ROTATOR CUFF TEAR

Type of manuscript: A review

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Running title : Rotator cuff tear 

Revathi.B
Undergraduate student

Saveetha Dental College, 
Saveetha university 

Dr.K.Yuvraj Babu

Department of anatomy
Saveetha Dental College 
Saveetha university 
Chennai 
Tamil Nadu  
India 

Corresponding author

Student Email: [email protected]

Contact number : 9176789720

Author name : Revathi.B

Guide name :  Dr.K.Yuvraj Babu

Year of study : l-BDS :2017-2018

ABSTRACT:
INTRODUCTION

Rotator cuff tears are common and are a frequent source of shoulder pain and disability. A wide variation in the prevalence of rotator cuff tears has been reported.Pain is the most common symptom of patients with a tear.The frequency of pain varies from patient to patient. It depends on patient’s sustainability. It is actually a disability of tendon. A study says that it’s prevalence increases with age.

Rotator cuff tear is the most commonest shoulder pain. It has wide variation and prevalence among the society. The subacromial bursa is the muscle of source of pain for rotator cuff tear.It develops mostly on the older people. This tear is uncertain where the pain starts suddenly and lasts long forever. The tear leads to gradual increase in pain and acute onset of particular symptom.

Treatment is mostly the shoulder surgery.Imaging such as ultra sound and magnetic resonance are used for the treatment. Physiotherapy and regular exercise was also given as the primary relief treatment during initial stages.Surgery is advised only in case of acute tear where there is no improvement.

Cuff tears are either traumatic or degenerative. Traumatic tears are due to significant trauma, whereas degenerative tears are far more frequent and multifactorial in aetiology. The rotator cuff is weakened by both extrinsic and intrinsic factors, leading to gradual failure of tendon with or without superimposed acute injury, which finally results in full-thickness tear.
 
ANATOMY:

The shoulder is made up of three bones: upper arm bone (humerus), shoulder blade (scapula), and collarbone (clavicle). The shoulder is a ball-and-socket joint: the ball, or head, of upper arm bone fits into a shallow socket in the shoulder blade.
The rotator cuff is a group of four muscles that come together as tendons to form a covering around the head of the humerus. The rotator cuff attaches the humerus to the shoulder blade and helps to lift and rotate your arm.

Supraspinatusupraspinatus,infraspinatous, subscapularis and teres major are the four main muscles take part in rotator cuff tear. There is a lubricating sac called bursa in between the Bone and rotator cuff. This fluid is helpful in gliding freely in the movement of rotator cuff.If there is a damage in rotator cuff , this bursa will also get inflamed and damaged.

All these muscles originate from scapula and inserts into humerus. The subscapularis muscle is helpful in internal rotation of humerus .The teres minor muscle originates from the lateral scapula border and inserts on the greater tubercle of the humerus.The supraspinatus muscle has its origin in the supraspinatus fossa and inserts on the greater tubercle of the humerus – similar to the teres minor muscle. The fourth muscle of the rotator cuff is the infraspinatus muscle. It originates in the infraspinatus fossa of the shoulder blade and inserts on the greater tubercle as well.

The infraspinatous and teres minor fuse near their musculotendinous junctions, while the supraspinatus and subscapularis tendons join as a sheath that surrounds the biceps tendon at the entrance of the bicipital groove.The supraspinatus is most commonly
involved in a rotator cuff tear.

TEAR TYPES:

There are some types of rotator cuff tear. Partial thickness tear is common and it leads to non operative treatment. It rarely requires surgery . Full thickness tear is quite complicated where the condition is severe . It often needs shoulder surgery repair or  replacement. After that it can be relieved through orthopaedic treatment or physiotherapy. The tear can either be acute or degenerative.

DISCUSSION:

AETIOLOGY AND SYMPTOMS:

Rotator cuff tear is the most commonly occurring tear in our body . It may lead to various consequences. Many studies says that rotator cuff is common in males than females .But now recent studies prove that it is common for both males and females. It’s is actually due to the repetitive usage or movement of rotator cuff in the same direction for a prolonged period. Prior treatment is necessary to halt this in the middle stage itself . Many tear might also occur due to trauma.

The consequences varies from person to person. Symptoms are different for those in young people, adolescents and older people. Not all people are suspected , but people who have excessive hand work are suffered the most. The pain is gradual and sudden onset of pulling of muscles. Rotator cuff injuries are commonly associated with motions that require repeated overhead motions or forceful pulling motions. Such injuries are frequently sustained by athletes whose actions include making repetitive throws, athletes such as weightlifters, boxers, baseball or hockey players etc. Recent studies says that  rotator cuff tear is also occurring in people who are drummers, swimmers, fast bowlers , martial artists who are continually giving strain to rotator cuff tendons.

Some articles reveal that the symptoms of rotator cuff tear is almost same from person to person. Since the pain depends upon the size of the tear and how much the rotator cuff is actually torn. The pain at first appears only in the shoulder and gradually reaches along the side of the shoulder and reaching up while turning the steering of the car wheel or pain while sleeping. Most patients experience severe pain only while sleep at night. They find it difficult to sleep on one side pressing the shoulder.

Traumatic rotator cuff tear is another case. In this the active surgeons favour early rotator surgery for larger traumatic rotator cuff injury. The person feel weakness , acute pain and if left untreated the size of the tear may increase and cause complications . This is because your tissue was most likely normal prior to trauma and so the surgeons expect the results of surgery should be good with regards to improvement in strength, range of motion and elimination of pain.

Tendon degeneration is also the common aetiology among older people where the tendon is degenerated completely losing its sac and have difficulty in free gliding of shoulder.
It’s due to aging. Repetitive stress is the most significant factor. In older populations there is a impairment of blood supply in which the circulation of blood to the tendons decreases ultimately leading to, or contributing to tears .

Another main aetiology is impingement Syndrome. It is the factor among non-sports related injury. In this tendons of the rotator cuff rub on the underside of the acromian. This happens while elevating the arm upwards , the space between the tendon and the shoulder is narrowed. And hence the bursa is inflamed leading to damage. Recent studies says that spurs might develop that can actually damage the tendon to such an extent that the tendon becomes eroded away and tear. It is of primary tendonitis and secondary impingement.

DIAGNOSIS:

 The diagnostic methods is also advanced. In case of normal pain mostly physical therapies are recommended. Only if the pain increases or accurate ,Magnetic resonance imaging  is used. An MRI will be helpful to see if the weakness is secondary to pain or an actual tear. 

Rotator cuff fatty infiltration is also discussed mainly in some articles. In this if the rotator cuff is torn for a long time , the muscle which is torn might turn into fat. Fat is not like muscle tissue , this may not allow the surgery to be successful leading to dis improvement of function. And even after the surgery the fat will never  turn into a muscle tissue. Now MRI scanning is useful to determine the degree of fatty infiltration in rotator cuff.

Ultrasound is used to diagnose both partial and full thickness tear. But however studies confirm that MRI is the best method for diagnosing partial thickness rotator tear. Ultra sound has 90% sensitivity and specificity. Ultrasound is used in case of higher tear and helpful in dynamic testing , assessing the affected shoulder and the healthy shoulder.

X-rays don’t show up that clear in rotator cuff. Recent studies says that it helps in the diagnosis of bone spurs. This one is normally used in case of acute tears showing degenerative type changes.

TREATMENT:

Rotator cuff tears are one of the most common shoulder problems that usually require operative treatments. Therapeutic options used to repair ruptured tendons have consisted of suture, autografts, allografts (transplants), and synthetic prostheses.
Although surgical treatments have improved dramatically up to now, shoulder pathology is still challenging to orthopaedic surgery primarily because these injuries often respond poorly to treatment and require prolonged rehabilitation.
Recent attention has focused on several biologic pathways which can augment function to tendon healing, consequently leading to the identification of growth factors involved in this process.

The treatment varies from person to person based on the size or type of the tear. Recent studies says that rotator cuff tears are linked to a reduction in the natural number of functional stem cells in the tissue. And hence sometimes tear can heal on its own. In a recent analysis over 24 patients who has complete thickness tears where left untreated for some periods. In this out of 24 ,  2 patients the tear healed on its own . In 9 of 24 the tear was smaller. In another 9 out of 24 patients the rotator cuff tear size  didn’t change. In 6 patients , tear was found to be bigger. Since 75% of the patients, the tear was either healed ,smaller or didn’t change.

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