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The name “Rotator Cuff” is used to describe the group of small but important muscles around the shoulder joint and their tendons that helps control shoulder joint movement. The supraspinatus is at the top of the joint, the subscapularis is in front and the infraspinatus and teres minor are at back side. These muscles insert or attach to the humeral head by way of their tendons. The tendons fuse together giving rise to the term “cuff.” Although each muscle acting alone may produce an isolated rotational movement of the shoulder, the role they play together is to help keep the humeral head (ball) centered within the glenoid (socket) as the powerful deltoid and other larger shoulder muscles act to lift the arm overhead.
Acromion a bony projection forms the roof of shoulder apartment. Between the rotator cuff tendons and the acromion is a protective fluid-filled sack called a “bursa”. With normal humeral elevation there is some contact between the rotator cuff, the bursa, and the acromion. A healthy and strong rotator cuff holds the humeral head down in the socket and minimizes the upward pressure on the acromion.
Disease:
Rotator cuff problems may be because of outside or inside reasons. Outside examples include a tear because of fall or vehicular accident. Overuse injuries from repetitive lifting, pushing, pulling, or throwing are also extrinsic in nature. Inside reasons include poor blood supply, normal attrition or degeneration with aging, and calcification of the tendon.
Rotator cuff tendinitis is the term used to describe irritation of the tendon either from excessive pressure on the acromion or less commonly from intrinsic tendon pathology. Irritation of the adjacent bursa is known as “bursitis.” Repetitive overhead activities resulting in irritation of the tendon and bursa from repeated contact with the undersurface of the acromion is called “Impingement Syndrome.”
Rotator cuff malfunction is typically a pendulum of pathology ranging from tendinitis and bursitis on one end of the spectrum to partial tear, to a complete tear in one or more of the tendons on the other extreme end. Although the earlier stages may recover with conservative treatment, actual tearing of the tendon can be more problematic. Because this area has a relatively poor blood supply, injury to the tendon here is very unlikely to actually heal. Additionally, the constant resting tension in the muscle-tendon unit, or “muscle tone” with basic day to day movements, pulls any detached fibers away from the bone, preventing their healing. This is the reason why complete rotator cuff tears do not heal with rest.
Arthroscopic view of a rotator cuff tear
Above image shows a typical rotator cuff tear. Reality is that not all tears need operation and not all tears increase in size. Sometimes a tear causes minimal pain and do not worsen with time. The bigger the tear, the more likely it will need operation. Patients with rotator cuff problems commonly present with an movement related dull pain in their upper outer arm and shoulder. Above chest level movement are usually most difficult.
X-rays technology is meant to see bones and not tissues. It will not show the rotator cuff (Muscles), but they will reveal any Changes of arthritis, Calcification, loose bodies, fractures from a fall, Dislocation, calcific nodules, and congenital (birth) related diseases. They can also show changes of massive long standing tears. Therefore, good quality x-rays are a must in the proper evaluation of the shoulder.
Contrary to what many patients believe, a plain xray can be very helpful. In this case the humeral head is located a bit higher than expected. This is a sign of a massive tear.
Magnetic Resonance Imaging or MRI is gold standard for diagnosis and prognosis (future recovery) of rotator cuff tears. An MRI can saw us tendinitis, Bursitis, partial tears and complete tears of the rotator cuff. While an MRI is not always necessary to diagnose a torn rotator cuff, it can be very helpful to determine which tendons are torn, how large the tear is, the degree of tendon retraction, the extent of muscle atrophy and any other related other problems.
ARTHROSCOPIC ROTATOR CUFF REPAIR
Rotator cuff tears are now repaired with state of the art machineries. Yes I mean Machineries. We have very sophisticated cameras which are attached to Arthroscope (4 mm). Surgery is done seeing at camera. (Watch the video below.) Hardly 4 holes are made according to requirement.
This is a simple 1 day surgery. You will be seen by an anesthesiologist prior to surgery, who will discuss the option of putting another kind of injection in your shoulder so that your whole arm goes to sleep prior to the surgery and stays asleep for 12 to 24 hours afterwards. Additionally, you will go to sleep with general anesthesia for the entirety of the surgery. The surgery takes 1 to 2 hours. When you wake up, you will have a Shoulder brace. You will stay in the recovery room for around an hour. Then you are shifted to room, you are ready to go home next day.
During the operation, we will use suture anchors to sew the torn muscle and tendon back down to the bone where it was originally attached. Those stitches hold the rotator cuff down to bone for the next three months while the two grow and heal back together.
