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Dr Priyadarshi Amit is one of the best orthopaedic surgeon to perform arthroscopic rotator cuff repair in Delhi NCR (Gurgaon, Faridabad, Noida, Ghaziabad). In this interview, he talks about the commonly asked questions in the clinic for patients with rotator cuff tear. 

Rotator cuff tear is one of the commonest shoulder problem in my clinic. It can be very debilitating at times. It needs proper evaluation, counselling and treatment. But fortunately, with various treatments we are able to get the patients back to their normal activity.

What is rotator cuff tear?

Rotator cuff is a group of four tendons which wraps around the shoulder joint. Their function is to stabilize the shoulder and control movements. They are called supraspinatus, infraspinatus, teres minor, and subscapularis. The tear in the rotator cuff tendon is called rotator cuff tear.

What causes rotator cuff tear?

The tear in rotator cuff tendon commonly involves supraspinatus and infraspinatus tendon more than subscapularis or teres minor. It may happen due to

• injury – road traffic accidents or sports injury
• degeneration or wear and tear in the tendon – overuse, age > 40 years, professions such as carpenter or painter

How common is rotator cuff tear?

The rotator cuff tear is relatively common, esp in elderly patients due to wear and tear. Few people may not be even aware of the tear in their tendon as they would be absolutely asymptomatic or would have very mild symptoms.

What are the symptoms?

Few patients will have compensation from the other muscles, and they will be all fine. While in others, it can cause varying degree of symptoms including

• pain in the shoulder especially while performing overhead activity or lifting heavy weights.
• night pain
• difficulty in shoulder movements too and limit function.
• weakness in shoulder with inability to lift arm

In the long term, it can cause arthritis (Rotator cuff arthropathy) when it becomes severely painful and cause further deterioration of movement and overall function.

How is rotator cuff tear diagnosed? 

The plain X ray can show some indirect evidence of rotator cuff disease. The tear is usually confirmed with ultrasound scan or MRI scan.

How is it treated?

The treatment options for this condition include

• Physiotherapy
• Painkillers
• Injections
• surgery

The treatment is individualized based on the nature of the symptoms or the demands of the patients. Usually, the non-operative treatment options are tried first, before recommending surgery.

Do I have to have surgery?

No, good proportion of patients improve well with non-operative options who then don’t need surgery. It depends on how well other muscles compensate for the torn tendons. If you do not improve with non-operative measures, you will be considered as candidate for surgery.

What are my surgical options?

The most common surgery performed for rotator cuff tear is surgical repair of rotator cuff tendon which is done through key-hole surgery (Arthroscopic rotator cuff repair). In some occasions if the tear is large in size or the tendon is of very poor quality, you may need other procedures such as superior capsular reconstruction (SCR) or a tendon transfer (Lower trapezius transfer) or a joint replacement procedure (Reverse shoulder arthroplasty).

When does one need rotator cuff repair?

The rotator cuff repair is performed for tear in the rotator cuff tendon. You will considered a candidate for repair if you have

• severe pain in the shoulder enough to affect your function
• night pain
• poor strength in performing activities
• no improvement with non-operative measures such as physical therapy, injections, painkillers.

What does rotator cuff repair involve?

Rotator cuff repair is performed arthroscopically (key-hole surgery) with stab incision around the shoulder joint (Arthroscopic rotator cuff repair). This procedure is performed under combination of general and regional anaesthesia.

• In this procedure, a camera is introduced into the joint, through which the whole joint is inspected first.
• Following the diagnostic arthroscopy, the torn tendon is freed of adhesions or degenerative tissue and then stitched back to the bone with the synthetic sutures and anchors. The anchors are small hard pellets (usually plastic) with tails of strong suture material that are fired into the bone in the humeral head. The suture tails are passed through the tendon and then tied down. Depending on the tear pattern, the surgeon may opt for single-row or double-row repair.
• The operation will also involve removing some bone from the underside of the bony arch (acromion) which is positioned just above the rotator cuff tendons (Subacromial decompression). This prevents the bony arch from rubbing on the tendons and repair when the shoulder is moving.

One may also need

• removal of the biceps tendon from the shoulder (Biceps tenotomy or Biceps tenodesis)
• removal of the joint between the collar bone and shoulder-blade (Distal clavicle Excision).

Is double-row rotator cuff repair better than single-row?

The double-row repair involves the placement of suture anchors in two rows, the medial (inner aspect of head of humerus) and lateral (outer aspect of humeral head). It has shown to offer stronger repair integrity than single-row. There are few reports suggesting better outcome after double-row than single-row repair.

How long is the hospital stay?

The patients are usually discharged on the same day of surgery or the next day once they are comfortable.

What are the precautions after surgery?

Following surgery, you will be advised post op rehabilitation where a sling will be applied to support the arm for 4-6 weeks along with supervised exercise regimen under guidance of a physiotherapist which starts the next day of surgery. The physiotherapy will include exercises for shoulder blade, shoulder, elbow and hand and wrist. The exercises will aim to improve the range of movement (pendulum and passive range of movement exercises) initially followed by strength of the shoulder.

For initial 6 weeks, you should avoid

• sleeping on the operated side
• reaching behind the back
• driving
• lifting weights with operated arm

You should try and keep arm relaxed and still while taking shower and putting on dresses.

How long does it take to get back to normal?

Usually the patients would be able to move their shoulder freely without pain in about 2 to 3 months. However, the strength in the shoulder takes almost 4-6 months to improve. You can start doing household chores and resume your duties from 6 weeks onwards, given you keep it as light duties. It usually takes around three months to get to do heavy duties.

When can I drive?

You will be allowed to drive from 6 weeks after surgery. You can start swimming at 3 months. It might take 4-6 months to get back to sports at previous level.

What are the chances that my shoulder will be normal after surgery?

Vast majority of the patients will get their shoulder back to normal following surgery and rehabilitation. We do see some complications such as stiff shoulder or re-tear of the repaired tendon, fortunately, they occur in only small percentage of patients. This again depends on multiple factors such as the extent of the tear or the chronicity of symptoms, the quality of tendons, age, quality of bone, and how well one has followed the rehabilitation program. Moreover, not all the patients with re-tear need a revision surgery. Even with re-tear patients will gain benefit from the operation as the shoulder will be much less painful although one may not regain all your strength.

If you wish to get more information about arthroscopic rotator cuff repair, kindly book appointment with Dr Priyadarshi Amit or get in touch with us on +91 8882554692.