Rupture of the rotator cuff tendons

Following a traumatic injury, repeated friction beneath an overly aggressive acromion, or progressive tendon degeneration, the tendons of the rotator cuff may tear, causing pain and loss of shoulder function (loss of mobility and strength, stiffness, etc.).

Diagnosis of a rotator cuff tear

What is the rotator cuff?

The rotator cuff is a group of four interconnected tendons (teres minor, infraspinatus, supraspinatus, and subscapularis) located beneath the deltoid muscle of the shoulder. These tendons cover the head of the humerus and help keep it centered relative to the shoulder blade.

These tendons play a major role in rotation and elevation movements of the shoulder. They are particularly vulnerable because they lie beneath the acromion, a bone structure that may become aggressive and progressively “wear through” the tendons (this is referred to as subacromial impingement).

Causes of a rotator cuff tear

A rotator cuff tear most commonly affects people over 50 years old who present degenerative tendon changes. However, tears may also occur in younger adults following trauma, sports injuries, domestic accidents, or road accidents.

The rotator cuff tendons are positioned “sandwiched” between the acromion and the head of the humerus. With age, these tendons tend to become thinner and more fragile. They may progressively tear at their insertion on the upper part of the humerus due to tendon degeneration.

However, tendon rupture is often the result of chronic subacromial impingement or rotator cuff tendinopathy.

Diagnosis

The signs of a rotator cuff tear can vary considerably.

In the case of a progressive tear, the rupture often follows subacromial impingement. Over time, repeated friction causes the tendons to wear out and eventually tear. In some cases, the tear may be well tolerated, as the intact tendons progressively compensate for the damaged ones.

In other cases, pain may worsen, making it difficult to raise the arm sideways, with night pain, pain during everyday activities, and progressive loss of shoulder function. Over time, this condition may evolve into destructive shoulder arthritis (called omarthrosis in the shoulder). In cases of arthritis associated with rotator cuff degeneration or tears, a shoulder replacement may be considered.

In the case of a traumatic tear (sports injury, domestic accident, or road accident), there is usually immediate major functional limitation with a painful shoulder.

In most cases, these lesions are not visible on standard X-rays. An arthro-CT scan, MRI, or ultrasound is therefore necessary to confirm the diagnosis of a rotator cuff tear.

Treatments for a rotator cuff tear

Several techniques may be combined to treat a rotator cuff tear: physiotherapy, injections, and shoulder surgery.

Whatever the treatment, managing rotator cuff lesions is often long and challenging, with recovery that is not always complete. Tendon lesions may worsen over time because of the often degenerative nature of the tendons.

Physiotherapy after a rotator cuff tear

In cases of a well-tolerated chronic tear in patients who place limited demands on their shoulder in daily life, especially elderly patients, physiotherapy alone may be considered. Rehabilitation with a physiotherapist may help reduce pain and restore acceptable shoulder function.

In cases of an “old” tear associated with shoulder stiffness, a rehabilitation program will in any case be initiated before considering surgery.

Subacromial corticosteroid injections

Corticosteroid derivatives may be injected, preferably under radiological or ultrasound guidance, between the acromion and the rotator cuff in order to reduce tendon inflammation, which may help relieve pain and promote healing.

However, the number of injections should remain limited.

Surgical treatment

Surgery is not always necessary for rotator cuff tears, but it remains the most appropriate treatment in many cases.

In cases of major functional impairment or recent tendon rupture, tendon repair is recommended in order to restore shoulder function as effectively as possible.

Treatment of shoulder tendinopathies has evolved considerably in recent years thanks to advances in arthroscopic surgery. In the past, a large incision through the deltoid muscle was required to repair the cuff. Arthroscopic tendon repair now makes it possible to reduce post-operative pain and facilitate rehabilitation.

In this report from the TV program “Allô Docteurs” (France 5), viewers follow the course of arthroscopic shoulder surgery performed on a patient suffering from chronic rotator cuff tendinitis that ultimately led to tendon rupture.

Arthroscopic rotator cuff tendon repair

Principle of the surgical procedure

This procedure consists of reattaching the torn tendons to the humerus using an arthroscopic technique, meaning through two or three small incisions of approximately 1 cm allowing insertion of a camera and miniature instruments.

Summary of the procedure

• Technique: arthroscopic surgery
• Anesthesia: general anesthesia or regional anesthesia in some cases
• Hospital stay: 1 overnight stay after surgery
• Immobilization: arm supported in a sling (3 to 6 weeks) with immediate self-rehabilitation exercises. The hand and elbow may be used immediately.
• Return to sports: after 3 months

How rotator cuff surgery is performed

A miniature camera is inserted into the joint to first perform an assessment of the lesions. If associated lesions of the labrum or the long head of the biceps tendon are identified, these structures may be treated or removed.

After removal of the degenerative portion of the tendons, the tendons are reattached to the humeral head using intraosseous implants called anchors, which are inserted into the humeral bone. Sutures attached to these anchors are then used to secure the tendons back onto the bone. The undersurface of the acromion is enlarged in order to reduce friction on the cuff.

In cases of severe tendon retraction, especially in chronic or longstanding tears, the tendons cannot always be fully reattached to the humerus. Removal of degenerative tendon fragments and, if necessary, sectioning of the long head of the biceps tendon (when degenerative) are usually sufficient to improve shoulder function.

The small incisions are then closed with a few sutures.

Post-operative care after rotator cuff surgery

After surgical treatment of the rotator cuff tendons, the arm is kept immobilized in a sling to allow the tendons to heal back onto the bone. The patient must avoid using the shoulder — particularly lifting the arm sideways or performing rotational movements — for approximately one month. In practice, the patient may immediately use the elbow and hand for daily activities. The sling may be removed at home while resting, with the arm kept alongside the body.

Rehabilitation after surgery

Beginning the day after rotator cuff surgery, the patient must perform passive rehabilitation exercises several times a day. The aim is to reduce shoulder stiffness.

Rehabilitation with a physiotherapist, or preferably in a rehabilitation center, generally begins between the fourth and sixth week after surgery. The goal is to restore passive and active range of motion as effectively as possible.

After approximately three months, it is generally possible to return to sports activities.

Possible complications

• Recovery is often long and challenging. The patient must remain highly motivated regarding both the surgery and the rehabilitation process in order to achieve the best possible outcome.
• In cases of severe degenerative lesions, persistent pain and functionally limiting shoulder stiffness may remain.
• Secondary tendon rupture is always possible if the tendons are significantly degenerated.

Pain

Pain often persists for several months after surgery. Improvement occurs progressively over 3 to 6 months, corresponding to the healing period following elimination of the bony impingement.

Depending on tendon degeneration and associated lesions, residual shoulder pain may persist.

Risks

Although they are rare and unpredictable, surgical treatment of a rotator cuff tear may involve certain risks.

• Algodystrophy (complex regional pain syndrome) may occur. It causes pain and stiffness of the shoulder that may extend to the arm. The course of this condition is often long and difficult and may leave residual shoulder stiffness.
• Septic arthritis is rare but remains possible. Additional surgery or appropriate medical treatment may be necessary.
• Hemarthrosis (bleeding within the joint) may require a second procedure.
• Depending on skin type, inflammatory scar healing may occur.
• In some cases, persistent shoulder stiffness may last for several months.