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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Torn rotator cuff: Symptoms, diagnosis, and treatment options | Orthopaedics and Rehab

Physical therapy strengthens the muscles in the shoulder, which can prevent a torn rotator cuff from getting worse.

Rotator cuff injuries are often associated with athletes – a star pitcher or quarterback makes headlines because they are scheduled for surgery to repair a tear in their shoulder.

But more often than not, torn rotator cuffs affect carpenters, construction workers, painters, and people in their 40s and older who have worked at jobs where they lift heavy objects and make repetitive overhead arm movements over a long period of time.

Traumatic rotator cuff tears are caused by sudden, forceful injuries, such as falling or being involved in a vehicle accident. But those injuries are much less common.

Most rotator cuff tears are progressive, beginning as tendinitis or inflammation in the tissue that connects the shoulder muscles to the shoulder joint, helping to stabilize it. Over time, the tissue can split, resulting in a partially or fully torn rotator cuff.

Less than half of patients with full rotator cuff tears report pain, and some may walk around with a torn rotator cuff for 20 years or longer without issues. Then, one day, they wake up with disruptive pain, day and night. In fact, sleep loss is a major reason patients seek care for rotator cuff injuries. When nearly every position puts pressure on the shoulder, it can be difficult to lie down comfortably.

Many patients delay care because they don’t want to have surgery. But not every patient needs surgery to repair a torn rotator cuff.

UT Southwestern is one of 17 sites participating in a nationwide clinical trial called ARC (Arthroscopic Rotator Cuff) that will compare outcomes between surgical repairs and physical therapy in hopes of learning which therapies work best for rotator cuff tears and why. We expect this comprehensive research will only enhance our ability to help patients select the best option for treatment and recovery based on their anatomy and functionality goals.

Currently, the best approach for torn rotator cuff treatment is a close evaluation of your injury, daily activities, and goals. Using this information, we can personalize the most effective, least invasive path to long-term pain management and improved shoulder function. This plan starts with an accurate diagnosis.

How is a torn rotator cuff diagnosed?

We typically begin assessing most rotator cuff injuries with a physical exam. Your doctor will ask you to make a series of arm movements, which might include:

Most rotator cuff tears are progressive, beginning as tendinitis or inflammation in the tissue that connects the shoulder muscles to the shoulder joint, helping to stabilize it. Over time, the tissue can split, resulting in a partially or fully torn rotator cuff.

• Giving yourself a bear hug
• Rotating your arm at a 90-degree angle
• Reaching behind and up your back as far as you can

The goal of the physical exam is to gauge the approximate location and severity of your injury. Patients with a tear that warrants treatment may experience symptoms including:

• Pain when lifting or rotating the affected arm
• Pain when lying on the affected shoulder
• Weakness of the affected arm
• Popping sounds when the arm moves in certain directions

The physical exam also helps us rule out other conditions, such as a pinched nerve or one of these common concerns:

• Rotator cuff tendinitis can occur when you have inflammation of a single tendon, which will produce pain when you make specific movements, such as reaching upwards or even combing your hair.
• Bursitis is another common shoulder condition and it occurs when inflammation spreads into the subacromonial bursa, or sac filled with fluid that lubricates the tendons. The pain from this condition is usually worse at night.

If we suspect you have a torn rotator cuff, we’ll need to know whether it’s a total or partial tear. An MRI exam will allow us to see inside your shoulder and analyze the bone, muscle, and connective tissues.

This information helps us determine what type of treatment might benefit you most. For small to moderate tears, physical therapy may provide adequate relief. Large or irregular tears may require surgery.

What is the best treatment for a torn rotator cuff?

The best treatment usually depends on the type of tear and your age. Traumatic rotator cuff tears typically require surgery due to the severity of the injury. However, physical therapy or surgery may work for an atraumatic rotator cuff tear.

Your doctor can help you weigh the pros and cons of your treatment options. In general:

• Consider physical therapy if you:
  • Have a mild-to-moderate atraumatic tear
  • Are older than 50: While the tear may progress, it is unlikely to do so quickly enough to warrant shoulder replacement surgery.
• Consider surgery if you:
  • Have a traumatic tear or a severe atraumatic tear
  • Are younger than 50: Research shows that for patients in this age group, 50 percent of tears increase in size within two years.

Research has shown that patients who expect physical therapy to help them have better results than those who expect no benefit. While physical therapy can help decrease pain and improve your range of motion, it won’t heal the tear. A combination of assisted and unassisted range of motion and strength exercises can help strengthen the shoulder muscles and improve flexibility, protecting the tear and potentially preventing it from getting worse.

In advanced cases, physical therapy alone might not be enough to manage pain or prevent further tearing. At this point, patients may need to consider surgery.

Our surgeons treat a high volume of shoulder injuries each year and we are experts in determining the least invasive, most effective treatments to get patients – athletes, professionals, and Average Joes – back to their activities safely and quickly.

If you choose surgery, physical therapy will be an essential part of your recovery. We work closely with our Physical Medicine and Rehabilitation (PM&R) team to personalize care plans for patients with rotator cuff tears. Our therapists and board-certified PM&R doctors will help you achieve the highest physical function possible after surgery.

Related reading: Unraveling the mystery – and misery – of frozen shoulder

Rotator cuff repair surgery: What to expect

UT Southwestern offers minimally invasive rotator cuff repair surgery, which decreases pain, scarring, and recovery time compared with traditional open surgery. The procedure takes 2 to 2 ½ hours, with an hour or two of recovery afterward. Most patients can go home the same day.

During surgery, the surgeon will insert an arthroscope – a slender tube with a small lens and light attached – through a 1-inch to 2-inch incision in your shoulder. The arthroscope allows us to see inside your shoulder joint and use pencil-sized instruments to remove damaged tissue, repair the tear, and reaffix the connective tissue to the shoulder joint using tiny metal anchors.

Some surgeons perform anchorless repairs to reduce the amount of foreign material left in the bone. Originally done in open surgeries, anchorless repairs are now making their way into arthroscopic surgeries. Here, wire sutures are passed through bone tunnels, then again through the tendon to be knotted around – rather than anchored to – the bone.

Shoulder specialist Michael Khazzam, M.D., performed the first augmented reality shoulder arthroplasty in Texas in April 2021. UT Southwestern is one of only 15 centers in the world using the advanced technology, which provides increased precision in the OR.

Learn more

Recovery after surgery

Most patients will regain a functional range of motion and adequate strength four to six months after surgery.

Recovery begins with short-term immobilization to protect the tendons while they heal. Your surgeon will recommend that you wear a sling and avoid arm movement for up to six weeks.

Next is passive exercise, which begins four to six weeks after surgery. Your physical therapist will support your arm while you move through different positions, personalized to your healing needs. Many patients whose jobs require minimal arm movement can return to work four weeks after surgery.

After four to six weeks, you’ll progress to active exercises without assistance from your therapist. These exercises help increase strength and improve control. Between eight and 12 weeks, you will begin your strengthening exercises. If you have a more active job, such as lifting things above your head, you may be advised to wait three or four months to return to work.

The future of rotator cuff repair

In addition to the ARC clinical trial, we plan to become a site for another study, with funding from the National Institutes of Health, to explore the genetics of rotator cuff tears. Together with Nitin Jain, M.D., M.S.P.H., who leads our Physical Medicine and Rehabilitation team, we hope to learn more about who might benefit from rotator cuff surgery.

Dr. Jain and UT Southwestern are leading the future of healing rotator cuffs without surgery using platelet-rich plasma and stem cell therapies. This field, known as regenerative medicine, builds on the body’s healing capabilities to improve the growth, repair, or replacement of damaged and diseased tissues without invasive procedures.

If shoulder pain is disrupting your sleep or daily activities, visit with a rotator cuff expert at UT Southwestern. We can help relieve your pain and restore your functionality.

To request an appointment, call 214-645-8300 or request an appointment online.

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.