By Dr Dan Laptoiu, MD, Bucharest, Romania
About the rupture of the rotator cuff
The rotator cuff is essential for normal function and strength of the shoulder. Ruptures of the rotator cuff reduce the strength of the joint and lead to arthritis. It is therefore logical to attempt to repair them. Many authors consider intrinsec rotator cuff degeneration and rupture as the primary etiology, with secondarily developed lesions of the subacromial space like impingement sindrome. Tears usually occur at the supraspinatus insertion.
The rotator cuff consists of three main musculo-tendinous elements: supraspinatus, infraspinatus and subscapularis. To these should be added teres minor and the long head of biceps. The rotator cuff ensures that the head of the humerus is centred in relation to the glenoid.
Muscular or tendinous ruptures of the cuff
The tendons of the cuff muscles which rupture undergo progressive fatty infiltration termed `fatty muscular degeneration'. This degeneration is seen on CT horizontal slices with soft tissue windows and fatty degeneration has been quantified according to the percentage of the muscle which it occupies.
Rotator cuff tears are usually associated with chronic pain at overhead activities and night pain. Examination is performed with the arm at side and the elbow flexed at 90 degrees – the examiner resists external/internal rotation; thus appreciating the force of the muscles.
Treatment of rotator cuff ruptures
A factor that may contribute to chronicity and recurrence of pain in the shoulder is weakening of the rotator cuff muscles from reflex inhibition or from actual disuse. Such weakening would predispose to subacromial impingement during elevation of the arm and further mechanical irritation to the site of the lesion. Rotator cuff strengthening is, therefore, an important part of the treatment program in any shoulder lesion. However, if recent or repeated steroid injections of the tendon have been performed, a gradually strengthening program should be taken into account. While local steroids do relieve the pain through inhibiting the inflammatory response, they have an antianabolic effect on connective tissue, which may result in structural weakening of the injected tendon.
Reconstructive surgery must use techniques which include the reinsertion of healthy tendon without tension with healthy or reinforced muscle. The patient must be warned of the difficulty of postoperative physiotherapy and of slow recovery.
The more the tears are of degenerative origin in elderly patients, with no clear injury, the smaller is the possibility of a satisfactory simple repair.
Isolated ruptures of supraspinatus do not necessarily need to be repaired. Nevertheless, it seems wise to do so in young patients. If plastic surgery – involving realocation of other muscles - is necessary for a good repair, it should be performed. In older patients, repair of isolated ruptures of the supraspinatus should be done only if the shoulders remain symptomatic after conservative treatment. In such cases, however, palliative surgery can also be recommended.