Rotator cuff repair leads to good and excellent outcomes in most patients. However, structural failure of the repair occurs in a substantial number of cases and can lead to an unsatisfactory result. Several factors have been implicated, including patient related factors (eg. patient age, tear size) and extrinsic factors (eg, surgeon surgical volume, biomechanical failure). Structural failure requires a detailed patient evaluation to elucidate the cause of persistent symptoms. Function can be maintained despite a recurrent tear; therefore, a recurrent tear alone is not an indication for revision repair. The major indication for revision rotator cuff repair is the persistence clinical symptoms, despite nonsurgical management, in the absence of substantial risk factors for failure. Although the outcome is poorer than after primary repair, satisfactory results have been reported following revision repair of recurrent rotator cuff tears, particularly with arthroscopic techniques.
About rotator cuff injuries
Shoulder pain affects around one in five people in the UK and a rotator cuff injury is the most common cause.
Your shoulder joint is a ball and socket joint, formed by the ball-shaped end of your upper arm bone (humerus) and a shallow socket on the edge of your shoulder blade (scapula).
Your rotator cuff is made up of a group of four muscles (the subscapularis, supraspinatus, infraspinatus and teres minor) and their tendons. It plays a crucial role in keeping your shoulder joint stable. Tendons wrap around your shoulder joint, forming a cuff around the ball of your humerus.
On top of your shoulder joint is a bone called the acromion. In the gap between your shoulder joint and acromion is a space that some of your rotator cuff tendons run through. In this space is a fluid-filled pad called the subacromial bursa, which cushions your tendons.
Rotator cuff injury is a general term to describe inflammation (soreness and swelling) or damage to one or more of the muscles or tendons that make up your rotator cuff.
Types of rotator cuff injury
There are a number of conditions that can affect your rotator cuff. The most common are inflammation of your rotator cuff tendons and tearing of your muscles or tendons.
Rotator cuff tendonitis
If the tendons of your rotator cuff become inflamed, this is known as tendonitis. The tendons can become pinched against one of the other structures that make up your shoulder joint. This can be both the cause and the result of tendonitis. Tendonitis most often affects the tendons that run underneath your acromion. When a tendon becomes trapped or squeezed, it’s known as impingement syndrome.
Calcium is sometimes deposited in your rotator cuff tendons if they are inflamed for a long period of time. The tendons become ‘calcified’ and this is called calcific tendonitis.
Your subacromial bursa can also become inflamed – this is called bursitis.
Rotator cuff tear
This is when one or more of the muscles and tendons that make up your rotator cuff become completely or partially torn. It may be a result of trauma, such as a fall, or due to tiny tears in the tendon caused by use and wear over time. It may also be caused by impingement syndrome.
Symptoms of rotator cuff injuries
Symptoms of a rotator cuff injury include:
- pain and tenderness in your shoulder (this may extend down your arm too), particularly when you raise your arm out to the side, reach behind you or lift or pull a heavy weight
- pain at night, particularly when you sleep on the affected side
- a feeling of weakness in your shoulder
- being unable to move your shoulder as you usually would
Depending on the type of injury you have, the pain may come on gradually (common if you have tendonitis) or you may have sudden twinges of pain (common if you have a tear).
If you have any of these symptoms, contact your GP or a physiotherapist (a health professional who specialises in maintaining and improving movement and mobility).
Causes of rotator cuff injuries
Rotator cuff injuries may occur for a specific reason, for example:
- lifting or pulling an object that is too heavy for you or lifting it in the wrong way can cause you to strain or tear a rotator cuff tendon or muscle
- landing on an outstretched hand to break a fall can tear or strain a rotator cuff muscle or tendon
There are some things that increase the likelihood of you getting a rotator cuff injury, including the following.
- Age – if you’re over 40, you’re at an increased risk of rotator cuff injuries because your tendons start to wear down with age and become more prone to injury.
- Certain sports, activities and jobs – you’re more likely to have a rotator cuff injury if you do something that involves repetitive overhead motions with your arms. Examples include swimming, weight lifting, playing racquet sports and occupations such as painting, decorating or window cleaning.
- Musculoskeletal diseases, such as rheumatoid arthritis, can cause your rotator cuff muscles to become weaker making an injury more likely.
Diagnosis of rotator cuff injuries
Your GP or physiotherapist will ask about your symptoms and examine you. He or she may ask about your medical history and any activities that may be causing your condition.
You may be referred for further tests such as an MRI scan, ultrasound scan or X-ray so that your doctor can look at your shoulder in more detail.
Treatment of rotator cuff injuries
Treatment of a rotator cuff injury depends on the type of injury you have and how severe it is.
The following measures may help.
- Rest your shoulder initially, avoiding any movements that cause you pain. Start to do gentle movements as soon as possible to prevent any stiffness in your shoulder.
- Apply an ice pack or ice wrapped in a towel to your shoulder to reduce swelling and bruising. Don’t apply ice directly to your skin as it can damage your skin. Don’t use ice if you have a skin disorder that makes your skin sensitive. Also, don’t put ice on your left shoulder if you have any known heart problems.
- Take an over-the-counter anti-inflammatory medicine, such as ibuprofen, to reduce pain and inflammation. Always read the patient information leaflet that comes with your medicine and if you have any questions ask your pharmacist for advice.
Stretches and strengthening exercises can help build up strength and flexibility in your shoulder. It’s important to get advice from a medical professional, such as a physiotherapist, on which exercises and stretches you should do and how to do them correctly. The exercises will be tailored to your specific injury.
If you have rotator cuff tendonitis, your doctor may recommend an injection of a medicine called a corticosteroid. This is usually only done when other treatments haven’t helped.
You may be able to have extracorporeal shock wave lithotripsy (ESWT) if you have calcific tendonitis. ESWT uses vibrations caused by sound waves to break up the calcium deposits.
Rotator cuff injuries can usually be successfully treated without the need for surgery. However, sometimes you may need to have an operation, for example to repair a tear in your rotator cuff or to remove calcium deposits.
Rotator cuff repair surgery is done under general anaesthesia. This means you will be asleep during the operation.
In general, there are two different procedures that may be used to repair a rotator cuff injury: open surgery and shoulder arthroscopy. The type of surgery you have will depend on where your injury is, and if it’s a tear, how big it is and it’s shape.
Open surgery means that your surgeon makes a cut in the skin over your shoulder and repairs your injury through the cut. In an athroscopy, a narrow, flexible, tube-like telescopic camera called an arthroscope is inserted through a small incision in your shoulder and this is used to repair your injury. It’s commonly known as keyhole surgery.
If you have a rotator cuff tear, the two sides of your muscle or tendon will be stitched back together and, if necessary, attached back on to your humerus. Your surgeon may also carry out a procedure called debridement. This means that he or she will remove any damaged tissue, so that the remaining healthy tissue can heal.
If you have impingement syndrome, your surgeon will remove excess bone from the front part of your acromion. This will create more room for your rotator cuff and prevent pinching of the rotator cuff, when you move your arm above your head. This procedure is called subacromial decompression.
Your surgeon will be able to give you advice on which type of surgery you need for your condition.