THE LESIONS OF THE ROTATOR CUFF
What is the rotator cuff?
The rotator cuff is composed of a group of muscles with the respective tendons of the shoulder which originate from the shoulder blade and are inserted as a fan in correspondence of the humerus, allowing the normal articular functionality. The muscles are: subscapularis, supraspinatus, infraspinatus and teres minor.
How does a rotator cuff injury originate?
Injuries are frequent in patients aged over 55 years and rise with the increase of age while they are rare in patients under the age of 40 years. The explanation is that the tendons weaken and become less resistant with the aging. This explains how an older patient injury can occur as a result of a minor trauma or in the absence of a trauma while in young patients a trauma at high energy necessary is. In some cases, the lesion can be favored by the continuous friction of the tendons against the “roof of the shoulder blade”, which is called “acromion” to a curved or hooked morphology, that leads to a progressive wear of the same tendons.
The lesions are not all equal
The lesions of the rotator cuff are not all equal firstly for the size of the lesion itself: we define as partial lesions when affecting only a part of the tendon while the lesions are complete when the entire thickness of the tendon is involved. The lesions can also include one or more tendons up to be massive (sometimes beyond repair) and based on the era where they occurred they may be recent or old (inveterate).
What does a rotator cuff injury implicate?
Not always a subject with lesion of the rotator cuff is symptomatic but in most cases it is or becomes. The two typical symptoms are pain, especially at night that the patient experiences in the shoulder, often radiating to the arm until the elbow and functional limitation in the movements of external rotation and/or internal that can go from a weakness until the complete inability to perform one specific movement.
How does a rotator cuff injury evolve?
Unfortunately, like all tendon injuries it is very difficult that they heal by themselves. Indeed over time often they tend to increase in size, and so the possibility to create serious biomechanical alterations to the shoulder joint and in some cases a joint wear that can result in a severe arthrosic framework. The upgradeability of the lesion is mainly related to the age of the onset of the injury and to how much and how the shoulder is employed.
How is it possible to make the diagnosis?
An orthopedic specialist evaluation in most cases in sufficient to establish a diagnosis of suspicion which, moreover, will be confirmed by instrumental examinations, in particular from the ultrasound (very widespread examination, but strictly dependent from the operator) and especially from the magnetic resonance imaging (if not contraindicated), which is able to confirm the presence of the lesion and also to define its reparability, allowing also to highlight any concomitant diseases.
When can the injury be repaired?
Not all the tears of the rotator cuff should be repaired surgically. The indication for surgery must be evaluated from the result of a thorough specialist evaluation and depends on several factors including the age of the patient, functional requirements and of course the reparability of the lesion. But there are also extensive traumatic injuries that occur mostly in younger patients that require a surgical repair in a short time.
How is the surgery performed?
The modern surgery allows the use of minimally invasive techniques that are performed endoscopically with the help of an arthroscope that is a fiber optic instrument that allows the visualization of the joint structure and with the appropriate toolkits the treatment of lesions through the execution of small incisions in the skin.
The repair of a tendon rupture borne by the rotator cuff cannot always be complete, but sometimes must be partial. The surgical technique essentially uses metallic or absorbable little anchors, which are stuck to the bone in correspondence with the area of the tendon insertion; the anchors are featured with wires which are passed in the tendon tissue with the appropriate instruments and then knotted allowing the closure of the lesion. If there are those lesions, in association or not with the use of anchors, stiches are put between the two free edges of the tendon with a technique called “side to side” with the effect of reducing the area and give a correct balance of the lesion.
What can happen . . .
In rare cases (about 4%) a chronic insufficiency of the rotator cuff causes a progressive wear of the articular surface until a particular form of arthrosis called eccentric.
Faced with this pictures, the initial treatment will be conservative, so fisiokinesiterapic and pharmacological but sometimes it is necessary to resort to a surgery, not so much arthroscopic (able to determine, however, a temporary palliative effect) as prosthetic; particularly in recent years prostheses have been developed and dedicated to this specific type of arthrosis known as “inverse prostheses” that allow a partial recovery of the functionality and an improvement or regression of the painful symptomatology.