Some patients with small rotator cuff tears function fairly well with only aggravating or annoying pain. In patients with satisfactory function and tolerable pain, surgery is probably not indicated and use of some conservative treatment methods described above will suffice. For those with increased pain and difficulty with normal daily activities and/or work activities, surgery is probably the best option.
Failure to respond to nonsurgical, conservative treatment is often an indication for arthroscopic surgery. Surgical treatment of rotator cuff tendinitis and rotator cuff tears or ruptures involves examining the shoulder with an arthroscope into two different areas of the shoulder. First is examining the joint, or the glenohumeral articulation itself. This helps to determine if there is any instability (subluxation), or rotator cuff tears and to identify other possible problems (i.e. labral tears or SLAP lesions) inside the shoulder joint itself. The undersurface of the rotator cuff can be inspected and any tears can be seen and identified from this view.
The second area to be examined is called the subacromial space. This is a space between the acromion (the bone on the top of the shoulder) and the top of the rotator cuff tendons. The space is normally occupied by a bursa which is the protective,lubricating sac between the acromion and the rotator cuff. In cases of rotator cuffitis, it is often thick and inflamed. During the procedure, it is usually partially or completely removed. Tears of the rotator cuff can now be identified from this view. Spurring of the acromioclavicular joint and the acromion can be seen. If no tear of the rotator cuff is present, this subacromial space can be decompressed” or made larger by removing the bursa and spurs. An “acromioplasty” is when arthroscopically the undersurface of the acromion is burred or shaved away to enlarge the space where the rotator cuff moves. If a small to moderate-sized rotator cuff tear is identified, then in addition to the above, the rotator cuff will be repaired. This amounts to sewing it back to the bone where it was originally attached. Often, all this can be performed completely arthroscopically; on rare occasions, a small, one inch open incision will be made to repair the cuff to bone. When repair is done for small to moderate-sized tears, a sling is used for 2-3 weeks after the surgery. Patients that have tears that are old or chronic, and large present difficult treatment problems. In rotator cuff tears, the tendon pulls off the bone. Since the tendon is attached to the muscle, the muscle contracts and causes the tendon to shorten or retract. This results in a gap between its original attachment site and its eventual resting place. When the gap is sometimes very large and the muscle-tendon unit is shortened in that position for some time, it resists being stretched out to its original position and makes repair difficult.
In very rare cases, it is necessary to cut through the acromion to expose the retracted tendon muscle so as to lengthen it and to allow repair. In routine tears, it is not necessary to lengthen the muscle and tendon. In some cases in which the rotator cuff has been retracted, the repair is made under some tension. Because of this tension, it is necessary to splint the arm away from the side using a foam pillow to relieve some of this tension. This splint will have to remain in place for about one month after surgery. In some older patients with very large, old tears which cannot be repaired, simple spur removal with an arthroscope will give satisfactory pain relief, but function (motion) of the shoulder and arm will probably not be improved. This approach does avoid the somewhat prolonged and difficult rehabilitation after repair of a large tear and may be desirable in some patients. This will be discussed with those of you that I feel may need or would want to consider this approach.