Rotator cuff tears are not always treated with surgery: Prof. Simone Cerciello, expert in Orthopaedics in Rome, explains the causes of these injuries and the alternatives to surgery.
What is the rotator cuff and what does it do?
The rotator cuff is a structure composed of four tendons and as many muscles that surround the head of the humerus. The four muscles (supraspinatus, infraspinatus, subscapularis and teres minor) originate from the scapula and insert onto the greater and lesser tuberosities of the humerus. Elevation and rotation of the arm, together with the stabilisation of the humeral head within the shoulder joint, are the main functions of the rotator cuff.
What causes a rotator cuff tear and how do I know if I have one?
The causes of a rotator cuff tear can be blunt trauma or the result of chronic wear related to tendon degeneration. Impingement of the tendon against the anterior portion of the scapula, the acromion, is considered one of the main causes of cuff tears in individuals over 40. Typically, pain is felt in the anterior region of the shoulder and can radiate along the arm. It may arise during activities where the arm is raised, lifted or extended above head level, and it may be difficult to sleep on the affected side. Weakness of the arm and difficulty in daily activities such as combing hair or reaching behind the back can also be noticed.
Is there room for a conservative, non-surgical approach to rotator cuff tears?
Many rotator cuff tears can be treated non-surgically. The symptoms can benefit from the use of anti-inflammatory drugs, cortisone injections and physical therapy. The goal of treatment is to relieve pain and restore shoulder strength. Although a cuff tear cannot heal without surgery, satisfactory function can still be achieved without it. However, if the patient is an active person and performs work or sports activities where the arm is used above head level, surgery is more indicated because the tear cannot heal on its own. Moreover, a rotator cuff tear can extend and become larger over time. This may occur due to repeated shoulder use or following new trauma. It is common for patients with a known rotator cuff disease to feel acute pain and weakness even after minor trauma. This clearly represents the extension of a pre-existing injury.
When to propose surgical repair of a rotator cuff tear?
Surgery is indicated in case of persistent pain or shoulder weakness that do not improve with non-surgical treatment. Patients requiring surgery frequently complain of night pain and difficulty using the arm for lifting or reaching. Surgery is also indicated in active individuals who perform work or sports activities using the arm above head level, such as pitchers, swimmers and tennis players.
What options are available for surgical repair?
Open surgery was the option of choice for decades. More recently the arthroscopic technique has spread thanks to its clear advantages. This technique offers a better visualisation of the cuff and of the other anatomical structures of the shoulder (e.g. the long head of the biceps, the articular cartilage, the labrum, etc.). This is very important because an accurate assessment of the anatomical lesions is fundamental for subsequent rehabilitation. With the arthroscopic technique all types of cuff tears can be repaired: from partial to massive lesions, guaranteeing a lower aesthetic impact and reduced post-operative pain compared to the traditional open technique. It should be emphasised that this operation requires specific surgical skills that must be refined over time.