Description:

The rotator cuff is an important group of muscles which surrounds the shoulder joint, keeping the ball and socket in a good position and powering a range of movements which allow positioning of the hand for all sorts of daily activities and sports.

The rotator cuff may be affected by degenerative disease (wear and tear) and injury leading to the development of pain, limitation of movements, and difficulty with everyday tasks such as reaching up or dressing, as well as causing wakeful sleep.

Initial management includes rest, activity modification, tablets/medication, physiotherapy and steroid injection, which may give temporary relief.

Apart from evaluation with plain X-ray, you may need more detailed imaging in the form of ultrasound or MRI scan which may pick up a tear in the rotator cuff.

Near to the shoulder joint, and occasionally also a cause of pain, is the acromioclavicular joint (ACJ) which may be affected by arthritis or injury.

Operative Treatments:

Arthroscopy (keyhole) examination of the shoulder is the first step. The rotator cuff tendons are inspected from within the shoulder joint and also from above in the subacromial space or bursa, which lies just under the bony roof of the shoulder (acromion). Impingement may be identified where the worn or frayed rotator cuff tendons are catching under the acromion. Alternatively, a worn tendon may have progressed to a torn tendon.

Other structures which may contribute to symptoms are checked, including the long tendon of biceps which runs through the shoulder joint, the joint surfaces themselves which may be affected by arthritis, and the structures around the edge of the socket (labrum and capsule) which may be inflamed or damaged.

If the diagnosis is of subacromial impingement without a tear, then arthroscopic acromioplasty is performed which entails the shaving of ligament and bone from the undersurface of the acromion to remove inflamed scar tissue and enlarge the space below for the tendons.

If a cuff tear is identified and it is repairable, then reattachment of tendon to bone is done using suture anchors, usually also through a keyhole approach or sometimes a mini-open approach. Other procedures which may be necessary include tenotomy (division) or tenodesis (fixation) of the long tendon of biceps, repair of the biceps tendon attachment and excision (trimming) of the outer end of the clavicle for arthritis in the acromioclavicular joint (ACJ). Depending on the findings at arthroscopy, more than one procedure may be necessary.

Rehabilitation:

Depending on the exact procedure carried out, physiotherapy is tailored to the individual such that repairs are protected but the shoulder is not allowed to stiffen while it recovers. Usually a collar and cuff is worn to rest the shoulder for the first 2 weeks and only gentle pendulum exercises are done. Progressive movements are introduced until, at around 6 weeks, overhead activity can be re-started. Once a full range of movement has been restored, the strengthening exercises are introduced.

Complications:

Superficial wound infections at the surgical incisions can occur, but deep infections are very rare. Shoulder stiffness is a complication that can significantly prolong recovery if it occurs. Early gentle movements after surgery minimise the risk of this.