Rotator Cuff degeneration

If the impingement is not recognized or treated, the next stage in the degeneration of the shoulder is the giving way or tearing of the rotator cuff. This structure is made up of the muscles and capsule joining together to move and stabilize the shoulder joint. If this stage is not treated, the last stage in the full degeneration of the shoulder is of wearing of the joint surface or severe osteoarthritis. This is called cuff arthropathy and this is difficult to treat because even if an artificial joint prosthesis is inserted there are no muscles to move it adequately.

Most patients presenting with tears of the rotator cuff are usually in the 55+ year age group and often complain of the following:

1. continual aching in the shoulder, often worse at night
2. can't sleep on that side
3. sharp pains with reaching (but not always)
4. often grating, crunching, clicking with movements
5. sometimes loss of movement
6. nearly always weakness and
7. frequently pins and needles or tingling in the hands

Occasionally younger patients do present with a tear of the rotator cuff but this is generally after some considerable trauma such as fall from a height, or after a work or car accident.

Investigations include:

1. X-rays to show the bony structures. This is useful to exclude other diagnoses and to determine the size of bone spurs and the severity of any associated arthritis.
2. Dynamic ultrasound demonstrates the soft tissues - in particular the integrity or otherwise of the muscle, cuff and capsule
3. Bone scan occasionally to determine a contribution from the adjacent acromioclavicular joint.
4. MRI when the condition is not straight forward and the clinical picture does not fit in with the findings of the other investigations.

Surgery

Firstly the shoulder joint is inspected accurately with the arthroscope to remove any flaps of cartilage, torn ligaments or labrum and synovial flaps. The ends of the torn cuff and tendons are trimmed with the Laser or mechanical instruments, the excessive synovium or joint lining sclerosed with the Laser and all loose material removed or washed out.

The edges of the cuff or muscles are mobilized or freed from the surrounding tissues and then reattached back to a groove in the bone of the head of humerus (ball of the shoulder). This is usually performed through a small 5cm incision or the outer aspect of the shoulder which normally heals with minimal scarring. Any bone spur must be removed at the same time to allow the repair to glide easily under the bony arch without any further wearing.

After the surgery

1. Most patients stay 1 night in hospital, but often report loss of the "deep burning pain" immediately but of course experience pain from the cut of recent surgery.
2. Younger patients often experience more pain because of larger muscle bulk and tone. This can be controlled overnight in hospital with IV analgesia, and simple tablets when they leave the next morning.
3. A sling is applied in surgery and kept on for 6 weeks, but can be removed for showers. This must be worn behind the shoulder and not around the neck or else the patient may experience neck pain.
4. Discharged the day after surgery, the patient is usually independent for dressing ,washing and self care. May need some help with food preparation and house chores.
5. Review at 3 and 6 weeks. Exercises explained in hospital by the physiotherapist and at these reviews.
6. No driving for 8 weeks. Need 2 weeks after the sling is removed to develop sufficient strength to control the car safely !
7. No lifting with this arm for 3 months, no heavy lifting for 6 months, thereafter I suggest restricting to less than 20 Kg permanently!
8. Work depends on the environment but can use hand in the sling immediately, no reaching out or carrying. Most can resume light duties by 6 weeks (but no driving) and normal duties (with weight limit) at 6 months.

Sport such as golf - putting and chipping from 3 months, full game about 6 months!

Complications:

Complications such as anaesthetic, medical and surgical can occur after any surgery but fortunately are uncommon. The anaesthetist will discuss risks of anaesthetic with you prior to the operation and advise on the safest form (you may contact him/her before the day of surgery if you wish or your doctor is concerned).

Possible complications with shoulder surgery include:

• infection - we take all steps to minimise this, including covering the operation with an antibiotic
• bleeding, swelling, stiffness and possible nerve injury
• frozen shoulder and/or adhesions often self limiting, more common in Diabetics and minimised by starting movement early. Muscle tension and spasm tend to make patients more prone to this so must be controlled.
• scar formation is usually minimal because of the arthroscopic technique
• pulling out of sutures if you fall over or reach out suddenly e.g. catching a falling object. Sometimes the tissue being repaired is not strong enough to hold the stitches - especially if the tear has been left a long time.