic rotator cuff repair techniques.

Tears up to 3 cm in size do quite well with any of these techniques. However as the tear size increases over 4 cm the results are less predictable.

The size of the tear is not proportional to the degree of severity of symptoms. Inflammation of the bursa and impingement syndrome are largely responsible for symptoms. Pathology in the biceps tendon and the acromioclavicular joint can also produce pain in the area.

NATURAL HISTORY OF UNTREATED ROTATOR CUFF TEARS


It appears that if a group of patients are followed with untreated rotator cuff tears, that many of these tears will go on to increase in size with time if no surgical treatment is performed.

This does not always lead to recurrent symptoms but a high percentage of patients, perhaps greater than 60%, will get recurrent pain and increase the size of the tear.

It is important to note that no tendon will heal back to the bone without surgical intervention.

More recent information would suggest that acute tears are best treated surgically, as results when followed up for the longer term, show that acute tears repaired early have a better function and return of strength than tears that have delayed repairs.

This may reflect the changes that occur in the muscle if a tear remains unrepaired for a long period of time (atrophy).

SURGICAL MANAGEMENT


A large advance in shoulder surgery over the last 20 years has been the use of the Arthroscope, which has both diagnostic and therapeutic roles for the treatment of cuff pathologies and can be used to perform acromioplasty, acromioclavicular joint resections, bursectomy, cuff debridement and also more recently, rotator cuff repair.

With rotator cuff repair the tendons are repaired to the bone from which they were torn by the use of anchor fixation sites, and the sutures emanating from those anchors in the bone are used to re-attach the tendon footprint to the bone.

After shoulder surgery, whether done through the “arthroscopic” technique or through an “arthroscopic” mini open assisted technique, a period of immobilisation is required in an arm brace for a period of six weeks.

It is essential that this is worn for the majority of the day and night and that rehabilitation exercises be performed regularly as prescribed by your Doctor and Physiotherapist.

Every patient is different and each individual rehabilitation programme will vary depending on the patient needs, outcome expectations, size of tear and other factors.

As a guide the recovery period following rotator cuff repair is six months until the person is back to the majority of activities.

SUMMARY


The rotator cuff is an integral part of an effective functioning shoulder.

It is involved in all movements of the shoulder and defects in the tendon attachments can lead to disruption of the shoulder biomechanics.

Repair of rotator cuff tendons requires significant surgical expertise, good postoperative rehabilitation and a compliant patient for the best outcome.
  Any surgical or invasive procedure carries risks. Should you wish to discuss your rotator cuff tear with Dr MacDougal, please make an appointment to do so in order that your individual treatment needs can be prescribed for your particular situation.

Graeme MacDougal Shoulder and Elbow Surgeon

North Sydney Sports Medicine Centre
60 Pacific Highway
St Leonards NSW 2065