The rotator cuff of the shoulder is formed by four muscles and their tendons, which «embrace» the head of the humerus. These muscles are: supraspinatus, infraspinatus, subscapularis, and teres minor. The main roles of the rotator cuff are two: a) maintaining the stability of the shoulder joint; and (b) lifting and rotating movements of the arm.
Causes of tear
The two main causes are injuries and degeneration.
Injuries are more frequent in younger people and can be caused by weight lifting or a fall on an extended arm. Rotator cuff tear may be accompanied by other shoulder injuries such as shoulder dislocation or fractures of clavicle, shoulder blade and head of the humerus.
Tears due to degeneration affect mainly people aged over 40 and are the result of gradual wear of the tendons. The dominant upper limb suffers more often, but if one shoulder is damaged, there is an increased probability of the other shoulder being also damaged, even if there are no symptoms. Factors responsible for tendon degeneration are:
- Repeated light injuries, for example, repeated lifting and rotating motions of the arm while at work or sporting activities, such as basketball, weightlifting, throws, football and tennis.
- Reduced blood perfusion of the rotator cuff due to age
- development of osteophytes (bone protrusions) in the area of the acromium, which cause so-called subacromial impingement syndrome.
Clinical presentation - diagnosis
The main symptoms of rotator cuff tears are pain and restriction in movement of the shoulder joint. Pain may be present at rest or during sleep, especially if the patient is sleeping on the affected side. It may also appear when lifting or lowering the arm, or with rotating motions. Restriction of movement is due to muscle weakness, caused by tendon rupture. This most often affects the supraspinatus and mainly restricts lifting of the arm. Diagnosis is made with special testing during clinical examination and is confirmed by MRI or ultrasound.
Aim of the treatment is to reduce pain and restore shoulder functionality. Determination of the indicated treatment is based on type of injury, age, level of activity and general state of health of the patient.
In approximately 50% of the patients conservative treatment has satisfactory results, with alleviation of pain and improvement of shoulder motility, although it can not achieve perfect rehabilitation. It consists initially of rest, restriction of movement over the shoulder level, wearing a sling and administration of non-steroidal anti-inflammatory drugs. Having achieved control of pain with these measures, physiotherapy protocols are implemented for the strengthening of the remaining intact rotator cuff and improvement of joint functionality. In case of failure to treat pain with the above measures, injections of a combination of local anaesthetic and steroid may be helpful.
The main advantage of conservative treatment is avoidance of surgical intervention. Its disadvantage is that it cannot attain great improvement of muscle strength and the tear may increase, making an eventual surgery more complicated.
Surgical treatment is applied in cases where pain relief is not achieved with conservative treatment. It may be the first choice in recent injuries or in large tears (above 3 cm) with marked weakness and loss of functionality of the shoulder. The operation is performed arthroscopically. This means that camera and instruments are introduced into the joint without a large incision and stripping of soft tissues. With this technique duration of hospitalization and postoperative rehabilitation are reduced.
Surgery is followed by a program of progressive rehabilitation. The stiches are protected by relative immobilization for a period of 4-6 weeks, using a special sling. The treatment protocol initially includes passive motion (movements made by the physiotherapist), followed by active motion exercises and strengthening of the rotator cuff. The duration of the rehabilitation program varies depending on patient characteristics.