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Rotator Cuff Tear

Rotator Cuff Tear

INTRODUCTION

The shoulder blade is made up of three bones – upper arm bone (humerus), shoulder blade (scapula), and collarbone (clavicle). The upper arm bone (humerus) fits into a socket in the shoulder blade (scapula).  A rotator cuff keeps the head of the upper arm bone firmly in the socket of the shoulder.

A rotator cuff is a group of four muscles – supraspinatus, infraspinatus, subscapularis and teres minor that come from the scapula (shoulder blade) – whose tendons have a covering around the upper arm bone (humerus) and the top of the shoulder that forms sort of like a “cuff”. Together with the joint capsule, ligaments and labrum, it stabilizes the shoulder joint and allows a person to lift and rotate one’s shoulders and arms.

There are two types of rotator cuff tears which are: partial and complete. A partial tear renders a damaged tendon that protects the top of the shoulder. A complete tear renders a whole tendon torn or pulled from the bone.

A rotator cuff tear develops more overtime than through a sudden injury. Usually it occurs in people who perform constant overhead motions or activities in their jobs such as carpenters, painters, basketball players, etc. The normal wear and tear or repetitive arm motions develop. The risk of developing this diseases increases with age.

However, it can also develop as a result of a single event. It is especially common to happen in an instant in high-impact sports such as football, or accidents such as falling on one’s arm.  Dislocating a shoulder can also result to a rotator cuff tear. In these cases, most of the time immediate medical attention is required, since it may require an immediate surgical operation.

CAUSES

As mentioned in the introduction, there are two ways a rotator cuff is incurred. It can be a one-time event that exposes the rotator cuff to enough force to cause it to tear such as in high-impact sports called an injury. It can also be a development that happened overtime such is the case of a painter, heavy lifter and is called degeneration.

SYMPTOMS

Symptoms from a rotator cuff are due to the inflammation from the strain, which causes swelling, leading to localized pain and decreased mobility. Since the rotator cuff is hidden well below, the swelling is not so easily felt. However, the swelling is enough to fill up the already small space that exists in the shoulder joints to reduce mobility of the shoulder and shoots pain with movement.

The following symptoms that may be felt with a rotator cuff tear:

  • Numbness in shoulder
  • Pain when lying on shoulder
  • Decreased mobility in shoulder
  • Arm weakness
  • Inability to lift arm high due to pain
  • Decreased mobility in the arm
  • Inability to lift things as one normally does
  • Clicking and popping in arm movements

RISKS

The following are risk factors that increase the chances of a rotator cuff development:

  1. Age

Most causes for rotator cuffs are degeneration rather than injury. This means that it usually develops over a long period of time due to normal wear and tear. It is most common for people at the age of 40.

  1. Work related strain

Jobs and sports that involve repetitive arm motion such as baseball pitchers have a higher risk of developing a rotator cuff. When constant lifting and overhead motion is involved, people are more prone to overuse tears

  1. Genetics

If a family is involved with a medical history in rotators cuffs, then the risk is higher. There may be a genetic explanation as to rotator cuff injuries occurring more in certain families.

PREVENTION

Rotator cuff tears are more common as one grows older. However, the chances increase with other risk factors such as sports activity or jobs activities that involve repetitive overhead motions that contribute to the constant wear and tear in the rotator cuff. The following are examples of prevention methods that can be done to prevent the development of a rotating cuff tear:

  • Exercise

Stretching before doing any strenuous activity helps the body warm up. Otherwise, the rotator cuff can easily get inflamed. Strengthening the rotator cuff through low resistance exercises also helps avoid this injury. These strengthening exercises are essential to provide the shoulder a balanced strength. The key is to keep the shoulder strong and flexible along with the other muscles in the shoulder.

  • Be physically aware

Once soreness is felt in the shoulders after performing a certain activity, don’t simply ignore it. Further exercises or doing other activities might only worsen the condition of a rotator cuff tear. If the conditions continue to worsen, consult a physician immediately.

  • Proper posture and lifting

Most of the time during work, arms are stretched in front of the body. This posture ruins the shoulder balance, which eventually leads to a rotator cuff tear. Some work also requires plenty of lifting, if improperly done can also lead to a rotator cuff tear. Hence, proper lifting techniques must be learned and practiced.

TREATMENT

Conservative Treatment

A rotator cuff is a group of four muscles whose tendons have a covering around the upper arm bone (humerus) and the top of the shoulder that forms sort of like a “cuff”. Together with the joint capsule, ligaments and labrum, it stabilizes the shoulder joint and allows a person to lift and rotate one’s shoulders and arms. Sometimes, either a partial or complete tear can develop in the tendons, which cause excruciating symptoms such as localized pain, numbness, muscle weakness, immobility in shoulders and arms, etc.

However, not all rotator cuff tears need immediate surgery. Where possible, conservative treatments are first administered to patients before a surgery is considered. The following are examples of conservative treatments for rotator cuff tears:

  • Medication

Usually, the medications given are over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs). This helps reduce the inflammation that has occurred in the rotator cuff tear to reduce the pain from the symptoms.

Steroid injections administered in the shoulder joint can be recommended to reduce the pain from the symptoms however, they are detrimental to one’s health if used too often. Therefore, they should be used carefully as they can weaken the tendon.

  • Physical Therapy

This is one of the initial treatments that are suggested by the physician. Some exercises can specifically target the location of the rotator cuff injury. This will help improve the flexibility and strength of one’s shoulder. A physical therapy plan must be developed together with a physician to ensure that the exercises performed are correct.

Surgical Treatment

In most cases, conservative treatment is enough to heal the rotator cuff tear. However, in severe conditions a surgery may be required such as a complete tear of the tendon from the bone.

Bankart Repair – A procedure where anchors hold your labrum together

Rotator Cuff Repair – Surgeon uses sutures to repair rotator cuff

Open Repair

This is the more traditional surgery performed to address rotator cuff tears. It is often done as well when the tear is quite large. It involves an incision about seven centimetres long. The incision is made over the shoulder and the surgeon opens a flap in the shoulder muscles to access the torn tendon. The surgeon either reattaches the tendon to the bone or does a tendon transfer.

A tendon transfer is performed when a tendon is severely damaged to be reattached. A tendon from a different location is used to repair the rotator cuff. Usually, the Latissimus dorsi tendon is used. Two incisions are made: on the front of the shoulder and the other at the back. In the back, the surgeon detaches a part of the Latissimus dorsi tendon, attaches a suture (threadlike material used to reattach tendons) then reaches for it through the front incision then secures it in a new position. It is connected to the remaining rotator cuff tendons and bones.

All-Arthroscopic Repair

In an arthroscopic repair, the surgeon makes small incisions each about 1 cm. The surgeon then uses a tiny camera called an arthroscope to insert it in the shoulder joint. The arthroscope is a tiny fibre optic camera that has a tiny lens, light source and video camera. The camera allows a visual on the television screen. This serves as a guide to the surgeon to perform the surgery, and uses miniature surgical instruments. The surgical instruments are about 3 to 4 mm in diameter. This allows the surgeon to assess the severity and type of injury, and then take steps to fix it. Using a special instrument called the suture passer, the suture is passed from side to side of the limb of the tear. Both ends of the tied suture are brought together, and this is repeated until the whole tear is repaired. Suture anchors are then inserted using a long insertor. The sutures from the anchors are pulled and passed through the tendon. Both sutures are then tied sequentially, and this process is repeated until the whole tear is repaired. This is an outpatient surgery and is more minimally invasive compared to Open Repair surgery.

RECOVERY

The recovery period will depend on the kind of surgery the patient underwent, the severity of the damage, and a number of other factors unique to each patient. The recover process may take only little time for others while others may experience a longer period of recovery. An arthoscoopical surgery has a shorter recovery span compared to open repair surgery considering that less incisions were made in the shoulder.

After surgery, the surgeon and a therapist will provide the patient with specific instructions for exercise and other recovery methods. One should strictly follow these instructions. One may feel better already and will eagerly go back to work. However, one should always follow the physician’s instructions otherwise it may not heal. The muscles around the arm may have suffered loss of strength and must therefore be accompanied by sure and deliberate rehabilitation.

After the surgery, you may be given a shoulders sling. In most activities one must wear with exceptions when bathing, dressing and easy light activities.

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