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Dr MARC BEAUCHAMP MD FRCSC
Private orthopedic surgery clinic, Montreal, Canada Shoulder and elbow surgery, arthroscopy
Private orthopedic surgery Montreal, Canada
Shoulder anatomyCommon shoulder and elbow problemsBursitis tendinitis and shoulder impingement syndromeRotator cuff tearRecurrent shoulder dislocationSuperior labrum tear: SLAP lesionTendinitis of the long head of the bicepsAcromioclavicular joint disordersAdhesive capsulitisOsteoarthritis and arthritis of the shoulder
Elbow anatomy
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Rotator cuff tear

The term "rotator cuff tear" most often refers to the detachment of the tendon from its point of insertion on the humerus. Most tears occur in the supraspinatus tendon but other tendons can also be affected. In more serious cases, all the rotator cuff tendons may be involved. A tear can occur insidiously and gradually due to wear and tear or a chronic impingement mechanism (common in people over 60 years of age), or acutely following a fall, a sudden effort or a jerking motion of the upper limb that causes the tendon to tear away. Since a normal tendon is an extremely strong structure, tears occur in tendons that probably already show some degeneration.

Pain (on exertion or at night) is the most common symptom and is occasionally accompanied by shoulder weakness. In chronic cases, loss of muscle mass (or atrophy) is also observed in the upper and posterior parts of the shoulder blade.

Since tendons do not show up on conventional X-rays, a magnetic resonance imaging (MRI) scan or ultrasound are usually required to detect the tendon tear. Formerly popular, arthrography (injection of dye into the shoulder associated with conventional X-rays) is sometimes used to show the passage of fluid across a torn rotator cuff.

Rotator cuff tears do not always cause pain, weakness or muscle atrophy. These are usually less than 1 cm in diameter and are diagnosed during a routine physical examination. They often occur in people over 60 or 70 years of age and are called "well-compensated benign cuff tears." They generally do not require any particular treatment other than an annual follow-up to ensure that the tear has not progressed.

Surgery is indicated for rotator cuff tears that cause a significant loss of function or chronic pain and fail to respond to nonsurgical treatment. The torn tendon cannot heal on its own. Also, when a tendon is completely ruptured, it implies that the corresponding muscle cannot work and consequently, atrophies. If this atrophy becomes chronic, it may be irreversible. Therefore, the best surgical outcomes are achieved when the rotator cuff is repaired within weeks or months of the tear. On the other hand, repairing a muscle that is chronically atrophied by fatty material (fatty metaplasia) will not be very effective in terms of restoring function. Hence the importance of early diagnosis and management.

What does rotator cuff repair surgery involve?

There are a number of possible techniques, but I will describe only the one I use. Since the patient stays awake the whole time, regional or local anesthesia (the entire shoulder and upper limb are numbed) is administered by the anesthetist. The patient is then placed in a semi-seated position on the operating table. If he wants to, he can watch the surgery on a video monitor. He can also bring his MP3 player and listen to his music quietly until the operation is over.

After cleaning and sterilizing the skin, I insert the arthroscope through a tiny incision a few millimetres long and fill the shoulder with water to expand the joint. The image appears on my video screen (with the movement of the water, it resembles the underwater images in Cousteau's films). One or two additional tiny incisions are made to insert instruments to resect the bursa, calcium deposits or any prominent bone spurs that are causing impingement or to repair and reinsert the tendon into the bone. I sometimes use small bioabsorbable (dissolvable) or metal anchors with sutures attached. These are inserted securely into the bone of the humerus and the tendon is then attached to the bone. Sometimes, the tendon is reattached after passing sutures through small tunnels drilled in the greater tuberosity. This is actually the same reattachment technique that was practised in the days of "open" shoulder repair and which fell into disuse following the advent of arthroscopy, for it could no longer be reproduced. However, since more suitable instruments have been developed, we have been able to resume using this technique, which eliminates the need for foreign materials, for most of our repairs.

The surgery usually lasts 30 to 90 minutes and after an hour or so under observation in the recovery room, the patient is allowed to leave the clinic with the person who is accompanying him. Before the patient leaves, I determine the follow-up and/or physiotherapy protocol. Appointments are scheduled, pain medication is prescribed. My assistant gives the patient a document with all the postoperative instructions and useful telephone numbers.

After surgery

Oral pain medication will be necessary for a few days. A semi-seated position (e.g., as in a Lay-Z-Boy) is recommended for sleeping. It is also helpful to use a reading cushion or several pillows. The operated limb can usually be used for very light activities (eating, writing, driving an automatic car, using a computer) a few days after surgery. The patient will need to start doing pendulum exercises in the first postoperative days to prevent adhesions. The two or three sutures on the skin are removed two weeks after surgery. Strength training of the repaired cuff only starts when the tendon insertion site is well healed, i.e., two to three months after the intervention. It is important to allow healing to take place before starting strengthening exercises to prevent a re-tear.

Physiotherapy is not prescribed for all patients. Some simple repairs will only need a personal exercise program. Others will need physiotherapy, either to restore function or range of motion. Others will require the assistance of an osteopath or a massage therapist to treat cervical pain and myalgia (fairly common in patients suffering from cervical osteoarthritis).

Healing time (measured in months) and the final outcome vary widely from case to case and depend on multiple factors (size of the tear, degree of chronicity, quality of the tissue repaired, the patient's overall health, quality of the surgery, motivation to heal, etc.).

To date, I have operated on more than 3000 shoulders and what I realize is that every case is unique and requires a "made to measure" approach. For this reason, I believe sincere, personal contact with my patients before and after surgery is important. I often tell my patients: "In soft tissue surgery, 50 percent of the credit for a positive clinical outcome goes to the surgeon and 50 percent to the patient." Although very simple, this is something I believe. I add that sometimes, some of this shared credit goes to the physiotherapist.

Copyright 2011 © Dr. Marc Beauchamp M.D.
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