Subacromial conflict and
rotator cuff tear

Traumatic injuries are fairly rare, and usually occur in the event of shoulder dislocation or severe sprain. Symptoms of a rotator cuff injury are usually pain on movement and pain at night. Depending on the size of the tear, there is often a loss of strength, especially with the arm outstretched, where considerable effort is required. In some cases, this weakness can worsen, leading to loss of arm function. Frequently, the rupture may increase in size and, over time, become irreparable. If the retraction becomes too great, fatty degeneration of the muscles may occur. It is important to consult a doctor for diagnosis and appropriate treatment of shoulder pain.

The patient describes pain in the shoulder for no particular reason (no trauma). Everyday movements requiring arm mobility are painful. Pain is particularly intense when the arm is raised to 90°.

X-rays can be used to identify the shape of the acromion, in case the syndrome is due to a bony beak (anatomical cause). To do this, front and side views of the joint are taken. However, this method does not allow us to visualize the tendons. The subacromial impingement is then confirmed by ultrasound or MRI, which can be used to visualize the associated tendonitis.

In the first instance, medical treatment of subacromial impingement and physiotherapy are preferred. Treatment consists of anti-inflammatory drugs to relieve pain, possibly infiltrations into the area under the acromion, and rehabilitation sessions with a physiotherapist.

Re-education is essential, and in the vast majority of cases can avoid the need for surgery. It should be active, and consist in strengthening the external rotators to dynamically lower the head of the humerus. In rare cases of failure (persistence of pain even after 3 months of well-performed re-education), surgery may be indicated.

In a second stage, medical professionals opt for surgery. Surgery for subacromial impingement is known as shoulder acromioplasty. It is generally performed in 30 minutes under local or general anaesthetic. It is also performed under arthroscopy, which involves inserting a small camera into the shoulder to visualize the joint. This makes it possible to correct dysmorphism using a small mechanical burr. This operation enables sub-acromial decompression.

The main function of the rotator cuff tendons is to keep the head of the humerus centered on the glenoid. The rotator cuff is made up of 4 muscles that start at the scapula and insert themselves into the proximal part of the humerus. Together, these four tendons surround the head of the humerus almost completely. The tendon of the long head of the biceps interrupts the tendon cuff at a point called the rotator interval, inserting onto the glenoid. If the rotator cuff is torn, the biceps tendon can become unstable, causing intense pain in the arm. The rotator cuff muscles not only stabilize the shoulder, but are also responsible for external rotation (infraspinatus and petit rond muscles) and the last few degrees of internal rotation (subscapularis muscles), as well as the onset of abduction (supraspinatus muscle) of the shoulder. Rotator cuff tears are a frequent source of shoulder pain, and their incidence increases with age. Repetitive movements, physical exertion or subacromial impingement can cause tendon degeneration. Traumatic injuries are relatively rare, and usually occur as a result of shoulder dislocation or severe sprain. Symptoms of a rotator cuff injury are usually pain on movement and pain at night. Depending on the size of the tear, there is often a loss of strength, especially with the arm outstretched, where considerable effort is required. In some cases, this weakness can worsen, leading to loss of arm function. Frequently, the rupture may increase in size and, over time, become irreparable. If the retraction becomes too great, fatty degeneration of the muscles may occur. It is important to consult a doctor for diagnosis and appropriate treatment of shoulder pain.

During the diagnostic phase, damage to tendons, cartilage and fibrocartilaginous structures is assessed using an intra-articular camera. The damaged tendons are then prepared and fixed using a variety of techniques. Today, small anchors of various materials, connected to high-strength sutures, are generally used to suture the tendon.
The treatment of rotator cuff tears depends on various factors, such as the reparability of the injury, the patient’s functional needs and age. It is important to take into account the impact of the injury on daily life and sporting activities, as well as the size of the tear. The treatment of choice for cuff tears is surgical repair, which generally maintains the shoulder’s functional status in the long term. Whenever possible, attempts are made to fix the tendon in its original position to promote healing. Depending on the anatomical and radiological findings, subacromial decompression, tenotomy and tenodesis of the biceps may also be opted for. In the case of subscapularis muscle rupture, the biceps tendon is often displaced. When the subscapularis muscle is repaired, the biceps tendon is cut (tenotomy) and fixed (tenodesis).

Healing is a process that takes months, so it’s important to follow the instructions of your doctor and physiotherapists. In the first few months, it’s important to keep the arm abducted with a splint. This slightly abducted position in neutral rotation reduces tension on the tendons.

The rotator cuff is a group of four muscles and their tendons (supraspinatus, infraspinatus, teres minor, subscapularis) that connect the humerus to the scapula and help lift and rotate the arm.

Rotator cuff tears are a common problem, particularly in the elderly. The prevalence of complete ruptures in people over 60 is around 28%, rising to 65% in people over 70. There are various associated risk factors, including age, smoking, hypercholesterolemia and family history. Aging is the most important risk factor, as degeneration of the tendons and muscles of the rotator cuff occurs naturally over time. Smoking is also a risk factor, due to its negative effects on tendon vascularization and collagen synthesis. High cholesterol levels can lead to atherosclerosis, which can reduce blood flow and compromise the integrity of the cuff.

Rotator cuff tears can have a variety of etiologies. Chronic degenerative tears are the most common and are seen in elderly patients, with intrinsic degeneration being the main cause. These tears usually involve the SIT muscles (supraspinatus, infraspinatus, teres minor), but can extend forward to involve the upper part of the subscapularis tendon in larger tears. Chronic impingement is another tearing mechanism, usually starting at the surface of the bursa or within the tendon. Acute avulsion injury is also a cause, with acute subscapularis tears seen in younger patients after a fall and acute SIT muscle tears seen in patients over 40 with shoulder dislocation. Associated conditions include acromioclavicular joint pathology, proximal biceps subluxation, proximal biceps tendinitis and internal impingement.

This pathology can present with a variety of symptoms. The most common symptom is pain, which usually has an insidious onset and is exacerbated by physical activity. Pain is generally localized in the deltoid region and can also be felt in the upper arm. Nocturnal pain is also common, and may be a poor indicator of conservative management. Acute pain and weakness can occur with a traumatic tear. Weakness is another common symptom and may manifest as a loss of active range of motion while maintaining a greater or intact passive range of motion. It’s important to note that some patients with cuff tears may be asymptomatic, particularly those with partial tears. Therefore, a thorough physical examination and appropriate imaging studies are necessary for accurate diagnosis and treatment.

Imaging plays a crucial role in diagnosis and management. Standard radiographs are often the initial imaging modality. They may reveal signs such as calcific tendonitis, calcification of the coracohumeral ligament, cystic changes of the major tubercle, elevation of the humeral head and type 3 (hooked) acromion. Arthrograms are not commonly used in isolation, but can be used when MRI is contraindicated. MRI is considered the gold standard and should be obtained in cases of suspected cuff pathology. Its findings can include important information such as muscle quality (size, shape, degree of tear retraction and degree of muscle atrophy), subluxation of the medial biceps tendon, which indicates a subscapularis tear, and the presence of the tangent sign. In addition, a cyst in the humeral head is observed in almost all patients with chronic tears. Ultrasound may be indicated when a dynamic examination is required. It is advantageous because it is inexpensive and readily available in most centers. Ultrasound is also useful for confirming intra-articular injections. However, it has certain disadvantages, such as high user dependency and limited ability to assess other intra-articular pathologies.

Surgery is generally recommended for patients with complete tears. For some patients with partial tears (less than 50%) on the articular side and of low grade, subacromial decompression and cuff debridement may be indicated. For acute complete tears or tears on the bursal side deeper than 3 mm, arthroscopic or mini-open repair is generally recommended. Partial tears on the articular side (greater than 50%) can be treated by tear repair. In the case of partial avulsion of the supraspinatus tendon (often in athletes), in younger patients with acute traumatic tears, in situ repair is recommended to leave the bursal-side tissue intact, whereas in older patients with degenerative tears, tendon release, debridement of degenerative tissue and repair are generally required. Tendon transfer techniques such as pectoralis major transfer, dorsalis major transfer or trapeze may be indicated for massive cuff tears. Superior capsular reconstruction is recommended for massive irreparable cuff tears with an intact subscapularis. Finally, reverse total shoulder prosthesis is recommended for massive tears with associated glenohumeral osteoarthritis and an intact deltoid. Post-operative rehabilitation with limited passive range of motion (no active movement) is recommended.

Surgery can lead to a number of complications. One of the most common is recurrence or failure of the repair. This is often caused by the inability of the tissue to heal properly, resulting in a tear in the suture. Patients with risk factors such as advanced age, large tears, muscle atrophy, diabetes, smoking, medial retraction of the tear relative to the glenoid and poor compliance with postoperative protocols have a higher risk of failure. Other complications include infection (less than 1% of cases) and stiffness, which may occur despite early physical therapy and range-of-motion exercises. There is also a risk of nerve damage, such as axillary nerve damage and suprascapular nerve damage.

Recovery from surgery usually involves a period of immobilization, followed by physical therapy to help regain strength and range of motion in the shoulder. It can take several months to fully recover from surgery and resume normal activities, and in some cases full recovery is not possible.

Prognosis varies according to the above-mentioned risk factors. It is important to note that 50% of asymptomatic tears can become symptomatic within 2-3 years. Furthermore, studies have shown that symptomatic complete tears have a 50% progression rate at 2 years, and that larger tears tend to progress more rapidly. Patient age is also an important factor to consider, as older patients are more likely to experience non-healing of tears and subsequent repair failure.