Synonyms
Lesion of the rotator cuff, rotator cuff rupture, supraspinatus tendon rupture, periathropathia humeroscapularis pseudoparetica, torn tendon, tendon fissure.
Definition
The rotator cuff forms the cap of the shoulder joint and it is composed of four muscles and their tendons, which extend from the scapula to the head of the humerus (Tuberculum majus and Tuberculum minus).
The four muscles (of the rotator cuff) are:
Musculus infraspinatus,
Musculus supraspinatus,
Musculus subscapularis,
and Musculus terres minor.
The rotator cuff has important functions. It stabilizes the shoulder joint and it is responsible for the lateral and inward rotation of the arm. It is also partially involved in the abduction of the arm.
If a rotator cuff rupture occurs, the tendon sheaths of these rotators are torn. The tendon of the Musculus supraspinatus is most frequently affected, due to its anatomically cramped position under the shoulder cap.
Such a rupture can be caused either by a serious trauma, for instance falling onto an outstretched arm, or subsequent to the degeneration (deterioration) of a weakened supraspinatus tendon.
Diagnosis
Various examination techniques can be applied with regard to diagnosing a rotator cuff rupture.
Normally, a functional examination of the shoulder joint is initially performed. Among other things, this form of examination includes an analysis of the muscular power performance of the rotator cuff against resistance during abduction of the arm, during lateral rotation and during medial rotation. The lateral rotation is analyzed with a bent elbow joint and while the arm is extended.
While the abduction of the arm reveals information about the functional capability of the Musculus supraspinatus, the performance of the lateral rotation against applied resistance is related to the functionality of the Musculus teres minor and the Musculus infraspinatus. The analysis of the powerful inward rotation of the arm monitors the functionality of the Musculus subscapularis.
Apart from functional examinations of the shoulder joint, imaging techniques such as x-ray, sonography (ultrasonic) and magnetic resonance imaging (MRI, NMR) are also available.
However, a rupture of the rotator cuff cannot be directly detected by an X-ray, because muscles and tendons are soft tissues of the body and they are completely transparent to X-rays.
Since the malfunction of the rotator cuff results in the elevation of the head of the humerus toward the shoulder cap, the observance of this phenomenon is an indirect indication of a severe rotator cuff rupture. But minor fissures of the tendons do not cause this phenomenon. However, it is more significant that x-rays can reveal concomitant morbidities (e.g. omarthritis or Tendinosis calcarea), which can provide information about the cause of the rotator cuff rupture. An osseous spur beneath the shoulder cap, for instance, can have torn a hole in the rotator cuff (subacromian spur; refer to Impingement syndrome).
The great advantage of sonography lies in its operational facility and practicality. This imaging technique provides a dynamic examination of the shoulder joint, during which the arm may be moved. This enables an examination of the rotator cuff while it is “at work”. Even small holes in the rotator cuff can be identified by a proficient examiner.
Nuclear magnetic resonance is increasingly used, most notably for examining injuries of the rotator cuff. Ruptures in the rotator cuff can be reliably recognized by this method. Furthermore, the quality of tendons and their retraction can readily be assessed, which can have direct consequences for the therapy that is recommended by the doctor.
A suspected diagnosis can be confirmed by performing an arthroscopy (endoscopy of the shoulder joint). Furthermore, the degree of the rotator cuff lesion (a total or partial rupture) can also be evaluated. As needed, treatment (such as a rotator cuff suture) can be applied simultaneously.
Symptoms
Symptoms may differ, according to the basic cause of the rotator cuff rupture.
The most frequent cause of a rotator cuff rupture is general deterioration, which means that the cuff tendons become thinner due to physiological stress and attrition in the course of time. Consequently, the quality and resistance of the tendons decrease.
Minor injuries or accidents can, therefore, ultimately lead to a rupture, even without the application of any external force. In such cases, the patient will at first sense a loss of power while performing certain arm movements. For instance, the patient can no longer maintain his arm at shoulder level at all, or only with great effort. Pains occur during the performance of certain movements (refer to functional analysis of the shoulder joint); consequently, the patient will generally start to avoid these painful movements. This phenomenon is also described as the patient’s adoption of a protective posture.
If the rotator cuff is torn due to an accident, sudden pain will occur. A total rupture of the rotator cuff is accompanied either by an inability to rotate the arm outwardly or to elevate it, or both of these movements can only be performed with great effort (refer to functional analysis of the shoulder joint).
In both cases, pressure pain is a typical syndrome at the onset of the supraspinatus tendon (Tuberculum majus).
The pain that is caused by a rotator cuff rupture can radiate from the upper arm right down into the hand. Generally, however, the pain is mainly concentrated on the lateral upper arm.
An impingement syndrome is often simultaneously evident.
Examinations
With regard to various diagnostic methods, some functional tests have already been described to verify the efficiency of the shoulder joint. In addition, there are other examination methods that ought to be applied within the scope of a physical examination. This form of examination generally comprises the differentiation between two clinical pictures: the impingement syndrome and the rotator cuff rupture.
- Elicitation of the so-called painful arc. Hereby, the arm is passively elevated sideways. At an angle of between 60 and 120°, the arc passes a point of constriction, which evokes pain if an impingement syndrome exists. Thus, by means of this method, disorders can be diagnosed that are caused by a constriction beneath the shoulder joint.
- In the event that the pain is so severe that the arm cannot be moved autonomously, an anesthetic is injected into the bursa. If the patient remains unable to move his arm despite the anesthetic injection, a rotator cuff rupture can be assumed. If the symptoms do not merely relate to functional deficits, but also resemble paralysis, this is designated as a pseudo paralysis.
Therapy
Within the scope of a rotator cuff rupture, both conservative and surgical methods can be implemented as therapeutic measures. Generally, a conservative form of therapy is favored for a partial rupture of the supraspinatus tendon. If a total rupture exists, the form of treatment must be decided upon individually. Patients over 65, who do not exhibit severe, functional limitations of the arm, and who are suffering pain that is tolerable, generally receive conservative treatment.
Conservative therapy may include the following procedures:
- Protection: for example by immobilizing the arm with the help of thorax abduction brace. After removing the brace, mobilization occurs via physiotherapeutic measures.
- Administration of anti-inflammatory medication (non-steroid anti-rheumatic drugs - NSAR), such as Diclofenac, Ibuprofen, Indometacin or non-steroid anti-rheumatic drugs of a newer generation (Cox2-inhibitors), such as Celebrex.
- Cryotherapy (therapeutic hypothermia): especially after an accident.
- Physiotherapeutic, painless exercises, including stretching and strengthening exercises, in order to prevent a stiffening of the joint.
This trains the remaining musculature.
- Infiltration under the shoulder cap to reduce pain.
As opposed to surgical treatment, the conservative therapy does not facilitate the “adhesive healing” of torn tendon parts. This is partially due to the fact that those parts of the tendons that were torn have retracted; thus, an adhesive healing of these parts is impossible. Despite this fact, conservative treatments are, nevertheless, able to restore the function of the shoulder joint to the extent that normal “everyday life” can be resumed.
If such a result is not evident after approximately three months, you should consider and discuss with your physician, whether conservative treatment still promises some success, or whether surgical treatment ought to be considered. These measures are described in the following.
Surgical treatment
Criteria that indicate the need for surgical treatment of a rotator cuff rupture are, for instance:
- Severe pain
- Age (< 65 Years) in combination with job-related or sport-related activities
- A rotator cuff rupture of the dominantly used arm
- Non-response to treatment or degenerative modifications of the shoulder joint.
Surgical therapy differentiates between the partial and the complete rupture with regard to a surgical procedure. Whether the surgery is performed as an arthroscopy or as open surgery depends on the size of the fissure. The smaller the fissure, the easier it is to operate by means of an arthroscopy of the shoulder joint. However, major fissures can generally only be cleaned by means of an arthroscopy and pain can be alleviated by a subacromion decompression (ESD). Various different procedures are possible, such as Neer’s plastic surgery of the acromion or the excision of the affected areas of the tendons. If for example, the existing fissure of the rotator cuff is transverse, a suture of the supraspinatus tendon is also possible. In this case, one refers to a trans-osseous suture (a suture going through the bone), i.e. a suture that fixes the tendon to its original point of onset. Various possibilities exist for securing the tendon in this operation:
- A screwed anchor, which is manufactured from either titan or bio-degradable material (self-resolving). All operations require surgical aftercare.
- Trans-osseous sutures that are sewn with special sutures and knotting techniques. (Mason-Ellen-Technique).
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