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Rotator Cuff Tear
Overview
The rotator cuff is a group of four muscles and tendons that play a critical role in stabilizing the shoulder joint.
When the rotator cuff becomes torn, the damaged area is usually located where the tendon connects with the bone of the humerus, the tendon insertion site. Rotator cuff tears can occur acutely with traumatic injury or from chronic impingement or age-related degenerative processes that weaken the tendon over time.
Patients with rotator cuff tears will often present with pain and sometimes restricted range of motion or weakness. Activities requiring raising the upper extremity overhead or reaching can become difficult.
Partial-thickness tears
A “partial-thickness” rotator cuff tear exists when some but not all the fibers in the tendon are disrupted. A partial tear is considered “low-grade” when less than 50% of the tendon thickness is torn. It is regarded as a “high-grade” partial tear when a tear involves more than 50% of the tendon thickness. Another subset of partial-thickness tears is intra-tendinous tears. These tears involve fibers inside the tendon rupturing while the fibers on the outside (at the top and bottom) of the tendon remain intact.
Treatment of partial-thickness rotator cuff tears may begin with a short course of anti-inflammatory medication and physical therapy to address any biomechanical deficits. While this will not heal the tear, it can diminish symptoms, particularly in low-grade tears. High-grade tears often require more advanced treatment.
For more persistently symptomatic partial tears, injection therapy can be beneficial. Corticosteroid injections have been used traditionally, but there are concerns about adverse effects and the fact that corticosteroids do not promote healing; in fact, they inhibit it. More recently, orthobiologic injection therapy has been showing considerable promise in treating partial-thickness tears. Dr. Meier has been using bone marrow aspirate concentrate (BMAC) to treat partial-thickness rotator cuff tears since 2015, with approximately 70% of patients reporting good-to-excellent results in terms of symptomatic relief and improved function. Tendon healing has also been noted in some cases with follow-up diagnostic ultrasound. Many patients prefer to try orthobiologic injection therapy before resorting to surgery to avoid the need for surgical treatment. BMAC provides a safe alternative to try without burning any bridges.
When patients fail to experience the desired diminution of their symptoms with conservative treatments, arthroscopic shoulder surgery provides a minimally invasive surgical means for effectively addressing partial-thickness tears. At the time of arthroscopy, the magnitude and pattern of the tear can be directly assessed visually and measured to determine the best course of surgical treatment. Generally, partial tears of less than 50% of tendon thickness are debrided or “cleaned up” with a suction shaver to remove unstable torn tendon fibers, so they no longer cause irritation and inflammation in the joint. Higher-grade partial tears over 50% tendon thickness are usually repaired with suture anchors to re-establish the tendon insertion site on the humerus bone, much like repairing a full-thickness tear.
Full-thickness tears
When all the fibers throughout the depth of the rotator cuff tendon are entirely torn, this constitutes a “full-thickness” tear, creating a through-and-through hole in the rotator cuff. Once a rotator cuff tear has occurred, it will never heal on its own because of tendon retraction. Tendon retraction refers to the gap that forms within the tendon hole due to the pull of the rotator cuff muscles. The only way to heal a full-thickness rotator cuff tear is with surgical repair. Rotator cuff repair involves reattaching the torn tendon back to its bony insertion site on the humerus. Traditionally this has been done through an open incision that requires cutting or detaching the overlying deltoid muscle to access the underlying rotator cuff. More recent technology has allowed the development of less invasive arthroscopic surgical techniques that enable surgery to be conducted through multiple, half-inch size “portals” instead of a formal incision using fiber-optic camera technology. Dr. Meier prefers to perform all rotator cuff repairs arthroscopically due to the better visualization and access to the joint that it provides and decreased surgical trauma and postoperative discomfort.
Initially, surgeons performed rotator cuff repairs by stitching sutures into the edge of the torn tendon and then passing the sutures through drill holes placed into the bone of the humerus. They performed this procedure through an open incision. In the 1980s, suture anchors emerged, eliminating the need for passing sutures through drill holes in the bone. The use of suture anchors allowed all-arthroscopic surgical techniques to flourish since the compact size of these implants permitted their placement into the joint through narrow cannulas.
In the late 1990’s Dr. Meier pioneered the surgical technique of double-row rotator cuff repair. Until that time, rotator cuff repairs were performed by lining up suture anchors on the humerus in a single file (single-row). But once clinical follow-up studies began to emerge revealing an alarmingly high rate of tendons failing to heal, surgeons became interested in developing ways to improve rotator cuff repair results. Dr. Meier performed and published several biomechanical studies in the laboratory showing that the standard single-row rotator cuff repair technique produced a repair that did not fully restore the native tendon insertion site’s anatomy, was relatively weak, and also allowed excessive tendon-bone motion. It was suspected that each of these factors likely played a role in the healing failures. Dr. Meier then described a new double-row rotator cuff fixation technique wherein the implants were placed geometrically instead of in a single file. Dr. Meier’s laboratory work demonstrated that double-row fixation was biomechanically superior to single-row fixation. It increased the tendon-bone contact area by fully re-establishing the native tendon insertion anatomy. Additionally, it exponentially increased the repair’s strength and durability and minimized tendon-bone motion.
At first, this new double-row fixation technique received mixed responses from other surgeons. Criticisms included the perception that double-row repairs were much more complex and thus excessively difficult to perform. The increased cost of using more implants per surgery also became a sticking point, at least initially. However, other surgeons recognized the logic in this new approach and that it had the potential to improve patients’ functional outcomes. Over time, numerous clinical follow-up studies have indeed demonstrated that, as Dr. Meier theorized, healing rates in rotator cuff repairs are significantly better with double-row versus single-row fixation.
Nowadays, more and more orthopedic surgeons are making an effort to learn the double-row technique, realizing that it is in the best interest of their patients. Dr. Meier has devoted his time and energy to travel the world to teach other surgeons how to perform this procedure.
After optimizing surgical technique and tendon fixation, the last frontier in rotator cuff healing is the body’s healing response. Rotator cuff tears tend to occur in degenerative tissue where the blood supply is poor. The longer a patient lives with a torn rotator cuff, and the larger the tear becomes, the less of a biological healing response the patient will be able to mount to heal the repair. Studies of bone marrow biopsies have shown that the bone of the humerus loses marrow cells over time with greater tendon tear chronicity. Since the tendon lacks a sufficient blood supply for healing, the bone is from where rotator cuff mending must come. Not even the most perfectly performed surgical repair will endure if the body does not bond the tendon back to the bone in the first twelve weeks after surgery. In his never-ending quest to optimize the healing of rotator cuff repairs, Dr. Meier pioneered the proprietary Double-Row with Bio-Boost Rotator Cuff Repair technique. This method involves infusing the bone at the tendon repair site with concentrated, healthy marrow cells from the pelvic bone to restore an improved healing response. While the healing rate of conventional rotator cuff repairs is only 60-70%, Dr. Meier has achieved a 98% healing rate with the Double-Row with Bio-Boost Rotator Cuff Repair.
Massive, Irreparable Rotator Cuff Tears
Massive and irreparable rotator cuff tears are full-thickness tears that have been allowed to increase in size and severity over time. Studies show that untreated tears tend to enlarge progressively due to ongoing muscle contraction. Tears that become irreparable are very large, involving more than one rotator cuff tendon, and feature severe tissue retraction and contracture. The rotator cuff muscle tissue will atrophy due to long periods of inactivity and become replaced by fat through fatty infiltration. As a result, the rotator cuff tissue shrinks and becomes stiff, so it is no longer possible to pull the torn edge of the tendon back to its attachment point on the bone. Once significant muscle atrophy and fatty infiltration set in, these processes are typically irreversible.
One can make an excellent argument to repair tears proactively. And to do so while they are still small and manageable with surgery to avoid the problems associated with massive and irreparable rotator cuff tears. Once a tear has progressed to the point where it is irreparable, a primary repair is no longer an option, and only reconstructive procedures remain. There can be a tendency for less experienced surgeons to incorrectly label a complicated rotator cuff tear as “irreparable” when it is a failure to recognize and restore the proper tear pattern. Dr. Meier has encountered numerous revision cases where the first surgeon had told the patient that their tear was irreparable. Still, after appropriate scar tissue release and restoration of the tear pattern, Dr. Meier obtained a complete primary repair.
For rotator cuff tears that are truly irreparable, there are several options. It is often worthwhile to try a rehabilitation program for strengthening and conditioning. By building up the compensatory muscles such as the pectoralis major, latissimus dorsi, and deltoid, these muscles can be recruited to compensate for the lack of stabilizing force usually provided by an intact rotator cuff. This can be a preferable option, particularly in elderly, frail patients in whom surgery may pose undue risks. This rehabilitation approach can be coupled with injection therapy such as corticosteroids or hyaluronic acid to reduce painful inflammation, facilitating the return of motion.
Surgeons can treat irreparable tears that continue to cause pain or significant weakness with reconstructive surgery. A procedure called superior capsular reconstruction (SCR) involves sewing a collagen graft into the rotator cuff defect to restore the stabilizing effect of the superior capsule of the shoulder joint. This newer procedure can be desirable to the younger patient with an irreparable rotator cuff tear. While long-term follow-up is still limited, initial clinical results show improvement in shoulder function in most selected patients.
Rotator cuff arthropathy (RCA) is the destruction of the shoulder joint due to longstanding instability resulting from a massive rotator cuff tear. RCA can cause worsening pain and loss of the ability for overhead activity. Patients with RCA can benefit from reverse shoulder arthroplasty, a type of joint replacement surgery where a prosthetic ball and socket replace the ball and socket of the shoulder joint but in a reversed position. In other words, an artificial “socket” replaces the natural “ball” of the patient’s shoulder, and a prosthetic “ball” replaces the patient’s “socket”. By altering the biomechanics cleverly in this way, the deltoid muscle is recruited to substitute for the absent rotator cuff, reducing pain and allowing the patient to forward elevate their arm again.
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