Rotator cuff rupture
(Tear of the tendon cap)
The rotator cuff tears generally rare as a result of an accident, but due to the constant jamming under the roof of the shoulder when lifting the arm (also see section impingement syndrome). Impingement syndrome can thus be caused at the tendon and the associated bursa by constant rubbing of the tendon cap with the shoulder roof, leading not only to swelling, inflammation and calcification, but also to a complete rupture in the final stage.
Of course, a more or less severe injury to the shoulder (a fall or shock) can lead to a rupturing of the strongly pre-damaged tendons cap, and an injured rotator cuff can also tear by itself (chafing).
Mostly the affected patients are at an advanced age.
The rotator cuff can, though less frequently, also be torn in young patients after a given injury.
Pain in the affected shoulder are the given complaints, during the night, or during stress.
The arm is often weak and can be only badly uplifted in the shoulder. "Reaching for the neck" and the so-called "apron tying" are painful and restricted.
In young patients, in some cases the pseudoparalysis occurs (apparent paralysis) - the arm can no longer be lifted. The diagnosis of tendon rupture is done by physical examination, x-ray, magnetic resonance, and if needed by a sonography (ultrasound).
Rotator cuff rupture
The treatment of rotator cuff tears depends on the type and size of the tendon rupture as well as on the extent of the pain, the age and the desired activities of the patient's.
The treatment does not follow a rigid pattern, but is circumstancially made given a rotator cuff rupture, therefore applied "a la carte".
In case of a surfacial partial rupture of the tendon (usually affects older patients), conservative treatment (infiltration, physical therapy) often leads to to success.
Should they fail, then the arthroscopic decompression (see section impingement syndrome) and smoothing of the tendon are performed. The tearing then does not proceed further, because the tendon has more cap space.
a) In case of young patients with acute injury-caused ruptures of the rotator cuff, a diagnostic arthroscopy and an arthroscopic or open (transosseous) reconstruction (suture of the tendon) is always performed (open and transosseous means an approximately 8 cm incision and that the tendon is thereby attached to the bone).
b) In elderly but active patients with acute injury and pre-damaged tendons, conservative therapy is also dispensed with and the operation is performed after the arthroscopy. For these patients, a acromioplasty is connected with the treatment (see section impingment syndrome).
c) For some active patients with a creeping rupture, intensive conservative therapy is first tried for about six weeks. In case of failure, the operation is carried out as below.
d) In elderly patients with low levels of activity and severe pain, which can not be controlled conservatively, usually there is a larger rupture ("humerus bald").
The humeral head is no longer covered by a tendons cap and the tendon edges are completely frayed.
The sessions are held arthroscopically in case of such pain.
The edges of the tendon tears are smoothed, the joint itself, which mostly has signs of strong osteoarthritis is cleaned and smoothed with a milling machine (debridement). Also the lower surface of the acromion is merely smoothed and not thinned out, as otherwise the high-lying humeral head would rise further due to the missing rotator cuff .
If this minor procedure is not enough, then these patients are treated with a special endoprosthesis (artificial joint) - see corresponding section.
1. After tendon repair: depending on the defect size, complete rest for five to six weeks in a knapsack bandage (the arm is flexed 90 degrees at the elbow and fixed to the body with a strap). Passive physiotherapy starts from the second postoperative day, active physiotherapy starts in the third week. Underwater therapy from the sixth week.
2. After arthroscopic smoothing: the same as in the treatment of impingement syndrome - see above.
Ability to work
1. Office work after the open tendon repair, with the bandage can be started after two to three weeks, heavy physical work can begin after about four months.
2. After arthroscopic smoothing: see impingement syndrome.
Shoulder-friendly sports can be exercised after 3 months, shoulder stressing sports (overhead sports, contact sports) after 4 to 6.
1. The tendon repair provides about 90 per cent satisfactory results regarding pain relief and powerful, free movability.
2. After arthroscopic treatment of partial tears of the shoulder tendons cap, almost all patients gain relief from pain (98 percent) and have a fully mobile shoulder.
3. The method described in d) does not represent a reconstructive, but just a pain-relieving intervention. The pain often lessens, the mobility however improves little or not at all. If the patient can not cope with it, a special prosthesis is implanted.
In about 3 percent of the cases, a wound healing disorder caused by infection can delay the postoperative process, but the end result is usually not adversely affected. In about 1 percent there remains a small gap in the large deltoid muscle, and in about 5 per cent the operated rotator cuff tears again. The complications occur much rarely in arthroscopic procedures.