Rotator Cuff Tears

The Rotator Cuff is a group of muscles and tendons around the shoulder. These muscles are important for the shoulder to function normally. They help balance the ball of the upper arm on the shoulder blade socket. A tear in one or more of these tendons can unbalance the shoulder and cause pain and weakness. It is common for these tendons to tear as people get older. Greater than 50% of people over 70 years of age have a full thickness tear at autopsy.The rotator cuff tears do not spontaneously heal. Despite the lack of healing there is greater than a 90% chance that a patient will have no pain and a return of most shoulder strength after 6-12 months.

a. Tendon firmly attached to bone	b. Full thickness tear of tendon from bone

The non-operative treatment of a painful rotator cuff tear includes activity modification, pain management and physiotherapy.

• Activities should be modified to decrease the demands and stress on the effected shoulder during the painful phase
• Pain management includes simple analgesics, anti-inflammatories and steroid injections
• Physiotherapy helps restore shoulder range of motion and strength
  

Surgery is generally reserved for those who despite 6-12 months of non-operative therapy have ongoing pain and disability that is interfering with their quality of life. If a patient is considering surgery an MRI scan is organised to better define the abnormalities and ensure surgery is worthwhile.

Surgery involves restoring the anatomy, by attaching the torn tendon back to where it was originally attached. Traditionally, this was done via a large "open" incision. Recent technological advances have allowed arthroscopic rotator cuff repairs. These are technically demanding surgical techniques which aim to achieve equal results as traditional open surgery, while minimizing the surgical trauma to the patient. The surgery is performed with an underwater camera on the end of a thin metal rod through 1cm incisions that penetrate but do not strip off muscles. This reduces the surgical insult, improves the cosmesis of the surgery and reduces risks such as infection.

If surgery is performed to repair the rotator cuff, then in general a period of sling immobilisation is required for six weeks. You are not able to drive while in a sling. Physiotherapy may be required for 3 to 6 months assist recovery of motion and strength.

There are some situations when surgery should be considered as the best form of early treatment. These include but are not limited to:

• A patient who has a massive rotator cuff tear and an inability to perform active shoulder movements following trauma
• A rotator cuff tear that has lead to an "unbalancing of the force couples" of the shoulder joint. This usually means that the tear is a massive tear and now the patient cannot lift their arm above shoulder level
• A full thickness rotator cuff tear in a "physiologically younger" patient. As this tear will never heal, some surgeons believe that the tear should be repaired in a younger patient. It is important to appreciate however that these patients may attain a pain free and functional shoulder with non-operative management