Rotator Cuff Tear Repair

What is rotator cuff?

Rotator cuff is a group of four muscles-tendons which cover the ball & socket shoulder joint from front to back.

One muscle-tendon, Subscapularis (which provides 60% power to rotator cuff) is in the front and is a major stabiliser of the shoulder joint.

Other three muscle-tendons namely, Supraspinatus (on the top) and Infraspinatus & Teres Minor (at the back) are also important stabilisers and provide external rotations so that one could reach the top of the head e.g. in combing one’s hair! The top and back tendons are joined with each other to form a sheet like structure and hence the name cuff. What is the function of rotator cuff?

1) Stability: is the most important function of rotator cuff. All four muscles hug the big ball of the shoulder and compress it into tiny socket so that a dynamic fulcrum could be created and the bif muscle all around the shoulder a.k.a Deltoid could lift the arm above head in conjunction with muscles of the shoulder blade.
Rotations: in both positions i.e. with the arm by the side of the body (adduction) and also with the arm at 90 degrees to the body i.e. abduction is dependent on intact rotator cuff and hence the name!

Why do the rotator cuff tears occur?

1) Genetic factors: There is some evidence of familial predisposition of rotator cuff disease
2) Degenerative factors: Constant over-head activities produce friction between the rotator cuff and overlying acromial bone of shoulder blade. This produces fraying of the tendons, inammation of the overlying bursa and eventually tears!
3) Trauma: Falling even from standing height where we try to break the fall to protect ourselves puts a huge demand on rotator cuff especially in elderly.
4) Delay in diagnosis: Most commonly, rotator cuff disease starts in susceptible individuals at around 40 years of age as impingement and then progresses to tears. If diagnosed properly at this stage, most people are able to ward of the problem by preventive exercises. At times, arthroscopic surgery is needed to widen the passage of tendons under the impinging acromial bone.
5) Delay in treatment: Once cuff tears develop, they can be successfully dealt with arthroscopic surgery. However, lack of awareness and expertise prevails and patients kkep on suffering. With time, tears increase in size because of zipping phenomenon and produce disability

What is the incidence/prevalence of cuff tears?

Typically, app. 30% general population at the age of 50 years is having rotator cuff tears and this increases to 70-80% at 80 years of age!

Is rotator cuff tear a disease?

Yes, we can call it a disease as it happens in majority without injury!

There are different stages:

1) Posterior capsular tightness
2) Sub-acromial bursitis and impingement
3) Partial tears (Articular sided PASTA / Bursal sided)
4) Full thickness tears
5) Retracted tears (On an average, tears double in size in 3 years!)
6) Chronic retracted Irreparable tears
7) Rotator cuff tear Arthropathy (around 10% people with rotator cuff tears develop arthritis of the shoulder joint)

What is the treatment of rotator cuff disease?

Treatment depends on the stage of the disease:

1) Cuff disease without tears: is usually managed without surgery with NSAIDs. Physiotherapy and cortico-steroid injections. The success rate of this approach is more than 80%. Fewer people need arthroscopic surgery at this stage
2) Cuff disease with tears: usually and should be treated with arthroscopic surgery where we reattach the torn tendons back to the bone to restore the anatomy and hence the function of the shoulder joint
3) Irreparable tears with or without arthritis: are treated with Reverse Shoulder Replacement.

Can we prevent the rotator cuff tears?

Yes, but only in the initial phase when it is confined to rotator cuff disease without tears! There are certain set of preventive exercises which help in opening up the passage to avoid friction between the tendon and bone.

Once the tears happen, they progress steadily over a course of time in pretty much predictable way.

What is the success rate of arthroscopic surgery for rotator cuff tears?

Again, this depends upon the time a patient presents for treatment. If the patient comes at a stage where tendon quality is good, not retracted, involves less than two tendons and there is no arthritis and patient is younger than 65 years of age, then the outcome is generally good with retear rate as low as 10%. However, once these criteria are breached alone or in combination, then failure rates start to rise. But, even if re-tears happen after surgery, the patients remain painless though the strength in the affected arm deceases.

What if the tear has become irreparable?

Then there are some options like:

1) Superior capsular reconstruction (to prevent ball of the socket from riding up in the socket)
2) Tendon transfers (Taking other tendons around shoulder and rerouting them for cuff tendons)
3) Reverse Shoulder Replacement: is by far the most predictable and successful surgery for either irreparable tears or tears with arthritis of shoulder!