Rotator Cuff Repair

The rotator cuff tendons can encounter several issues, including tendinitis, partial tears, and full-thickness tears. Tendinitis: Inflammation of the tendon caused by trauma, stretching, friction, pinching, or calcium deposition within the tendon. Partial Thickness Tears: These involve incomplete tearing of the tendon across its width, with some fibers remaining intact and attached to the bone. The muscle can still perform its intended actions. These tears can be less than or greater than 50% across its width and come in three types: Bursal Surface Partial Tears: Occur on the top surface of the tendon due to constant friction and impingement. Articular Surface Partial Tears: Occur on the underside of the tendon within the joint, often due to overuse or repetitive throwing activities. Intra-substance Tears: Involve tearing of collagen fibers deep within the tendon substance, with intact superior and inferior surfaces. These tears are not visible during arthroscopy but can be seen on MRI scans. Full Thickness Tears (Complete Tears): The tendon tears completely across its full width and pulls away from its attachment site on the upper humerus. This prevents the tendon from properly moving the humeral head within the shoulder socket. Over time, the torn tendon may retract, increasing the gap between its torn end and its original attachment site. Such tears often originate from the supraspinatus tendon and can progress to involve other tendons.

Rotator cuff tears can stem from various causes: Acute Injuries: Traumatic falls, hard hits during sports, workplace incidents, or automobile accidents can lead to sudden tears. These injuries may coincide with shoulder dislocations or fractures of the upper humerus. Chronic Overuse: Continuous strain from work-related tasks or athletic training, particularly in sports involving repetitive overhead movements like pitching in baseball, cricket, badminton, tennis, or swimming, can gradually wear down the rotator cuff tendons. Degeneration and Aging: As muscles and tendons age, there's a natural breakdown of collagen, rendering them more susceptible to injury. Approximately 30% of individuals over 60 may have some form of rotator cuff tears, with or without symptoms. Aging also reduces blood supply to the rotator cuff tendons, impairing their ability to repair. Associated Shoulder Conditions: Rotator cuff tears often coincide with other shoulder issues such as tendinitis and impingement. Friction between surrounding bony structures and the tendon surface can exacerbate tendon wear and tear.

Symptoms of a rotator cuff tear can vary depending on factors such as the type and location of the tear, as well as the severity of the injury. However, common symptoms include: Pain: Patients often experience pain over the top of the arm and shoulder, which may extend towards the elbow. Limited Range of Motion: Difficulty lifting the arm overhead due to pain or weakness, as well as challenges lowering the arm. This can interfere with everyday tasks like combing hair, changing clothes, or holding objects. Sleeping Difficulties: Patients may find it uncomfortable or impossible to sleep on the affected shoulder due to pain, leading to disturbed sleep. Crepitus: Some individuals may notice a cracking or grinding sensation when attempting to move the shoulder. While the acute pain of a tear may subside over time, weakness typically persists, especially when the shoulder is stressed or loaded.

Diagnosing rotator cuff tears typically involves: History and Clinical Examination: Gathering a detailed medical history and conducting a thorough physical examination to assess symptoms, range of motion, and strength of the shoulder. X-rays: These help evaluate the bony anatomy of the shoulder joint, including the presence of any bony spurs or signs of arthritis. MRI Scan: Provides detailed information about the type of tear, the condition of the muscles and tendons, any retraction of the torn tendon from its original attachment, presence of fatty atrophy in the muscles, and any bony spurs that may be causing compression of the tendon. Ultrasound (USG) Scan: Sometimes used as an alternative to MRI, particularly in patients who cannot tolerate an MRI scan. Some doctors may also use ultrasound in outpatient settings to diagnose rotator cuff tears.

Treatment for rotator cuff tears can either be conservative (non-surgical) or surgical. Non-Surgical Management includes: Pain and Inflammation Management: This involves the use of painkillers and anti-inflammatory medications to alleviate discomfort. Hot and Cold Therapy: Applying warm and cold compresses 2 to 3 times a day can help reduce pain and inflammation. Pain Relief Gel: Using pain-relieving gel twice a day after applying hot or cold therapy can help alleviate muscle spasms and pain. Physiotherapy: Once pain is controlled, physiotherapy is initiated to maintain shoulder mobility, improve muscle strength, and enhance overall shoulder function. Steroid Injections: These injections help reduce inflammation and manage pain. However, they are typically limited to a single shot, as repeated use can weaken the tendon and should be avoided. Conservative treatment is usually recommended for older patients over 65 years with minimal pain, weakness, and good shoulder mobility. It is also preferred for patients with significant medical conditions that may pose risks for surgical intervention.

Surgery for rotator cuff tears is recommended under the following circumstances: Acute Full Thickness Tears: When there are complete tears with significant tendon retraction, surgery is necessary as these tears typically will not heal on their own. Full Thickness Tears with Symptoms: Patients experiencing significant pain, weakness, and sleep disturbances due to full thickness tears may require surgical intervention to alleviate symptoms and restore function. Partial Tears: Surgery may be indicated for partial rotator cuff tears that exceed 50% of the tendon width, as well as smaller tears that do not respond adequately to non-surgical treatments.

Rotator cuff repair surgery aims to mend the torn tendon, enhance shoulder strength, and restore mobility, ultimately returning the shoulder to its pre-injury state. This procedure is commonly conducted using either arthroscopic (keyhole surgery) or mini-open techniques. Arthroscopic surgery, favored by Dr. Nirajranjan Srivastava, offers several advantages: Tiny Scars: The incisions made during arthroscopic surgery are minimal, resulting in smaller scars compared to open surgery. Reduced Pain: Patients typically experience less pain following arthroscopic rotator cuff repair. Shorter Hospitalization: Many patients can undergo arthroscopic surgery on a day-care basis or with just a one-day hospital stay. Faster Recovery: Arthroscopic surgery generally leads to quicker recovery times compared to open surgery. Lower Risk of Wound Complications: The minimally invasive nature of arthroscopic surgery reduces the risk of wound-related complications.

In arthroscopic rotator cuff repair surgery, a series of precise steps are undertaken: An array of small incisions, called portals, are strategically made at predetermined sites on the skin. Following this, an arthroscope, resembling a miniature telescope, is carefully inserted to grant a clear visualization inside the joint. Utilizing specialized instruments, any soft tissue debris and obtrusive bony projections or thickened soft tissues are meticulously cleared to alleviate any impingement on the rotator cuff. This intricate process ensures thorough preparation for the subsequent stages of tendon reattachment and repair.

Following rotator cuff repair surgery, patients can anticipate a structured recovery trajectory: Hydration and Nutrition: Patients are typically allowed to consume water and food within 4 to 6 hours post-surgery to support their recovery process. Pain Management: Adequate pain relief is ensured through the administration of appropriate medications, either via intravenous injections or oral tablets, tailored to individual needs. Cold Therapy: Ice packs are applied to the shoulder multiple times a day for specified durations, usually 15 to 20 minutes per session, over a period of 4 to 6 weeks post-surgery to alleviate discomfort and reduce swelling. Dressing Changes: Shoulder dressings are replaced the day after surgery to maintain cleanliness and support wound healing. Shoulder Sling: Patients are advised to wear a shoulder sling for 4 to 6 weeks following surgery, removing it only for essential activities such as cleaning, bathing, and engaging in prescribed shoulder exercises. Physiotherapy: Under the guidance of a physiotherapist, patients undergo daily shoulder exercises performed twice a day before meals, gradually progressing over a span of 3 to 4 months to restore strength and mobility. Pain Medications: Pain management remains a priority during the initial 2 weeks post-surgery, with medications administered as needed to ensure comfort. Wound Care: Close monitoring of wound healing is maintained, with any non-dissolving sutures typically removed approximately 10 days after the surgical procedure to promote optimal recovery.

Recovery from rotator cuff repair surgery can vary, typically taking 6 to 12 weeks for the tendon to heal fully. The healing duration depends on factors such as the size of the tear, the quality of the tendon tissue, and the type of repair performed. Patients should be informed about the potential for a slower recovery after cuff repair and advised to proceed with caution during the healing process.

An acute tear of the rotator cuff remains mobile and can often be brought back to its original attachment site on the upper humerus. However, if left untreated or neglected, these tears can progress to become chronic. Chronic tears are characterized by retracted and weakened tendons that may be scarred to surrounding tissues, rendering them immobile and unable to be brought back to their original attachment sites. Surgical repair may not be feasible in such cases due to the poor tissue quality, which can cause sutures to cut through the tendon substance when attempting to secure them. Consequently, attempts to repair weak tendons are often unsuccessful. Patients with chronic, retracted, immobile, and severely weakened tendons may require alternative major treatments, such as shoulder tendon transfer or superior capsular reconstruction surgery, especially if the joint is normal and non-arthritic. In tendon transfer surgery, a healthy tendon is transferred and sutured to the defect within the rotator cuff tendon. In superior capsular reconstruction surgery, a portion of flat body tissue, such as fascia lata from the thigh, is used as a patch to repair and augment the rotator cuff defect. These surgical procedures aim to restore some useful shoulder movements and functions while providing pain relief. However, if the shoulder joint develops arthritic changes secondary to the torn rotator cuff, a reverse shoulder replacement may be recommended.