Rotator cuff injury

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

The decision to treat a rotator cuff tear surgically or non-surgically should be based on several factors, including size of tear, patient age, expected activity level, degree of tendon retraction, and presence of rotator cuff muscle atrophy and fatty replacement.

Earlier surgical intervention may be needed when there is weakness and substantial functional disability, or if pain continues despite several months of physiotherapy and medical therapy.[32][33][34] In addition, if the patient requires full use of the arm for vocational or recreational needs, then repair should be considered.

The time since injury is also an important consideration, as the function and appearance of a torn rotator cuff generally deteriorate with time. With chronic tears, muscle tissue may atrophy in time and is replaced with fatty tissue, often termed fatty degeneration.[31] Risk factors for re-tear after arthroscopic (minimally invasive) rotator cuff repair include fatty infiltration (subscapularis and infraspinatus) and symptom duration.[35] A direct correlation has been described between the extent of the fatty degeneration of the rotator cuff muscle and the time from injury.[36] Researchers found improved outcomes and a reduced re-tear rate when repair was performed when fatty degeneration was minimal. In patients over 60 years of age, a favourable outcome can still be expected after repair, provided tissue quality remains sufficient.[37]

Acute tears (identified within 6 weeks of a significant known trauma)

Treatment options for acute tears are determined in large part by the size of tear and how symptomatic the patient is at the time of presentation. Involvement of a physiotherapist is often helpful. If there is external rotation weakness, then infraspinatus involvement is present and surgery is more likely to be necessary since shoulder biomechanics are adversely affected in the presence of two tendon tears.

Surgical repair of acute small tears

Surgical repair is the first-line treatment for patients with good functional status, especially if functional demands are high. When surgery is undertaken before the onset of atrophy, more predictable results are ensured. One randomised controlled trial of people with rotator cuff tear not exceeding 3 cm found that primary tendon repair improved pain, motion, and strength at 10 years compared with physiotherapy.[38]

Surgical options include arthroscopic, mini-open, and open repair. The primary goal is to provide a pain-free joint with good function.

Conservative measures for small acute tears

Non-surgical options should be considered first for older and sedentary patients with small tears with mild loss of range of motion (ROM) and strength, and for patients with low functional demands. Ice, stretching, and non-steroidal anti-inflammatory drugs (NSAIDs) are the initial treatments. Once ROM returns (usually at about 4 weeks), toning exercises can be started while stretching continues. A single subacromial corticosteroid injection can be used to control inflammation and reduce pain if rehabilitation therapy and NSAIDs are ineffective.[39] Rehabilitation can resume a few days after the injection.[40] Repeated injections are to be avoided, as healing of a potential surgical repair may be compromised.[41] Contraindications for subacromial corticosteroid injections include septic arthritis, a previous adverse reaction, or systemic infection.[41]

One systematic review and meta-analysis suggested that NSAIDs are less effective than corticosteroid injection at achieving remission in patients with shoulder pain at 4-6 weeks after treatment.[42] However, as this review included a limited number of small studies, the results should be interpreted with caution.[42]

Activity should be modified to reduce overhead lifting. When returns ROM (usually around 4 weeks), toning should be added while stretching is continued.

Lack of response to at least 10-12 weeks of medical and physiotherapy should prompt consideration of open, mini-open, or arthroscopic repair for patients with non-operative treatment for smaller or partial tears. Surgeons generally should perform the technique that provides the best and most reliable results in their hands.

[Figure caption and citation for the preceding image starts]: Subacromial injection. Insert needle just inferior to posterior edge of acromion (x), aiming parallel to the undersurface of the acromionFrom the collection of Daniel J. Solomon, MD; used with permission [Citation ends]. com.bmj.content.model.Caption@53116e50

Management of acute medium, large, or massive reparable tears

Surgical repair is the first-line treatment for patients with good functional status, especially if functional demands are high , or the injury is on the dominant side. Options include arthroscopic, mini-open, and open repair. The primary goal is to provide a pain-free joint with good function.

If the patient is older and sedentary, rehabilitation therapy with NSAIDs, ice, stretching, and exercise should be considered before surgery. Rehabilitation should be managed by a physiotherapist. Focus should be on strengthening remaining cuff, deltoid, and scapular stabilisers, as well as posterior capsular stretching.

Irreparable tears

Debridement may be appropriate for patients with pain as their predominant symptom and lower demands for shoulder strength. The ideal debridement patient has good deltoid function and an intact coracoacromial arch.

Arthroscopic debridement can include bursectomy, acromioclavicular joint resection, and smoothing of the greater tuberosity. Subacromial decompression alone for the treatment of symptomatic rotator cuff disease presenting with impingement features and without full‐thickness rotator cuff tears does not provide clinically important benefits compared with placebo surgery with respect to pain, function, or quality of life, and is no longer routinely recommended.[39][43][44] BMJ: subacromial decompression surgery for adults with shoulder pain: a clinical practice guideline Opens in new window However, decompression in the presence of rotator cuff repair may, in some cases, lower recurrent tear rates.[45]

Reverse shoulder arthroplasty (RSA) is an established surgical option that is used for the treatment of massive, irreparable rotator cuff tear with or without arthritis in cuff tear arthropathy settings, or in elderly patients with dislocation and cuff tear that fail non-operative management, or rotator cuff tear.[46][47] Systematic reviews and meta-analyses indicate that newer designed prostheses that offer a lateralised centre of rotation RSA may be the preferred approach.[48][49]

Tendon transfer is appropriate for patients with high demands for shoulder strength. Patients must be able and willing to perform extensive postoperative rehabilitation. Muscle transfers have been effective for anterosuperior tears involving the subscapularis and supraspinatus, and for posterosuperior tears involving the supraspinatus and infraspinatus. Effective donors are the pectoralis major for anterosuperior tears and the latissimus dorsi for posterosuperior tear.[50][51] Lower trapezius transfer is becoming increasingly popular, because this transfer closely mimics the line of pull of the infraspinatus.[52][53]

Superior capsular reconstruction prevents superior humeral head migration, resulting in enhanced deltoid function. This procedure may be offered to patients with isolated irreparable rupture of the supraspinatus, where medical treatment has not been successful.[54] Other indications include a massive, irreparable tear of the rotator cuff or an intact or repairable subscapularies tendon (if there is intolerable pain despite conservative treatment and minimal or absent evidence of arthritis), or for patients who do not wish to undergo arthroplasty.[54][55][56] The results have been inconsistent but investigators maintain that technique success depends on graft type and thickness.[54][55]

Chronic tears

In general, chronic tears should be treated initially with conservative therapies (e.g., ice and stretching, cuff strengthening, scapular stabilisation, NSAIDs, and subacromial corticosteroid injections). Involvement of a physiotherapist is often helpful.

Surgery can be pursued if a tear is unresponsive to non-operative treatment after 10-12 weeks. Younger patients are typically treated with a more aggressive approach, with surgery considered earlier in their treatment course, especially if they complain of weakness.[32] Patients must be engaged in their treatment. The patient’s belief in the success of rehabilitation is the strongest predictor of non-operative outcome, more so than tear size.[57]

In an older patient with a large chronic tear, the quality of the tissue is often less than optimal for healing. These patients and others with low functional demands are frequently less interested in powerful overhead actions and more interested in pain relief with a functional arc of motion. A well-designed, non-operative rehabilitation programme, consisting of stretching and strengthening, can often attain these goals.[57][58] The focus of this rehabilitation is pain control, restoration of full passive motion, and optimisation of rotator cuff and periscapular muscle strength and co-ordination.

Subacromial corticosteroid injection can be used if symptoms limit rehabilitation exercises, but should be used with caution if surgery is a reasonable possibility due to the adverse effects of corticosteroids on cuff healing and infection risk.[41] Exercises can be resumed a few days after injection.

One meta-analysis found that suprascapular nerve block had similar efficacy compared with intra-articular corticosteroid injection for shoulder pain, and may be used as an adjunct therapy if corticosteroid injection alone does not provide sustained pain relief.[59]

For patients with considerable pain after 10-12 weeks of therapy, the following surgical options should be considered on a case-by-case basis.[32][50][51][52][53][56][60][61][62]

Arthroscopic, mini-open, or open surgical repair: typically considered for patients with both pain and functional limitations who are anticipating return to an active lifestyle.
Debridement: typically used for patients with minimal functional limitations but pain as a primary complaint, and for patients with limited functional goals and expectations. Tuberoplasty can be performed when there is a prominent greater tuberosity, which may abut the acromion on abduction.
Hemiarthroplasty and reverse total shoulder arthroplasty: salvage procedures for patients who have long-standing tears and develop cuff tear arthropathy.
Superior capsule reconstruction: typically used for younger active patients with irreparable tears. The procedure employs a graft to reconstruct the superior capsule and may inhibit proximal humeral migration. This technique should not be used in the presence of advanced arthropathy or irreparable subscapularis tear.
Balloon spacer: indicated for irreparable tears in patients who are not suitable candidates for arthroplasty. An inflatable biodegradable balloon is inserted under the acromion to act as a physical barrier to reduce subacromial friction. This device may help enhance deltoid rehabilitation; however, the reported success of this intervention has been inconsistent.[63][64][65]
A balloon may also be used to ‘protect’ a cuff repair as well as prevent subacromial adhesions.[66]
Tendon transfer: appropriate for patients with high demands for shoulder strength and considered when muscle belly tissue is poor and may not function, even in the presence of a successful tendon repair.
Glenohumeral arthrodesis: can be considered as a last resort for intolerable pain but will eliminate all glenohumeral motion. Rarely used in younger patients but may be considered in those who have failed reverse total shoulder arthroplasty, especially in the presence of persistent infection.

Physiotherapy

The typical postoperative course normally involves a period of formal physiotherapy/rehabilitation. The length and type of rehabilitation varies based on the type of intervention performed.

Tear size may be an influential factor in the rate of retearing after early passive ROM is performed.[67] One study showed that early motion does not necessarily lead to an increased risk of retear compared with 6 weeks of immobilisation in double-row repairs of smaller (i.e., <3 cm) tears.[68] However, for larger tears and in the presence of poor tissue quality, delayed mobilisation is preferable.[69]

Postoperative care can safely be accelerated to 4 weeks of immobilisation in medium to large tears. One study found that 8 weeks of immobilisation offers no advantages compared with shorter periods in patients with medium-sized tears.[70]

Early ROM exercise accelerated recovery from postoperative stiffness for patients after arthroscopic rotator cuff repair, but was likely to result in improper tendon healing in shoulders with large-sized tears.[71]

For subacromial debridement/tuberoplasty, physiotherapy typically involves 6-12 weeks of passive/active motion, rotator cuff strengthening, and other physiotherapy modalities. After a rotator cuff repair the schedule may involve 6-12 months of rehabilitation (e.g., motion, strength, other physiotherapy modalities) with slower progression to allow adequate healing of the repair. After arthroplasty there may be a 4- to 6-month programme with emphasis on regaining motion, strength, and function.

Superior capsule reconstruction requires 6 weeks of immobilisation followed by active assisted ROM for an additional 6 weeks.

Subsequent to balloon spacer insertion, patients are required to engage in early rehabilitation focusing on deltoid and scapular strengthening.

Following tendon or muscle transfer procedures there might typically follow an extensive 12-month rehabilitation programme with the goal of retraining muscles to provide shoulder function.

In more complex surgeries, regional anaesthesia with an interscalene block provides good immediate pain control for the first 12-24 hours.[72][73] Following this, most patients are initially placed on opioid analgesics for the first 2-4 weeks. Most patients are able to wean off opioids by their second postoperative visit.

Techniques for surgical repair

Surgical options include arthroscopic, mini-open, and open repair. The primary goal is to provide a pain-free joint with good function.

In open rotator cuff repairs, the surgeon is constrained to the area visualised within the incision to perform the repair. Arthroscopy, a minimally invasive technique, allows the surgeon to approach and assess the tear from multiple angles to better define the tear and repair it anatomically. The ability to address glenohumeral pathology at the time of rotator cuff repair, in conjunction with enhanced visualisation, is a major benefit.

Randomised control trials, systematic reviews, and meta-analyses report similar outcomes following open, mini-open, or arthroscopic repair.[74][75][76][77] Arthroscopy may be associated with decreased short-term pain.[76]

Results from systematic reviews with meta-analyses typically indicate that double-row suture repairs facilitate improved healing rates, but not recognisable differences in outcome scores.[39][78][79][80][81][82] Double-row suture repair is a more demanding technique than single-row repair. Single-row repair augmented with microfracture may offer some benefit in enhancing the biology of healing by microfracture or abrasion of the greater tuberosity.[83]

Associated pathology and biological augmentation

Superior labrum anterior posterior (SLAP) tears and biceps tendon pathology frequently accompany rotator cuff tears. Subscapularis tears may also be present and are often difficult to recognise. The subscapularis is the largest cuff muscle and tears may be associated with significant pain and dysfunction. Recognition and concurrent treatment of these lesions may contribute to improved postoperative function.[84]

Platelet-rich plasma (PRP) has been used to augment rotator cuff repair of full-thickness tears with inconsistent results.[85][86][87][88] Practice guidelines conclude that the use of PRP in patients undergoing rotator cuff repair does not improve patient reported outcomes.[39] Long-term re-tear rates may be reduced in patients who receive PRP.[87]

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