What are the symptoms of a rotator cuff tear. How is a rotator cuff tear diagnosed. What are the non-surgical treatment options for a rotator cuff tear. When is surgery recommended for a rotator cuff tear. What are the different surgical techniques for repairing a rotator cuff tear. How important is rehabilitation in treating a rotator cuff tear. What can be expected during recovery from rotator cuff surgery.

Understanding the Rotator Cuff: Anatomy and Function

The rotator cuff is a crucial component of the shoulder joint, playing a vital role in arm movement and stability. It consists of four muscles that converge into tendons, forming a protective cover over the head of the humerus (upper arm bone). These muscles – supraspinatus, infraspinatus, subscapularis, and teres minor – originate from the scapula (shoulder blade) and attach to the humerus at specific bony prominences called the greater and lesser tuberosities.

The primary functions of the rotator cuff include:

• Lifting and rotating the arm
• Stabilizing the shoulder joint
• Enabling smooth movement of the shoulder

Understanding the anatomy and function of the rotator cuff is essential for comprehending the impact of injuries and the importance of proper treatment and rehabilitation.

Causes and Symptoms of Rotator Cuff Tears

Rotator cuff tears can occur due to various factors, including acute injuries and degenerative processes. Common causes include:

• Sudden trauma, such as a fall or shoulder dislocation
• Repetitive overhead activities
• Age-related wear and tear
• Chronic overuse in sports or occupations requiring frequent arm elevation

Recognizing the symptoms of a rotator cuff tear is crucial for early diagnosis and treatment. Typical signs include:

1. Pain in the front of the shoulder, often radiating down the arm
2. Discomfort during overhead activities
3. Pain when lying on the affected side
4. Weakness in the arm
5. Difficulty with routine tasks like combing hair or reaching behind the back
6. A snapping sensation and sudden weakness following an acute injury

Can rotator cuff tears worsen over time? Yes, rotator cuff tears can extend or enlarge, either naturally or due to repetitive use or re-injury. Patients with known rotator cuff issues may experience increased pain and weakness after minor injuries, potentially indicating an extension of an existing tear.

Diagnostic Approaches for Rotator Cuff Injuries

Accurate diagnosis of rotator cuff tears is essential for developing an effective treatment plan. The diagnostic process typically involves:

1. Medical history review
2. Physical examination
3. Imaging studies

Which imaging techniques are commonly used to diagnose rotator cuff tears? The most frequently employed diagnostic imaging methods include:

• Magnetic Resonance Imaging (MRI): Provides detailed images of soft tissues, allowing for accurate assessment of tear size and location
• Ultrasound: Offers real-time imaging and is particularly useful for evaluating tendon integrity and muscle quality
• X-rays: While not directly showing soft tissue injuries, they can help rule out other shoulder conditions or associated bone abnormalities

Early diagnosis is crucial, as it can prevent the progression of symptoms such as loss of strength and range of motion. If you suspect a rotator cuff injury, consulting an orthopedic surgeon promptly is advisable for a comprehensive evaluation and tailored treatment recommendations.

Non-Surgical Treatment Options for Rotator Cuff Tears

Many rotator cuff tears can be effectively managed without surgery. Non-surgical treatments aim to alleviate pain, restore function, and improve quality of life. The primary non-surgical approaches include:

1. Anti-inflammatory Medications

Nonsteroidal anti-inflammatory drugs (NSAIDs) can help reduce pain and inflammation associated with rotator cuff tears. These may include over-the-counter options like ibuprofen or naproxen, or prescription medications as recommended by a healthcare provider.

2. Steroid Injections

Corticosteroid injections into the shoulder joint can provide significant pain relief and reduce inflammation. While effective, these injections are typically used judiciously due to potential side effects with repeated use.

3. Physical Therapy

A structured physical therapy program is crucial for improving shoulder function and strength. Therapy may include:

• Range of motion exercises
• Strengthening exercises for the rotator cuff and surrounding muscles
• Posture correction techniques
• Activity modification strategies

How long should non-surgical treatment be tried before considering surgery? The duration of non-surgical treatment can vary depending on the individual’s response and the severity of the tear. Generally, a period of 6-12 weeks is recommended to assess the effectiveness of conservative management. However, this timeline may be adjusted based on the patient’s progress and specific circumstances.

Surgical Interventions for Rotator Cuff Repair

When non-surgical treatments fail to provide adequate relief or in cases of severe tears, surgical intervention may be necessary. The decision to pursue surgery is based on several factors, including:

• Persistent pain and weakness despite conservative treatment
• Functional limitations affecting daily activities or work
• Patient’s activity level and demands (e.g., athletes, manual laborers)
• Size and location of the tear
• Overall health and age of the patient

What are the main surgical techniques for rotator cuff repair? The three primary approaches to rotator cuff repair are:

1. Traditional Open Repair: Involves a larger incision and is typically used for complex or extensive tears
2. Mini-Open Repair: Combines arthroscopic techniques with a smaller incision, offering a balance between visualization and tissue preservation
3. Arthroscopic Repair: Minimally invasive approach using small incisions and a camera, resulting in less tissue damage and potentially faster recovery

The choice of surgical technique depends on factors such as tear size, tissue quality, and surgeon expertise. Your orthopedic surgeon will recommend the most appropriate method based on your individual case.

Rehabilitation and Recovery After Rotator Cuff Treatment

Rehabilitation plays a pivotal role in both non-surgical and surgical management of rotator cuff tears. A well-designed rehabilitation program aims to:

• Restore shoulder strength and flexibility
• Improve overall function and range of motion
• Prevent re-injury and complications
• Facilitate a safe return to daily activities and sports

What does the typical rehabilitation process involve? The rehabilitation journey usually progresses through several phases:

1. Initial Phase: Focus on protecting the repair, managing pain, and gentle passive motion exercises
2. Intermediate Phase: Gradual introduction of active-assisted and active range of motion exercises
3. Strengthening Phase: Progressive resistance exercises to rebuild muscle strength and endurance
4. Functional Phase: Sport-specific or job-specific training to prepare for return to full activities

The duration and intensity of each phase may vary depending on the individual’s progress and the specifics of their injury or surgery. Close collaboration between the patient, surgeon, and physical therapist is essential for optimal outcomes.

Long-Term Outlook and Preventing Future Injuries

Understanding the long-term prognosis and taking steps to prevent future rotator cuff injuries is crucial for maintaining shoulder health. While the outlook can vary depending on factors such as age, tear size, and treatment approach, many individuals experience significant improvement in pain and function with appropriate care.

What strategies can help prevent rotator cuff injuries or re-injuries?

• Maintaining good posture and ergonomics
• Regular shoulder strengthening exercises
• Proper warm-up before physical activities
• Avoiding repetitive overhead motions when possible
• Using correct techniques during sports and work-related activities
• Addressing early signs of shoulder discomfort promptly

By incorporating these preventive measures and staying vigilant about shoulder health, individuals can reduce their risk of rotator cuff injuries and maintain optimal shoulder function over time.

Advances in Rotator Cuff Treatment and Research

The field of rotator cuff treatment is continually evolving, with ongoing research and technological advancements promising improved outcomes for patients. Some of the emerging areas of interest include:

1. Biologics and Growth Factors

Researchers are exploring the use of platelet-rich plasma (PRP), stem cells, and other biologic agents to enhance healing and tissue regeneration in rotator cuff repairs. While still in investigational stages, these approaches show potential for improving surgical outcomes and potentially reducing recovery times.

2. Augmentation Techniques

For large or complex tears, various augmentation methods are being developed to reinforce repairs. These may include the use of patches or scaffolds to provide additional support to the repaired tendon.

3. Advanced Imaging and Surgical Planning

Improvements in imaging technology and 3D modeling are enabling surgeons to plan and execute repairs with greater precision. This may lead to more personalized treatment approaches and potentially better long-term results.

4. Minimally Invasive Techniques

Continued refinement of arthroscopic and mini-open techniques aims to further reduce surgical trauma and enhance recovery. This includes the development of specialized instruments and implants designed for less invasive procedures.

How might these advancements impact future rotator cuff treatment? As research progresses, patients may benefit from:

• More effective and durable repairs
• Shorter recovery times
• Improved functional outcomes
• Expanded treatment options for complex cases
• Potentially reduced risk of re-tears or complications

While many of these approaches are still in developmental stages, they highlight the ongoing commitment to improving rotator cuff treatment and underscore the importance of staying informed about the latest advancements in orthopedic care.

Living with a Rotator Cuff Injury: Lifestyle Adaptations and Management

Adapting to life with a rotator cuff injury, whether treated surgically or non-surgically, often requires some lifestyle modifications. Understanding how to manage daily activities and maintain shoulder health is crucial for long-term success.

Daily Living Strategies

What are some effective ways to manage daily activities with a rotator cuff injury?

• Use assistive devices: Long-handled reachers or grabbers can help with tasks that require reaching or overhead motions
• Modify sleeping positions: Use supportive pillows to find comfortable sleeping positions that don’t aggravate the shoulder
• Adapt work environments: Adjust desk setups, computer positions, and frequently used items to minimize shoulder strain
• Practice energy conservation: Break tasks into smaller, manageable parts and alternate between activities to avoid overuse
• Maintain proper posture: Be mindful of shoulder and neck positioning throughout the day

Pain Management Techniques

Beyond medications, several non-pharmacological approaches can help manage pain associated with rotator cuff injuries:

1. Heat and cold therapy: Alternating between heat and ice can help reduce pain and inflammation
2. Gentle stretching: Regular, controlled stretching can improve flexibility and reduce stiffness
3. Stress reduction: Techniques like deep breathing, meditation, or yoga can help manage pain perception
4. Activity pacing: Balancing periods of activity with rest to avoid overexertion

Maintaining Overall Health

How does overall health impact rotator cuff recovery and management? Maintaining good general health is crucial for optimal shoulder function and recovery. This includes:

• Regular exercise: Focus on low-impact activities that don’t stress the shoulder, such as walking or stationary cycling
• Balanced nutrition: A healthy diet supports tissue healing and maintains a healthy weight, reducing stress on joints
• Adequate sleep: Proper rest is essential for tissue repair and overall well-being
• Stress management: Chronic stress can exacerbate pain and impede healing

By incorporating these lifestyle adaptations and management strategies, individuals with rotator cuff injuries can optimize their recovery, minimize discomfort, and maintain a high quality of life. It’s important to work closely with healthcare providers to develop a personalized plan that addresses specific needs and goals.

Rotator Cuff Tears: Frequently Asked Questions – OrthoInfo

The rotator cuff is a group of four muscles that come together as tendons to form a “cuff,” or cover, over the head of the humerus (upper arm bone).

The four muscles — supraspinatus, infraspinatus, subscapularis and teres minor — originate from the scapula (shoulder blade). The rotator cuff tendons attach to the head of the humerus in bony spots referred to as the greater and lesser tuberosities.

The rotator cuff helps to lift and rotate the arm and to stabilize the ball of the shoulder within the joint.

The rotator cuff tendons cover the head of the humerus (upper arm bone), helping you to raise and rotate your arm.

A rotator cuff tear may result from an acute injury, such as a fall, or may be caused by normal aging-related wear and tear with degeneration of the tendon.

• Typically, you will feel pain in the front of your shoulder that radiates down the side of your arm. It may be present with overhead activities such as lifting or reaching (e. g., serving in tennis, painting a ceiling).
• You may feel pain when you try to sleep on the affected side.
• You may note weakness of your arm and difficulty with routine activities such as combing your hair or reaching behind your back.
• If the tear occurs with injury, you may experience acute pain, a snapping sensation, and immediate weakness of the arm.

 Front view (left) and overhead view (right) of the tendons that form the rotator cuff. The blue arrows indicate a full-thickness tear in the supraspinatus tendon, the most common location for rotator cuff tears.

A rotator cuff tear can extend or get larger over time. This can occur normally over time, or with repetitive use or a re-injury. It is common for patients with known rotator cuff disease to have acute pain and weakness following a minor injury. This likely represents extension of an existing tear.

If you know you have a rotator cuff tear, worsening pain and decreasing strength may mean the tear is getting larger.

If you have injured your shoulder or have chronic shoulder and arm pain, it is best to see an orthopaedic surgeon. They can then make a diagnosis and begin treatment. Your doctor may recommend a diagnostic imaging study such as a magnetic resonance imaging (MRI) scan or ultrasound to confirm the diagnosis.

Early diagnosis and treatment of a rotator cuff tear may prevent symptoms such as loss of strength and loss of motion from setting in.

If your primary physician has already made the diagnosis, an orthopaedic surgeon can review both surgical and nonsurgical options and start treatment.

The majority of rotator cuff tears can be treated nonsurgically using one or more of these treatments:

• Anti-inflammatory medications
• Steroid (cortisone) injections
• Physical therapy

The goals of treatment are to relieve pain and restore strength to the involved shoulder.

Even though most tears cannot heal on their own, you can often achieve good function without surgery.

If, however, you are active or use your arm for overhead work or sports, surgery is most often recommended because many tears will not heal without surgery.

Surgery is recommended:

• If you have persistent pain or weakness in your shoulder that does not improve with nonsurgical treatment. Frequently, patients who require surgery will report pain at night and difficulty using the arm for lifting and reaching. Many will report ongoing symptoms despite several months of medication and limited use of the arm.
• In active individuals who use the arm for overhead work or sports. Pitchers, swimmers, and tennis players are common examples.

Additionally, surgery may be recommended for complete tears that are acute and due to a trauma.

The type of repair performed is based on the findings at surgery.

• A partial tear may require only a trimming or smoothing procedure called a débridement.
• A full-thickness tear, which usually means the tendon is torn from its insertion on the humerus (the most common injury), is repaired directly to bone.

Three techniques are used for rotator cuff repair:

• Traditional open repair
• Mini-open repair
• Arthroscopic repair

Your orthopaedic surgeon can recommend which technique is best for you.

Rehabilitation plays a critical role in both the nonsurgical and surgical treatment of a rotator cuff tear.

When a tear occurs, there is frequently atrophy of the muscles around the arm and loss of motion of the shoulder. An exercise or physical therapy program is necessary to regain strength and improve function in the shoulder.

After surgery, the repair must be protected from certain activities that may put healing at risk. As such, a therapist can provide a safe and progressive therapy program.

Even though surgery repairs the defect in the tendon, the muscles around the arm remain weak, and a strong effort at rehabilitation is necessary for the procedure to succeed. Complete rehabilitation after surgery may take several months or even up to a year.

Your orthopaedic surgeon can prescribe an appropriate program based on your needs and the findings at surgery.

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Information on this topic is also available as an OrthoInfo Basics PDF Handout.

For more information:

Basics Handouts

Rotator Cuff Tears: Surgical Treatment Options – OrthoInfo

The following article provides in-depth information about surgical treatment for rotator cuff injuries and is a continuation of the article “Rotator Cuff Tears.” For a good introduction to the topic of rotator cuff injuries, please refer to Rotator Cuff Tears .

Surgery to repair a torn rotator cuff most often involves re-attaching the tendon to the head of the humerus (upper arm bone). A partial tear, however, may need only a trimming or smoothing procedure called a debridement. A complete tear is repaired by stitching the tendon back to its original site on the humerus.

The rotator cuff tendons cover the head of the humerus (upper arm bone), helping you to raise and rotate your arm.

Your doctor may offer surgery as an option for a torn rotator cuff if your pain does not improve with nonsurgical methods. Continued pain is the main indication for surgery. If you are very active and use your arms for overhead work or sports, your doctor may also suggest surgery.

Other signs that surgery may be a good option for you include:

• Your symptoms have lasted 6 to 12 months
• You have a large tear (more than 3 cm) and the quality of the surrounding tendon tissue is good
• You have significant weakness and loss of function in your shoulder
• Your tear was caused by a recent, acute injury

Front (left) and side (right) views of the tendons that form the rotator cuff. The blue arrows indicate a full-thickness tear in the supraspinatus tendon, the most common location for rotator cuff tears.

There are a few options for repairing rotator cuff tears. Advances in surgical techniques for rotator cuff repair include less invasive procedures. While each of the methods available has its own advantages and disadvantages, all have the same goal: getting the tendon to heal back to bone.

The type of repair performed depends on several factors, including:

• Your surgeon’s experience and familiarity with a particular procedure
• The size of your tear
• Your anatomy
• The quality of the tendon tissue and bone

Most surgical repairs can be done on an outpatient basis and do not require you to stay overnight in the hospital. Your orthopaedic surgeon will discuss with you the best procedure to meet your individual health needs.

You may have other shoulder problems in addition to a rotator cuff tear, such as:

• Biceps tendon tears
• Osteoarthritis
• Bone spurs
• Other soft tissue tears

During the operation, your surgeon may be able to take care of these problems, as well.

The three techniques most commonly used for rotator cuff repair are:

• Traditional open repair
• Arthroscopic repair
• Mini-open repair

In the end, patients rate all three repair methods the same for pain relief, strength improvement, and overall satisfaction.

Open Repair

A traditional open surgical incision (several centimeters long) is often required if the tear is large or complex. The surgeon makes the incision over the shoulder and detaches or splits part one of the shoulder muscles (deltoid) to better see and gain access to the torn tendon.

During an open repair, the surgeon typically removes bone spurs from the underside of the acromion (this procedure is called an acromioplasty). An open repair may be a good option if:

• The tear is large or complex
• Additional reconstruction, such as a tendon transfer, is needed

Open repair was the first technique used for torn rotator cuffs. Over the years, new technology and improved surgeon experience has led to less invasive procedures.

All-Arthroscopic Repair

During arthroscopy, your surgeon inserts a small camera, called an arthroscope, into your shoulder joint. The camera displays a live video feed on a monitor, and your surgeon uses these images to guide miniature surgical instruments.

During arthroscopy, your surgeon can see the structures of your shoulder in great detail on a video monitor.

Because the arthroscope and surgical instruments are small and thin, your surgeon can use very small incisions (portals), rather than the larger incision needed for standard, open surgery.

Illustration and photo showing an arthroscope and surgical instruments inserted through portals in a shoulder joint.

All-arthroscopic repair is usually an outpatient procedure and is the least invasive method to repair a torn rotator cuff.

(Left) Arthroscopic view of a healthy shoulder joint.
(Right) In this image of a rotator cuff tear, a large gap can be seen between the edge of the rotator cuff tendon and the humeral head.

(Left) The same rotator cuff tear, as seen from above the tendon.
(Right) The rotator cuff tendon has been re-attached to the greater tuberosity of the humeral head with sutures.

Mini-Open Repair

The mini-open repair is performed through a smaller open incision than is used in traditional open repair.

This technique typically uses arthroscopy to assess and treat damage to other structures within the joint. Bone spurs, for example, are often removed arthroscopically. This avoids the need to detach the deltoid muscle.

Once the arthroscopic portion of the procedure is completed, the surgeon repairs the rotator cuff through the mini-open incision. During the tendon repair, the surgeon views the shoulder structures directly, rather than through the video monitor.

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Pain Management

After surgery, you will feel pain. This is a natural part of the healing process. Your doctor and nurses will work to reduce your pain.

Medications are often prescribed for short-term pain relief after surgery. Many types of medicines are available to help manage pain, including opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and local anesthetics. Your doctor may use a combination of these medications to improve pain relief, as well as minimize the need for opioids.

Be aware that although opioids help relieve pain after surgery, they are narcotics and can be addictive. Opioid dependency and overdose have become critical public health issues. It is important to use opioids only as directed by your doctor and to stop taking them as soon as your pain begins to improve. Talk to your doctor if your pain has not begun to improve within a few weeks after your surgery.

Rehabilitation

Rehabilitation plays a vital role in getting you back to your daily activities. A physical therapy program will help you regain shoulder strength and motion.

Immobilization. After surgery, therapy progresses in stages. At first, the repair needs to be protected while the tendon heals. To keep your arm from moving, you will most likely use a sling and avoid using your arm for the first 4 to 6 weeks. How long you require a sling depends on the severity of your injury.

Active exercise during rehabilitation may include isometic external rotation exercises, such as the one shown here.

Passive exercise. Even though your tear has been repaired, the muscles around your arm remain weak. Once your surgeon decides it is safe for you to move your arm and shoulder, a therapist will help you with passive exercises to improve range of motion in your shoulder. With passive exercise, your therapist supports your arm and moves it in different positions. In most cases, passive exercise is begun within the first 4 to 6 weeks after surgery.

Active exercise. After 4 to 6 weeks, you will progress to doing active exercises without the help of your therapist. Moving your muscles on your own will gradually increase your strength and improve your arm control. At 8 to 12 weeks, your therapist will start you on a strengthening exercise program.

Expect a complete recovery to take several months. Most patients have a functional range of motion and adequate strength by 4 to 6 months after surgery. Although it is a slow process, your commitment to rehabilitation is key to a successful outcome.

The majority of patients report improved shoulder strength and less pain after surgery for a torn rotator cuff.

Each surgical repair technique (open, mini-open, and arthroscopic) has similar results in terms of pain relief, improvement in strength and function, and patient satisfaction. Surgeon expertise is more important in achieving satisfactory results than the choice of technique.

Factors that can decrease the likelihood of a satisfactory result include:

• Poor tendon/tissue quality
• Large or massive tears
• Poor patient compliance with/participation in restrictions and rehabilitation after surgery
• Patient age (older than 65 years)
• Smoking and use of other nicotine products
• Workers’ compensation claims

After rotator cuff surgery, a small percentage of patients experience complications. In addition to the risks of surgery in general, such as blood loss or problems related to anesthesia, complications of rotator cuff surgery may include:

• Nerve injury. This typically involves the nerve that activates your shoulder muscle (deltoid).
• Infection. Patients are given antibiotics during the procedure to lessen the risk for infection. If an infection develops, additional surgery and/or prolonged antibiotic treatment may be needed.
• Deltoid detachment. During an open repair, this shoulder muscle may be partially detached to provide better access to the rotator cuff. It is stitched back into place at the end of the procedure. It is very important to protect this area after surgery and during rehabilitation to allow it to heal.
• Stiffness. Early rehabilitation lessens the likelihood of permanent stiffness or loss of motion. Most of the time, stiffness will improve with more aggressive therapy and exercise.
• Tendon re-tear. There is a chance for re-tear following all types of repairs. The larger the tear, the higher the risk of re-tear. Patients who re-tear their tendons usually do not have greater pain or decreased shoulder function. Repeat surgery is needed only if there is severe pain or loss of function.

To assist doctors in the management of rotator cuff tears, the American Academy of Orthopaedic Surgeons has conducted research to provide some useful guidelines. These are recommendations only and may not apply to every case. For more information: Plain Language Summary – Clinical Practice Guideline – Management of Rotator Cuff Injuries – AAOS

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Rupture (damage) of the rotator cuff of the shoulder joint

Rupture of the rotator cuff (rotator cuff injury) of the shoulder is a fairly serious injury that requires urgent attention traumatologist . Contribute to such an injury is a strong load on the shoulder, which is the cause of degenerative damage to the tendons.

Shoulder joint is one of the most mobile joints in the human body, the structure of which allows you to perform movements of the upper limbs in a wide range: flexion and extension, rotation, adduction and abduction, circular movements are carried out in the joint.

Rotator cuff

Rotator cuff – the anterior outer part of the capsule of the shoulder joint, which combines the tendons of the supraspinatus, infraspinatus, small round muscles. Each of them performs its own function, but due to the anatomically close place of fixation, traumatologists attribute them to the general group (rotator cuff of the shoulder).

A rupture of one tendon (or group of tendons) that make up the rotator cuff is considered an injury. The reason for this can be injuries, dislocations or inflammatory and degenerative processes. Traumatic injury to the rotator cuff usually occurs in elderly patients, but young people can get this injury as a result of a dislocation or fracture of part of the humerus.

• A common cause of rotator cuff injury is chronic chronic tendon injury . This applies to people whose sphere of work is associated with serious physical exertion. Tension and regular monotonous movements lead to inflammation and pain in the shoulder area.
• Rupture of the rotator cuff can occur due to genetic predisposition or as a result of degenerative-dystrophic changes , which appear due to a lack of blood supply.
• Another cause of damage to the rotator cuff can be called individual human anatomy. The distance between the head of the humerus and the tip of the scapula is insufficient, resulting in constant friction and injury to the tendons of the rotator cuff. In addition, the hook-shaped form of the acromial process and the presence of an additional bone at the tip of the scapula, damaging the tendons, are anatomically determined.

Rotator cuff tear symptoms

A rupture of the rotator cuff results in acute pain in and around the shoulder joint. The pain may radiate to the neck, forearm, or hand. The patient either cannot move his hand at all, or experiences pain even with minimal movements with it (it is impossible to move the hand to the side or raise something). In some cases, it is impossible to sleep on the side of the damaged joint. Symptoms are individual for each clinical case and depend on whether the rupture was partial or complete.

The center of pain usually indicates the site of the injured tendon. Most often there is a rupture of the tendon of the periosteal muscle. The patient cannot move his arm to his side on his own.

Diagnosis of rotator cuff injuries

To establish an accurate diagnosis, a traumatologist conducts a set of diagnostic measures:

• A survey of patient allows to identify the circumstances under which pain occurred and to build a relationship between a person’s professional activity, the presence of old injuries and the moment of the onset of pain.
• A thorough examination of the using specific tests helps the specialist understand the degree of damage to the rotator cuff, the level of pain syndrome, the condition of the muscles and their motor activity. With a complete rupture of the rotator cuff, the symptoms are quite bright – it is not difficult to determine the presence of damage.

Dawburn’s Painful Arch

The arm is passively and actively retracted from the initial position along the body.

Estimated. If pain develops on arm abduction between 70° and 120°, this can be considered a symptom of supraspinatus tendon injury. This tendon undergoes compression between the greater tubercle of the humerus and the acromial process during this phase of movement (“subacromial impingement”).

Zero Position Abduction Test

The patient’s arms are initially lowered along the body and relaxed. He then tries to spread his arms while the doctor resists by grasping the distal third of each patient’s forearm

Estimated. The supraspinatus and deltoid muscles are responsible for moving the arm away from the body. If there is pain and weakness with this test, it is indicative of a ruptured rotator cuff.

The eccentric position of the head of the shoulder in the form of its upper displacement in the event of a rupture of the rotator cuff occurs due to an imbalance in the muscles that surround the shoulder joint. Partial ruptures, which can be functionally compensated, disrupt function to a lesser extent with the same severity of pain. Complete tears are invariably characterized by weakness and loss of function.

Jobe supraspinatus test

This test can be performed with the patient either standing or sitting. With the forearm extended, the patient’s arm is fixed in 90° abduction, 30° horizontal flexion, and internal rotation. The doctor resists this movement by applying pressure to the proximal shoulder.

Estimated. If this test causes significant pain and the patient cannot independently hold the allotted 90° hand against gravity, this is called a positive falling hand symptom. The upper portions of the rotator cuff (supraspinatus) are assessed mainly in the position of internal rotation (the first finger points down), and the state of the anterior portion of the cuff – in the position of external rotation.

Falling hand test (symptom of falling flag, chess clock)

The patient is seated while the doctor passively abducts the patient’s extended arm to approximately 120°. The patient tries to independently hold the hand on weight, and then smoothly lower it.

Estimated. If the patient is unable to hold the arm, and severe pain occurs or the arm cannot be lowered smoothly, this indicates damage to the rotator cuff. The most common cause is a defect in the supraspinatus muscle. With pseudoparalysis, the patient cannot independently raise the injured arm. This is the main symptom confirming the pathology of the rotator cuff.

External rotation abduction test for infraspinatus tendon rupture

The patient’s arm is fixed in 90° abduction and 30° flexion. In this position, the action of the deltoid muscle as an external rotator is excluded. The patient is then asked to begin external rotation, which is prevented by the doctor.

Estimated. Decreased active external rotation in abducted arm position is characteristic of clinically significant infraspinatus tendon injury.

After performing functional tests, the patient is sent for an x-ray. Based on the results of this study, the doctor can draw up a complete picture of the disease, characteristic of a particular case. Note that it is the gap that is not always clearly defined – it is indicated by indirect signs.

MRI is one of the most informative diagnostic methods for damage to the rotator cuff of the shoulder joint. This research method allows you to visually illustrate the tendons, ligaments and muscles of the shoulder joint, assessing the condition of the soft tissues.

Treatment of rupture (damage) of the rotator cuff

Treatment of a rotator cuff injury begins with pain relief for the patient. For this, the doctor prescribes special ointments and anti-inflammatory painkillers. It is better to fix the injured arm with a splint or bandage to avoid further injury. Puffiness is removed by applying cold (ice pack).

Surgical treatment of rotator cuff injuries

In the event of a complete rupture of the rotator cuff, surgical intervention is mandatory in order to preserve the motor function of the joint. If you experience acute pain in your shoulder, be sure to make an appointment with an orthopedic traumatologist at our clinic in St. Petersburg (we provide a link to https://www.gosmed.ru/staff/travmatolog-ortoped/). The sooner you do this, the higher the likelihood of avoiding various kinds of complications. Remember that an old injury can lead to a shortening of the muscle, which in the future will not be able to stretch to its original state. In any case, surgery will have to be performed, but it will last longer and require more effort from the surgeon in order to put the tendon in place. The optimal period for the operation is considered to be several months from the moment of rupture.

During surgery, the damaged tendon is stretched and attached to its original position. If necessary, hem. Tissues that have been subject to degenerative changes are removed to allow the tendon to better adhere to the site of artificial attachment.

The tendon is usually attached to the starting position with anchors. The anchor is screwed into the area of ​​the bone where soft tissues will subsequently be connected. Threads attached to the anchor are passed through the rotator cuff and pulled to the bone with interrupted sutures. This procedure allows you to hold the tissues until they are completely fused at the site of the rupture.

The operation to restore the functions of the rotator cuff of the shoulder joint is not minimally invasive and is rightly considered quite complicated.

Arthroscopic treatment of a rotator cuff injury

Arthroscopy is the most effective method of surgical treatment of a rupture of the rotator cuff of the shoulder joint. It is considered less traumatic, performed without large incisions. During arthroscopy, a small puncture is made with a diameter of 1-2 cm, through which an arthroscope is inserted, that is, a special camera. The doctor on the monitor screen sees the whole picture of the internal space of the joint and performs all the necessary manipulations.

The operation of arthroscopy of the shoulder joint is minimally invasive – the tissues around the joint are not damaged during the intervention, and the further healing process is significantly reduced. After carrying out all the necessary manipulations, the patient’s hand is immobilized with a splint, which can be removed after a few weeks. During this time, tissue fusion will occur, and by fixing the arm, the risk of recurrence is significantly reduced.

Rehabilitation after rotator cuff injury

The rehabilitation process after surgery to repair damage to the rotator cuff of the shoulder is quite long and takes up to six months. At the same time, it is important not to heavily load the damaged limb so as not to disrupt the fusion process.

Specialists of the Department of Traumatology of our clinic in St. Petersburg prescribe recovery exercises in the form of special gymnastics for each patient. They will allow you to develop the joint and after a while return it to good motor activity. Physiotherapy may be prescribed to reduce swelling and pain.

Your health is in your hands, therefore, in case of detection of symptoms of various traumatological diseases, make an appointment and consultation with experienced specialists of the KVMT named after. N.I. Pirogov St. Petersburg State University by phone 8 (812) 676-25-25. Call!

Arthroscopic treatment of rupture of the rotator cuff

Damage to the rotator cuff.

The shoulder joint is the most mobile joint in the human body. It allows us to raise our hand, put it behind our back, reach our own back of the head. It is believed that it was thanks to labor and one’s own hands that a person became a person, but it would not be an exaggeration to say that the whole variety of functions of the human hand is based precisely on the amazing mobility of the shoulder joint. Movements in the shoulder joint are carried out in all three planes, but for an increase in the range of motion in the joint, we have to pay with a decrease in its stability and a high risk of damage to its structures, which include the rotator cuff of the shoulder.

Anatomical structure of a normal shoulder joint.

The shoulder joint is formed by three bones: the head of the humerus, the glenoid cavity of the scapula and the clavicle, which is not anatomically connected with the joint, but significantly affects its function.

The head of the humerus corresponds in shape to the articular cavity of the scapula, also called the glenoid cavity (from the Latin term cavitas glenoidalis – articular cavity). Along the edge of the glenoid cavity of the scapula there is an articular lip – a cartilaginous roller that holds the head of the humerus in the joint.

The tough connective tissue that forms the capsule of the shoulder joint is essentially the ligament system of the shoulder joint that helps the head of the humerus stay in the correct position relative to the glenoid cavity of the scapula. The ligaments are firmly fused with the thin capsule of the joint. These include the coraco-brachial and articular-humeral ligaments (has three beams: upper, middle and lower). Also, the shoulder joint is surrounded by powerful muscles and tendons, which actively provide its stability through their own efforts. These include the supraspinatus, infraspinatus, teres minor, and subscapularis, which form the rotator cuff. Each of these muscles performs its own function: the subscapularis rotates the arm inward, the supraspinatus – 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 abduction force 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 also rotates outward and brings the arm to the body.

Together they function as a rotator cuff.

Rotator cuff

The supraspinatus muscle is located above all in the rotator cuff, while its tendon passes in a narrow space between the acromial process of the scapula and the head of the humerus, which determines the tendency to injury to the tendon.

Rotator (rotator) cuff of the shoulder: general appearance, tenopathy and infringement of the tendons of the rotator cuff in the subacromial space (impingement – syndrome)

You can learn more about the anatomy of the rotator cuff and the anatomy of the shoulder joint on our website (click on the mouse to go to the articles about the anatomy).

Causes of diseases and injuries of the rotator cuff

The tendons of the rotator cuff muscles, like all other tendons, have a relatively poor blood supply. Insufficient blood supply to the tendons of the rotator cuff leads to the frequent development of degenerative changes: the so-called tenopathy occurs. It should be noted that not only insufficient blood supply contributes to the development of tenopathy (a number of scientists generally deny the role of blood supply in the development of tenopathy). Another reason for the development of tenopathy is a hereditary pathology of the connective tissue. Tendons are mainly made up of a special protein called collagen, which comes in 4 types. With an abnormally high percentage of collagen types 3 and 4, tenopathy develops more often. In general, tenopathy can develop in any of the tendons of the rotator cuff (and in several tendons at the same time), which can lead to pain in the shoulder joint during movements in which the corresponding muscle is involved. For example, with tenopathy of the tendon of the supraspinatus muscle, the pain increases when the arm is abducted to the side, with tenopathy of the subscapularis muscle, when bringing a spoon or fork to the mouth, when combing, when putting the hand behind the back. Often these tenopathies are called humeroscapular periarthritis , but this is an absolutely illiterate diagnosis, which has already been abandoned around the world several decades ago. “Shoulohumeral periarthritis”, manifested by pain in the shoulder, can actually be not only a tenopathy of one or another tendon of the rotator cuff, but also a number of other diseases, which deserves consideration in a separate article. In addition, the development of tenopathy contributes to the use of certain antibiotics (fluoroquinolones).

The most common cause contributing to the development of tenopathy is chronic traumatization of the tendons, which is possible with two principal options:

Three types of anatomical form of the acromial process (lateral view). The hook-like shape of the acromial process contributes to traumatization of the tendons of the rotator cuff

With age, degenerative changes in the tendon progress, tenopathy becomes more pronounced, the tendon weakens and may rupture. The most common tendon rupture occurs at the age of 35-55 years. However, with a sufficiently severe injury (fractures of the greater tubercle of the humerus, other fractures of the proximal part of the humerus, dislocations in the shoulder joint, etc.), a rupture can occur without previous tenopathy, i.e. in relatively young people.

Complete supraspinatus tendon rupture and partial subscapularis tendon rupture

Symptoms

shoulder due to injury occurs against the background of previous degenerative changes (tenopathy) . The gap is characterized by a sharp increase in pain and weakening of the arm, up to the complete inability to move the arm. Ruptures are partial or complete, when the tendon of a particular muscle is completely torn off from its attachment to the humerus. The intensity of pain depends on the size of the gap – as a rule, the larger the gap, the greater the pain, and the greater the restriction of movement. With partial ruptures, the possibility of hand movements is preserved.

The localization of pain depends on which rotator cuff tendon is injured. Most often, the supraspinatus tendon is damaged, which is usually manifested by a complete inability to move the arm to the side (with a complete rupture) or increased pain when the arm is abducted to the side in an amplitude of 30 to 60 degrees. Many patients note that they cannot sleep on the side of the affected shoulder joint.

Diagnosis

To make a diagnosis, the doctor will ask you about the mechanism of injury, the age of injury, the nature of pain in the shoulder, whether and how long the shoulder hurt before the injury. Let us recall once again that with significant tenopathy, tendon rupture can occur without injury at all.

Next, the doctor conducts an examination, during which he performs special tests (moves your hand or asks the patient to make a special movement), during which it is already possible to find out with a high degree of certainty which particular tendon is damaged.

As a rule, when the tendon is completely torn (or detached from its attachment to the bone), the movement for which this muscle is responsible is impossible.

With partial tears, the ability to move the arm is preserved, but the movements are painful.

An x-ray is mandatory, which shows characteristic signs on the lower surface of the acromial process, the so-called subchondral sclerosis, in case of ruptures of the tendons of the rotator cuff. It is formed as a defensive reaction of the bone against repeated impact of the head of the humerus and the lower surface of the acromion (impingement syndrome), and these impacts lead to damage to the tendons of the rotator cuff, cause their tenopathy, and, ultimately, rupture. Of course, the absence of these signs on the radiograph does not mean that the rotator cuff tendons are not damaged, but the presence of these radiological signs with a high degree of probability indicates problems with the rotator cuff tendons. On the x-ray, it is important to evaluate the acromioclavicular joint: arthritis of this joint can cause similar pains.

X-ray: collision of the humeral head (blue arrows) and the inferior surface of the acromial process (red arrows) leads to damage to the supraspinatus tendon passing between them.

In case of an unclear diagnosis and in order to clarify the extent of damage, ultrasound or magnetic resonance imaging is performed, which allows using magnetic waves to see and capture soft tissues and bones in the form of layered sections.

Magnetic resonance imaging showing complete supraspinatus tendon rupture

Treatment

Initial treatment 90 185 for acute, recent rotator cuff tendon rupture is to reduce pain. As a rule, non-steroidal anti-inflammatory drugs are used, such as aspirin, voltaren, xefocam, etc. Also, in the acute period, it is necessary to observe rest for the sore hand – the hand is immobilized on a scarf bandage or on a special abduction splint. To reduce pain and swelling, applying ice packs wrapped in a towel to the shoulder is effective.

Gusseting Rules

A special abduction splint used to treat rotator cuff tendon ruptures. Most often, the tendons of the supraspinatus muscle are torn off from the place of its attachment to the humerus. Immobilization of the arm in the abduction position brings the end of the torn tendon closer to the place of its attachment to the humerus. The same abduction splint is also used after surgery for rotator cuff tendon ruptures

Complete rupture of the supraspinatus tendon and partial rupture of the subscapularis tendon. When the arm is abducted to the side, the torn ends of the tendon come together. The red arrow shows the axis of the humerus. On the left – the shoulder is brought to the body, on the right – the shoulder is laid to the side.

Conservative therapy. For tenopathies and minor, small tears, when movements in the shoulder joint are preserved, conservative therapy is prescribed. 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. This will gradually return the patient’s arm to its previous range of motion. Usually the duration of conservative therapy is from 6 to 8 weeks. During this time, pain in the shoulder completely stops, and there is a partial restoration of strength in the muscles of the arm.

Surgical treatment. With significant tears, conservative treatment is futile, because the broken ends simply cannot heal. However, the size of the gap and the very fact of the presence of a gap are not at all the criteria by which the need for surgery is assessed, since sometimes even with complete gaps, the movements in the shoulder joint are preserved or practically painless due to the fact that the function of the torn tendon is partially taken over by neighboring tendons. However, with complete ruptures, this does not occur often.

Surgery is indicated if:

• there is a complete tear that makes movement in the shoulder joint impossible or restricts some movement;
• there is a partial tear that restricts movement and causes pain;
• conservative treatment was unsuccessful.

During the operation, the torn tendon is pulled back to its place of attachment and sutured.

The essence of the operation is that the rupture is sutured, and if the tendon is detached from the place of fixation, then I perform the suture using special “anchor” fixators. At the first stage of the operation, all non-viable, degeneratively altered tissues of the rotator cuff are removed. The area of ​​the humerus where the rotator cuff has been torn or torn off is then cleared of soft tissue remnants in order for the tendon to grow. Breaks are different in their form. The most common are U-shaped and L-shaped gaps.

Quite often, 2-3 already mentioned anchors are required to fix a torn tendon. This retainer 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. First of all, we can distinguish FASTIN®, PANALOK , VERSALOK ™, BIOKNOTLESS ™, GII, HEALIX ™ from DePuy Mitek (a division of Johnson and Johnson), PushLock® Knotless Anchor from Arthrex and TWINFIX ™ from Smith & Nephew.

Repair of a torn rotator cuff tendon is a rather complicated operation. Reconstruction of the rotator cuff can be performed both openly through an incision and arthroscopically, i.e. without the traditional cut. Through one puncture 1-2 centimeters long, a video camera (arthroscope) is inserted into the joint and all injuries are examined from the inside. Through 1-2 other small punctures, special instruments are introduced into the joint, with which the tendon suture is performed.

Repair of a torn tendon is not possible in all cases. If a sufficiently long period of time has passed between the moment of injury and the operation, then cicatricial degeneration of the muscle and tendon may occur, as a result of which it will be impossible to tighten this tendon during the operation to fix it to the bone. In other cases, pronounced degenerative processes can be observed in the tendon, which leads to a significant decrease in the breaking load. In this case, even after successful reconstruction of the tendon, a relapse of the disease is likely in the near future.