Last updated: Wednesday, January 26, 2005
Good judgement on the part of the patient and surgeon is needed to plan treatment of rotator cuff tears.
Acute tears of healthy tendons should usually be repaired promptly to restore strength and function to the shoulder. Rotator cuff surgery is particularly helpful in this acute situation. Chronic defects in weakened tendon tissue may not be repairable. Exercises or surgery to smooth the working surfaces may be preferable to cuff repair in these circumstances.
Although cuff repair may increase the strength of the shoulder, our preference is to avoid having the patient return to heavy lifting, pushing, pulling, or overhead work after a major cuff repair. Thus, we attempt to initiate vocational rehabilitation as soon as the diagnosis of cuff tear is made, indicating that in spite of optimal treatment, there is a substantial risk of retearing if the repaired cuff is subjected to major loads. It is important to remind both the patient and the employer that a cuff tear usually occurs through abnormal cuff tendon. Repairing the tear does not restore the quality of the tendon tissue; thus the repaired cuff remains vulnerable to sudden or large loads.
Patients with rotator cuff tears may present with problems of shoulder stiffness or shoulder roughness. Here we are concerned with the potential for improving strength through rotator cuff repair. Critical determinants of the success of operative treatment are the quality of the tendon and muscle and the amount of cuff tendon tissue that has been lost. As we have seen previously, the expected strength of the cuff diminishes with age and disuse. Thus, the chances of a durable cuff repair likewise decrease in older and less active shoulders. This is particularly the case if the cuff defect has been long-standing.
Durability and functional needs
Many of the factors that determine the durability of a repair can be determined without special imaging of the rotator cuff; they are discernible from the history, physical examination, and plain radiographs. MRI is not necessary to determine muscle atrophy. Factors that are encouraging about repair durability include: age less than 55, acute traumatic onset, short duration of weakness, no history of smoking, no steroid injections,no systemic steroids or antimetabolites, no concurrent disease, no infections, no previous shoulder surgery, no failed soft tissue repairs (eg. dehiscence, infections complicating herniorraphy), good nutrition, mild weakness, minimal spinatus atrophy, shoulder stability, intact acromion, no stiffness,and normal radiographs (without upwards displacement of head against coracoacromial arch).
Treatment of shoulder weakness caused by cuff failure is determined by the functional needs of the patient and the likelihood of a durable surgical repair. Patients with low functional requirements and a substantial number of the "discouraging" factors from the list above are given a nonoperative program to help optimize the strength and coordination of the muscles about the shoulder that remain intact. At the opposite extreme, patients with major functional demands and mostly "encouraging" factors are presented with the option of an attempted surgical repair, and informed that the success of this repair will be determined primarily by the quality of the tendon and muscle and the amount of tissue lost.
Cuff repair is a shoulder tightening operation. It is not a treatment for the shoulder with functional limitation caused by tightness, even if a cuff defect is present.
Not an emergency
If the shoulder demonstrates stiffness, especially of the posterior capsule, a shoulder mobilization program is instituted before consideration of surgery.
In chronic cuff deficiency, surgical repair is not an emergency: there is time to explore nonoperative management, including a general shoulder strengthening program along with the stretching program. This nonoperative program may be the treatment of choice in patients with chronic weakness who are not candidates for surgery or for those in whom achieving a durable repair seems unlikely. This program emphasizes strengthening the muscle groups which provide elevation of the shoulder.