Summary

Rotator Cuff tears range from tendinopathy and partial tears to massive, irreparable ruptures. They are overwhelmingly degenerative (part of the aging process), with asymptomatic tears present in >50% of people over 60. The Supraspinatus is most commonly affected. Symptomatic tears present with night pain (unable to sleep on affected side) and functional weakness (especially abduction/overhead). Management has shifted conservatively for degenerative tears, as physiotherapy is often non-inferior to surgery. Acute traumatic tears, however, require early repair to prevent retraction and fatty atrophy. End-stage disease results in Cuff Tear Arthropathy, managed with Reverse Shoulder Arthroplasty. [1,2]

Key Facts

• Anatomy: SITS (Supraspinatus, Infraspinatus, Teres Minor, Subscapularis).
• Most Common: Supraspinatus Tendon (90%).
• Function: Compresses the humeral head into the glenoid ("Dynamic Stabiliser") to allow the Deltoid to lift the arm. Without it, the Humeral head migrates superiorly.
• Epidemiology: Presence increases with age. (20% at age 60, 50% at age 80).
• Key Symptom: Night pain. Painful Arc (60-120 degrees).
• Signs: Jobe's Test (Supraspinatus), External Rotation Lag (Infraspinatus), Belly Press (Subscapularis).
• Imaging: MRI is Gold Standard.

Clinical Pearls

"Treat the Patient, Not the MRI": It is normal to have a cuff tear at age 70. If it doesn't hurt, leave it alone. We don't fix grey hair, we don't fix all degenerative cuff tears.

"Pseudoparalysis vs Palsy": If a patient cannot lift their arm, is it a massive tear or a nerve injury (Axillary/Suprascapular)? Inject Lidocaine (Impingement Test). If strength returns, it was pain (Impingement). If still weak, it's a tear or nerve.

"Don't Miss the Subscap": Subscapularis tears are often missed because they hide anteriorly. Check the "Lift Off" or "Belly Press" test. An isolated subscap tear is often traumatic and needs fixing.

"The Clock is Ticking": In acute tears, the muscle turns to fat (Fatty Atrophy) over months. Once Goutallier Grade 3-4 (Fat > Muscle) is reached, repair is impossible even if you stitch it (the muscle is gone).

            ROTATOR CUFF TEAR
                    ↓
        ACUTE OR DEGENERATIVE?
        ┌───────────┴───────────┐
      ACUTE                   DEGENERATIVE
(Trauma, Weakness)           (Insidious, Age)
        ↓                       ↓
    MRI SCAN                 PHYSIO + INJECTION
    (Urgent)                 (Trial 3-6 months)
        ↓                       ↓
   REPAIRABLE?                FAIL?
   ┌────┴────┐                  ↓
 YES         NO             CONSIDER MRI
  ↓          ↓                  ↓
REPAIR    SALVAGE           SURGERY
        (Reverse)          (If repairable)

Risk Stratification

• Red Flag: Acute tear in active patient = Surgery.
• Yellow Flag: Chronic large tear = Controversy.
• Green Flag: Small degenerative tear = Physio.

1. Conservative Management

• Indication: Degenerative tears, Low demand, Goutallier 3-4 (Irreparable).
• Physio: Anterior Deltoid strengthening program. Scapular stabilisers.
• Injection: Steroid (Subacromial). Good for pain relief to allow physio. Max 3 injections.

2. Arthroscopic Repair

• Indication: Acute tears, Failed conservative management in young/active.
• Technique:
  • Debridement: Cleaning up partial tears.
  • Repair: Reattaching tendon to footprint using Suture Anchors (Peek/Biocomposite/Metal).
  • Single Row vs Double Row: Double row (Suture Bridge) is mechanically stronger and restores footprint contact area better.

3. Superior Capsular Reconstruction (SCR)

• Indication: Irreparable Supraspinatus tear in YOUNG patient (no arthritis).
• Technique: Using a patch (dermal allograft or fascia lata) to reconstruct the superior capsule. Keeps the head down (preventing migration).

4. Reverse Shoulder Arthroplasty (RSA)

• Indication: Cuff Tear Arthropathy (Arthritis + Massive Tear) in elderly.
• Concept: Reverses the ball and socket. The "Ball" is put on the glenoid, the "Cup" on the humerus.
• Biomechanics: Medialises the centre of rotation and lengthens the arm. This gives the Deltoid a huge mechanical advantage, allowing it to lift the arm without a cuff.

Step 1: Portals

• Posterior: Viewing.
• Anterior: Instrument.
• Lateral: Working (for anchors).

Step 2: Assessment

• Evaluate tear shape (Crescent, U-shape, L-shape).
• Mobilisation: Release adhesions (Coracohumeral ligament) to allow tendon to reach footprint without tension.

Step 3: Footprint Preparation

• Abrade the greater tuberosity to bleeding bone (Marroy vents) to encourage healing.

Step 4: Fixation (Double Row)

• Medial Row: Anchors placed at articular margin. Sutures passed through tendon.
• Lateral Row: Sutures from medial row brought over the top and fixed laterally. Compresses tendon to bone.

The "Forgotten" tendon.

• Presentation: Anterior shoulder pain. Pain with internal rotation.
• The Comma Sign: On arthroscopy, the superior glenohumeral ligament (SGHL) and medial coracohumeral ligament (MCHL) form a "comma" that marks the superior border of the subscap. If you see the comma, the subscap is torn.
• Treatment: Needs repair. Biceps often involved (subluxes medially) -> Tenodesis.

Phase 1: Protection (0-6 Weeks)

• Sling: Abduction sling (to take tension off repair).
• Passive ROM: Pendulums. Passive Forward Flexion.
• Avoid: Active lifting. External rotation (stressing the repair).

Phase 2: Active Assist (6-12 Weeks)

• Wean sling.
• AAROM (Pulleys, Stick exercises).
• Regain full ROM.

Phase 3: Strengthening (3-6 Months)

• Theraband exercises.
• Scapular control.
• Return to driving.

Phase 4: Return to Sport (6+ Months)

• Overhead activity.

Key Studies

1. CSAW Trial (Can Shoulder Arthroscopy Work, Lancet 2018): Decompression vs Placebo surgery for impingement. No difference. Changed practice (Stopped doing SADs).
2. UKUFF Trial: Open vs Arthroscopic repair. No difference in outcome, but arthroscopic has less pain initially.
3. Grammont (1985): Invented the Reverse Shoulder Arthroplasty. Revolutionised salvage surgery.
4. MOON Shoulder Group: Physical therapy is effective for atraumatic full thickness tears. 75% avoid surgery.

Guidelines (AAOS)

• Strong recommendation for physio in degenerative tears.
• Option for repair in acute tears or failed physio.

What is the Rotator Cuff?

It is a group of four small muscles that grab the ball of your shoulder and hold it against the socket. They act like a dynamic stabiliser.

Why did it tear?

Most tears are like worn-out fabric in jeans. It happens with age. Sometimes a fall finishes it off.

Do I need surgery?

• Young/Acute: Yes. We should fix it before the muscle turns to fat (Use it or lose it).
• Older/Worn: Try physio first. We can train the big muscle (Deltoid) to do the work. Surgery to stitch rotten cloth often fails (re-tears), so we save it for when physio fails.

What is a Reverse Shoulder Replacement?

It sounds crazy, but we swap the ball and socket around. It changes the physics of your shoulder so you can lift your arm using just your Deltoid muscle, bypassing the torn rotator cuff completely. It is a fantastic operation for pain relief and function in older people.

Bigliani Acromion Types

• Type I: Flat (Low risk).
• Type II: Curved.
• Type III: Hooked (High risk of impingement/tears).

Seddon Nerve Injury (relevant to Axillary Nerve)

• Neurapraxia: Conduction block. Recovers hours/weeks.
• Axonotmesis: Axon cut, sheath intact. Recovers 1mm/day.
• Neurotmesis: Both cut. Needs repair.

Q1: What are the borders of the Rotator Interval? A: Superior: Supraspinatus. Inferior: Subscapularis. Medial: Coracoid. Lateral: Transverse Ligament. Contents: Biceps tendon (LHB), SGHL, CHL.

Q2: Why use a Reverse Arthroplasty for Cuff Arthropathy? A: Because a normal Hemi or Total shoulder relies on an intact cuff to center the head. Without a cuff, the Deltoid pulls the head up (Rocking Horse phenomenon) and the glenoid component loosens early. The Reverse constrains the head and lengthens the lever arm for the Deltoid.

Q3: What is the "Critical Zone" of Codman? A: An area of hypovascularity in the supraspinatus tendon ~1cm proximal to its insertion. It is the most common site for tears.

• Codman (1934): The father of shoulder surgery. Described the "rim rent" tear.
• Neer (1972): Described Impingement Syndrome and Anterior Acromioplasty. (Now controversial).
• Snyder: Coined the term "SLAP lesion".

(End of Topic)