Rotator Cuff Tears and Treatment Options

8/10/2019 Rotator Cuff Tears and Treatment Options

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Rotator Cuff Tears and Treatment Options

Anatomy and Pathophysiology

Natural History

Surgical and Nonsurgical Options

Nonsurgical Treatment: Benefits and Limits

Surgical Intervention and onsiderations

Surgical Procedure

omplications

!eha"ilitation#onvalescence

Summary

!otator cuff tears are a common source of shoulder pain$ The incidence of rotator cuff damage increases%ith age and is most fre&uently caused "y degeneration of the tendon' rather than in(ury from sports ortrauma$ Although the information that follo%s can "e used as a guide for all types of rotator cuff tears' it isintended specifically for patients %ith complete degenerative tears of the rotator cuff$

Treatment recommendations vary from reha"ilitation to surgical repair of the torn tendon)s*$ The "est

method of treatment is different for every patient$

The decision on ho% to treat rotator cuff tears is "ased on the patient+s severity of symptoms' functionalre&uirements' and presence of other illnesses that may complicate treatment$

In consultation %ith an orthopaedic surgeon' the information that follo%s is intended to assist patients indeciding on the "est management of their rotator cuff tear %ith the understanding that all patients areuni&ue$

Anatomy and Pathophysiology

Illustrations of the s,eletal structure (left)and muscles and tendons (right)of a normal shoulder$

The rotator cuff is a group of four muscles that surround the humeral head )"all of the shoulder (oint*$ Themuscles are referred to as the -SITS- muscles: supraspinatus' infraspinatus' teres minor' and su"capularis$The muscles function to provide rotation' elevate the arm' and give sta"ility to the shoulder (oint)glenohumeral (oint*$ The supraspinatus is most fre&uently involved in degenerative tears of the rotator cuff$.ore than one tendon can "e involved$ There is a "ursa )sac* "et%een the rotator cuff and acromion thatallo%s the muscles to glide freely %hen moving$ /hen rotator cuff tendons are in(ured or damaged' this"ursa often "ecomes inflamed and painful$
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Pain' loss of motion' and %ea,ness may occur %hen one of the rotator cuff tendons tears$ The tendonsgenerally tear off at their insertion )attachment* onto the humeral head$

Incidence!otator uff Tearsincrease in fre&uency %ith age' are more common in the dominant arm' and can"e present in the opposite shoulder even if there is no pain$1,7The true incidence of rotator cuff tearsin the general population is difficult to determine "ecause 01 to 231 of people %ithout shoulder pain

may have a torn rotator cuff$ This %as determined "y studies using45rays' T Scans and .!Istoassess the shoulders of patients %ith no symptoms$ One study revealed a 621 overall incidence ofrotator cuff tears$6The highest incidence occurred in patients %ho %ere older than 73 years$ Thisstudy supported the concept that rotator cuff damage has a degenerative component and that a tearof the rotator cuff is compati"le %ith a painless' normal functioning shoulder$

EtiologyThere are intrinsic and e8trinsic factors that cause rotator cuff tears$ An e8ample of an intrinsic factoris tendon "lood supply$ The "lood supply to the rotator cuff diminishes %ith age and transiently %ithcertain motions and activities$ The diminished "lood supply may contri"ute to tendon degenerationand complete tearing$3,4,5The su"stance of the tendon itself degenerates over time$ Because of anage5related decrease in tendon "lood supply' the "ody+s a"ility to repair tendon damage isdecreased %ith age9 this can ultimately lead to a full5thic,ness tear of the rotator cuff$

Illustration of shoulder impingement and partial rotator cuff tears$ A "one spur appears on theundersurface of the acromion$

An e8trinsic factor that can cause damage to the rotator cuff is the presence of "ones spursunderneath the acromion$ The spurs ru" on the tendon %hen the arm is elevated9 this is oftenreferred to as Shoulder ImpingementBone spurs are another result of the aging process$ Theru""ing of the tendon on the "one spur can lead to attrition )%ea,ening* of the tendon$ om"iningthis %ith a diminished "lood supply' the tendons have a limited a"ility to heal themselves$ Thesefactors are at least partly responsi"le for the age5related increase in rotator cuff disease and thehigher fre&uency in the dominant arm$

uring surgery to repair a torn rotator cuff in this instance' the spur is typically removed to relieve the

impingement$ !emoving the spur is referred to as an -acromioplasty-$

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atural !istory

/hat %ill happen if a torn rotator cuff is not treated %ith surgery; /ill I lose the use of my arm; /ill the tearget larger over time; These are common concerns patients have' and the ans%ers are not al%ays clear$ Inone study' 231 of patients %ith a rotator cuff tear sho%ed enlargement of the tear over a 05year period9ho%ever'


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tear %ill have tear enlargement' "ut =31 of patients %hose tear enlarges %ill develop symptoms$7Thesedata' ho%ever' are "ased on a small group of patients9 it is important to reali>e that once symptoms develop'progression may have already progressed and enlarged$

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"urgi#al and onsurgi#al Options

Treatment options include:

?$ Nonsurgical )conservative* treatment


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"urgi#al *nter+ention and Considerations

Surgical management is indicated for a rotator cuff tear that does not respond to nonsurgical managementand is associated %ith %ea,ness' loss of function' and limited motion$ Because there is no evidence of"etter results in early versus delayed repairs' many surgeons consider a trial of nonsurgical management to"e appropriate$1Tears that are associated %ith profound %ea,ness' are caused "y acute trauma' and#or arevery large )greater than 6 centimeters* on initial evaluation may also "e considered for early surgical repair$Surgical treatment of a torn rotator is designed to repair the tendon "ac, to the humeral head )"all of theshoulder (oint* from %here it is torn$ This can "e accomplished in a num"er of %ays$ ach of the methodsavaila"le has its o%n advantages and disadvantages9 all have the same goalCgetting the tendon to heal tothe "one$ The choice of surgical techni&ue depends on several factors' including the surgeon+s e8perienceand familiarity %ith a particular procedure' the si>e of the tear' the patient+s anatomy' the &uality of thetendon tissue and "one' and the patient+s needs$ !egardless of the repair method used' studies sho%similar levels of pain relief' strength improvement' and patient satisfaction$

The three commonly used surgical techni&ues for rotator cuff repair are:

?$ Open repair


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acromion* as %ell$ The incision is typically several centimeters long$ Open repair %as the firsttechni&ue used to repair a torn rotator cuff9 over the years' the introduction of ne% technology andimproved surgeon e8perience has led to the development of less invasive surgical procedures$

Although a less invasive procedure may "e attractive to many patients' open repair does restorefunction' reduce pain' and is dura"le in terms of long5term relief of symptoms$1,13

Mini-Open Repair

In this intraoperative photograph' the typical incision si>e for a mini5open rotator cuff repair is sho%nin "lac, on a patient++s left shoulder$ The yello% arro% indicates the incision used to perform thearthroscopy$

(Courtesy of Louis Rizio, MD.)

As the name implies' mini5open repair is a smaller version of the open techni&ue$ The incision istypically 6 cm to 0 cm in length$ This techni&ue also incorporates arthroscopy to visuali>e the tearand assess and treat damage to other structures %ithin the (oint )it is used to asses the ShoulderSurgery 8ercise Euideand remove the spurs under the acromion*$ Arthroscopic removal of spurs)acromioplasty* avoids the need to detach the deltoid muscle$ Once the arthroscopic portion of theprocedure is completed' the surgeon proceeds to the mini5open incision to repair the rotator cuff$.ini5open repair can "e performed on an outpatient "asis$ urrently' this is one of the mostcommonly used methods of treating a torn rotator cuff9 results have "een e&ual to those for open

repair$ The mini5open repair has also proven to "e dura"le over the long5term$14

All-Arthroscopic Repair

Arthroscopic photographs of a rotator cuff tear )left* and the final repair )right*$ This %as performedall5arthroscopically$ Sutures )green* %ere used to reattach the tendon "ac, to "one )arro%*$

(Courtesy of Louis Rizio, MD.)

This techni&ue uses multiple small incisions )portals* and arthroscopic technology to visuali>e andrepair the rotator cuff$ All5arthroscopic repair is usually an outpatient procedure$ The techni&ue is
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very challenging' and the learning curve for surgeons is steep$ It appears that the results arecompara"le to those for mini5open repair and open repair$15

ResultsAfter rotator cuff repair' =31 to F01 of patients achieve a satisfactory result' defined as ade&uatepain relief' restoration or improvement of function' improvement in range of motion' and patientsatisfaction %ith the procedure$ ertain factors decrease the li,elihood of a satisfactory result:16

?$ Poor tissue &uality


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o "$ Pain relief

o c$ Strength


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Surgical repair results in pain reduction and improved function and strength in more than =31 of patients$A"out one in ten surgeries can result in complications$ Surgical procedures to repair a torn rotator cuff have"ecome increasingly less invasive$ .inimally invasive procedures are less painful and have less "lood loss'shorter hospital stays' and a generally easier reha"ilitation period$ Although less invasive procedures aremore attractive' they are often more difficult for the surgeon to perform and re&uire an e8perienced surgeonfor "est results$ Lastly' all repair methods appear e&ual in outcomes %hen the surgery is performed %ell$

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Rotator Cuff Tears and Treatment Options