What are the common causes of rotator cuff injuries. How can rotator cuff tears be diagnosed. What are the traditional and new treatment options for rotator cuff injuries. Is the subacromial balloon implant a viable alternative for irreparable rotator cuff tears. Who is an ideal candidate for the subacromial balloon procedure.

Understanding Rotator Cuff Injuries: Anatomy and Function

The rotator cuff is a crucial group of muscles and tendons that play a vital role in shoulder stability and function. These muscles work together to provide strength and allow for a wide range of motion in the shoulder joint. When injury occurs to this area, it can significantly impact an individual’s daily activities and quality of life.

To fully grasp the importance of the rotator cuff, it’s essential to understand its anatomy:

• Supraspinatus muscle
• Infraspinatus muscle
• Teres minor muscle
• Subscapularis muscle

These muscles originate from the shoulder blade (scapula) and attach to the upper arm bone (humerus), forming a “cuff” around the shoulder joint. Their primary functions include:

1. Stabilizing the shoulder joint
2. Enabling arm rotation and elevation
3. Maintaining proper alignment of the humeral head within the glenoid socket

Common Causes and Risk Factors for Rotator Cuff Injuries

Rotator cuff injuries can occur due to various factors, ranging from acute trauma to gradual wear and tear. Understanding these causes can help individuals take preventive measures and seek timely treatment.

Acute Injuries

Sudden, traumatic events can lead to rotator cuff tears. These may include:

• Falls on an outstretched arm
• Lifting heavy objects improperly
• Sports-related injuries (e.g., baseball, tennis, weightlifting)

Degenerative Causes

Over time, the rotator cuff can weaken and become more susceptible to injury. Factors contributing to degenerative tears include:

• Age-related wear and tear
• Repetitive overhead motions
• Poor posture and shoulder mechanics
• Reduced blood supply to the tendons

Are certain individuals more prone to rotator cuff injuries? Yes, several risk factors can increase the likelihood of developing a rotator cuff problem:

• Age (more common in people over 40)
• Occupations involving repetitive arm movements
• Athletes participating in overhead sports
• Family history of rotator cuff problems
• Smoking (which can impair blood flow and healing)

Recognizing Symptoms of Rotator Cuff Injuries

Early detection of rotator cuff injuries is crucial for effective treatment. Recognizing the symptoms can help individuals seek timely medical attention and prevent further damage.

Common symptoms of rotator cuff injuries include:

• Shoulder pain, especially when lifting or lowering the arm
• Weakness in the affected arm
• Limited range of motion
• Clicking or popping sensations during shoulder movement
• Pain that worsens at night, especially when lying on the affected side

How can you differentiate between acute and chronic rotator cuff injuries? Acute injuries typically result in sudden, sharp pain and immediate weakness, while chronic injuries may develop gradually with persistent discomfort and progressive loss of function.

Diagnostic Approaches for Rotator Cuff Tears

Accurate diagnosis is essential for developing an effective treatment plan. Healthcare providers employ various methods to assess rotator cuff injuries:

Physical Examination

A thorough physical exam includes:

• Assessing range of motion
• Testing muscle strength
• Evaluating pain patterns
• Performing specific maneuvers to isolate rotator cuff function

Imaging Studies

Advanced imaging techniques provide detailed information about the extent and nature of the injury:

• X-rays: To rule out bone spurs or arthritic changes
• Magnetic Resonance Imaging (MRI): Offers detailed soft tissue visualization
• Ultrasound: Provides real-time imaging of the rotator cuff tendons

Why is MRI considered the gold standard for diagnosing rotator cuff tears? MRI offers high-resolution images of soft tissues, allowing physicians to assess the size, location, and severity of the tear, as well as the quality of the remaining muscle tissue.

Conservative Treatment Options for Rotator Cuff Injuries

Many rotator cuff injuries respond well to non-surgical treatments. These conservative approaches aim to reduce pain, improve function, and prevent further damage.

Physical Therapy

A structured physical therapy program is often the first line of treatment. It may include:

• Strengthening exercises for the rotator cuff and shoulder muscles
• Range of motion exercises
• Posture correction techniques
• Manual therapy to improve joint mobility

Medications

Pain management and inflammation reduction can be achieved through:

• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Oral corticosteroids (in some cases)

Cortisone Injections

For persistent pain, cortisone injections may provide temporary relief. However, their use should be limited due to potential side effects on tendon health.

How long should conservative treatment be tried before considering surgical options? Generally, a period of 3-6 months is recommended to assess the effectiveness of non-surgical treatments before exploring surgical interventions.

Surgical Interventions for Rotator Cuff Repairs

When conservative treatments fail to provide adequate relief or in cases of large or complete tears, surgical repair may be necessary. Modern surgical techniques offer less invasive options with faster recovery times.

Arthroscopic Repair

Arthroscopy is the most common surgical approach for rotator cuff repairs. This minimally invasive procedure involves:

• Small incisions for camera and instrument insertion
• Visualization of the shoulder joint on a monitor
• Reattachment of torn tendons to the bone using sutures and anchors

Open Repair

In some complex cases, an open surgical approach may be necessary. This traditional method involves a larger incision and direct visualization of the rotator cuff.

Tendon Transfer

For irreparable tears, tendon transfer surgery may be considered. This procedure uses nearby tendons to compensate for the damaged rotator cuff.

What factors influence the choice between arthroscopic and open repair? The decision depends on the size and complexity of the tear, the surgeon’s expertise, and patient-specific factors such as overall health and tissue quality.

Innovative Treatment: Subacromial Balloon Implant

A recent advancement in the treatment of irreparable rotator cuff tears is the subacromial balloon implant. This minimally invasive procedure offers a new option for patients who may not be candidates for traditional repair techniques.

Procedure Overview

The subacromial balloon implant procedure involves:

• Arthroscopic insertion of a biodegradable balloon
• Inflation of the balloon with saline solution
• Placement between the humeral head and acromion

Mechanism of Action

The balloon implant works by:

• Preventing friction between the humeral head and acromion
• Restoring proper alignment of the humeral head within the glenoid socket
• Improving shoulder joint mechanics

Benefits and Limitations

Advantages of the subacromial balloon implant include:

• Minimally invasive procedure
• Potential for pain relief and improved function
• No burning of bridges for future treatment options

Limitations to consider:

• Does not increase strength
• Not effective for arthritic pain
• Long-term outcomes still being studied

Who is an ideal candidate for the subacromial balloon implant? The procedure is best suited for patients with irreparable, painful rotator cuff tears, minimal or no arthritis, reasonable shoulder motion, and who are not seeking significant strength improvements.

Recovery and Rehabilitation After Rotator Cuff Treatment

Regardless of the treatment approach, proper recovery and rehabilitation are crucial for optimal outcomes. The rehabilitation process typically involves several phases, each with specific goals and activities.

Immediate Post-Treatment Phase

In the initial period following treatment, the focus is on:

• Pain management and inflammation control
• Protection of the healing tissues
• Gentle passive range of motion exercises

Progressive Rehabilitation

As healing progresses, rehabilitation aims to:

• Gradually increase range of motion
• Introduce strengthening exercises for the rotator cuff and surrounding muscles
• Improve scapular stability and overall shoulder function

Return to Activity

The final phase of rehabilitation focuses on:

• Sport-specific or occupation-specific training
• Functional exercises mimicking daily activities
• Education on proper body mechanics and injury prevention

How long does it typically take to recover from rotator cuff surgery? Recovery timelines vary depending on the extent of the injury and the type of procedure performed. Generally, patients can expect a recovery period of 4-6 months, with full return to high-demand activities often taking 6-12 months.

Throughout the recovery process, adherence to the rehabilitation program and close communication with healthcare providers are essential for achieving the best possible outcomes. Patients should be prepared for a gradual return to activities and may need to modify certain movements or techniques to protect their shoulder in the long term.

As research continues and new technologies emerge, the field of rotator cuff injury treatment is likely to see further advancements. Patients and healthcare providers alike should stay informed about the latest developments to ensure optimal care and outcomes for those affected by rotator cuff injuries.

Mayo Clinic Q and A: How are rotator cuff tears treated?

• By

  Cynthia Weiss

  June 5, 2022

DEAR MAYO CLINIC: I injured my rotator cuff recently and was told I was not a candidate for surgery. However, a friend shared that there’s a new minimally invasive treatment option that uses a balloon implant. How does this procedure work, and how does it compare to traditional treatments?

ANSWER: The rotator cuff is a group of muscles critical for the strength, stability and function of the shoulder. Tears of the rotator cuff tendons are a common source of shoulder pain, weakness and other problems. Imaging studies, such as radiographs, MRIs or ultrasounds, are used to evaluate rotator cuff tears.

Physical therapy and the occasional use of cortisone injections may improve pain and function for some people with a torn rotator cuff. However, many rotator cuff tears do not improve with therapy, and in those circumstances, surgery needs to be considered.

Repair of the torn rotator cuff tendons is the most performed procedure when surgery is required. Most rotator cuff repairs are performed using arthroscopy. A small camera is inserted into the shoulder through a small incision or cut, and additional small cuts are used for instruments to complete the repair.

Many times, rotator cuff repair is successful. However, certain rotator cuff tears have so much damage that the tear cannot be repaired. These irreparable tears are excessively large and stiff, and oftentimes, the muscles are atrophied and largely replaced by fat tissue, so that even if the repair were to heal, weakness and poor function would remain. Expert evaluation is paramount to select the various options to manage rotator cuff tears.

Irreparable cuff tears can improve with alternative or salvage surgical procedures, which traditionally include superior capsular reconstruction, tendon transfers and shoulder replacement with implantation of a reverse prosthesis. A fourth new procedure just approved in the U.S. involves implantation of a subacromial balloon.

The inflatable subacromial balloon is made of a copolymer that is not toxic, does not elicit inflammation and is biodegradable. This balloon comes folded inside a protective canula. It is deployed at the ball of the shoulder, or humeral head, under arthroscopy. Liquid saline is then injected inside the balloon to inflate it before being sealed. The balloon is resorbed in the human shoulder within a year.

To understand how a temporary subacromial balloon works, it is important to understand what happens to the shoulder in the presence of an irreparable rotator cuff tear. Specifically, the ball of the shoulder moves up and rubs against another bone on top, the acromion.

In these circumstances, several factors may contribute to pain and loss of function:

• The torn rotator cuff muscles cannot power the shoulder.
• The mechanics of the joint are poor with such a high-riding humeral head that is no longer aligned with the socket.
• Rubbing or friction occurs between the humeral head and acromion.
• In some instances, the articular cartilage of the joint can progressively wear with arthritis.

Placement of an inflated balloon in the subacromial space is believed to improve pain and function two ways. First, the balloon does not allow the humeral head to rub with the acromion. Also, with the placement of the balloon, the humeral head is returned down to a more normal position across the glenoid socket, which improves mechanics of the joint.

It is not clear why people experience pain relief and improved function well after the balloon has already resorbed, but the theory is that temporary physical centering of the humeral head across the socket and improvements in pain allow patients to strengthen the rest of the intact muscles around the shoulder so that they can permanently compensate for the torn rotator cuff.

The ideal candidate for implantation of a subacromial balloon is a person with an irreparable, painful rotator cuff tear with minimal or no arthritis and reasonable motion. One North American study showed an 87% success rate two years after implanting a subacromial balloon in patients 65 or older.

Balloon implantation is a minimally invasive and relatively short procedure that does not burn any bridges. However, it neither increases strength nor improves arthritic pain. There is some interest in using the balloon as an add-on to a rotator cuff repair in certain people at risk for incomplete tendon healing, but this use has not been investigated in detail.

If you have been diagnosed with an irreparable rotator cuff tear and have not developed arthritis yet, implantation of a subacromial balloon may be a good option for you. That’s provided your motion is reasonable, and you are not looking for major improvements in strength. It appeals to many as a minimally invasive procedure that, when unsuccessful, does not leave any material behind. As such, it does not negatively affect further surgeries that may be needed in the future. — Dr. Joaquin Sanchez-Sotelo, Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota

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• How a new rotator cuff balloon procedure helps some patients get better published 3/18/22

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By Mayo Clinic Staff • July 7, 2023

Rotator Cuff Injury | Johns Hopkins Medicine

What is a rotator cuff injury?

Your rotator cuff consists of muscles and tendons that hold your shoulder in place. It is one of the most important parts of your shoulder.

Your rotator cuff allows you to lift your arms and reach upward. Each year, millions of people in the United States go to their healthcare providers because of a rotator cuff problem. A rotator cuff tear is a common cause of pain and disability among adults.

What are the symptoms of a rotator cuff tear?

The following are the most common symptoms of a rotator cuff tear. However, you may experience symptoms differently. Symptoms may include:

• Recurrent pain, especially with certain activities

• Pain that prevents you from sleeping on your injured side

• Grating or cracking sounds when moving your arm

• Limited ability to move your arm

• Muscle weakness

The symptoms of a rotator cuff tear may resemble other conditions or medical problems. Always talk with your healthcare provider for a diagnosis.

How is a rotator cuff injury diagnosed?

In addition to a complete medical history and physical exam, diagnostic procedures for a rotator cuff injury may include the following:

• X-ray.  A diagnostic test which uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film.

• Magnetic resonance imaging (MRI). A diagnostic procedure that uses a combination of large magnets, radiofrequencies, and a computer to produce detailed images of organs and structures within the body.

A rotator cuff may tear partially or fully. Partial-thickness tears do not completely sever the tendon from the shoulder.

What causes a rotator cuff injury?

There are 2 main causes of rotator cuff tears: injury and degeneration. An injury to the rotator cuff, such as a tear, may happen suddenly when falling on an outstretched hand. It may also develop over time due to repetitive activities. Rotator cuff tears may also happen due to aging, with degeneration of the tissues.

How is a rotator cuff injury treated?

Treatment may include:

• Rest

• Nonsteroidal anti-inflammatory medicines

• Strengthening and stretching exercises

• Ultrasound therapy

• Corticosteroid injection

• Surgery (for severe injuries)

Johns Hopkins Shoulder and Elbow Surgery

Our team of orthopaedic shoulder and elbow specialists diagnoses and treats common and complex shoulder and elbow conditions, including rotator cuff tears, ulnar collateral ligament (UCL) tears, and shoulder and elbow arthritis. Our specialists are also skilled in different shoulder replacement approaches.

Learn more about shoulder and elbow surgery

When should I call my healthcare provider?

Notify your healthcare provider if:

Key points about rotator cuff injury

• Your rotator cuff allows you to lift your arms and reach upward.

• There are 2 main causes of rotator cuff tears: injury and degeneration.

• The symptoms of a rotator cuff tear may resemble other conditions or medical problems. It is important to talk with your healthcare provider for a diagnosis.

• Your healthcare provider will determine specific treatment for your rotator cuff injury.

Treatment Rotator cuff injury

WHAT IS A ROTATORIAL (ROTATOR) CUFF AND WHAT IS IT FOR?

Rotational (rotator) cuff of the shoulder – includes the supraspinatus, infraspinatus, small round and subscapularis muscles. These muscles are necessary to stabilize the head of the humerus and prevent it from moving when moving in the joint. In addition, these muscles allow for rotational movements in the shoulder in all directions.

The subscapularis muscle rotates the arm inward, the supraspinatus muscle raises the shoulder and “anchors” it, i.e. presses the head of the humerus into the articular cavity of the scapula when the shoulder is abducted to the side. In this case, the main force of abduction is determined by the deltoid muscle, and the supraspinatus muscle works as a commander, directing the efforts of the deltoid muscle. The infraspinatus muscle rotates the shoulder outward, and the small round muscle rotates outward and brings the arm to the body. Damage to at least one of the four muscles leads to a sharp limitation of movement and loss of function of the shoulder joint.

CAUSES OF DAMAGE OR RUPTURE OF THE ROTATOR (ROTATOR) CUFF OF THE SHOULDER:

Rotator cuff injury can result from acute trauma. In this case, patients often describe a specific injury, after which pain appeared and the function of the shoulder was impaired.

In some cases, rupture of the rotator cuff is the result of chronic microtrauma to the muscles. Most often this occurs in persons whose professional activities are associated with frequent elevated position of the hand or throwing movements. For example, athletes in sports such as baseball, tennis, weightlifting and rowing. Constant microtraumatization of the tendons of the rotator cuff when hitting the ball, serving, throwing can lead to micro-ruptures of muscle fibers, the muscles gradually become thinner and over time, even with a minor injury, they can easily tear.

The rotator cuff tendons are prone to overstressing in teachers who write with chalk on a blackboard with their hand up, painters who paint walls, builders, and the like.

In some patients, rupture of the rotator cuff may be due to the development of degenerative-dystrophic changes in the muscles associated with aging, for example, in the elderly or a genetic predisposition.

TYPES OF DAMAGE OR RUPTURES OF THE ROTATOR (ROTATOR) CUFF OF THE SHOULDER:

Due to the cause of the rupture – traumatic or degenerative ruptures. According to the nature of the damage, partial and complete ruptures are distinguished. Partial ruptures do not pass through the entire thickness of the tendon, full ones extend through the entire thickness of the layers of the cuff. Traumatic injuries are divided into fresh, stale and chronic.

SYMPTOMS OF DAMAGE TO THE ROTATOR (ROTATOR) CUFF OF THE SHOULDER:

Signs of damage to the rotator cuff are pain and weakness in arm abduction or external rotation of the shoulder.

Pain intensifies in certain phases of movement, especially when abducting the arm

at an angle of 70 – 120 °.

DIAGNOSTICS OF DAMAGE TO THE ROTATOR CUFF:

Diagnostic tests:

To diagnose damage to the rotator cuff, special tests are used in which the doctor, bringing the patient’s hands to a certain position, evaluates the motor ability of the injured arm, and observes the patient’s reaction to his actions. The most informative tests are for weakness of abduction and weakness of external rotation of the shoulder. With extensive damage to the rotator cuff, symptoms of a falling arm are also characteristic (the patient cannot hold the passively abducted arm) and raising the shoulder girdle when trying to abduct the arm (Leclerc’s symptom).

Ultrasound – diagnostics

MRI – research

X-ray – research

TREATMENT OF A ROTATOR CUFF INJURY:

Treatment of a rotator cuff injury can be conservative or surgical. Conservative treatment is indicated for partial injuries, when there is hope for restoration of function without surgery. Conservative treatment is carried out along with immobilization of the shoulder joint with a special bandage (orthosis), and includes:

physiotherapy, the use of anti-inflammatory and analgesic drugs, with severe pain – blockade with long-acting glucocorticoids. A very good clinical effect is given by intra-articular injections of platelet-rich plasma into the shoulder joint (“growth factors”, PRP).

If the duration of unsuccessful conservative treatment exceeds 2-3 months, it is necessary to raise the question of surgery.

SURGICAL TREATMENT OF DAMAGES TO THE ROTATOR (ROTATOR) CUFF OF THE SHOULDER:

Repairing a torn rotator cuff tendon is a fairly complex operation. Reconstruction of the rotator cuff can be performed both openly, through an incision on the shoulder, and arthroscopically. The disadvantages of open surgery are the need for large, traumatic incisions on the shoulder to provide access to damaged tendons, which carries a high risk of side effects, and a long recovery after surgery.

In our Medical Center, surgical treatment of rotator cuff injury is performed in a modern way, without incision of the joint – under arthroscopic control. Instead of an incision, local mini-punctures are performed, into one of which an arthroscope with a video camera is inserted, and into the other, instruments for the operation. An enlarged image from the video camera is transmitted to the video monitor, which allows the doctor to examine in detail all the structures of the joint and identify the location of the damage.

The essence of the arthroscopic operation is that the rupture is sutured, and if the tendon is torn off from the place of fixation, then a suture is performed using special “anchor” fixators.

At the first stage of the operation, the joint is cleaned – the removal of all non-viable, degenerative – altered tissues of the rotator cuff. Then the area of ​​the humerus where the rotator cuff was torn or torn off is cleared of soft tissue remnants so that the tendon grows better to it. Usually, 2-3 anchors are required to fix a torn tendon. The latch consists of an anchor and threads. The anchor is attached to the bone, and the tendon is stitched with threads.

The choice of a specific type of anchor is made by the operating surgeon, but in general, the patient should also be informed about which anchor is planned to be used in his case. We recommend using clamps from world-famous companies that have proven themselves for a long time.

REHABILITATION AFTER SHOULDER ARTHROSCOPY:

Properly performed surgery allows you to quickly start active rehabilitation, to prevent the development of complications and optimize the recovery time.

After shoulder arthroscopy, the arm is immobilized in the abduction position for several weeks using a special splint. Such immobilization reduces tendon tension and reduces the risk of re-rupture, creates favorable conditions for better healing of the tendon. The duration of immobilization is determined by the surgeon who performed the operation, since only he can assess the condition of the tendons and the strength of the suture.

Already from the first weeks after shoulder arthroscopy, patients are recommended to perform special exercises aimed at developing movements in the shoulder joint. However, their intensity and sequence should be selected by the operating doctor and an experienced rehabilitation specialist.

In our Medical Center, patients after shoulder arthroscopy are offered a whole range of rehabilitation measures. The rehabilitation program is selected individually and includes:

Special exercises and exercise therapy by rehabilitators of our Medical Center using the kinesiotherapy method. Exercises are aimed at improving the range of motion in the joint, preventing the development of contractures, increasing strength and endurance in the muscles of the shoulder girdle. Exercises are selected on an individual basis and performed on professional equipment in the rehabilitation room, under the supervision of experienced instructors – rehabilitologists. Some of the exercises are signed for the patient to carry out at home.

Physiotherapy using professional BTL equipment: magnetotherapy, ultrasound therapy with the introduction of drugs, electrotherapy – reduce pain and swelling in the operated shoulder, prevent the formation of adhesions and scars, promote better healing, restore muscle tone.

TRUST THE CARE OF YOUR HEALTH TO REAL PROFESSIONALS!

Treatment. Shoulder joint. Rotator Cuff Injuries Company Blog

Description of the disease, symptoms and causes, methods of treatment.

Damage to the rotator cuff of the shoulder joint is a pathological condition characterized by the presence of local inflammation in the tendons of the muscle group involved in the movement of the shoulder joint. Often this disease is combined with the term “tenopathy”, which in some respects can be used as a synonym. According to WHO statistics, about 40% of the adult population of the world suffers from various types of tenopathy that lead to damage to the rotator cuff of the shoulder joint.
The pathogenetic basis for the development of the disease is associated with primary inflammation, necro-dystrophic changes occurring in the tendon tissue. Emerging foci of dystrophy quickly develop into necrosis, in place of which connective tissue quickly grows. As a result, the elastic tissue of the tendons loses its functional properties, also provoking further patho-biochemical changes. As the disease progresses, ruptures are observed during injury, i.e. damage to the rotational (rotator) cuff of the shoulder joint. a number of scientists refer to the development of tenopathy due to autoimmune diseases that occur latently in the human body. At present, due to the development of diseases, constantly inflicted microtraumas and anatomical features of the blood supply to the tendons of the muscles of the shoulder joint are brought to the fore.

Symptoms

The clinical symptoms of damage to the rotational (rotator) cuff of the shoulder joint manifest themselves depending on the severity of the injury. if there is a complete rupture of one of the tendons, the patient complains of pain, mobility in the shoulder joint is limited, it may even be completely absent due to the localization of damage. If an incomplete rupture occurs, i.e., a tear of the tendon, the clinic of damage is moderate.

Swelling of the shoulder joint is usually small. To make a diagnosis, the clinic of pathological standing is atypical and requires an additional examination. Currently, for a detailed layer-by-layer study of the tissues of the shoulder joint, tomography is successfully used to assess the presence of tendon defects.

Depending on the severity and completeness of the rupture, the doctor prescribes conservative or surgical treatment for damage to the rotator cuff of the shoulder joint. It should be noted that due to the pathogenetic basis of the development of the disease, the treatment is long with a smoothly transitional course of rehabilitation. In general, it does not cause discomfort for the patient, taking into account modern methods and developments.

Conservative treatment

Conservative treatment of patients with injuries of the rotator cuff of the shoulder joint is indicated for the first and second degrees of damage (partial or small tears) and when movements in the shoulder joint are preserved. When a partial tear of the tendon occurs. In this case, a set of measures is assigned:

peace;
non-steroidal anti-inflammatory drugs;
tire overlay;

After pain relief, light physical exercises are prescribed to develop the joint. In a later period, strength exercises are added to these exercises aimed at strengthening the muscles of the upper limb.

The term of conservative therapy is from 6 to 8 weeks.

Surgical treatment

Repairing a torn rotator cuff tendon is a fairly complex operation. Reconstruction of the rotator cuff can be performed both openly through an incision on the anterior surface of the shoulder, and arthroscopically.