Prof. N. Reha Tandoğan, M.D. - Asım Kayaalp, M.D.
The rotator cuff is a group of 4 muscles that surround the shoulder joint and are responsible for rotation and elevation of the arm. Rotator cuff tears are very common in elderly patients due to wear and tear of the muscle. Less commonly, tears may occur in younger patients due to a traumatic event.

What are the signs of rotator cuff tears?

The main complaint of a rotator cuff tear is pain. The pain usually starts around the shoulder and may extend to the side and front of the arm. The pain typically increases with overhead activities and lifting weights above the head. This may occur when the patient tries to get a box from a high shelf. Shoulder range of motion is preserved until the late stages of the disease. Another sign is weakness of the arm during elevation; this weakness may be due to pain or loss of muscle function after a complete tear. Rotator cuff tears may be partial or full thickness tears (Figures 1 & 2). Although the signs and symptoms are similar, they are more prominent in full thickness tears. Long standing tears may retract and may become irreparable. The normal coupled motion in the shoulder is lost in these irreparable tears, the humeral head moves upwards and impinges under the collarbone, resulting in a destruction of the joint called a “cuff-tear arthropathy”. Cuff-tear arthropathy may result in pain at rest, inability to raise the arm (called pseudo-paralysis) and loss of shoulder range of motion.

Figure 1: Partial rotator cuff tear.
Figure  2: Full thickness rotator cuff tear

How is a rotator cuff tear diagnosed?

The diagnosis of a rotator cuff tear starts with a careful physical examination. After listening to your symptoms, your physician will perform specialized tests for shoulder range of motion, muscle strength and pain producing maneuvers. X-rays are necessary to see the amount of degeneration in the joint and rule out cuff-tear arthropathy; they are also helpful to show a condition called a “calcifying tendinitis” where painful calcium deposits are present in the muscle tendons. The most accurate diagnostic method in rotator cuff tears is magnetic resonance imaging (MRI). MRI can describe the location & extent of the tear, fatty degeneration of the muscle belly and arthritic changes in the shoulder in detail (Figure 3 ). Ultrasonography is cheaper and can also be helpful, however requires a radiologist with an extensive experience in musculoskeletal imaging. A diagnostic injection of local anesthetic might also be helpful. The gold standard in diagnosis is an arthroscopic examination. The extent & reparability of the tear, and the condition of the shoulder joint can be visualized with clarity (Video 1). Arthroscopic evaluation of all the involved structures is also the first step of surgical treatment.

Figure 3: Arrows point out the location of a full thickness tear on MRI images.
Video 1: Arthroscopic view of a normal rotator cuff.

How are rotator cuff tears treated?

An initial period of non-surgical treatment is preferred in patients over 65 years and partial rotator cuff tears and good muscle strength. Anti-inflammatory medication, physical therapy and exercises are started. An injection of cortisone may be helpful. Patients not responding to non-surgical treatment may require surgery. Arthroscopic (keyhole) surgery is preferred in these cases, since it allows excellent visualization, minimal pain and good cosmesis (Figure 4). The surgery is performed through 1 cm skin cuts called “portals”, allowing a faster recovery . Tears involving less than 50% of the tendon may be treated with cleaning of the degenerative tissue and removal the offending bone prominences (acromioplasty). Tears involving more than 50% of the tendon should be repaired.

Figure  4: Arthroscopic surgery of the shoulder performed through small “portals” Patients with loss of elevation of the arm and muscle weakness require surgery. Younger patients with full thickness tears, who actively use their arm are best treated with surgical repair. Full thickness tears larger than 1.5 cm are likely to progress and should be repaired. Most tears can be repaired arthroscopically. Elderly patients with irreparable tears may benefit from an implantation of a sheet of collagen tissue between the humeral head and the collarbone; this procedure is called “superior capsular reconstruction. Irreparable tears in the elderly may also benefit from an implantation of a synthetic balloon between the humeral head and collarbone to alleviate the pain, although this pain relief is temporary. Patients over 70 years with advanced degenerative changes and cuff tear arthropathy are best treated with reverse shoulder replacement. Your doctor will choose the most appropriate treatment for you, after reviewing your findings and imaging studies.

How is arthroscopic rotator cuff repair performed?

Arthroscopic rotator cuff repair is performed under anesthesia in a designated surgical theater (Video 2). The shoulder joint is visualized with a camera called an arthroscope through 1 cm portals. The condition of the cartilage, biceps tendon and the rotator cuff is evaluated, bone spurs causing impingement on the tendon are noted. Following treatment of accompanying intra-articular pathologies, the cuff tendon is mobilized, its bed freshened and then fixed to the bone using special devices called “suture anchors” (Figures 5 & 6). These anchors can be titanium or plastic like materials called PEEK. An overnight stay in the hospital is usually required.
Arthroscopic rotator cuff repair

Figure 5: Rotator cuff repair
Figure 6: X-ray image of a patient who underwent rotator cuff repair using a titanium suture anchor.

How is the recovery after arthroscopic rotator cuff repair?

Depending on the quality of the tendon tissue and strength of the repair, a shoulder sling is used for 3-6 weeks after surgery. Slight pain is expected after surgery, the can be managed easily with pain tablets and cold compressive devices. Passive shoulder exercises (someone else helps you move your arm) can be started in the first 2 weeks. Active exercises may be started after 6 weeks. You can start driving after the 6th week. Your shoulder will continue to improve until the 6th month after surgery. Impact sports such as tennis are permitted after 6 months if there is adequate healing.

Can the rotator cuff repair fail after surgery?

Risk factors for failure after rotator cuff repair are advanced age, fatty degeneration of the muscle, poor tissue quality, massive tears, smoking, inappropriate rehabilitation and trauma after surgery. The failure rate after surgery is around 10-30% depending on tear size and tissue quality. Most of the re-tears are smaller than the original tear and not all re-tears cause symptoms. Patients without symptoms after failure may be followed without surgery. Patients with muscle weakness and pain are re-evaluated for revision surgery.

© Prof. Dr. Reha Tandoğan - Op. Dr. Asım Kayaalp