Arthroscopic Repair of Shoulder Muscle Tears

What Is the Rotator Cuff (Shoulder Muscles) and What Is Its Function?

The rotator cuff is a structure made up of the tendons of four muscles that surround the shoulder joint and attach to the upper part of the arm bone (humerus). These muscles are:

1. Supraspinatus: The most commonly torn tendon; it initiates raising the arm to the side (abduction).
2. Infraspinatus: Enables outward rotation of the arm (external rotation).
3. Teres Minor: Assists in outward rotation of the arm.
4. Subscapularis: Enables inward rotation of the arm (internal rotation).

The main functions of these muscles and tendons are:

• To enable the arm to move in various directions (lifting, rotating).
• To preserve the stability of the shoulder joint — that is, to keep the head of the arm bone (humeral head) centered in the shallow socket of the shoulder blade (glenoid).

Rotator Cuff Tear: This is the condition in which one or more of these tendons separates, partially (partial-thickness) or completely (full-thickness), from its attachment site on the bone.

Why Do Rotator Cuff Tears Occur? Risk Factors

Rotator cuff tears occur through two main mechanisms:

1. Degenerative Tears (Wear-Related): This is the most common type of tear. It generally develops gradually over time. Its causes include:
   
   • Aging: As age advances, blood supply to the tendons decreases and their structure weakens, making them more prone to tearing. Risk increases after age 40-50.
   • Overuse and Repetitive Stress: Especially occupations involving frequent overhead activities (painters, plumbers, teachers) or sports (volleyball, tennis, swimming, weightlifting).
   • Shoulder Impingement Syndrome: Compression of the tendons due to bone spurs in the shoulder joint or other structural problems, leading to gradual wear and tearing.
   • Smoking: Impairs blood supply to the tendon, hindering healing and increasing the risk of tearing.
   • Genetic Predisposition: Family history may play a role.
2. Acute (Traumatic) Tears: These can also occur in younger individuals and result from a sudden event:
   
   • Falling onto an outstretched arm.
   • Suddenly lifting or pulling a heavy object.
   • Shoulder dislocation.

What Are the Symptoms of a Rotator Cuff Tear?

Symptoms vary depending on the size and type of the tear (degenerative or traumatic) and the person’s activity level. Some small or degenerative tears may not cause symptoms initially. Common symptoms include:

• Shoulder Pain: Usually a deep, dull pain felt on the side or front of the shoulder. It increases when lifting the arm or pushing or pulling something. Night pain in particular is typical and can wake the patient from sleep or make it impossible to lie on the affected shoulder. In acute tears, pain begins suddenly and severely.
• Weakness: Difficulty and loss of strength when lifting the arm (especially to the side or forward) or rotating it. Difficulty may occur even with simple tasks such as holding a cup or combing hair. In large tears, the patient may be unable to lift the arm at all (pseudoparalysis).
• Restricted Movement: Shoulder movements may be limited due to pain and weakness.
• Crepitus (Popping/Cracking): A clicking, crackling, or grinding sensation/sound during shoulder movement.
• Muscle Wasting (Atrophy): In long-standing or large tears, there may be visible thinning of the muscles around the shoulder.

How Is a Rotator Cuff Tear Diagnosed?

An accurate diagnosis is important for determining the presence, type, and size of the tear, as well as any accompanying problems. Prof. Dr. Murat Bozkurt follows these steps for diagnosis:

• Detailed History: The onset, duration, and severity of symptoms, the mechanism of injury (if any), occupation, sports activities, and prior treatments are noted.
• Physical Examination: The appearance of the shoulder (swelling, atrophy), tender points, and active and passive range of motion are assessed. Special examination methods that test the strength of the rotator cuff muscles are performed (e.g., the “Empty Can” test for the supraspinatus, the “Lift-off” test for the subscapularis, external rotation tests for the infraspinatus/teres minor). Shoulder impingement tests are also applied.
• Imaging Methods:
  
  • X-ray: Does not directly show tendon tears, but reveals indirect findings such as bone spurs, calcification, or upward migration of the humeral head (a sign of a large tear), as well as other bony problems.
  • Ultrasonography (US) or Magnetic Resonance Imaging (MRI): These are the most valuable methods for diagnosing rotator cuff tears. These methods;
    
    • Definitively show the presence and location of the tear.
    • Determine whether the tear is full-thickness or partial-thickness.
    • Define the size (small, medium, large, massive) and shape of the tear.
    • Show how far the tendon has retracted.
    • Assess whether there is muscle wasting (atrophy) or fatty infiltration (fatty degeneration), as these affect the success of repair.
    • Detect other accompanying pathologies such as bursitis or biceps tendon problems. MRI generally provides more detailed information.

Treatment Options: Does Every Tear Require Surgery?

Treatment of a rotator cuff tear varies depending on the type of tear (acute/degenerative), its size, thickness (full/partial), the patient’s age, activity level, occupation, and the severity of symptoms. Not every rotator cuff tear requires surgery.

Non-Surgical (Conservative) Treatment:

Especially for age-related (degenerative), partial-thickness, or small full-thickness tears where symptoms are not very severe, non-surgical treatment is usually the first choice. The goal is to reduce pain and improve function.

• Activity Modification: Avoiding painful movements and overhead activities.
• Medication: NSAIDs for pain and inflammation.
• Physical Therapy and Rehabilitation: Very important. The program includes:
  
  • Modalities aimed at reducing pain.
  • Stretching exercises to preserve shoulder range of motion.
  • Strengthening exercises for the intact rotator cuff muscles, the deltoid muscle, and the muscles around the shoulder blade. These muscles help compensate for the function of the torn tendon.
• Corticosteroid Injections: Cortisone injections into the subacromial space can temporarily relieve pain, especially if there is accompanying bursitis or impingement. However, they should be used cautiously, as they may have adverse effects on the tendon.

Conservative treatment is generally continued for 3-6 months. If sufficient improvement is not achieved during this time, or if the tear is initially large/traumatic, surgery may be considered.

Surgical Treatment: Arthroscopic Rotator Cuff Repair

Surgical treatment is generally recommended in the following situations:

• Persistent pain and loss of function despite adequate conservative treatment (at least 3-6 months).
• Acute (traumatic), full-thickness tears in young and active patients.
• Large or massive full-thickness tears causing functional limitation.
• The need for full recovery of shoulder function due to the patient’s occupation or lifestyle.

Today, rotator cuff repair is largely performed using the arthroscopic (closed) method.

Arthroscopic Rotator Cuff Repair Surgery

In this minimally invasive surgical method:

1. A thin camera (arthroscope) and special surgical instruments are inserted into the joint through several small incisions (approximately 0.5 cm) made around the shoulder.
2. The surgeon views the inside of the joint and the rotator cuff tear in detail on a screen. The size and shape of the tear and the quality of the tendon are assessed.
3. Worn tissue at the edges of the tear is removed (debridement).
4. The bone surface where the tendon will reattach (the attachment site on the humeral head – footprint) is lightly prepared to increase blood supply.
5. Repair: Small screws or anchors called suture anchors are placed into the bone. Strong, specialized suture threads attached to these anchors are passed through the edge of the torn tendon. The sutures are tightened, pulling the tendon back to its original anatomical attachment site on the bone and securing it firmly. Depending on the size and shape of the tear, a single-row or double-row anchor technique may be used.
6. If there are also findings of shoulder impingement syndrome, subacromial decompression (bursectomy and acromioplasty) is generally performed in the same session.

Prof. Dr. Murat Bozkurt is a surgeon in Ankara experienced in arthroscopic rotator cuff repair, and aims to achieve a strong, anatomical repair using the most current techniques.

Risks, Benefits, and the Long Recovery Process

• Benefits: After successful repair — substantial relief of pain, recovery of shoulder strength and function, increased range of motion, and prevention of complications such as progression of the tear and long-term “rotator cuff arthropathy” (shoulder osteoarthritis related to the tear).
• Risks:
  
  • General surgical risks: Infection (less than 1%), shoulder stiffness (frozen shoulder), nerve damage, anesthesia risks.
  • Repair-specific risks: Failure of the repaired tendon to heal to the bone, or re-tearing. This risk varies depending on factors such as the size of the tear, the quality of the tendon, the patient’s age, and smoking (it can be 5-25% or higher). There are also risks such as loosening or displacement of the suture anchors, and persistent pain or weakness.
• Recovery Process: Recovery after rotator cuff repair is a long, patience-requiring, and gradual process. The success of the surgery largely depends on adherence to this process.
  
  • Use of an Arm Sling: Wearing an arm sling for 4 to 6 weeks after surgery (sometimes longer) is mandatory to allow the repaired tendon to heal securely to the bone. Actively lifting the arm during this period is strictly forbidden.
  • Gradual Physical Therapy Program:
    
    • Passive Motion Period (First 4-6 weeks): The shoulder is only allowed to be moved passively, with the help of a physiotherapist or special devices. The goal is to prevent stiffness.
    • Active-Assisted and Active Motion Period (After week 6): The patient gradually begins moving the arm using their own strength.
    • Strengthening Period (Generally after month 3): Strengthening exercises for the rotator cuff and the muscles around the shoulder are gradually introduced.
  • Full Recovery: Return to normal daily activities can take about 3 months, while return to more demanding activities can take 6 months. Return to heavy labor or overhead sports (tennis, volleyball, etc.) generally takes 9 to 12 months or longer, and regaining full strength can take time.
  • Patient Compliance: Strict adherence to sling use, movement restrictions, and the physical therapy program is vital for the successful healing of the tendon.

Shoulder Muscle Tear Surgery in Ankara and Prof. Dr. Murat Bozkurt’s Approach

Rotator cuff tears are among the leading causes of shoulder pain and functional loss in Ankara. Prof. Dr. Murat Bozkurt adopts the following principles in treating this common problem:

• Accurate and Detailed Diagnosis: Clarifies the cause (degenerative/traumatic), type, size, tendon quality, and any accompanying problems using methods such as MRI.
• Evaluating Conservative Treatment Options: Especially in degenerative and small tears, or in patients not suited for surgery, he tries non-surgical treatment methods (physical therapy first) and follows their results.
• Surgical Treatment in Suitable Patients: When surgery is required, he makes the most appropriate decision based on the patient’s age, activity expectations, and the characteristics of the tear.
• Minimally Invasive Arthroscopic Techniques: Performs rotator cuff repair using the arthroscopic (closed) method, which provides less tissue damage, less pain, and a better cosmetic result. Uses the most current and strongest repair techniques (e.g., double-row repair) depending on the condition of the tear.
• Management of Rehabilitation: Emphasizes the importance of the long and critical postoperative rehabilitation process, directs the patient to the right program, and closely monitors the process.

Prof. Dr. Bozkurt offers patients with rotator cuff tears in Ankara comprehensive care, starting with accurate diagnosis and including conservative or modern arthroscopic surgical treatment options and postoperative rehabilitation.

Rotator cuff tears are common problems that can significantly affect shoulder function. However, with an accurate diagnosis, appropriate treatment (conservative or arthroscopic surgery), and a patient rehabilitation process, it is possible to relieve pain and regain your shoulder function. You can trust the expertise of Prof. Dr. Murat Bozkurt for the shoulder problems you experience in Ankara.

For detailed information and appointments, you can contact Prof. Dr. Murat Bozkurt at 0312 502 70 74.