Summary

Rotator Cuff tears are the most common cause of shoulder pain and disability in adults. They range from partial thickness tears (PASTA lesions) to massive irreparable tears leading to Cuff Tear Arthropathy (Hamada Classification). The pathophysiology is usually age-related degeneration within Codman's "Critical Zone" (hypovascular area). Management is strictly dichotomized: Acute Traumatic Tears in active patients require early surgical repair (<3 months) to prevent retraction and fatty infiltration (Goutallier). Chronic Degenerative Tears (the vast majority) are initially managed with physiotherapy (Anterior Deltoid rehabilitation), with surgery reserved for failed conservative care. [1,2,3]

Key Facts

• Most Common Tendon: Supraspinatus.
• Incidence: 50% of people >60 have asymptomatic tears. 80% of people >80 have tears.
• "Fatty Infiltration": Once a muscle detaches, it turns to fat (Goutallier grade). This is irreversible. If Goutallier >2, successful repair is unlikely.

Clinical Pearls

"Treat the Patient, not the MRI": An MRI showing a "full thickness tear" in a 75-year-old is a normal finding of aging (like grey hair). If they are pain-free and functional, DO NOT OPERATE.

"The Hornblower Sign": If a patient cannot externally rotate their arm in abduction (blow a trumpet), their Teres Minor is gone. This carries a terrible prognosis for standard repair.

"Pseudoparalysis": The patient has full passive ROM but cannot lift the arm actively (drop arm). This mimics a stroke/nerve injury but is mechanical failure of the cuff fulcrum.

                 ROTATOR CUFF TEAR
                        ↓
             ACUTE TRAUMA? YOUNG (<65)?
             ┌──────────┴──────────┐
            YES                    NO
        (Weakness)           (Degen/Pain)
             ↓                     ↓
         URGENT MRI           PHYSIOTHERAPY
             ↓                (Conservative)
        REPAIRABLE?                ↓
       (Goutallier <2)       FAILS AT 3-6M?
       ┌─────┴─────┐         ┌─────┴─────┐
      YES          NO       NO          YES
       ↓           ↓        ↓            ↓
    SURGICAL    REVERSE    DISCHARGE    MRI
     REPAIR    SHOULDER                  ↓
                                    REPAIRABLE?
                                   ┌─────┴─────┐
                                  YES         NO
                                   ↓          ↓
                                REPAIR     SALVAGE
                                          (Debride/SCR/RSA)

1. Conservative (First Line for Degenerative)

• Aim: Rehabilitate the Anterior Deltoid and remaining cuff to compensate.
• Protocol:
  • NSAIDs.
  • Subacromial Steroid Injection (Diagnostic and therapeutic). Note: Repeated injections weaken tendon.
  • Physio: Scapular setting, Deltoid strengthening.
• Success: 75% of patients avoid surgery.

2. Surgical Repair (Arthroscopic)

• Indication: Acute traumatic tears. Failed conservative care with repairable tendon.
• Technique: Double Row Suture Anchors (SpeedBridge).
• Rehab: Sling 4-6 weeks (protect repair). Passive ROM only. Stiffness is the enemy but re-tear is the risk.

3. Management of Irreparable Tears (The "Massive" Tear)

If Goutallier 3/4, repair will fail (pull through cheese). Options:

• Debridement (Smooth & Move): Clean up frayed edges. Pain relief only.
• Partial Repair: Fix what you can to restore force couples.
• Superior Capsular Reconstruction (SCR): Fascia lata graft to keep head down.
• Balloon Interposition: Biodegradable spacer above head to depress it.
• Tendon Transfer: Latissimus Dorsi transfer (for Post-Sup deficiency).
• Reverse Shoulder Arthroplasty (RSA): The ultimate salvage. Deltoid powers the arm.

The UKUFF Trial (Carr et al.)

• Comparison: Open vs Arthroscopic Repair.
• Finding: No significant difference in outcome.
• Conclusion: Arthroscopic has lower morbidity (infection/pain) but is technically harder.

CSAW Trial (Can Shoulder Arthroscopy Work?) (Beard et al.)

• Comparison: Decompression vs Arthroscopy only vs No Treatment (for Impingement/Cuff pain).
• Finding: Surgery (Decompression) offered no benefit over placebo surgery for pure impingement/degenerative cuff pain.
• Conclusion: DO NOT OPERATE for pain alone without a structural tear that needs fixing.

What is the Rotator Cuff?

It is a sleeve of 4 muscles that hugs the ball of your shoulder. It does two things: (1) Turns the arm, and (2) Holds the ball down in the socket so the big Deltoid muscle can lift it.

Why does it tear?

Like a pair of jeans, the fabric wears thin over the knee (or shoulder) with age. By age 60, it is "threadbare". A small stumble can turn a frayed tendon into a tear.

Do I need surgery?

• Acute Injury: Yes. If you pulled the tendon off the bone yesterday, we need to stitch it back before the muscle turns to fat.
• Wear and Tear: Usually No. We can teach your other muscles (Deltoid) to do the job. Surgery involves 6 months of rehab and the stitches often pull out in older bone.

What is a Reverse Shoulder Replacement?

It is a special artificial joint designed for people with NO rotator cuff. We switch the ball and socket. This changes the mechanics so your Deltoid muscle can lift the arm without needing the torn cuff.

Q1: What is the "Critical Zone" of the Supraspinatus? A: An area of relative hypovascularity approximately 1cm proximal to the insertion on the greater tuberosity. It is the watershed area between the osseous and tendinous blood supply and is the most common site for degenerative tears.

Q2: Describe the Goutallier Classification. A: A system to grade fatty infiltration of the cuff muscles on CT/MRI.

• 0: Normal.
• 1: Streaks.
• 2: Less fat than muscle.
• 3: Equal fat and muscle.
• 4: More fat than muscle. Significance: Grades 3 and 4 are considered irreparable.

Q3: Explain the biomechanics of Reverse Shoulder Arthroplasty in Cuff Arthropathy. A: In cuff deficiency, the humeral head migrates superiorly (fulcrum is lost). RSA medializes the center of rotation and lengthens the lever arm of the Deltoid, allowing it to recruit more fibers (anterior and posterior) to elevate the arm, functioning independently of the cuff.

(End of Topic)