Rotator Cuff Disease

Rotator Cuff Disease (Impingement, Supraspinatus Tendonits, Rotator Cuff Tear)

  • The Rotator Cuff is the commonly used name to describe the group of 4 Tendons that originate from the muscles that come off of the Scapula (Shoulder Blade) and insert around the Humeral Head (Ball part of the Shoulder). Their main job is to help centralize the Humeral Head (Ball) within the Glenoid (Socket). They are required to work constantly to keep the shoulder in joint as it goes through any movement.

  • find out more about the Rotator Cuff Tendons….

  • Over time the Rotator Cuff Tendons undergo a certain amount of wear and tear. Most of the problems that affect the Rotator Cuff Tendons are usually related to this wear and tear process. As a result, Rotator Cuff problems only usually start to affect people over the age of 35 - 40 years.
  • Rotator Cuff problems usually occur along a continuum starting with Tendonitis or Impingement, leading to fraying and a Partial Thickness Tear and then potentially progressing to a Full Thickness Tear. This process is going on in everyone’s shoulder to a greater or lesser extent. Sometimes a Rotator Cuff Tear occurs slowly over time, whilst on other occasions the weakened Tendon can be torn by a specific incident or sudden load.
  • However, not everyone who has wear and tear in their Rotator Cuff necessarily has symptoms. In an MRI scan study of people over 60, who felt that they had no problems with their shoulder, over 40% had a tear, of some size, to their Rotator Cuff on their scans! Taking that into account Rotator Cuff Disease, or wear and tear, is going on in everyone’s shoulder as they get older but we only need to treat patients in whom this becomes symptomatic.

Supraspinatus Tendonitis (Impingement)

  • The Supraspinatus Tendon lies over the top of the Humeral Head (Ball) and runs underneath the Acromion (arch of the Scapula). The action of the Supraspinatus Tendon is to help Elevate and ABduct the arm, it is one of the most heavily used Rotator Cuff tendons and the one that is most prone to wear and tear changes.

    find out more about the Supraspinatus Tendon and the Acromion…

  • The clearance space for the healthy Supraspinatus Tendon to run underneath the front of the Acromion is usually adequate. However, there is usually not a great amount of reserve space available. As a result, if the Tendon becomes at all inflamed or enlarges, for any reason, it can begin to ‘impinge’ or rub on the undersurface of the Acromion. When the Tendon becomes inflamed it is also weakened which makes it is less effective at pulling the head downwards. These factors can then lead to further damage or inflammation to the Tendon, starting a ‘vicious circle’ of ‘Impingement’.

  • The shape and angle of inclination of the Acromion can vary between people. Sometimes people refer to a ‘hook’ or ‘spur’ at the front of the Acromion that is related to their Impingement. As a general rule, the shape of someone’s Acromion does not change significantly over time, and it is likely that their Acromion has always been that shape resulting in them having less ‘reserve’ space available for any underlying tendon enlargement. Acromioclavicular (AC) joint osteoarthritis often develops in patients as they get older. Sometimes an inferior osteophyte from the AC joint can also impinge on the rotator cuff.

    find out more about AC joint osteoarthritis ….

  • There is a small Bursa (fluid filled sac) that lies on top of the Supraspinatus Tendon and beneath the Acromion. Its job is to try and ease the movement of the tendon underneath the bone. This can sometimes get inflamed, along with the tendon, but often has eroded away over time.

    Find out more about the subacromial bursa….

  • Whilst the mechanism of Impingement is a major factor in the development of Supraspinatus Tendonitis, there are a number of other extrinsic and intrinsic factors that can also play a part.

  • Supraspinatus Tendonitis and Impingement are inter-changeable names to describe inflammation and swelling of the Supraspinatus Tendon, which usually has a ‘wear and tear’ element.

What are the Symptoms of Supraspinatus Tendonitis / Impingement?

  • As ‘wear and tear’ plays a considerable part in the development of Supraspinatus Tendonitis the onset of symptoms can often be quite insidious. As a result, many people find that their Supraspinatus Tendonitis gradually develops over time. In other cases a specific injury or incident can aggravate the degenerate tendon and spark off a sudden onset of symptoms.

  • There is a bulge on the side of the Humeral Head (Greater Tuberosity) where the Supraspinatus and Infraspinatus Tendons insert into the bone. As the shoulder moves, this bulge lies directly under the acromion between 60 and 120 degrees of elevation. This is the point where the space between the top of the Humeral Head and the Acromion is the narrowest. This is known as the ‘Painful Arc’ of movement.

  • The early symptoms of Supraspinatus Tendonitis tend to be a background pain over the shoulder with particular discomfort when elevating the shoulder within the ‘Painful Arc’. The shoulder is often uncomfortable to lie on at night.

  • As symptoms deteriorate the shoulder becomes increasingly painful all of the time. Pain tends to occur on more directions of movement and the shoulder can appear to become weaker. Night discomfort often becomes more of a feature.

  • With chronic shoulder pain, the muscles that help to stabilize the scapula often try to hold the shoulder up, in a more protected position. Overtime these muscles can begin to ache so that the pain can appear to radiate up towards the neck and over the shoulder blade.

    find out more about the Scapular Stabilising muscles…

How do you Diagnose Supraspinatus Tendonitis (Impingement)?

  • History – Most people notice a gradual onset of pain and discomfort over the top and side of their shoulder. Sometimes people can identify a specific injury or incident that triggered their problem. They may notice particular pain on elevating their arm and in bed at night. As the condition deteriorates they may get pain more of the time and on more directions of movement. They also might notice some weakness.

  • Examination – Occasionally the patient can experience some discomfort on palpation over the front edge of their Acromion. People may have a ‘painful arc’ on elevating their shoulder and positive ‘impingement signs’. People with Supraspinatus tendonitis often have associated problems with Acromioclavicular Joint (ACjt) arthritis and Long Head of Biceps Tendonitis and may have symptoms and signs of these as well.

    find out more about examination of the shoulder for rotator cuff disease…

    • Investigations –
      • X-Ray – An x-ray does not usually demonstrate the soft-tissues of the Rotator Cuff. However, the shape of the acromion, ACjt osteoarthritis and calcific deposits can sometimes be noted

        find out more about x-rays….

    • Ultrasound Scan (USS) – An USS will nicely demonstrate the Rotator Cuff tendons and the Long Head of Biceps. It is able to show whether there is a tendonitis, partial or full thickness tear of the tendons.

      find out more about USS….

    • MRI Scan- An MRI scan is the best investigation to visualize the rotator cuff. It can show all of the tendons and whether there is a tendonitis, partial or full thickness tear. It will also demonstrate the acromion and ACjt and their relationship with the tendons. An MRI scan will also show up any other problems around the shoulder.

      Find out more about MRI scans….

    Supraspinatus Tendonitis – Treatment

    Management of Supraspinatus Tendonitis(Impingement)

    The vast majority of patients with a Supraspinatus Tendonitis can be successfully treated non-operatively with a combination of NSAIDs (Non-Steroidal Anti-Inflammatory Drugs) and Physiotherapy.

    • Physiotherapy – Physiotherapy and specific Rotator Cuff Strengthening exercises are the main-stay of the initial treatment for Supraspinatus Tendonitis. By specifically strengthening the Supraspinatus muscle it can work and contract more efficiently pulling the humeral head downwards and allowing the tendon to move more freely. If pain is a particular feature a short course of NSAIDs prescribed by a Physician can help.

    find out more about Rotator Cuff Strengthening Exercises….

    • Analgesia/Pain Relief
      • NSAID (Non-Steroidal Anti-Inflammatories) –
        • NSAIDs work be reducing the painful inflammatory response
        • NSAIDs can damage the stomach lining and affect the kidneys. It is important that a patient’s Family Doctor prescribes this medication if it is going to be used for a longer term
    • Codeine based Analgesics –
      • Codeine based analgesics are pain killers and affect a patient’s perception of pain. As a result, they can have some effect on consciousness depending on their strength
      • Codeine based analgesics can lead to constipation if taken for a longer time. Having a high-fibre diet or even taking laxatives might need to be considered
    • Nociceptive Analgesics –
      • Nociceptive pain killers work on nerve generated pain
      • Amitriptyline in lower doses works as a nociceptive pain killer. It has a useful side-effect in that it can make patients drowsy
      • in cases of severe pain Amitriptyline can be prescribed at night
    • Subacromial Cortisone Injection –
      • If someone’s Supraspinatus Tendonitis has failed to settle, after an adequate course of Physiotherapy, a Subacromial Cortisone injection can help to settle the symptoms down. Cortisone is a corticosteroid that is naturally produced by the body’s Adrenal Gland. Injectable Cortisone is synthetically produced and has a very powerful ant-inflammatory action. When injected into the Subacromial space it has the potential of settling severe inflammation, allowing the patient to undertake their rehabilitation exercises.
      • A Subacromial Cortisone can be easily administered in the Out-Patient Clinic. It is a quick and relatively painless procedure. Afterwards patients can continue with their normal day-to-day activities. Occasionally patients can feel a bit of soreness around their shoulder later that day, but this usually passes fairly quickly.
      • It often takes several days before someone notices the benefits following a Cortisone injection and sometimes several weeks. The Cortisone works in the background and there is no specific requirement to particularly rest the shoulder or to do extra exercises. The full benefits of a Cortisone injection are usually felt within a month. In some cases, the Cortisone may not give any benefit, this may be an indication of the severity of the Supraspinatus Tendonitis.
      • A Cortisone injection only lasts in the body for a few days. Any benefit that someone gets from the Cortisone will be from its acute anti-inflammatory effect allowing the Supraspinatus Tendonitis to settle. If the symptoms do return after a while, it is not because the Cortisone has worn off, but because the inflammation has returned.
      • Infections can occur after any type of injection but are extremely rare (1 in 15,000). If someone feels that they are developing an infection within 48 hours of a Cortisone injection they should seek advice from their Family Practitioner.
    • Surgery for Supraspinatus Tendonitis – In some instances a Supraspinatus Tendonitis fails to respond, or continues to recur, despite adequate Physiotherapy and Cortisone treatment. In this situation the only treatment that is likely to settle the symptoms is Surgery.

    Arthroscopic Subacromial Decompression

    The best operation for someone with a Supraspinatus Tendonitis, that is refractory to treatment, is an Arthroscopic Subacromial Decompression. This is an operation where an Arthroscopic camera is positioned inside the Subacromial Space and, by using specialized instruments, the undersurface of the front of the acromion is burred away. This creates more space for the Supraspinatus Tendon to run underneath the Acromion stopping the Impingement.

    An Arthroscopic Subacromial Decompression can usually be done as a Day Case procedure and the patient’s shoulder does not need to be immobilized for anytime afterwards. The surgery aims to remove the part of the Acromion that has been causing the Impingement. It does not specifically deal with the underlying tendonitis. However, by enabling the Supraspinatus Tendon to run freely it allows for the Tendonitis to settle down. As a result it usually takes between 3 – 6 months to gain the full benefits of the procedure. It has a high success rate with around 95% of patients being happy with the result 6 months after their operation. My routine Arthroscopic Subacromial Decompression Procedure is described below,

    Watch a video of an Arthroscopic Subacromial Decompression…

    Find out more about arthroscopic shoulder surgery….

    • A posterior and a single lateral portal are used for to view the Gleno-Humeral Joint (Shoulder Joint) and Subacromial spaces
    • The Glenohumeral Joint is initially assessed to look for any other problems that might be associated with a Supraspinatus Tendonitis and, in particular, the Rotator Cuff and the Long Head of Biceps
    • The Subacromial Space is then entered and the undersurface of the Acromion identified.
    • A lateral portal is then created
    • Using a combination of a powered shaver and radiofrequency probe the coracoacromial ligament is released, revealing the Subacromial Spur.
    • A powered burr is then used to resect about 5mm of bone from the undersurface of the acromion
    • The Decompression is then assessed to check that sufficient bone has been resected to alleviate the Impingment
    • Again the Rotator Cuff is examined to check for any hidden fraying or damage
    • If any significant damage is found to the Rotator Cuff this will be then also be repaired
    • The Subacromial Space is then washed out and the wounds closed with sub-cuticular sutures

    find out more about having an operation…

    After the Surgery

    Post-Operative Care

    Following an Arthroscopic Subacromial Decompression the patient is usually able to go home on the same day as their surgery. I would see the patient after the surgery to discuss how the procedure has gone and arrange for further Follow-Up. The patient will be seen by the In-Patient Physiotherapy team, who will instruct them on the initial Rehabilitation Protocol for their shoulder. Further Out-Patient physiotherapy will then be organised.

    Find out more about Physiotherapy following an ASD….

    I would usually review patients in the clinic 1 month and 3 months after their procedure to assess their progress and recovery.

    Rehabilitation Protocol

    Immediately after the surgery, when the patient has woken up from their general anaesthetic, their shoulder and arm will be numb from the interscalaene nerve block. This will usually last for 18 – 24 hours after the surgery. For this period, we advise patients to keep their arm in a sling, purely for protection. After the nerve block has worn off the arm can begin to be taken out of the sling. I encourage patients to wean themselves off of using the sling as quickly as possible, within the limits of discomfort.

    My standard rehabilitation protocol is outlined below. The information and time to recovery are a general estimation and may vary from person to person.

    Post op

    Immediate
    • Sling 2 days (completely discarded by 1 week)
    • Postural and scapula setting
    • Neck, elbow, wrist & hand exercises
    Day 1-3

    Weeks

    • Active assisted progressing to Active ROM in all planes

     

    3-6 Weeks
    • Progress active range of movement
    • Progress strengthening
    Milestones
    Week 3 Full passive range of movement
    Week 6 Full active range of movement, good scapular control

    Return to Functional Activities

    Driving
    • Once ROM and muscular power restored & patient feels safe
    Swimming
    • As pain allows
    Golf
    • 6 weeks
    Racquet Sports/Repeated
    • 2-3 months
    Overhead Activities
    Lifting As able
    Work Sedentary - As able
    Manual - 6 weeks, may need to modify activity for 3 months

    Success of Surgery, Risks & Complications

    An Arthroscopic Subacromial Decompression is usually a very successful procedure but, because the surgery is only aimed at removing the spur of bone that has been impinging on the Supraspinatus Tendon, it usually takes between 3 – 6 months for the Tendonitis to settle and for the Shoulder to return to normal. For a standard Arthroscopic Subacromial Decompression>95% of patients’ will be happy with their shoulders after 6 months.

    There are always risks and complications associated with any operation.

    • Anaesthetic - The risks of having a General Anaesthetic and an Interscalaene Nerve Block are very low, but will always need to be assessed on an individual basis by an Anaesthetist. Suffice it to say, that whilst a Shoulder Operation can in no way be considered a ‘life-saving’ procedure, an Anaesthetist would not consider undertaking an anaesthetic if they had any concerns that an undue risk was being taken.
    • Infection – Infection following arthroscopic surgery is rare < 0.2%
    • Neurovascular Injury – Damage tosignificant neurovascular structures during arthroscopic shoulder surgery is rare < 0.2%
    • CRPS Type 1 – A Chronic Pain Syndrome following arthroscopic shoulder surgery is rare < 0.2%

    Outcome Measures

    Assessing patient outcomes following surgery, using validated scoring systems, is a very important and useful exercise.

    find out more about outcome measures and the SOS system…

    Rotator Cuff Tears

    Rotator Cuff Tears (Torn Tendon)

    • Everyones’ Rotator Cuff Tendons undergo ‘wear and tear’ over time. This can lead initially to a Tendonitis and then, as the tendons become weakened and thinned out, to Partial or Complete tears.

    • This process is often going on quietly in the background and many people, over time, develop tears without any symptoms and without knowing about it. In an MRI scan study of people over 60 who felt that they had no problems with their shoulder, over 40% had a tear of some size of their Rotator Cuff on their scans!

    • However, some people with a Rotator Cuff Tears do develop symptoms. These maybe sparked off by a specific incident or accident, where an acute tear occurs in an already weakened or previously torn tendon. In other people the symptoms may develop slowly representing the progression of a Supraspinatus Tendonitis.

    • Regardless of the way that the symptoms of a Rotator Cuff Tear start, when they do occur they usually require some form of treatment to settle it down.

    Types of Rotator Cuff Tears

    There are many different types of Rotator Cuff Tears and different ways that they can be classified. I prefer to look at Tears in the way that they can be treated. I categorise them as either being Acute or Chronic, which Tendons have been Torn, whether they are Partial or Full Thickness Tears, how big they are and whether it will be technically possible to repair them. Other considerations are the quality of the tissue and fatty atrophy, other associated shoulder problems and the age, health and expectations of the individual patient.

    • Acute v Chronic Tears – most Rotator Cuff tears are chronic and have slowly developed over time. However, sometimes patients can sustain an acute or an acute-on-chronic tear following a specific injury or event. If in Acute Tear is repaired within 3 – 4 months of its onset, it is likely that it will heal better than if the repaired later. For chronic tears this time window is less important.

    • Partial v Full Thickness Tears –Partial Thickness Tears tend to occur in younger patients and at an earlier stage of Rotator Cuff Disease.

      • 80% occur on the articular side of the tendon, which is thought to be the result of a ‘watershed’ in the blood supply to the tendon

      • Not all Partial Thickness Tears need to be repaired as they can sometimes heal or may not progress.

      • However, as a general rule, the bigger the size of the tear, the younger the age of the patient and the more severe the symptoms are indications to surgically repair the Tendon as the tear is likely to progress over time.

      • Full Thickness tears generally will NOT heal and probably, over time, will propagate further. Most symptomatic Full Thickness Tears will usually require a repair to settle the symptoms.

    • Size of the Tear – Rotator cuff tears tend to propagate over time.

      • Tear size tends to be measured with regards to the distance with which the torn tendon has retracted from its insertion on the greater tuberosity.
      • With advances in surgical technique and equipment it is now possible to repair even very large tears. However, there are still some situations where the tear is so massive, the tendon has begun to disappear or is so stuck and retracted that it may not be technically possible to undertake a repair.

    • Which Tendon is Torn? – Although the Supraspinatus Tendon is the most commonly torn tendon, Infraspinatus and Subscapularis tears can also occur. Sometimes more than one tendon may be torn at the same time. The best way to treat specific tendons and combination tears can differ depending on the tendons involved.

    • Quality of the Torn Tendon – Rotator Cuff Tears usually occur in degenerate tendons. Sometimes the degeneration / wear and tear is so advanced that the actual quality of the torn Tendon is not mechanically strong enough to hold a repair and probably will not heal.

    • Fatty Atrophy -When a Tendon is torn, the muscle that it was connecting to the bone will no longer be able to work and undergoes Disuse Atrophy. If this situation is sustained the muscle cells may then begin to be replaced by fat cells, Fatty Atrophy. Unfortunately, this is an irreversible process and, even if the Tendon is repaired and the muscle re-activated, the muscle cells cannot be restored. If the muscle of a torn tendon has undergone significant Fatty Atrophy, even if the tendon can be technically repaired, it will not regain its function.

    • Associated Shoulder Problems –Rotator Cuff Tears are often associated with other wear and tear problems in the shoulder. These include Long Head of Biceps Tendonitis, AC Joint problems and Shoulder Joint Osteoarthritis. How significant the Rotator Cuff Tear’s contribution is to a patient’s symptoms, when any of these associated problems are present, may determine how it is best treated.

    • Age, Health and Patient’s Expectations – I look at age Physiologically rather than Chronologically!! Younger patients usually have a better healing potential, are more active and will have higher functional expectations. As a result, they are likely to heal better and more quickly following a bigger procedure and may be more tolerant of undergoing a protracted recovery period to gain the best function possible. Older patients and patients with other significant health issues may not heal as well and are only looking for pain relief and a recovery of normal day to day function. They may be less prepared to undergo a ‘heroic’ procedure with a protracted recovery to gain the best function and would prefer a less complex procedure with a quicker recovery of acceptable function.

    What are the Symptoms of a Rotator Cuff Tear?

    • As with a Supraspinatus Tendonitis ‘wear and tear’ plays a considerable part in the development of Rotator Cuff Tears and the onset of symptoms can often be quite insidious. As a result, many people find that their symptoms gradually develop over time. In other cases, a specific injury or incident can create a tear or propagate further a chronic tear and spark off a sudden onset of symptoms.

    • There is a bulge on the side of the Humeral Head (Greater Tuberosity) where the Supraspinatus and Infraspinatus Tendons insert into the bone. As the shoulder moves, this bulge lies directly under the acromion between 60 and 120 degrees of elevation. This is the point where the space between the top of the Humeral Head and the Acromion is the narrowest. This is known as the ‘Painful Arc’ of movement..

    • The early symptoms of a Rotator Cuff Tear tend to be a background pain over the shoulder with particular discomfort when elevating the shoulder within the ‘Painful Arc’ and associated weakness. The shoulder is often uncomfortable to lie on at night.

    • As symptoms deteriorate the shoulder becomes increasingly painful all of the time. Pain tends to occur on more directions of movement and the shoulder can appear to become weaker. Night discomfort often becomes more of a feature.

    • With chronic shoulder pain, the muscles that help to stabilize the scapula often try to hold the shoulder up, in a more protected position. Overtime these muscles can begin to ache so that the pain can appear to radiate up towards the neck and over the shoulder blade.

      find out more about the Scapular Stabilising muscles…

    How do you Diagnose a Rotator Cuff Tear?

    • History – Most people notice a gradual onset of pain and discomfort over the top and side of their shoulder. Sometimes people can identify a specific injury or incident that triggered their problem. They may notice particular pain on elevating their arm and in bed at night. As the condition deteriorates they may get pain more of the time and on more directions of movement. They also might notice some weakness. In extreme cases they may not be able to actively elevate their shoulder at all

    • Examination – Occasionally the patient can experience some discomfort on palpation over the front edge of their Acromion. In the case of longstanding tears the Rotator Cuff muscles may undergo atrophy, which can be seen as ‘wasting’ of the muscles over the shoulder balde (scapula). People may have a ‘painful arc’ on elevating their shoulder and positive ‘impingement signs’. People with Rotator Cuff Disease often have associated problems with Acromioclavicular Joint (ACjt) arthritis and Long Head of Biceps Tendonitis and may have symptoms and signs of these as well.

      find out more about examination of the shoulder for rotator cuff disease…

    • Investigations –

      • X-Ray –An x-ray does not usually demonstrate the soft-tissues of the Rotator Cuff. However, the shape of the acromion, ACjt osteoarthritis and calcific deposits can sometimes be noted.

        find out more about x-rays….

      • Ultrasound Scan (USS) – An USS will nicely demonstrate the Rotator Cuff tendons and the Long Head of Biceps. It is able to show whether there is a tendonitis, partial or full thickness tear of the tendons.

        find out more about USS….

      • MRI Scan-An MRI scan is the best investigation to visualize the rotator cuff. It can show all of the tendons and whether there is a tendonitis, partial or full thickness tear. It will also demonstrate the acromion and ACjt and their relationship with the tendons. If there has been a longstanding tear the MRI can show evidence of how far the torn tendon has retracted and if there is any evidence of muscle belly atrophy. An MRI scan will also show up any other problems around the shoulder.

        Find out more about MRI scans….

    Management of Rotator Cuff Tears

    • There is a vast variation between the specific symptoms, types and chronicity of a tear and the needs and expectations of patients who present with a symptomatic Rotator Cuff Tear

    • There are also many different ways of treating and repairing Rotator Cuff Tears

    • My approach to treating a patient with a symptomatic Rotator Cuff Tear is to assess the specific issues and nature of their problem and to then base my recommendation of how to treat their Rotator Cuff Tear, based on this

    Surgery for Rotator Cuff Tears

    • I undertake all of my Rotator Cuff Repairs using Arthroscopic Surgery (keyhole surgery)

    • The basic aim of any Rotator Cuff Repair is to mobilise and freshen up the ends of the torn tendon, to freshen up the boney insertion on the humerus and then to position and re-attach the tendon back down to its original insertion, achieving a tensionless repair

    • To achieve this there are multiple techniques, implants and strategies that can be used

    • The descriptions of the procedures outlined below are based on the general technique. The specific details and pros and cons of the various implants and equipment that I use are covered in the Arthroscopic Surgery Section

      find out more about Arthroscopic Shoulder Surgery….

    Healing of Rotator Cuff Tears

    • Rotator Cuff Tears usually occur in tendons that have undergone ‘wear and tear’ and, as the tear occurs, the degenerate tendon is no longer strong enough to withstand the mechanical forces placed on it

    • When a Rotator Cuff Tendon is repaired it is still degenerate and, as a result, its healing potential is not as good as a normal, healthy tendon

    • Surgical techniques and implant technology are constantly advancing and we are currently able to mobilise and successfully repair nearly all tendon tears

    • However, despite this, a number of repairs still fail to heal

    • This is likely to be due to the poor healing potential of degenerate tendons

    • The latest advance in Rotator Cuff Repairs, ‘Ortho-Biologics’, involves trying to improve and optimize the healing potential of degenerate tendons

    • Although ‘Ortho-Biologics’ is in its infancy, it is an area where I have a great interest and I incorporate its use, where indicated, during Rotator Cuff surgery

      find out more about ‘Ortho-Biologics’…..

    Rotator Cuff Tears

    Rotator Cuff Tears (Torn Tendon)

    • Everyones’ Rotator Cuff Tendons undergo ‘wear and tear’ over time. This can lead initially to a Tendonitis and then, as the tendons become weakened and thinned out, to Partial or Complete tears.

    • This process is often going on quietly in the background and many people, over time, develop tears without any symptoms and without knowing about it. In an MRI scan study of people over 60 who felt that they had no problems with their shoulder, over 40% had a tear of some size of their Rotator Cuff on their scans!

    • However, some people with a Rotator Cuff Tears do develop symptoms. These maybe sparked off by a specific incident or accident, where an acute tear occurs in an already weakened or previously torn tendon. In other people the symptoms may develop slowly representing the progression of a Supraspinatus Tendonitis.

    • Regardless of the way that the symptoms of a Rotator Cuff Tear start, when they do occur they usually require some form of treatment to settle it down.

      There are many different types of Rotator Cuff Tears and different ways that they can be classified. I prefer to look at Tears in the way that they can be treated. I categorise them as either being Acute or Chronic, which Tendons have been Torn, whether they are Partial or Full Thickness Tears, how big they are and whether it will be technically possible to repair them. Other considerations are the quality of the tissue and fatty atrophy, other associated shoulder problems and the age, health and expectations of the individual patient.

      • Acute v Chronic Tears – most Rotator Cuff tears are chronic and have slowly developed over time. However, sometimes patients can sustain an acute or an acute-on-chronic tear following a specific injury or event. If in Acute Tear is repaired within 3 – 4 months of its onset, it is likely that it will heal better than if the repaired later. For chronic tears this time window is less important.

    • Partial v Full Thickness Tears –Partial Thickness Tears tend to occur in younger patients and at an earlier stage of Rotator Cuff Disease.

      • 80% occur on the articular side of the tendon, which is thought to be the result of a ‘watershed’ in the blood supply to the tendon

      • Not all Partial Thickness Tears need to be repaired as they can sometimes heal or may not progress.

      • However, as a general rule, the bigger the size of the tear, the younger the age of the patient and the more severe the symptoms are indications to surgically repair the Tendon as the tear is likely to progress over time.

      • Full Thickness tears generally will NOT heal and probably, over time, will propagate further. Most symptomatic Full Thickness Tears will usually require a repair to settle the symptoms.

    • Size of the Tear – Rotator cuff tears tend to propagate over time.

      • Tear size tends to be measured with regards to the distance with which the torn tendon has retracted from its insertion on the greater tuberosity.
      • With advances in surgical technique and equipment it is now possible to repair even very large tears. However, there are still some situations where the tear is so massive, the tendon has begun to disappear or is so stuck and retracted that it may not be technically possible to undertake a repair.

    • Which Tendon is Torn? – Although the Supraspinatus Tendon is the most commonly torn tendon, Infraspinatus and Subscapularis tears can also occur. Sometimes more than one tendon may be torn at the same time. The best way to treat specific tendons and combination tears can differ depending on the tendons involved.

    • Quality of the Torn Tendon – Rotator Cuff Tears usually occur in degenerate tendons. Sometimes the degeneration / wear and tear is so advanced that the actual quality of the torn Tendon is not mechanically strong enough to hold a repair and probably will not heal.

    • Fatty Atrophy -When a Tendon is torn, the muscle that it was connecting to the bone will no longer be able to work and undergoes Disuse Atrophy. If this situation is sustained the muscle cells may then begin to be replaced by fat cells, Fatty Atrophy. Unfortunately, this is an irreversible process and, even if the Tendon is repaired and the muscle re-activated, the muscle cells cannot be restored. If the muscle of a torn tendon has undergone significant Fatty Atrophy, even if the tendon can be technically repaired, it will not regain its function.

    • Associated Shoulder Problems –Rotator Cuff Tears are often associated with other wear and tear problems in the shoulder. These include Long Head of Biceps Tendonitis, AC Joint problems and Shoulder Joint Osteoarthritis. How significant the Rotator Cuff Tear’s contribution is to a patient’s symptoms, when any of these associated problems are present, may determine how it is best treated.

    • Age, Health and Patient’s Expectations – I look at age Physiologically rather than Chronologically!! Younger patients usually have a better healing potential, are more active and will have higher functional expectations. As a result, they are likely to heal better and more quickly following a bigger procedure and may be more tolerant of undergoing a protracted recovery period to gain the best function possible. Older patients and patients with other significant health issues may not heal as well and are only looking for pain relief and a recovery of normal day to day function. They may be less prepared to undergo a ‘heroic’ procedure with a protracted recovery to gain the best function and would prefer a less complex procedure with a quicker recovery of acceptable function.

    What are the Symptoms of a Rotator Cuff Tear?

    • As with a Supraspinatus Tendonitis ‘wear and tear’ plays a considerable part in the development of Rotator Cuff Tears and the onset of symptoms can often be quite insidious. As a result, many people find that their symptoms gradually develop over time. In other cases, a specific injury or incident can create a tear or propagate further a chronic tear and spark off a sudden onset of symptoms.

    • There is a bulge on the side of the Humeral Head (Greater Tuberosity) where the Supraspinatus and Infraspinatus Tendons insert into the bone. As the shoulder moves, this bulge lies directly under the acromion between 60 and 120 degrees of elevation. This is the point where the space between the top of the Humeral Head and the Acromion is the narrowest. This is known as the ‘Painful Arc’ of movement..

    • The early symptoms of a Rotator Cuff Tear tend to be a background pain over the shoulder with particular discomfort when elevating the shoulder within the ‘Painful Arc’ and associated weakness. The shoulder is often uncomfortable to lie on at night.

    • As symptoms deteriorate the shoulder becomes increasingly painful all of the time. Pain tends to occur on more directions of movement and the shoulder can appear to become weaker. Night discomfort often becomes more of a feature.

    • With chronic shoulder pain, the muscles that help to stabilize the scapula often try to hold the shoulder up, in a more protected position. Overtime these muscles can begin to ache so that the pain can appear to radiate up towards the neck and over the shoulder blade.

      find out more about the Scapular Stabilising muscles…

    How do you Diagnose a Rotator Cuff Tear?

    • History – Most people notice a gradual onset of pain and discomfort over the top and side of their shoulder. Sometimes people can identify a specific injury or incident that triggered their problem. They may notice particular pain on elevating their arm and in bed at night. As the condition deteriorates they may get pain more of the time and on more directions of movement. They also might notice some weakness. In extreme cases they may not be able to actively elevate their shoulder at all

    • Examination – Occasionally the patient can experience some discomfort on palpation over the front edge of their Acromion. In the case of longstanding tears the Rotator Cuff muscles may undergo atrophy, which can be seen as ‘wasting’ of the muscles over the shoulder balde (scapula). People may have a ‘painful arc’ on elevating their shoulder and positive ‘impingement signs’. People with Rotator Cuff Disease often have associated problems with Acromioclavicular Joint (ACjt) arthritis and Long Head of Biceps Tendonitis and may have symptoms and signs of these as well.

      find out more about examination of the shoulder for rotator cuff disease…

    • Investigations –

      • X-Ray –An x-ray does not usually demonstrate the soft-tissues of the Rotator Cuff. However, the shape of the acromion, ACjt osteoarthritis and calcific deposits can sometimes be noted.

        find out more about x-rays….

    • Ultrasound Scan (USS) – An USS will nicely demonstrate the Rotator Cuff tendons and the Long Head of Biceps. It is able to show whether there is a tendonitis, partial or full thickness tear of the tendons.

      find out more about USS….

    • MRI Scan-An MRI scan is the best investigation to visualize the rotator cuff. It can show all of the tendons and whether there is a tendonitis, partial or full thickness tear. It will also demonstrate the acromion and ACjt and their relationship with the tendons. If there has been a longstanding tear the MRI can show evidence of how far the torn tendon has retracted and if there is any evidence of muscle belly atrophy. An MRI scan will also show up any other problems around the shoulder.

      Find out more about MRI scans….

    Management of Rotator Cuff Tears

    • There is a vast variation between the specific symptoms, types and chronicity of a tear and the needs and expectations of patients who present with a symptomatic Rotator Cuff Tear

    • There are also many different ways of treating and repairing Rotator Cuff Tears

    • My approach to treating a patient with a symptomatic Rotator Cuff Tear is to assess the specific issues and nature of their problem and to then base my recommendation of how to treat their Rotator Cuff Tear, based on this

    Surgery for Rotator Cuff Tears

    • I undertake all of my Rotator Cuff Repairs using Arthroscopic Surgery (keyhole surgery)

    • The basic aim of any Rotator Cuff Repair is to mobilise and freshen up the ends of the torn tendon, to freshen up the boney insertion on the humerus and then to position and re-attach the tendon back down to its original insertion, achieving a tensionless repair

    • To achieve this there are multiple techniques, implants and strategies that can be used

    • The descriptions of the procedures outlined below are based on the general technique. The specific details and pros and cons of the various implants and equipment that I use are covered in the Arthroscopic Surgery Section

      find out more about Arthroscopic Shoulder Surgery….

    Healing of Rotator Cuff Tears

    • Rotator Cuff Tears usually occur in tendons that have undergone ‘wear and tear’ and, as the tear occurs, the degenerate tendon is no longer strong enough to withstand the mechanical forces placed on it

    • When a Rotator Cuff Tendon is repaired it is still degenerate and, as a result, its healing potential is not as good as a normal, healthy tendon

    • Surgical techniques and implant technology are constantly advancing and we are currently able to mobilise and successfully repair nearly all tendon tears

    • However, despite this, a number of repairs still fail to heal

    • This is likely to be due to the poor healing potential of degenerate tendons

    • The latest advance in Rotator Cuff Repairs, ‘Ortho-Biologics’, involves trying to improve and optimize the healing potential of degenerate tendons

    • Although ‘Ortho-Biologics’ is in its infancy, it is an area where I have a great interest and I incorporate its use, where indicated, during Rotator Cuff surgery

      find out more about ‘Ortho-Biologics’…..

    Factors that May Affect Rotator Cuff Healing

    There are a number of factors that have a relative effect on a rotator cuff repair healing and include,

    • Age of the patient
    • Size of the tear and retraction
    • Muscle atrophy
    • Chronicity of the tear
    • Smoking

    Management of Rotator Cuff Tears

    • In an MRI scan study of people over 60, who felt that they had no problems with their shoulder, over 40% had a tear, of some size, to their Rotator Cuff on their scans!
    • There is a vast variation between the specific symptoms, types and chronicity of a tear and the needs and expectations of patients who present with a symptomatic Rotator Cuff Tear
    • There are also many different ways of treating and repairing Rotator Cuff Tears
    • My approach to treating a patient with a symptomatic Rotator Cuff Tear is to assess the specific issues and nature of their problem and to then base my recommendation of how to treat their Rotator Cuff Tear, based on this

    Non-Operative Treatment

    • The vast majority of Rotator Cuff Tears occur on a background of longstanding degenerative changes / wear & tear
    • Sometimes symptoms develop gradually over time or sometimes as the result of an ‘Acute on Chronic’ injury
    • Whilst Rotator Cuff Tears do not heal, it is possible for some patients to gain a full functional recovery with an adequate rehabilitation programme without having to undergo surgery
    • Patients that are likely to recover well without an operation are patients with smaller tears, older patients and patients with low functional demands

     

    • Physiotherapy – Physiotherapy and specific Rotator Cuff Strengthening exercises are the main-stay of the initial non-operative treatment of a rotator cuff tear. By specifically strengthening the Supraspinatus muscle it can work and contract more efficiently pulling the humeral head downwards, allowing the tendon to move more freely and compensating for the tear. If pain is a particular feature a short course of NSAIDs prescribed by a Physician can help.

    find out more about Rotator Cuff Strengthening Exercises….

    • Analgesia/Pain Relief
    • NSAID (Non-Steroidal Anti-Inflammatories) –
      • NSAIDs work be reducing the painful inflammatory response
      • NSAIDs can damage the stomach lining and affect the kidneys. It is important that a patient’s Family Doctor prescribes this medication if it is going to be used for a longer term
    • Codeine based Analgesics –
      • Codeine based analgesics are pain killers and affect a patient’s perception of pain. As a result, they can have some effect on consciousness depending on their strength
      • Codeine based analgesics can lead to constipation if taken for a longer time. Having a high-fibre diet or even taking laxatives might need to be considered
    • Nociceptive Analgesics –
      • Nociceptive pain killers work on nerve generated pain
      • Amitriptyline in lower doses works as a nociceptive pain killer. It has a useful side-effect in that it can make patients drowsy
      • in cases of severe pain Amitriptyline can be prescribed at night
    • Subacromial Cortisone Injection –
    • If someone’s symptoms have failed to settle, after an adequate course of Physiotherapy, a Subacromial Cortisone injection can help to alleviate the pain and inflammation. Cortisone is a corticosteroid that is naturally produced by the body’s Adrenal Gland. Injectable Cortisone is synthetically produced and has a very powerful ant-inflammatory action. When injected into the Subacromial space it has the potential of settling severe inflammation, allowing the patient to undertake their rehabilitation exercises.
    • A Subacromial Cortisone can be easily administered in the Out-Patient Clinic. It is a quick and relatively painless procedure. Afterwards patients can continue with their normal day-to-day activities. Occasionally patients can feel a bit of soreness around their shoulder later that day, but this usually passes fairly quickly.
    • It often takes several days before someone notices the benefits following a Cortisone injection and sometimes several weeks. The Cortisone works in the background and there is no specific requirement to particularly rest the shoulder or to do extra exercises. The full benefits of a Cortisone injection are usually felt within a month. In some cases, the Cortisone may not give any benefit, this may be an indication of the severity of the Supraspinatus Tendonitis.
    • A Cortisone injection only lasts in the body for a few days. Any benefit that someone gets from the Cortisone will be from its acute anti-inflammatory effect allowing the damaged tendon to settle. If the symptoms do return after a while, it is not because the Cortisone has worn off, but because the inflammation has returned.
    • Infections can occur after any type of injection but are extremely rare (1 in 15,000). If someone feels that they are developing an infection within 48 hours of a Cortisone injection they should seek advice from their Family Practitioner.
    • Surgery for Rotator Cuff Tears – In some instances a rotator cuff tear fails to respond, or continues to recur, despite adequate Physiotherapy and Cortisone treatment. In this situation the only treatment that is likely to settle the symptoms is Surgery.

    Partial-Thickness Rotator Cuff Tears

    • Symptomatic Partial-Thickness Rotator Cuff Tears tend to occur in younger patients
    • Unlike full-thickness tears they often occur in relatively healthy tendons
    • They are often of some form of direct injury or an overuse injury, often related to sport
    • Partial-Thickness tears can be particularly painful and maybe the result of the increased load on the remaining, untorn tendon fibres

    Treatment of Partial Thickness Cuff Tears

    • The initial treatment for a Partial-Thickness Rotator Cuff Tear, as for any rotator cuff tear is non-operative
    • For patients who fail to respond to non-operative treatments or who symptoms recur, surgical repair is the best treatment

    Arthroscopic Partial Thickness Rotator Cuff Repair

    The best operation for someone with a symptomatic Partial Thickness Rotator Cuff Tear, that is refractory to treatment, is an Arthroscopic Partial Thickness Rotator Cuff Repair. This is an operation where the Arthroscopic camera is positioned and moved between the Glenohumeral Joint (Shoulder Joint) and the Subacromial Space above it. The Rotator Cuff Tendons can then be visualized from both sides and the damage identified. Using specialized instruments, the damaged tendon can be freshened and repaired back to its original bone origin, being held in place by specialized implants. During the repair a Subacromial Decompression is also undertaken to create more space for the repaired tendon to run underneath the Acromion.
    find out more about Arthroscopic Shoulder Surgery and Implants…

    Depending on the exact position and size of the Partial Thickness Tear, the tendon can either be repaired using a transtendinous technique. If the tear as almost completely through the tendon it can be converted into a Full Thickness tear and then be repaired in that way. The specific implants that are used can also vary depending on certain technicalities and using implants that are the most appropriate. My routine Arthroscopic Trans-Tendinous Partial Thickness Rotator Cuff Repair Procedure is described below,

    watch a video of a Partial Thickness Rotator Cuff Repair ….

    • The patient is anaesthetised with a general anaesthetic and interscaelane nerve block

    Find out more about having an anaesthetic….

    Find out more about an Interscalene Nerve Block….

    • A single prophylactic dose of broad-spectrum anti-biotics is administered
    • A posterior, anterior and 1 – 3 lateral portals are used to access the Gleno-Humeral Joint (Shoulder Joint) and Subacromial spaces
    • The Glenohumeral Joint is initially viewed to assess the exact position and size of the Rotator Cuff Tear and to look for any other associated problems, particularly with regards to the Long Head of Biceps
    • The Subacromial Space is then entered and the superior surface of the Rotator Cuff and undersurface of the Acromion identified and cleared.
    • With the arthroscope back in the Glenohumeral Joint a longitudinal split is made at the base of the Partial Tear
    • The bone of the exposed Greater Tuberosity is then prepared and de-corticated.
    • An appropriate number of Full Thread, Bio-composite Anchors are then inserted into the medial edge of the prepared bone.
    • The sutures from the anchors are then individually passed through the tendon from within the joint to the subacromial space
    • With the arthroscope back in the Subacromial space the individual pairs of sutures are identified and tied down. This will anchor the torn part of the tendon back down onto the exposed bone
    • At the end of the procedure a Subacromial Decompression is undertaken to create more clearance space for the repaired tendon to run underneath the Acromion.
    • The Joint and the Subacromial Space is then washed out and the wounds closed with sub-cuticular sutures

    find out more about having an operation…

    After the Surgery

    Post-Operative Care

    Following an Arthroscopic Partial Thickness Rotator Cuff Repair the patient maybe able to go home on the same day as their surgery or may stay in the Hospital over-night. This would depend on various other factors. I would see the patient after the surgery to discuss how the procedure has gone and arrange for further Follow-Up. The patient will be seen by the In-Patient Physiotherapy team, who will instruct them on the initial Rehabilitation Protocol for their shoulder and how to use their Sling. Further Out-Patient physiotherapy will then be organised.
    Find out more about Physiotherapy following Rotator Cuff Surgery….

    I would usually review patients in the clinic 1 month and 3 months after their procedure to assess their progress and recovery.

    Rehabilitation Protocol

    Immediately after the surgery, when the patient has woken up from their general anaesthetic, their shoulder and arm will be numb from the interscalaene nerve block. This will usually last for 18 – 24 hours after the surgery. After the nerve block has worn off the arm can come out of the sling for washing and dressing and for certain controlled movements, as directed by the physiotherapists.

    After a Rotator Cuff Repair, it is initially important to ‘protect’ the repair from any significant load as it begins to heal whilst, at the same time, it is preferable to not allow the shoulder to get too stiff. The physiotherapists will instruct the patient on the ‘safe zones’ of movement out of their sling over this period. Patients would usually need to have their arm in a sling for 2 weeks after a Partial Thickness Rotator Cuff Repair. Occasionally, this can vary depending on technical factors and tissue quality related to the surgery.

    My standard rehabilitation protocol is outlined below. The information and time to recovery are a general estimation and may vary from person to person.

    Post op

    Immediate
    • Standard Repair: sling 2 weeks
    • Postural and scapula setting
    • Neck, elbow, wrist & hand exercises
    Day 1-3

    Weeks

    • Passive table slides in safe zone
    • Progress to active assisted (closed chain) exercises in safe zone
    3-6 Weeks
    • Gentle resistance to closed chain exercises
    6 Weeks +
    • Scapula control through range
    • Low velocity rotator cuff strengthening
    12 Weeks
    • Start resistance exercises
    • Begin combined abduction and external rotation

    Milestones

    Week 8

    ROM 75%-80% of normal, sling completely discarded

    Week 12

    Full ROM

    Week 20

    Unrestricted activity

    Return to Functional Activities

    Driving
    • 3 - 6 weeks (recommended)
    Swimming
    • 6 - 8 weeks
    Golf
    • 3 months
    Heavy Lifting
    • 3 months +
    Work
    • Sedentary - once out of sling
    Manual - as guided by surgeon

    Success of Surgery, Risks & Complications

    An Arthroscopic Partial Thickness Rotator Cuff Repair is usually a very successful procedure with regards to alleviating pain and restoring good function. The surgery is aimed at freshening up the damaged tendon and its bone insertion and then fixing it back into position under no tension. At this point the ‘degenerate’ tendon can begin to try and heal. After this it can take more than 4 months for the healing process to be completed and, even at the end of that, the healed tendon will not be as good as new. As a result, it can take 6 months or more for the shoulder to be as good as it is going to be and the repaired Rotator Cuff will never be as strong as a 21 year olds. There is a danger of the Tendon failing to heal or re-tearing after a Partial Thickness Rotator Cuff Repair. However, this strangely does not always mean that the symptoms will return!

    At 6 months after a Partial Thickness Rotator Cuff Repair, about 75-80% of patients have an excellent result, 10-15% of patients still have occasional problems with their shoulder, but are pleased that they have had surgery and about 5% of patients do not feel that their shoulder has significantly improved, although it is no worse than before.

    There are always risks and complications associated with any operation.

    • Anaesthetic - The risks of having a General Anaesthetic and an Interscalaene Nerve Block are very low, but will always need to be assessed on an individual basis by an Anaesthetist. Suffice it to say, that whilst a Shoulder Operation can in no way be considered a ‘life-saving’ procedure, an Anaesthetist would not consider undertaking an anaesthetic if they had any concerns that an undue risk was being taken
    • Re-Tear / Failure to Heal – About 20% of tendons fail to heal after a Rotator Cuff Repair. However they are NOT always symptomatic
    • Infection – Infection following arthroscopic surgery is rare < 0.2%
    • Neurovascular Injury – Damage tosignificant neurovascular structures during arthroscopic shoulder surgery is rare < 0.2%
    • CRPS Type 1 – A Chronic Pain Syndrome following arthroscopic shoulder surgery is rare < 0.2%

    Outcome Measures

    Assessing patient outcomes following surgery, using validated scoring systems, is a very important and useful exercise.

    find out more about outcome measures and the SOS system….

    Management of Full Thickness Rotator Cuff Tears

    • There is a vast variation between the specific symptoms, types and chronicity of a tear and the needs and expectations of patients who present with a symptomatic Rotator Cuff Tear

    • There are also many different ways of treating and repairing Rotator Cuff Tears

    • My approach to treating a patient with a symptomatic Rotator Cuff Tear is to assess the specific issues and nature of their problem and to then base my recommendation of how to treat their Rotator Cuff Tear, based on this

    Surgery for Rotator Cuff Tears

    • I undertake all of my Rotator Cuff Repairs using Arthroscopic Surgery (keyhole surgery)

    • The basic aim of any Rotator Cuff Repair is to mobilise and freshen up the ends of the torn tendon, to freshen up the boney insertion on the humerus and then to position and re-attach the tendon back down to its original insertion, achieving a tensionless repair

    • To achieve this there are multiple techniques, implants and strategies that can be used

    • The descriptions of the procedures outlined below are based on the general technique. The specific details and pros and cons of the various implants and equipment that I use are covered in the Arthroscopic Surgery Section

    • find out more about Arthroscopic Shoulder Surgery….

    Healing of Rotator Cuff Tears

    • Rotator Cuff Tears usually occur in tendons that have undergone ‘wear and tear’ and, as the tear occurs, the degenerate tendon is no longer strong enough to withstand the mechanical forces placed on it

    • When a Rotator Cuff Tendon is repaired it is still degenerate and, as a result, its healing potential is not as good as a normal, healthy tendon

    • Surgical techniques and implant technology are constantly advancing and we are currently able to mobilise and successfully repair nearly all tendon tears

    • However, despite this, a number of repairs still fail to heal

    • This is likely to be due to the poor healing potential of degenerate tendons

    • The latest advance in Rotator Cuff Repairs, ‘Ortho-Biologics’, involves trying to improve and optimize the healing potential of degenerate tendons

    • Although ‘Ortho-Biologics’ is in its infancy, it is an area where I have a great interest and I incorporate its use, where indicated, during Rotator Cuff surgery

    find out more about ‘Ortho-Biologics’…..

    Full Thickness Rotator Cuff Repair

    The best operation for someone with a symptomatic repairable Full Thickness Rotator Cuff Tear, that is refractory to treatment, is an Arthroscopic Rotator Cuff Repair. Full Thickness Rotator Cuff Tears can be acute or chronic, come in all shapes and sizes and can occur in tendons that have undergone varying amounts of degeneration. As a result, every Rotator Cuff Tear is slightly different.

    In response to this, the exact technique, type and number of implants and potential beneficial use of ‘Ortho-Biologics’ is something that I consider individually for each Rotator Cuff tear before undertaking a surgical repair. Described below is the general operative technique that I use to undertake an Arthroscopic Rotator Cuff Repair, although this often varies slightly depending on the exact nature of an individual tear,

    Arthroscopic Rotator Cuff Repair

    watch a video of a Rotator Cuff Repair …

    Find out more about arthroscopic surgery….

    • The Glenohumeral Joint is initially viewed to assess the exact position and size of the Rotator Cuff Tear and to look for any other associated problems, particularly with regards to the Long Head of Biceps
    • The Subacromial Space is then entered and the Rotator Cuff Tear identified and assessed for its size, shape and tissue quality
    • Usually, at the outset of the procedure, a Subacromial Decompression is performed to create more clearance space to undertake the repair and then to protect the repair, after completion
    • The torn tendon is then fully mobilised and it edges freshened
    • The exposed bony Foot-Print of the tendon insertion on the Greater Tuberosity is then prepared and de-corticated down to bleeding cancellous bone
    • A combination of Full Thread, Bio-Composite Anchors are then inserted, usually in a double-row configuration, as is considered appropriate to obtain the best repair.
    • The sutures from the anchors are then individually passed through the tendon, tied and secured to anchor it securely down to the bone
    • Where considered appropriate, some form of ‘Ortho-Biologics’ may also be used to help promote tendon healing
    • At the end of the procedure the Repair is assessed, the joint and subacromial space washed out and the wounds closed with sub-cuticular sutures
    • find out more about having an operation…

    After the Surgery

    Post-Operative Care

    Following an Arthroscopic Rotator Cuff Repair the patient maybe able to go home on the same day as their surgery or may stay in the Hospital over-night. This would depend on various other factors. I would see the patient after the surgery to discuss how the procedure has gone and arrange for further Follow-Up. The patient will be seen by the In-Patient Physiotherapy team, who will instruct them on the initial Rehabilitation Protocol for their shoulder and how to use their Sling. Further Out-Patient physiotherapy will then be organised.

    Find out more about Physiotherapy following Rotator Cuff Surgery….

    I would usually review patients in the clinic 1 month and 3 months after their procedure to assess their progress and recovery.

    Rehabilitation Protocol

    Immediately after the surgery, when the patient has woken up from their general anaesthetic, their shoulder and arm will be numb from the interscalaene nerve block. This will usually last for 18 – 24 hours after the surgery. After the nerve block has worn off the arm can come out of the sling for washing and dressing and for certain controlled movements, as directed by the physiotherapists.

    After a Rotator Cuff Repair, it is initially important to ‘protect’ the repair from any significant load as it begins to heal whilst, at the same time, it is preferable to not allow the shoulder to get too stiff. The physiotherapists will instruct the patient on the ‘safe zones’ of movement out of their sling over this period. Patients would usually need to have their arm in a sling for 2 weeks after a Partial Thickness Rotator Cuff Repair. Occasionally, this can vary depending on technical factors and tissue quality related to the surgery.

    My standard rehabilitation protocol is outlined below. The information and time to recovery are a general estimation and may vary from person to person.

    Post op

    Immediate
    • Standard Repair: sling 2 weeks
    • Postural and scapula setting
    • Neck, elbow, wrist & hand exercises
    Day 1-3

    Weeks

    • Passive table slides in safe zone
    • Progress to active assisted (closed chain) exercises in safe zone
    3-6 Weeks
    • Gentle resistance to closed chain exercises
    6 Weeks +
    • Scapula control through range
    • Low velocity rotator cuff strengthening
    12 Weeks
    • Start resistance exercises
    • Begin combined abduction and external rotation

    Milestones

    Week 8

    ROM 75%-80% of normal, sling completely discarded

    Week 12

    Full ROM

    Week 20

    Unrestricted activity

    Return to Functional Activities

    Driving
    • 3 - 6 weeks (recommended)
    Swimming

    • 6 - 8 weeks
    Golf
    • 3 months
    Heavy Lifting
    • 3 months +
    Work
    • Sedentary - once out of sling
    Manual - as guided by surgeon

    Success of Surgery, Risks & Complications

    An Arthroscopic Rotator Cuff Repair is usually a very successful procedure with regards to alleviating pain and restoring good function. The surgery is aimed at freshening up the damaged tendon and its bone insertion and then fixing it back into position under no tension. At this point the ‘degenerate’ tendon can begin to try and heal. After this it can take more than 4 months for the healing process to be completed and, even at the end of that, the healed tendon will not be as good as new. As a result, it can take 6 months or more for the shoulder to be as good as it is going to be and the repaired Rotator Cuff will never be as strong as a 21 year olds. There is a danger of the Tendon failing to heal or re-tearing after a Rotator Cuff Repair. However, this strangely does not always mean that the symptoms will return!

    At 6 months after a Rotator Cuff Repair, about 75-80% of patients have an excellent result, 10-15% of patients still have occasional problems with their shoulder, but are pleased that they have had surgery and about 5% of patients do not feel that their shoulder has significantly improved, although it is no worse than before.

    There are always risks and complications associated with any operation.

    • Anaesthetic - The risks of having a General Anaesthetic and an Interscalaene Nerve Block are very low, but will always need to be assessed on an individual basis by an Anaesthetist. Suffice it to say, that whilst a Shoulder Operation can in no way be considered a ‘life-saving’ procedure, an Anaesthetist would not consider undertaking an anaesthetic if they had any concerns that an undue risk was being taken

    • Re-Tear / Failure to Heal – About 20% of tendons fail to heal after a Rotator Cuff Repair. However they are NOT always symptomatic

    • Infection – Infection following arthroscopic surgery is rare < 0.2%

    • Neurovascular Injury – Damage to significant neurovascular structures during arthroscopic shoulder surgery is rare < 0.2%

    • CRPS Type 1 – A Chronic Pain Syndrome following arthroscopic shoulder surgery is rare < 0.2%

    Outcome Measures

    Assessing patient outcomes following surgery, using validated scoring systems, is a very important and useful exercise.

    Find out more about Outcome Measures and the SOS system …..

    Irreparable Rotator Cuff Tears Non-Operative Management

    Irreparable Rotator Cuff Tears Non-Operative Management:

    Deltoid Re-Training Programme

    • A Deltoid Re-Training Programme is aimed at strengthening and re-training the Deltoid and other muscles around the shoulder to try and compensate for the absent Rotator Cuff muscles
    • It works by re-training these muscles to help re-centralise and hold the Humeral Head into the Glenoid Socket and allow the other muscles around the shoulder to work properly
    • The Deltoid Re-Training Programme is a set of relatively simple and easy exercises that need to be repeated every day
    • However, it can take many months to gain a good result. This is something that would initially best be supervised by a Physiotherapist
    • Sometimes pain and discomfort can be a big problem and significantly hamper a patient’s ability to do their exercises
    • If this is the case a Subacromial Cortisone injection or a temporary Suprascapular nerve block can help
    • Patients can often obtain quite a good function and range of motion following Deltoid Re-Training
    • However, their strength is often not particularly good and their shoulder muscles often fatigue quite quickly

    find out more about a Deltoid Re-Training Programme…

    Pain Management

    Analgesia/Pain Relief

    • pain is the most severe problem associated with a Frozen Shoulder, particularly in the Freezing Stage
    • there are no medals for bravery for a patient with a Frozen Shoulder
    • NSAID (Non-Steroidal Anti-Inflammatories) –
      • NSAIDs work be reducing the painful inflammatory response, they are useful at all Stages of Frozen Shoulder
      • NSAIDs can damage the stomach lining and affect the kidneys. It is important that a patient’s Family Doctor prescribes this medication if it is going to be used for a longer term
    • Codeine based Analgesics –
      • Codeine based analgesics are pain killers and affect a patient’s perception of pain. As a result, they can have some effect on consciousness depending on their strength
      • Codeine based analgesics can lead to constipation if taken for a longer time. Having a high-fibre diet or even taking laxatives might need to be considered
    • Nociceptive Analgesics –
      • Nociceptive pain killers work on nerve generated pain
      • Amitriptyline in lower doses works as a nociceptive pain killer. It has a useful side-effect in that it can make patients drowsy
      • in cases of severe pain Amitriptyline can be prescribed at night

    Find out more about Pain Management for shoulder problems….

    Subacromial Cortisone Injection

    • If someone’s Supraspinatus Tendonitis has failed to settle, after an adequate course of Physiotherapy, a Subacromial Cortisone injection can help to settle the symptoms down. Cortisone is a corticosteroid that is naturally produced by the body’s Adrenal Gland. Injectable Cortisone is synthetically produced and has a very powerful ant-inflammatory action. When injected into the Subacromial space it has the potential of settling severe inflammation, allowing the patient to undertake their rehabilitation exercises.
    • A Subacromial Cortisone can be easily administered in the Out-Patient Clinic. It is a quick and relatively painless procedure. Afterwards patients can continue with their normal day-to-day activities. Occasionally patients can feel a bit of soreness around their shoulder later that day, but this usually passes fairly quickly.
    • It often takes several days before someone notices the benefits following a Cortisone injection and sometimes several weeks. The Cortisone works in the background and there is no specific requirement to particularly rest the shoulder or to do extra exercises. The full benefits of a Cortisone injection are usually felt within a month. In some cases, the Cortisone may not give any benefit, this may be an indication of the severity of the Supraspinatus Tendonitis.
    • A Cortisone injection only lasts in the body for a few days. Any benefit that someone gets from the Cortisone will be from its acute anti-inflammatory effect allowing the Supraspinatus Tendonitis to settle. If the symptoms do return after a while, it is not because the Cortisone has worn off, but because the inflammation has returned.
    • Infections can occur after any type of injection but are extremely rare (1 in 15,000). If someone feels that they are developing an infection within 48 hours of a Cortisone injection they should seek advice from their Family Practitioner.

    Suprascapular Nerve Block

    • Occasionally a patient can have a shoulder problem that cannot be treated by surgery or continues to cause severe pain despite the mechanical problem having been adequately treated.
    • In this situation, it is possible to ‘block’ the nerve that supplies this area from registering pain, whilst the actual problem remains untreated.
    • When a nerve is ‘blocked’ it stops working completely, so this option is only possible for certain nerves that supply a very specific area
    • The commonest nerve block around the Shoulder is a Suprascapular Nerve Block
    • Suprascapular Nerve Block
    • The Suprascapular Nerve supplies the motor power for the supraspinatus and infraspinatus muscles and most of the pain sensation for the shoulder
    • A selective Suprascapular Nerve Block can alleviate a lot of the pain sensation from around the shoulder but does have some effect on muscle function
    • However, in patients with massive Rotator Cuff Tears and with severe arthritis the loss of muscle function has negligible effect
    • A Suprascapular Nerve Block is undertaken by an Aneasthetist who specializes in nerve blocks
    • The procedure is usually done as a Day Case procedure
    • An Ultrasound Scan and nerve stimulator are used to accurately locate and direct a hypodermic needle to the Suprascapular Nerve where it passes through the Suprascapular Notch
    • Long acting local anaesthetic is then injected around the nerve
    • An initial nerve block is always temporary and will last about 3 months, this is to make sure that there are no unwanted ‘side-effects’
    • A more permanent ‘nerve block’ can then be undertaken

    Find out more about nerve blocks….

    Surgery for Irreparable Rotator Cuff Tears

    Surgery for Irreparable Rotator Cuff Tears

    For patients who would like to try and achieve as good a function as possible and for those who have not been helped by Deltoid Re-Training, there are a number of different operative procedures that are available to treat Irreparable Rotator Cuff Tears. These can range from simple arthroscopic procedures, more complex arthroscopic reconstructions, large tendon transfers to specialised shoulder replacements. Each procedure involves varying levels of difficulty, varying levels of success, varying levels of functional recovery and varying levels of risks and complications. I consider it very important that all of these factors are taken into consideration, along with a realistic expectation of success, when discussing with a patient which procedure is likely to give them the best result.

    • There are a number of different procedures available for patients with symptomatic Irreparable Rotator Cuff tears.
    • They vary in complexity and in the functional recovery that they are likely to produce.
    • However, none of them are able to fully return a patient’s shoulder completely back to normal.

    Arthroscopic Debridement (for Irreparable Rotator Cuff Tears)

    An Arthroscopic Debridement is aimed at tidying up and removing all of the debris and damaged tissue from around the shoulder. It is primarily aimed at pain relief but often, as a result of reducing the level of pain, the patient’s shoulder function can be improved. In some cases, the Long Head of Biceps tendon, where it is still present, can be an additional source of pain and a Tenotomy (release of the tendon) may be of benefit. In other instances a component of someone’s pain may be due to irritation of the Suprascapular Nerve, addressing this with a Nerve Release or Ablation may also be of benefit. Both of these procedures can be done at the same time as an Arthroscopic Debridement.

    An Arthroscopic Debridement is a relatively small procedure which can often be done as a Day-Case. The shoulder does NOT need to be immobilised after the surgery and patients can often notice an improvement fairly quickly.

    However, like most operations for Irreparable Rotator Cuff Tears, results can be variable and it is not usually possible to predict how much any one person is likely to benefit from surgery until it has be done. My routine Arthroscopic Trans-Tendinous Partial Thickness Rotator Cuff Repair Procedure is described below,

    find out more about the Suprascapular nerve….

    Find out more about Arthroscopic Surgery….

    Watch a video of an arthroscopic debridement of the shoulder….

    Arthroscopic Debridement (+/- Biceps Tenotomy & Suprascapular Nerve Ablation)

    • The patient is anaesthetised with a general anaesthetic and interscaelane nerve block

    Find out more about having an anaesthetic….

    Find out more about an Interscalene Nerve Block….

    • A posterior, anterior and 1 – 2 lateral portals are used to access the Gleno-Humeral Joint (Shoulder Joint) and Subacromial spaces
    • The Glenohumeral Joint is initially viewed to assess the size and extent of the tear and to look for any other associated problems, particularly with regards to Osteoarthritic changes to the joint and problems with the Long Head of Biceps
    • Using a Shaver and Radiofrequency wand the joint is then cleaned out removing any loose fragments and excising any ragged tissue
    • If the Long Head of Biceps is considered to be damaged a Tenotomy is performed
    • The Subacromial Space is then entered and, using the Shaver and Wand, the stump of the torn Rotator Cuff Tendons are tidied up and any other ragged tissues excised
    • If the Suprascapular is considered to be a source of pain it is exposed using an accessory Nervaiser type portal. The nerve is then either released or ablated
    • At the end of the procedure the joint and subacromial space are assessed, washed out and the wounds closed with sub-cuticular sutures

    find out more about having an operation…

    After the Surgery

    Post-Operative Care

    Following an Arthroscopic Debridement the patient maybe able to go home on the same day as their surgery or may stay in the Hospital over-night. This would depend on various other factors. I would see the patient after the surgery to discuss how the procedure has gone and arrange for further Follow-Up. The patient will be seen by the In-Patient Physiotherapy team, who will instruct them on the initial Rehabilitation Protocol for their shoulder and will organise for further Out-Patient physiotherapy.

    Find out more about Physiotherapy following Rotator Cuff Surgery….

    I would usually review patients in the clinic 1 month and 3 months after their procedure to assess their progress and recovery.

    Rehabilitation Protocol

    Immediately after the surgery, when the patient has woken up from their general anaesthetic, their shoulder and arm will be numb from the interscalaene nerve block. This will usually last for 18 – 24 hours after the surgery. The patient’s arm will be in a Sling for this period to protect their arm. After the nerve block has worn off the arm can come out of the sling and can be used as normal.

    After an Arthroscopic Debridement patients are encouraged to try and use and move their arm as much as possible, within the limits of discomfort. No specific surgical repairs have been undertaking, so there is no danger of damaging anything in the shoulder in using it. We advise patients to keep their Sling so that it can be occasionally used if their shoulder gets at all ‘tired’. We also recommend that patients consider using the Sling for ‘Social Protection’. Sometimes when people are out in public, wearing a Sling can warn people that a patient has had recent surgery and prevent them from inadvertently knocking that arm.

    My standard rehabilitation protocol is outlined below. The information and time to recovery are a general estimation and may vary from person to person.

    Post op

    Immediate
    • Sling whilst nerve block is still working
    • Postural and scapula setting
    • Neck, elbow, wrist & hand exercises
    Day 1-3

    Weeks

    • Active assisted progressing to Active ROM in all planes
    • Sling – intermittent use for ‘Social Protection’
    3-6 Weeks
    • Progress active range of movement
    • Progress strengthening

    Return to Functional Activities

    Driving
    • Once ROM and muscular power restored & patient feels safe
    Swimming

    • As pain allows
    Golf
    • 6 weeks
    Racquet Sports/Repeated
    • 2-3 months
    Overhead Activities
    Lifting As able
    Work Sedentary - As able
    Manual - 6 weeks, may need to modify activity for 3 months

    Success of Surgery, Risks & Complications

    An Arthroscopic Debridement is a safe and is usually a very successful procedure with regards to alleviating pain and restoring variable function. Whilst some people notice a significant benefit within weeks of surgery it can take many months for others. It is extremely rare that anyone’s shoulder is ever any worse than before the surgery.

    There are always risks and complications associated with any operation.

    • Anaesthetic - The risks of having a General Anaesthetic and an Interscalaene Nerve Block are very low, but will always need to be assessed on an individual basis by an Anaesthetist. Suffice it to say, that whilst a Shoulder Operation can in no way be considered a ‘life-saving’ procedure, an Anaesthetist would not consider undertaking an anaesthetic if they had any concerns that an undue risk was being taken
    • Infection – Infection following arthroscopic surgery is rare < 0.2%
    • Neurovascular Injury – Damage tosignificant neurovascular structures during arthroscopic shoulder surgery is rare < 0.2%
    • CRPS Type 1 – A Chronic Pain Syndrome following arthroscopic shoulder surgery is rare < 0.2%

    Outcome Measures

    Assessing patient outcomes following surgery, using validated scoring systems, is a very important and useful exercise.

    Find out more about Outcome Measures and the SOS system …..

    Superior Capsular Reconstruction

    This is a very exciting new procedure that uses a Human Allograft Patch to reconstruct the Superior Capsule in ‘certain’ patients that have an Irreparable Rotator Cuff Tear. Using a fairly complex Arthroscopic technique, a very strong 4mm thick Patch is fixed between the edge of the Glenoid Socket and the Humeral Head using a combination of Anchors to secure the patch. It effectively reconstructs the Superior Capsule of the Shoulder and appears to re-centralise the Humeral Head and allow the other muscle groups around the shoulder to work effectively.

    However, not every Irreparable Rotator Cuff Tear is suitable for this procedure. If there is complete or significant damage to the Infraspinatus Tendon or if the Subscapularis Tendon is significantly damaged a Superior Capsule Reconstruction is very unlikely to work. In addition, it is a big operation with a protracted recovery and may not be the best option for every patient.

    Previously there were really no reliably successful surgical procedures available to improve ‘function’ for patients with a symptomatic Irreparable Rotator Cuff Tear. Although it is relatively early days, a Superior Capsule Reconstruction appears to be able to achieve this, certainly initially, when performed correctly on appropriate patients. I, personally, have been very pleased and impressed with the initial outcomes using this procedure on a limited number of patients. However, it is a new procedure and, as of yet, we do not know what will happen with patients’ shoulders over a longer time.

    My routine Superior Capsule Reconstruction Procedure is described below…

    Find out more about Arthroscopic Surgery….

    Arthroscopic Superior Capsular Reconstruction

    • The patient is anaesthetised with a general anaesthetic and interscaelane nerve block

    Find out more about having an anaesthetic….

    • A single prophylactic dose of broad-spectrum anti-biotics is administered
    • A posterior, 1 – 2 anterior and 2 - 3 lateral portals are used to access the Gleno-Humeral Joint (Shoulder Joint) and Subacromial spaces
    • The Glenohumeral Joint is initially viewed to assess the exact position and size of the Rotator Cuff Tear and to look for any other associated problems, particularly with regards to the Long Head of Biceps. At the outset of the procedure it is essential to confirm that the Infraspinatus Tendon is still present.
    • The Subacromial Space is then entered and the Rotator Cuff Tear identified
    • The Superior edge of the Glenoid Socket is then prepared and 2 Glenoid Anchors inserted
    • The Foot-Print on the Greater Tuberosity of the Humeral Head is then prepared and de-corticated
    • Exact measurements of the width of the Glenoid and Foot-Print distances are measured along with the anterior and posterior distances between the Glenoid and Humeral Head
    • These measurements are then used to cut out and prepare an Arthroflex 4mm patch which is used to reconstruct the capsule
    • The sutures from the Glenoid Anchors, that have been brought out of the shoulder through a lateral portal are then passed through the medial edge of the prepared patch
    • The patch is then ‘pulled’ into the joint and secured to the top of the Glenoid by tying the anchor sutures
    • Using a 4 anchor Speed Bridge system the patch is tightened and fixed to the Foot-Print of the Humeral Head
    • The posterior edge of the patch is then sutured to the anterior edge of Infrapinatus
    • At the end of the procedure the Reconstruction is assessed, the joint and subacromial space washed out and the wounds closed with sub-cuticular sutures

    Watch a Video of a Superior Capsular Reconstruction…

    find out more about having an operation…

    After the Surgery

    Post-Operative Care

    Following an Arthroscopic Superior Capsule Reconstruction the patient will need to stay in the Hospital over-night. I would see the patient after the surgery to discuss how the procedure has gone and arrange for further Follow-Up. The patient will be seen by the In-Patient Physiotherapy team, who will instruct them on the initial Rehabilitation Protocol for their shoulder and how to use their Sling. Further Out-Patient physiotherapy will then be organised.

    Find out more about Physiotherapy following Rotator Cuff Surgery….