In this episode of PodMD, Orthopaedic Surgeon Dr Shivan Jassim will be discussing the topic of rotator cuff repairs. We discuss what a rotator cuff tear is, how it usually presents, potential treatment options, and more.
- Transcript
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Today I’d like to welcome to the PodMd studio Dr Shivan Jassim.
Dr Shivan Jassim is a fellowship-trained Orthopaedic Surgeon, specialising in conditions of the shoulder, elbow, wrist and hand. Dr Jassim is based in Armidale and consults and operates in Armidale Private Hospital.
Dr Jassim is British and Australian-trained. He holds fellowships from both the Royal Australasian College of Surgeons (FRACS) and the Royal College of Surgeons of England (FRCS TrOrth), with additional qualifications including a MSc in Sports and Exercise Medicine from Cardiff Metropolitan University, and medical degrees from King’s College London.
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD. If you do have a patient on whom you require specific advice then please seek advice from a colleague with appropriate expertise in that area.
Shivan, thank you very much for talking with us on PodMD today.
Shivan: Thank you very much for having me.
The topic of today’s discussion is rotator cuff repairs. Can you describe for our listeners what a rotator cuff tear is?
Shivan: Sure, we’ll start with the basic anatomy. Our shoulder joints move and a combination of the scapula moving on the thorax and then the humerus moving within the glenoid. Now, when we talk about the humerus moving within the glenoid, we have 5 main muscles to do that.
We have our large deltoid on the outside that does all of our powerful forward elevation movements. And then we have our four rotator cuff muscles on the inside of that, which help with the finer rotation. We have subscapularis to do our internal rotation of the shoulder. We have infraspinatus and teres minor to do our external rotation and then we have supraspinatus to do our forward elevation and abduction.
Now, tears in these tendons can be common. They’re really a function of aging. So as we all get older, our hair gets thinner and grayer.The same thing happens with our rotator cuff tendons.And these tears can be either acute as a result of an injury, or they can be chronic as a result of aging, or somewhere in between. So you have a slightly unhappy tendon that has a very minor trauma and that becomes an acute or chronic tear.
How would a patient with a rotator cuff tear typically present?
Shivan: It would depend on whether or not the tear was acute or chronic. So an acute tear typically follows a large injury or a dislocation.There’ll be a lot of pain, a lot of weakness, and extremely limited movement above shoulder height.
A really classic feature of a rotator cuff tear is night pain, and that’s because when we’re lying down, the head of the humerus is not contained within the joint because of the tear of the tendon, and it starts to rub on the underside of the chromion.
Beyond that, the more chronic tears can be more incidental findings or a result of stiffness in the shoulder or generalized pain, but they may not have the associated weakness.
What is the natural history of a rotator cuff tear if left alone?
Shivan: Small or asymptomatic tears tend to become symptomatic tears about two or three years in 50% of these patients. If it’s a full thickness tear or a symptomatic tear, that tends to increase at the two year point from above 50%.
What are some of the treatment options?
Shivan: Treatment options for rotator cuff tears in the first instance tend to be non-operative. So for the small tears or those with minimal symptoms, we start with physiotherapy to try and strengthen some of the other rotator cuff muscles around it.
We try steroid injections to calm down any inflammation and bursitis as a result of the tear and non-steroidal anti-inflammatories. And they tend to work very well in people with very minor symptoms.
Now, beyond this, the treatment options tend to be guided by results of an MRI scan, which I tend to order, to look at the quality of the tendon that has torn and how much it’s retracted, because then that can very much guide the prognosis of repair. But then ultimately, the tendon can be repaired in a couple of ways, either as an open procedure or I prefer an arthroscopic procedure.
Have there been any developments in treatment in the last years or are there any trials or in development now?
Shivan: There are lots, this is a huge area looking into rotator cuff tears. They tend to divide in looking at patients who have a failed rotator cuff repair and the options for them, such as reconstructing the superior capsule.
Alternatively, to enhance the chance of a repair healing, there are lots of biological options such as dermal patches to try and improve the healing. They’re good for poor quality tendon rather than a technically poor repair. There’s a lot of interest at the moment in the long head of the biceps, which tends to be a large pain generator. And rather than just chopping that away, can it be used to augment our repairs? That’s quite a big area at the moment of success going on.
Are there any warning signs a GP or perhaps their patient can look out for?
Shivan: I think the two really important signs that I think a GP should know to prompt referral onto specialist services are significant night pain as I mentioned that means that the humerus tends to be high riding and is no longer really contained in the shoulder joint.
The other thing is pseudo paralysis, so patient is really unable to flex or abduct the shoulder beyond about 30 degrees.
What is the likelihood of recurrence of a tear?
Shivan: So depending on what you read in the literature, a tear that gets repaired can re-tear up to about 50% of the time. However, it’s not always asymptomatic and the reasons for that are unclear. We think that some of the reason might be that the head gets a period of being re-centered and the other muscles get a chance to compensate such that even if there is a small re-tear, the patient doesn’t have the pain, they don’t lose the power.
What are some of the treatment options for irreparable tears?
Shivan: The treatment options for an irreparable tear would depend on the level of arthritis in the shoulder and other degenerative changes. So in an otherwise normal shoulder, tendon transfers are a fairly popular option, although they’re quite complicated to do.
And one operation that’s done is a tendon transfer involving the lower trapezius muscle to regain external rotation of the shoulder.Now, in patients that have some degenerative changes, some advanced arthritis, then a more popular option nowadays, especially in the more older patient, is a reverse total shoulder replacement.
What are the treatment options for chronic rotator cuff tears?
Shivan: In patients with chronic rotator cuff tears, where there’s an element of arthritis and the chance of a successful repair is limited by the poor quality of the tendon, treatment options are really operative or non-operative.
And in the normal operative stages, it’s about a pain management programme, but there is a lot of success with nerve injection and ablation around the suprascapular nerve, because if the rotator cuff is no longer functional, then the suprascapular nerve can be blocked to turn off the pain signals.
Beyond this, as mentioned again, chronic rotator cuff tears do quite well with a reverse shoulder replacement.
When should a GP refer their patient?
Shivan: Once a diagnosis of a rotator cuff tear has been confirmed on an ultrasound, that should prompt a referral. I should also mention that it’s always worthwhile having an x-ray of the shoulder because that can also give us a bit more information about any arthritis changes in the glenohumeral joint, also in the AC joint, and any calcific deposits within the remaining tendon.
GPs can also refer if the patient has had a trial of physiotherapy but hasn’t really responded with respect to pain and improved function of our shoulder height. And finally, I think it’s important to refer if there are any of the warning red flag signs such as the pseudo-paralysis or the night pain.
What role does the GP play in the treatment of the condition?
Shivan: I think the GPs got a lot of important roles within this. First of all, timely referral of these cases in any patient that has a warning sign is crucial because an earlier operation can often mean a more successful operation.
They should always refer with the appropriate investigations, such as a simple X-ray and a simple ultrasound. GPs also have a really important responsibility for coordinating care with the surgeons and the physiotherapists afterwards, because after any surgery, the recovery can be long. And I often tell my patients that the surgeon and the patient aren’t going to be friends for a good three to six months.
Well, thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take-home messages from today’s podcast on rotator cuff repairs?
Shivan: I think my three key messages are as follows. Number one, not every rotator cuff tear requires an operation. Small tears with good shoulder range of motion and strength respond very well to physiotherapy and a simple steroid injection.
Number 2 is that the basic investigations are important. A plain radiograph and an ultrasound can guide further treatment. Investigations such as MRIs should probably be left to the discretion of the surgeon as that can help guide the surgical plan.
And third, if there is an acute tear, refer early because early repairs are more likely to succeed because of the lack of retraction and atrophy of the torn tendon.
Great. Well, thanks again for your time and insights you’ve provided, Shivan.
Shivan: Thank you for having me.
