ROTATOR CUFF TEARS

A rotator cuff tear is a common cause of pain and disability among adults. A torn rotator cuff will weaken the patient’s shoulder because it will be painful and difficult to do many daily activities, like combing the hair or getting dressed for the patient.

Anatomy
The shoulder is made up of three bones: upper arm bone (humerus), shoulder blade (scapula), and collarbone (clavicle).
The rotator cuff is a group of four muscles(supraspinatus, infraspinatus, subscapularis and teres minor) that come together as tendons to form a covering around the head of the humerus. The rotator cuff attaches the humerus to the shoulder blade and helps to lift and rotate the arm.
Description
When one or more of the rotator cuff tendons is torn, the tendon no longer fully attaches to the head of the humerus.
There are two different types of tears.

• Partial tear(Incomplete tear)
• Full-thickness tear(Complete tear)

Causes
Injury and degeneration are two main causes of rotator cuff tears.
Acute Tear: Fall down on outstretched arm or lift something too heavy with a jerking motion, the rotator cuff may torn.
Degenerative Tear: The term degeneration means deterioration and loss of function in the cells of a tissue or organ. Most degenerative tears occurs slowly over time by the age and more common in the dominant arm.
Several factors contribute to degenerative, or chronic, rotator cuff tears. These are repetitive stress (Repeating motions can stress the rotator cuff muscles and tendons), lack of blood supply (blood supply of rotator cuff tendons lessens by the age) and bone spurs(bone overgrowth underside of the acromion).
Symptoms
The most common symptoms of a rotator cuff tear include:

• Pain at rest and at night, during lying on the affected shoulder
• Pain when lifting and lowering the arm or with specific movements
• Weakness when lifting or rotating the arm

Doctor Examination
The orthopedics surgeon discusses about the patient’s symptoms and does the phyisical examination and needs some imagings (X-Ray, MRI, USG) and laboratory tests to decide about the treatment and plan about the operation.
Treatment
A rotator cuff tear cause pain and can get larger over time. Early treatment can prevent the symptoms from getting worse. It will also get the patient back to the normal routine that much quicker.
The goal of any treatment is to reduce pain and restore function. There are several treatment options for a rotator cuff tear, and the best option is different for every person. In planning the treatment, the doctor will consider the age, activity level, general health, and the type of tear the patient have.
Nonsurgical Treatment
Nonsurgical treatment options may include: Rest, activity modification, nonsteroidal anti-inflammatory medication, steroid(cortisone) injection, strengthening exercises and physical therapy.
Surgical Treatment
Surgery to repair a torn rotator cuff most often involves re-attaching the tendon to the head of humerus (upper arm bone).
Continued pain is the main indication for surgery. If the patient is very active and use the arms for overhead work or sports, if the tear was caused by a recent, acute injury and if the patient has significant weakness and loss of function in the shoulder the doctor may also suggest surgery.
Surgical Repair Options
The three techniques most commonly used for rotator cuff repair include traditional open repair, arthroscopic repair, and mini-open repair. In the end, patients rate all three repair methods the same for pain relief, strength improvement, and overall satisfaction.
1)Open Repair
The indication for open repair is limited. An open repair may be a good option if the tear is large or complex or if additional reconstruction, such as a tendon transfer, is indicated.
2)All-Arthroscopic Repair
Arthroscopy is a surgical procedure performed for diagnosis and treatment by enlarging the images and transferring them to the screen with the help of a small camera placed inside the joint. It is the most popular technic that is used in all over the world. All-arthroscopic repair is the least invasive method to repair a torn rotator cuff.
3)Mini-Open Repair
Once the arthroscopic portion of the procedure is completed, the surgeon repairs the rotator cuff through the mini-open incision (The incision is typically 3 to 5 cm long). During the tendon repair, the surgeon views the shoulder structures directly, rather than through the video monitor.
Rehabilitation
Rehabilitation plays a vital role in getting the patient back to the daily activities. A physical therapy program will help the patient regain shoulder strength and motion.
Immobilization: After surgery, therapy progresses in stages. At first, the repair needs to be protected while the tendon heals up to 3 to 6 weeks. How long the sling is required depends upon the severity of the injury.
Passive exercise: Even though the tear has been repaired, the muscles around the arm remain weak. Once the surgeon decides it is safe for the patient to move the arm and shoulder, a therapist will help the patient with passive exercises to improve range of motion in the shoulder. With passive exercise, the therapist supports the arm and moves it in different positions. In most cases, passive exercise is begun within the first 3 to 6 weeks after surgery.
Active exercise: After 4 to 6 weeks, the patient will progress to doing active exercises without the help of the therapist. Moving the muscles on the his/her own will gradually increase the strength and improve the arm control. At 8 to 12 weeks, the therapist will start on a strengthening exercise program.
A complete recovery is expected in several months. Most patients have a functional range of motion and adequate strength by 4 to 6 months after surgery. Although it is a slow process, the patient’s commitment to rehabilitation is key to a successful outcome.
Outcome
Factors that can decrease the likelihood of a satisfactory result include:

• Poor tendon/tissue quality
• Large or massive tears
• Poor patient compliance with rehabilitation and restrictions after surgery
• Patient age (older than 65 years)
• Smoking and use of other nicotine products

Complications
After arthroscopic rotator cuff surgery, the complications rate is low. These may include: Nerve injury, infection, stiffness and tendon re-tear.