Rotator Cuff Tears

Rotator cuff tears are a common disorder of the shoulder. Many patients, 50% over 60 years of age may have rotator cuff tear. Many of these tears are partial, asymptomatic, but many are causes of pain and loss of function. The four main muscles and their associated tendons of the rotator cuff are, Subscapularis muscle, Supraspinatus muscle, Infraspinatus muscle, Teres Minor muscle. A tear or part, one or several of these tendons causes different pain and symptoms. 

Tendon tears occur from different causes, the common cause of tendon degeneration, and less common cause of trauma related. These two aetiologies are treated slightly different with timing of surgery and possible repair options. Dr Drynan will go through your case in detail with you at your consultation. Degeneration of the tendon, approximately 3-4mm from its insertions to the humerus due to a mismatch in repair and degeneration of the tendon. There are intrinsic causes, such as genetics, medical conditions and others and extrinsic causes, such as muscle imbalance and over use injuries.

The most common symptoms are pain, located over the deltoid and upper arm. This can be a of other shoulder pathology as well, as shoulder pain is often poorly localised. Larger rotator cuff tears often lead to weakness and lack of function for the shoulder or fatigue of the shoulder with repetitive or over head activities.

Diagnosis is based on your history, examination and investigations. Gold standard non invasive investigation of choice is MRI. This is a non radiation imaging modality that allows good imaging for the rotator cuff, cartilage, bones, bursa, tendons and around the shoulder. This imaging requires  involves the use of strong magnetic field manipulation to obtain the imaging, thus may not be for everyone such as those with pacemakers, nerve stimulators and other causes, but speak to your imaging provider. Ultrasounds can be used when MRI is contraindicated, but imaging quality and other diagnostic power is not as thorough as with an MRI. 

Management of rotator cuff tears includes non operative and operative treatments, with the ultimate goal of improving your shoulder pain and function. 

Non-operative management may include:

• A period of rest
• Activity modification - (removing the stress to your shoulder)
• Physiotherapy - see YouTube channel Dr David Drynan Orthopaedics and links for rehabilitation
• Steroid injections with local anaesthetic

Operative management aims are to restore the tendon back to the anatomic insertion point, under physiologic stress (normal tension) and achieve healing. There are many steps involved to achieve this.

• Arthroscopic surgery (key hole) with multiple access ports
• Mobilising the tendon and preparing the foot print (area for the tendon to heal)
• Cleaning the rest of the shoulder and addressing other aspects that can cause pain
• Inserting anchors to the bone to help hold the tendon in the anatomic position
• holding the tendon to allow healing - this with anchors and sutures inside the shoulder and using a sling and following physiotherapy protocols post operatively.

Occasionally anatomic tendon repairs may not be possible. If this is the case, Dr Drynan will discuss other evidence based treatments that may assist in your shoulder treatment, such as superior capsule reconstruction, tendon transfers, and arthroplasty.

If surgery is the right choice for you, then understanding the surgery is beneficial. There are a few main considerations with surgical interventions.

Decision for operation:

• The decision to operate is yours. Dr Drynan is to inform you regarding treatment, risks and benefits and offer a medical opinion. When the timing is right for you and your condition, then together your treatment can be coordinated.

Operation:

• The operation itself will take 1-2 hours depending on the number of tendons and other pathology (problems) with the shoulder. Long head of Biceps tendon tears are common cause of pain with rotator cuff tears.
• You will wake up with a sling
• Your shoulder will be numb from an injection near the neck to nerves that supply the shoulder
• You will likely go home that day or early the next day.
• It takes time for the tendons to heal to the bone - 6 weeks very weak healing, 3 months strong enough for strengthening slowly, 4-6 months getting stronger and fibres in tendon healing zone aligning, 6-9 months improving in strength and range and recovery. Don't expect to be over this operation in a few weeks.

Pain control:

• Pain control is essential and includes multiple modes of treatment.
• Surgically - a nerve "block" is used and local anaesthetic to other sites, analgesia controlled by an anaesthetist 
• Post operative - pain is expected, but controlled pain with the use of a sling, ice or specific ice water machines, regular simple analgesia and as needed advanced therapies.
• Acknowledging other factors such as chronic pain, drugs of addiction use or abuse, anxiety and depression and the changes to your pain must be discussed at your consultation.

Rehabilitation and recovery time:

• In hospital as a day only or over night if at the end of the day.
• sling use for 6-7 weeks, full time 2 weeks, off for exercises, showers and resting at home after 2 weeks, until advised.
• No driving until you are physically safe to do so, likely 6 weeks for most rotator cuff repairs
• High intensity sport and overall recovery is often a little over 9 months

Post injury and post surgical rehabilitation is often beneficial. Many studies have assessed in home, remote and in person physical therapy following rotator cuff surgery and total shoulder replacement. Although the results are mixed to show a large benefit from in-person rehab, Dr Drynan still recommends some guidance by a Physiotherapist. To assist the rehabilitation process Dr Drynan has a protocol for you on your day of surgery and a downloadable document on the patient information page to guide home exercises following your shoulder surgery.