ROTATOR CUFF TEAR

The rotator cuff is a muscle-tendon plate that extends like a sheath around the shoulder joint. The muscles originate at the scapula and attach to the humeral head. The four tendons serve to provide mobility and stabilization of the shoulder joint.

A rotator cuff tear refers to a damage or an injury to one or more tendons of this muscle-tendon plate. A tear can affect parts or the entire tendon. Tears are partly a result of wear and tear. For instance, if you sent all 60-year-olds to an MRI exam, you would find a tear in the rotator cuff in about 50%. These tears do not always cause symptoms and do not require treatment in certain cases. Complete tears are a separation of the tendons from the bone.

Tears can occur within the tendon (intratendinous), on the top of the tendon (bursal partial tear), or at the bottom of the tendon (partial articular tear, also known as a PASTA lesion).

Many affected individuals experience pain in the shoulder, especially in the area of the upper arm. The complaints often present themselves during movements or while raising the arm away from the body (e.g., reaching for the wallet in the trouser pocket or doing one’s hair). Frequently, pain also occurs at night and may disturb sleep.

A tear caused by an accident is often associated with acute pain, restricted movement, and reduced strength. Slow, degenerative changes due to wear and tear can result in similar symptoms.

The physician can already make an initial assessment after interviewing and examining the patient. Imaging procedures such as X-rays, ultrasound examinations, magnetic resonance imaging (MRI), or computer tomography (CT) are performed to confirm the diagnosis and thus provide a basis for further therapeutic interventions.

X-rays can be used, for example, to assess bone structures, calcifications, arthrosis, and the position of the shoulder concerning other parts of the body. Ultrasound allows for dynamic examination and reveals rotator cuff injuries. MRI (ideally with a contrast agent) helps provide an accurate picture of the extent of retraction of the tendon and the quality or fatty nature of the muscles. The classification of muscles’ degree of fatty degeneration is divided according to Fuchs (MRI) or Goutallier (CT).

The CT examination shows the bone structures in detail. A 3D image of the shoulder can be reconstructed here. In addition, fatty degeneration of the muscles can be assessed.

The treatment of a rotator cuff tear depends on many individual factors. Accidental or degenerative injuries are evaluated differently concerning conservative and surgical treatments. The patient’s daily activity, occupation, and age play another essential role in selecting therapeutic interventions. The localization and extent of the tendon rupture are equally decisive. Pain medications and injections into the shoulder are often administered as initial treatment. At the same time, physical therapy or other functional approaches can help improve shoulder strength and mobility.

However, wholly torn tendons cannot grow back together on their own because the tension in the muscles pulls the torn ends apart. On the one hand, some tendon tears are quite treatable without surgery. For example, some muscles and tendons support each other in their movements.

For example, a patient can continue to move the arm despite a supraspinatus tendon rupture but has discomfort when lifting weights. Movement can be assisted by the infraspinatus and deltoid muscles. The body can partially compensate for the function of each tendon. On the other hand, a complete traumatic tear of the subscapularis tendon is more of an indication for surgery. Ruptures are classified according to Lafosse.

In the event of failure of conservative (non-surgical) therapy, the indication for surgical treatment is given. Nowadays, such operations are usually performed entirely arthroscopically, with the aid of an endoscope, also known as ‘the keyhole technique’. Before suturing a tendon, it is crucial to ensure that the muscle (the motor of movement) is not excessively (>50%) fatty. For example, it would not help a broken car engine to change the wheels of the car. The type of surgical treatment depends on the severity and the kind of damage. The possible surgical techniques are discussed in a personal consultation with the physician.