Detachment or rupture of the rotator cuff muscle from the bone attachment is commonly called as rotator cuff tear. The arm bone is coherently kept in the shoulder socket by the action of the muscles that form the rotator cuff. The function of the rotator cuff muscle is to lift and rotate the arm. It covers the head of the arm bone(humerus) at the shoulder joint and helps to keep the arm bone concentrically articulated with the shoulder blade cup (Glenoid. This also ensures that the shoulder is always well located in the joint. Rupture of the rotator cuff results in loss of normal function of the shoulder joint.
The exact cause of the rotator cuff tear is yet to be identified. It can occur as a result of trauma such as a fall. In this the force involved exceeds the strength of the tendon hence it ruptures. This is the mechanism of tear in an athlete during a forceful throwing activity as part of the involved sports such as cricket, tennis etc.
The other more common mode of tear is due to degeneration. Degeneration is the description given to the wearing of the tendon occurring gradually over a period of time due to the combination of various factors. The common factors that result in degenerative tear are repetitive overhead activities, reducing blood supply to the tendon and also rubbing of tendon by the spur coming from acromion bone which is part of the shoulder blade bone.
The common presenting symptom is pain in the shoulder and reduced ability or inability to lift the arm especially above the level of the head. This is particularly profound when carrying some weight in the hand. The severity of the pain can increase to the level that sometimes it affects the sleep in the night and also sometimes one could also feel a painful creaking sensation while moving the shoulder joint.
The condition is diagnosed by thorough evaluation of the problem, examining the shoulder for specific clinical tests. The clinical tests involve assessing the shoulder joint for individual muscle function, assessing neck movements and also examining the nerves and blood supply to the arm. After a through assessment, some tests such as X ray, ultrasound scan or an MRI scan may be needed to confirm the diagnosis. The tests that are carried out will give a guidance of how large is the tear and also to assess the quality of the muscle. This will help in giving a guidance on the treatment plan.
The initial treatment for this condition is to take adequate painkillers tablets. This can help to alleviate some symptoms. The function of the arm can partially be recovered by physiotherapy exercises. But the torn muscle would not attach by itself, hence the function of the shoulder never reaches normal.
Depending on the age, activity, general health and the type of tear an option to repair Rotator cuff repair by surgery can restore a satisfactory function. Continuing pain, significant weakness and loss of function in the shoulder are the reason why a rotator cuff tear needs repairing. The tears can vary in size and some of the tears are massive and are not repairable. In majority of the cases this repair is done by Arthroscopic surgery. Some times the arthroscopy assisted open rotator cuff repair would be undertaken.
Continuing pain, significant weakness and loss of function in the shoulder are the reason why a rotator cuff tear needs repairing. The tears can vary in size and some of the tears are massive and are not repairable. In majority of the cases this repair is done by Arthroscopic surgery. Some times the arthroscopy assisted open rotator cuff repair would be undertaken
Arthroscopic surgery is performed by three or four tiny stab incisions of less than 1cm in size. A miniature tubular camera is introduced into the shoulder joint and the joint is thoroughly visualized. The tear in the rotator cuff muscle is confirmed and depending on the size of the tear the repair is planned. Often there may be other pathology along with the rotator cuff tear. This could be fraying at the biceps tendon attachment, labial fraying, partial tear of the biceps tendon or subluxation of the biceps tendon. These are dealt with at the same time.
The camera is introduced into the space beneath the acromion bone(part of the shoulder blade bone). The camera in this space (subacromial space) gives much better appreciation of the size of tear, quality of the muscle and also gives a chance to assess whether the tear can be mobilized to fix it back in its original position.
Two or three cannula will be introduced through the skin incisions into the subacromial space. Two will be used as working portal and one will be used portal for application of knots.
Initial step is to mobilize the torn rotator cuff tear and with the help of a miniature grasper, the torn tendon is pulled to see whether it comes to its original attachment. The attachment site of this muscle is called as footprint in the upper end of the arm bone. This attachment site is freshened first with shaver and then with a burr.
The shape of the tear may differ; some of them are roughly a shape of U or V or L. The tear may initially need a side-to-side stitch with special instruments that can be reached through these small incisions. The side-to-side stitches converges the margins of the tear convert a large size tear into a small size tear. This is medically called as Marginal convergence.
Once it is done, the muscle is attached to the footprint. This is performed by initially drilling a hole in the footprint with a miniature drill. Then an absorbable screw with fibrewires in its end is introduced into the hole. The fibrewires are passed through the cuff muscle with the help of a special suture passer. Then the rotator cuff muscle is pulled to reach the footprint and can be anchored with another absorbable screw.
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