Rotator cuff lesion

The shoulder joint is stabilized by a muscle group consisting of 4 muscles, the rotator cuff. A rotator cuff lesion refers to a partial tear or complete tear of one or more tendons of the rotator cuff muscles.

The shoulder joint is a complex system consisting of bones, ligaments, bursae and tendons and is formed by the head of the humerus and the glenoid cavity, which is part of the scapula. Surrounding the shoulder joint is a capsule. Above this joint lies the acromion (roof of the shoulder). The head of the humerus is larger than average in relation to its socket, which leads to a large range of motion in the shoulder but also to a certain vulnerability. This makes the shoulder joint predestined for injuries, such as shoulder dislocation.

The shoulder joint is stabilized by 4 muscles called the rotator cuff. These muscles are located on the front and back of the scapula and surround the humeral head: supraspinatus muscle, infraspinatus muscle, teres minor muscle and subscapularis muscle.

The main function of the rotator cuff is to hold the humeral head in its socket during movements of the arm, thus stabilizing the shoulder joint. In addition, the rotator cuff muscles perform external rotation and internal rotation of the arm in isolation. If the muscles can no longer fully perform their stabilizing function due to a tear in one of the tendons, the humeral headmay become elevatedwith subsequent narrowing of the space between the humeral head and the acromion, the subacromial space. This can lead to secondary damage, for example impingement syndrome or shoulder arthrosis (omarthrosis).

Signs of a rotator cuff lesion may include:

• Pain during movements of the arm, especially when lifting the arm
• Limited mobility of the shoulder
• Feeling of weakness, loss of strength
• Pain at night when lying on the affected shoulder

The severity of the symptoms depends on the extent of the tendon tear. One of the most common symptoms of rotator cuff lesion is pain in the shoulder, not infrequently accompanied by radiating pain into the upper arm. This pain is exacerbated during twisting movements or when the arm is raised. With a rotator cuff rupture, there is characteristically a loss of strength in the rotational movements of the arm, such as the apron grip. This weakness may also be noticeable when lifting everyday objects, dressing, or driving/steering.

Causes of rotator cuff lesion include:

• Age-related (degenerative)
• Accidental (traumatic): e.g. fall on the outstretched arm or a shoulder dislocation
• Inflammatory

There are a variety of causes for a rotator cuff lesion. The shoulder muscles are constantly and heavily stressed in our everyday lives and are therefore predestined for degenerative processes. Age-related and initially still small, symptom-free tears of the tendons thus represent the most common cause of a rotator cuff lesion.
In addition, the supraspinatus tendon of the rotator cuff runs directly through the narrow space between the acromion and the humerus, where it can be easily pinched (impingement syndrome) and damaged by prolonged incorrect loading. The thinning of the tendon is favored by arthritic changes (degeneration) of the acromion. In the further course, this can lead to small tears in the tendon and consequently to a rotator cuff lesion.

In young people, the main causes are accident-related. Various accidental causes can lead to a lesion of the rotator cuff, e.g. a fall on the outstretched arm or catching a heavy object. Dislocation of the shoulder joint(shoulder luxation) can also lead to rotator cuff damage.

Furthermore, inflammation of the bursa in the shoulder joint (bursitis) or the tendons (tendinitis) can trigger a rotator cuff lesion. 

Our experienced shoulder specialists will interview you in detail about your exact complaints. Among other things, they will discuss the triggers, duration and severity of your complaints.

Furthermore, a thorough, functional examination with various functional tests of the individual muscles is performed in order to narrow down the extent of the damage more precisely. Individual tests are explained in more detail below.

• Jobe test: To check the function of the supraspinatus muscle, you will be asked to hold the affected arm stretched out in front, with the thumb pointing downwards, and upwards in the second part of the test. The examiner will now apply pressure to the arm from above and you will be asked to hold the position of the arm. If pain occurs or it is not possible to hold the arm in the position, this is an indication of a rotator cuff lesion.
• Lift-off test: This test is used to test the subscapularis muscle. The affected arm should be placed with the back of the hand on the lower back. Now the hand should be moved away from the back, the examiner holds against it. If there is pain or an inability to move the hand against the examiner's pressure, the test is positive.
• Belly-press test: The flat hand of the affected arm is placed on the abdomen. Now the hand is to be pressed against the abdomen. If the person being examined tends to bend the wrist and bring the forearm to the side of the body, this indicates a rotator cuff lesion.

If the suspicion of a rotator cuff lesion is confirmed, imaging diagnostics are performed following the examination. This may involve an ultrasound, an X-ray and/or an MRI examination. MRI imaging is particularly well suited for a reliable and accurate assessment of the rotator cuff muscles, the bursa, and other soft tissue structures.

Depending on the cause of the rotator cuff lesion, different treatment options exist. If the tendon is torn without rupture (partial rupture) and without great suffering, conservative therapy can be chosen.

On the other hand, surgery is recommended after accidents, in younger patients, if the tendon can be reconstructed well, and if the symptoms persist. Our surgeons will be happy to discuss with you in a personal consultation which treatment option is right for you.

Conservative therapy

The following conservative therapies are available:

• Drug therapy: painkillers
• Injection of cortisone under the roof of the shoulder (acromion)
• Injection of platelet-rich plasma under the acromion (roof of the shoulder)
• Physiotherapy: Strengthening of the shoulder joint stabilizing muscles

For short-term pain relief, painkillers from the group of non-steroidal anti-inflammatory drugs (NSAIDs) can be used (ibuprofen, paracetamol). If this is not sufficient to relieve your pain, cortisone can be injected under the acromion, especially if the pain has been present for a long time. In the case of acute tendon damage, infiltration therapy with platelet-rich plasma can be helpful.
In the further course, targeted physiotherapy treatment should be started to strengthen the intact rotator cuff parts and to relieve and compensate for the damaged tendons.

Operation

If the rotator cuff lesion is the result of an accident, surgery is almost always preferred. In the case of painful, degenerative tears accompanied by a loss of strength, the surgical procedure is also recommended. In the vast majority of cases and depending on the extent of the damage, a minimally invasive (arthroscopic) procedure can be chosen here. During surgery, the torn tendon is reattached to the humerus (rotator cuff suture). If the tendon rupture occurred a very long time ago and there is retraction of the tendon, i.e. the ends of the tendon have moved away from each other, in some cases it is no longer possible to reconstruct the tendon completely. In this case, partial closure of the tendon is then performed, i.e. the tendon tear is partially reclosed.

Our shoulder specialists at the Orthozentrum will be happy to advise you further in this regard.

Everything at a glance:

• Operation time: 1-1.5 h
• Anesthesia: General anesthesia
• Hospitalization: outpatient or inpatient
• Fit for work: 12 weeks
• Return to sports (RTS): min. 6 months

After the operation, the arm is placed on a so-called abduction cushion for 6 weeks to relieve the fresh tendon suture for better healing. Physiotherapeutic treatment is essential from the first day after surgery. The main focus is on maintaining passive shoulder joint mobility and, in the further course, on targeted and functional muscle development of the shoulder joint stabilizing muscles (rotator cuff).