Prof. Simone Cerciello, expert in Orthopaedics and Traumatology in Rome, discusses the main causes of rotator cuff tears and the possible surgical treatments.
What do we mean by rotator cuff tear?
The rotator cuff is a set of 4 muscles (supraspinatus, infraspinatus, subscapularis and teres minor). The balance between their action and that of the extrinsic muscles (mainly the deltoid) guarantees the function of the shoulder and the whole upper limb. Rupture of these tendons can be asymptomatic without repercussions on the patient's quality of life and limb function. When the patient is symptomatic, complaints include pain (very often even at night), reduced motion and loss of strength in the affected limb. The most frequently involved tendon is the supraspinatus.
What are the causes of rotator cuff tears?
Many theories have been proposed to explain the onset of these lesions. In general they are degenerative and more rarely post-traumatic. In the latter case the patient often reports an accidental fall with trauma occurring with the arm outstretched. More rarely trauma is directly on the shoulder. Degenerative lesions are much more frequent and result from repeated use of the limb over life, especially in activities occurring above the shoulder plane. The peak incidence of these injuries is between 60 and 65 years. Local factors such as impingement with the acromion and the coraco-acromial ligament, or altered tendon vascularisation may play an important role. External factors such as smoking and diabetes can in turn alter the metabolism of tendon cells. Diagnosis is based on patient history, clinical examination and imaging studies such as X-ray, ultrasound and MRI.
What categories of surgical treatment are possible?
The initial approach to a patient with a rotator cuff tear is always conservative, with medication, an appropriate rehabilitation protocol and possibly injection therapy. When this fails, surgical treatment is chosen. The aim of surgery is to restore anatomy by reinserting the injured tendons. In the past this was done through open surgery; more recently, arthroscopic techniques have been preferred. These are minimally invasive, preserve tissue and allow a better view of anatomical structures. The operation consists of recognising and treating any lesions or anatomical anomalies such as an aggressive acromion (by partial resection or acromioplasty) or acromio-clavicular arthritis (by removal of the lateral end of the clavicle). In extensive lesions, restoration of the original anatomy may be impossible. In such "massive" tears partial repair may be chosen. Research is directed at these "difficult" lesions with techniques that increase the healing capacity of the tendons (e.g. bone-marrow stimulation techniques), the strength of the repair (e.g. use of patches) or restore the correct function of the shoulder (e.g. superior capsule reconstruction).