Arthroscopic shoulder surgery for the treatment of rotator cuff tears: why, when and how it is done.

Edited By: Suzanne L. Slaney, PA-C, ATC, MMS, Christopher J. Wahl, M.D.
Last updated Tuesday, May 16, 2006

Figure 5a - Diagramatic (A) and arthroscopic (B) views of a partial thickness rotator cuff tear. (A) Rotator cuff tears usually begin as fraying of the deep fibers of the cuff as they insert at the bone of the humeral head (arrow).

Figure 5b - Diagramatic (A) and arthroscopic (B) views of a partial thickness rotator cuff tear. An arthroscopic view of the frayed cuff insertion, as seen from the back of the joint looking forward. This is the same tear visualized in Video 1. (Diagram courtesy of Frederick A. Matsen, MD, redrawn from: Matsen FA and Lippitt SB. Shoulder Surgery: Principles and Procedures. Saunders, Philadelphia, 2004.)

Figure 6a. Diagramatic (A) and arthroscopic (B) views of a small- to medium-sized rotator cuff tear. (A) Shoulder as viewed from above. The arrow marks the tear ?pulling away? from the site it is normally attached to the right.

Figure 6b. Diagramatic (A) and arthroscopic (B) views of a small- to medium-sized rotator cuff tear. (B) Arthroscopic view of a torn rotator cuff from above. The attachment site on the humeral head is visible to the lower right of the picture, the torn edge is in the middle of the picture. (Diagram courtesy of Frederick A. Matsen, MD, redrawn from: Matsen FA and Lippitt SB. Shoulder Surgery: Principles and Procedures. Saunders, Philadelphia, 2004.)

Figure 7a. Diagramatic (A) and arthroscopic (B) views of a massive, ?retracted? rotator cuff tear. (A) shoulder as viewed from above. The tear has pulled back (retracted) to the edge of the joint.

Figure 7b. Diagramatic (A) and arthroscopic (B) views of a massive, ?retracted? rotator cuff tear. (B) Arthroscopic view of a massive, retracted rotator cuff tear from above. The attachment site is out of the picture to the right, the glenoid socket is in view in the center of the picture. Blue sutures have been placed through the cuff edge, which must be used to repair the cuff by margin convergence and re-cover the humeral head (lower right of the photo). (Diagram courtesy of Frederick A.

Figure 8a. Arthroscopic images of a severly arthritic shoulder joint. (A) A view from the rear of the joint looking forward. Note the complete loss of cartilage over the bone. The probe sits upon a bare bone glenoid surface with a completely worn cartilage surface. The humeral head is to the right of the picture.

Figure 8b. Arthroscopic images of a severly arthritic shoulder joint. (B) View from above the rotator cuff. Note the small, full-thickness tear through the rotator cuff. The glenoid surface is visible just inside the tear.

Review of the condition

What are the different types of rotator cuff tears, arthroscopic, minimally-invasive and open management?

When the rotator cuff does not function normally, due to weakness, fraying or tearing, it may not function correctly to keep the humeral head (or “ball” at the top of the arm bone or humerus) centered on the glenoid (or “socket” attached to the shoulder blade). This causes abnormal motion at the joint, and can result in “impingement” of the surfaces of the cuff on the bony arch that surrounds it.  Problems of the cuff are varied, and there is a spectrum of problems related to the cuff from mild to severe:

• tendonitis (inflammation of the cuff tissue) is usually mild, and responds to rehabilitation
• tendinosus (repetitive injury to the cuff with poor healing) is a process by which healthy cuff tissue becomes weak or degenerative.  This problem also frequently responds to adequate rehabilitation
• partial-thickness or incomplete tears can occur.  While these tears may progress to complete tears, rehabilitation can frequently strengthen the remaining intact cuff tissue and halt the process.  Many persons with partial-thickness tears will never require surgery if they undergo an appropriate physical therapy rehabilitation to address muscle imbalances.  (Video 1)  (Figure 5)
• full thickness tears occur when portions of the rotator cuff tendon pull completely away from the bony insertion.  These are classified by surgeons as small (involving only part of one tendon with little retraction from the insertion), medium (involving one or at most 2 tendons with little retraction) (Figure 6), large (involving a substantial part of one or two tendons, and requiring extensive repair or mobilization to be fixed) or massive (tears involving at least 2 tendons that will extensive débridement, mobilization and reconstruction).  (Figure 7)  Occasionally, persons with small or even medium-sized tears can be rehabilitated back to normal function with physical therapy.  Persons with large and massive tears are unlikely to improve with rehabilitation, and in some rare cases, delaying surgery unnecessarily can lead to a wasting of tissues and muscles (called atrophy) that can make later repair difficult or impossible. 

Rotator cuff tears can occur in concert with other shoulder problems, and frequently, the rotator cuff tear is an “innocent bystander” to a more symptomatic problem such as shoulder instability or arthritis.  It is important for a shoulder specialist to perform a comprehensive examination of the shoulder and neck to be sure that other problems are not present or have not contributed to the shoulder pain or rotator cuff tear.

What else might be confused with or similar to rotator cuff tears, arthroscopic, minimally-invasive and open management? How can these be distinguished from the condition?

In fact, there are people who have perfectly normal shoulder function despite the fact that they have a rotator cuff tear. When the function of the rotator cuff is preserved, the shoulder may be painless and have normal strength.  Symptoms are likely to develop when a tear begins to affect the normal cuff function.  This is important, however, because many problems in the shoulder can cause pain or weakness.  These things include:

•  impingement--rubbing of the cuff surfaces on the undersurface of the acromion (or bony ‘roof’ of the shoulder)
•  instability—subtle dislocation of the shoulder joint
•  frozen shoulder—also called adhesive capsulitis is a temporary inflammation and scarring of the shoulder capsule
•  arthritis—joint wear between the humeral head and glenoid or at the end of the collar bone (clavicle) where it meets the acromion (bony ‘roof’ of the shoulder). (Figure 8)

Not uncommonly, these different problems can occur simultaneously (i.e. instability can lead to arthritis or to rotator cuff tears or to impingment, and alternatively a rotator cuff tear can lead to subtle instability).  For these reasons, a comprehensive shoulder examination by an experienced physician is important.

How common is rotator cuff tears, arthroscopic, minimally-invasive and open management (statistics, demographics, risk factors)?

It is difficult to estimate the number of persons who have injury to the rotator cuff, because even full-thickness tears may not necessarily affect function. However, painful or symptomatic rotator cuff tears are a common cause of shoulder pain.  They can occur in young or old persons, with or without a traumatic injury, and in active and sedentary populations alike. 

• overhead athletes or laborers
• traumatic injuries or dislocations of the shoulder joint
• those who perform repetitive overhead activities
• contact athletes (football, hockey, wrestling, lacrosse)
• persons who have had a rotator cuff tear on the opposite shoulder

How is rotator cuff tears, arthroscopic, minimally-invasive and open management diagnosed? What tests or exams may be used?

A physician can diagnose rotator cuff injury by reviewing the patients history, performing a thorough physical examination and shoulder examination, and through the use of imaging techniques such as X-rays and magnetic resonance imaging (MRI).

The physical examination and history are a reliable means to diagnose rotator cuff weakness and pain.  Many times, persons will have no abnormalities on X-ray (the cuff can not be visualized with x-ray), but MRI is very reliable in confirming a suspected diagnosis.  Frequently, and MRI arthrogram will be performed.  For this study, a contrast ‘dye’ is injected into the joint just prior to the MRI.  This study is nearly 100% accurate in diagnosing a tear.  (Figure 3)

X-rays may show bony injuries reactions to a dysfunctional rotator cuff tear.  Cysts can occasionally be visualized in the region of the cuff insertion at the humerus, the humeral head may migrate toward acromial roof, or bone spurs may develop on the undersurface of this roof.  MRI images give cross-sectional pictures of the rotator cuff.  Small tears or fraying of the cuff tissue are frequently seen, and large and massive tears are easily apprecitated.

Can medications help rotator cuff tears, arthroscopic, minimally-invasive and open management?

Because cuff tears are an essentially mechanical problem, there are no medications that can “cause” the cuff to heal spontaneously. However, some medications such as Non-steroidal Anti-inflammatory Drugs (NSAID’s) will frequently help to ease the pain and symptoms related to the torn cuff.  These medications can be quite helpful, but can also have side effects and therefore should be taken under the supervision of a physician experienced in their use.  Injections of steroids (cortisone) into the shoulder will occasionally be recommended to ease the symptoms of inflammation in the shoulder while a physical therapy program is initiated to rehabilitate the rotator cuff muscles and restore function.  While the effects of the cortisone are not permanent, if the cuff can be strengthened while the cortisone is helping ease inflammation, the symptoms may not return as the mechanics of the shoulder are restored. 

• the risks, possible interactions with other drugs
• the recommended dosage
• the cost

Can exercises help rotator cuff tears, arthroscopic, minimally-invasive and open management?

The normal function of the shoulder joint is dependent upon a balance of several factors, including:

• the fit or conformity of the humeral head (“ball”) to the glenoid (“socket”)
• the integrity of the lip of tissue around the glenoid socket (also called the labrum)
• the integrity of the ligaments within the shoulder capsule that act as “check reigns” to motion (termed the glenohumeral ligaments)
• a “vacuum effect” of the head in the glenoid socket
• the stabilizing effect of the rotator cuff muscles around the shoulder joint

Of all these factors, the one that can be addressed most easily is the strength and function of the rotator cuff muscles.  These muscles can be strengthened effectively with a supervised and home physical therapy program designed to selectively balance and strengthen the four muscles around the shoulder that comprise the “cuff” ( called the supraspinatus, infraspinatus, teres minor, subscapularis).  Most general shoulder exercisers in the gym do not adequately isolate and address rotator cuff strengthening, so it is important to learn which exercises are most beneficial.  This is usually done under the supervision of a physical therapist or athletic trainer.

 If the exercises are performed gently several times per day on an ongoing basis, many patients will obtain relief of their symptoms, and their strength will return.  These exercises will not cause the cuff to ‘heal’, but may allow the intact remaining cuff to take over the function of the injured portion.  It is important for patients to learn the possible risks of physical therapy as well as its cost.  The anticipated effectiveness of physical therapy is dependent upon the degree, nature, and chronicity of the tear.

Specifically, how is rotator cuff tears, arthroscopic, minimally-invasive and open management improved by arthroscopic rotator cuff repair and shoulder surgery?

In persons who continue to have symptoms despite an adequate trial of physical therapy, surgical repair of the rotator cuff is the most effective method to restore strength and eliminate pain.

Different shoulder surgeons have different preferences regarding how they like to repair torn cuff tissues. One of the obstacles to surgery of the shoulder (unlike the knee) is that the shoulder is surrounded by a bony and muscular “envelope”.  The shoulder blade, or scapula forms the bony glenoid socket of the joint, and also forms a bony “roof” over the humeral head called the acromion.  The rotator cuff muscles originate on the scapula, and surround the socket and humeral head under this acromial roof.  The larger deltoid muscles originate from the surface of the acromion, and form another muscular barrier to the cuff as well.  In short, the rotator cuff is “protected” in the front, side and back by the deltoid muscles, and is inaccessible from the top owing to the bony acromion.

Historically, surgeons had to make large incisions in the skin and split and move the deltoid muscles to gain access to the rotator cuff.  Serious and debilitating complications developed if the deltoid muscle origin did not heal back to the acromion, so surgeons now will now access the rotator cuff tear by leaving the deltoid muscle attached and simply splitting it (like ‘peeking through closed curtains’) to gain access to the rotator cuff where it attaches to the humerus.  This process is ideal for tears that have not pulled back, or retracted back away from the deltoid.  However, in cases of larger retracted rotator cuff tears, working through a deltoid split can become a little like building a ship in a bottle—trying to work through the narrow mouth of a bottleneck to get to the retracted cuff tissue.

With the advent of arthroscopy, innovative shoulder surgeons found that one could make a few very small incisions in the skin and deltoid muscles surrounding the shoulder joint and could have access to every part of the rotator cuff.  These incisions are small enough that they do not affect the function of the deltoid muscle or injure its origin on the acromion.  Using the arthroscope and instruments specifically designed for the purpose of manipulating and repairing the tissue, the surgeon can work from any angle around the tissue.  The techniques and skills required for an all-arthroscopic rotator cuff repair are relatively new, however, and require special training and a dedicated and skilled operating team.

Frequently Asked Questions (FAQ’s) about arthroscopic rotator cuff surgery:

1. Is my rotator tear “too big” to be fixed using arthroscopy?

The primary advantage of all-arthroscopic repair is that it allows a surgeon “global” access to the rotator cuff and tear for adequate cuff evaluation, repair and fixation to bone.  For this reason, the LARGEST tears are often that require the greatest degree of skill and familiarity with arthroscopic techniques.  Surgeons who are facile with arthroscopic techniques actually prefer to prepare and evaluate the cuff using the arthorscope, as this allows better visualization.

2. Will I recover or “heal” faster after arthroscopic rotator cuff repair?

Most people feel better faster, but they are not technically healed faster after an arthroscopic repair.  All surgeries done to repair the rotator cuff, whether performed through open incisions or using the arthroscope, are designed to replace the rotator cuff to its original site, called the insertion.  The sutures placed to hold the cuff would fatigue over time and the repetition of normal shoulder motion if it were not for the fact that the body “heals” the cuff to the repaired position with relatively normal tendon.  The rate of the healing process is not affected by the method used to repair the cuff, so the cuff will not “heal” more quickly if a less-invasive, arthroscopic procedure is performed.  However, most patients feel better much sooner after an arthroscopic procedure because these procedures do not require the extra healing of the deltoid muscle and longer skin incisions.  For this reason, a patient must be disciplined about adhering to a strict postoperative “rest” so that they don’t stress the repair before the body has completed the healing process, which goes on for several weeks and months.

3. Are the results as good as with “mini-open” techniques?

Most of the recent studies show that in the hands of surgeons who are expert in all-arthroscopic rotator cuff repair, the results are comparable to open techniques.  Specifically, the best results reported for open repairs are as high as 97% success.^1,7,11,14 Recent articles reported on arthroscopic fixation using the latest instruments and techniques demonstrate 93% to 95% good and excellent results.^{2-6,8-10,12,13} Reports of the traditional open fixation tend to demonstrate that the success rates are less favorable for larger tears. Interestingly, the studies of arthroscopic repairs show otherwise: the results do not appear to be significantly worse with larger tear sizes.⁴ This is probably due to the global access to larger tears with the arthroscopic techniques. 

Studies have shown that “retear” rates may be higher with arthroscopic techniques, and the durability of these relatively new techniques will be better understood over time.  It is interesting that when massive tears deemed “irreparable” by standard techniques are addressed with an arthroscopic technique called margin convergence, the results can be favorable even if the tear can’t be fully repaired to bone.

Surgery for Rotator cuff tears, arthroscopic, minimally-invasive and open management at the University of Washington

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