Dr Harry Papagapiou – Orthopedic Surgeon
MBCHB (WITS) MMED Orth (WITS) FC Orth (SA) Cert Knee Recon
What is it?
Shoulder pain accounts for one of the most common orthopaedic complaints. It’s disabling!
There are various intrinsic shoulder causes of pain, not to mention the referred patterns. For the purpose of a concise summary: Impingement & Bursitis together with rotator cuff or “Shoulder Tendon” problems accounts for a large percentage ± 35% of these.
Rotator Cuff (RC) is the confluence of tendons that hug the shoulder skeleton to aid rotatory movement & elevation of the shoulder joint.
Presenting symptoms include pain affecting sleep & functional inhibition including sporting activity, mainly overhead, but also daily activity.
In my practice, the demographics vary from elite to amateur athletes, active pensioners and even to the sedentary elderly population. Causes relate to repetitive shoulder activity, especially overhead, but acute traumatic episodes play a role too.
Clinical evaluation with provocative tests, ultrasonographic imaging and occasionally an MRI may assist in confirming a RC problem.
Being part of a sporty community linked to a highly specialised multidisciplinary centre, the patients generally reach me once failed conservative means have been reached. Conservative management is still the mainstay of management, although goals and expectations vary, additionally, the severity of the pathology is crucial to the management plan
Where to from here?
Understanding the problem
Tears can be partial or complete. The partial ones are the painful tears. Full-thickness tears are less painful but functional impairment is the problem.
Impingement and Bursitis usually are associated, and occasionally associated injuries such as bicep tendon problems tag along too.
What does the cuff & tear look like?
Below is an illustration of the side view of a torn rotator cuff. This is a full-thickness tear. This demonstrates one that is fresh enough to be docked at its native footprint without too much tension. Chronic or old injuries tend to retract and scar up making repair and docking a lot more challenging and even impossible. In this latter scenario, graft or synthetic reconstruction/augmentation options become necessary as are arthroplasties/salvage procedures. Lets stick to the repairable options!
What is a partial tear?
Imagine a sheet/layer peeling off, with the flap catching with every movement and tearing further.
Partial & Full Thickness tear
What is a Bursal & Articular sided tears
Articular sided means the torn layer is on the undersurface in the joint whereas bursal sided is on the top surface facing the bursa – Surgical significance
Although there are various techniques of surgically repairing the tears, I.e. open, mini-open-arthroscopic assisted, and all arthroscopic techniques, I personally
prefer arthroscopic repairs in my practice. Minimal Invasive Surgery not only allows for quicker recovery & less tissue damage but by navigating the camera
throughout the joint & subacromial space, the shoulder structures are visualised in clarity during the diagnostic step in the procedure, this ensures the ability to quantify & stratify tears and associated injuries, and also to strategically manage them appropriately. Although more technically demanding & slightly more time-consuming. Definitely beneficial!
Rehab & Return to Sport
Physiotherapy plays a vital role in postoperatively for a successful return to sport & general function. It is generally about a 6 week period in an arm splint, &
roughly a 3-6 months program. Studies report ± 84.7% return to competitive sport in full-thickness tears repaired surgically, and a range of 65.9 – 89% return to pre-injury level of play! Techniques & implants have improved dramatically since those studies were published!