Rupture of the rotator cuff: diagnosis and treatment at the San Siro Clinical Institute

“The rotator cuff is represented by 4 tendons that cover the head of the humerus and are connected to the respective muscles (supraspinatus, infraspinatus, teres minor and subscapularis). It is called the rotator cuff, because it wraps head of the humerus just like a cuff: its function is to center and stabilize the humerus and give it the necessary strength to perform the movements of daily life,” - explains Dr. Andrea Lisai.

As a result of aging, wear, repetitive strain or trauma, these tendons undergo stresses, lose elasticity and create partial injuries that can evolve into complete ruptures. The risk factors, in addition to age, are mainly smoking and diabetes.

“Ruptures can be of various sizes:

• partial injury ('fraying');
• small complete tears (the tendon that detaches from the bone);
• large tendon retractions.

The last one would be better to prevent because the cuff may no longer be repairable and would result in joint damage (glenohumeral arthropathy from massive rotator cuff injury)”.

The first alarm is pain: shoulder pains prior the age of 60-65 are usually due to trauma, instability, bursitis and / or subacromial conflict, or adhesive capsulitis.

Pain, especially at night, and the lack of strength and / or functional limitation after this age are symptoms that should not be underestimated. For a correct diagnosis, anamnesis is important, that is, the account of symptoms and risk factors, and the physical examination.

“The ultrasound evaluation that we perform to complete the visit allows us to immediately formulate diagnosis and recommend the appropriate treatment. In this way, unnecessary waiting or prescriptions for second level exams are avoided, saving patients’ time. In the event if a diagnostic is necessary, high-field magnetic resonance imaging (MRI – 1,5 T) is prescribed in order to provide precise images on the actual state of the tendons,” - Dr. Lisai points out.

“Fortunately, only a minority of patients that visit our Unit need surgery to solve the problem. In fact, if we face with bursitis, tendinitis or a partial injury, the treatment provided is conservative: physiotherapy and physical therapies (US waves, lasers) are very useful. The infiltrations that we always perform under ultrasound guidance are also very effective, in order to have maximum accuracy,” - emphasizes Dr. Lisai.

The products used for the infiltrations are hyaluronic acid, cortisone, anesthetics or PRP, i.e. the growth factors obtained from the centrifugation of a small sample of patient's venous blood: in this case we speak of regenerative medicine.

Outpatient treatment of calcific tendinopathy of the rotator cuff (RCCT)

Another pathology that until a few years ago was always destined for surgery was the calcific tendinopathy of the rotator cuff, i.e. the (very painful) presence of calcific deposits inside the tendons; today, these calcifications can be evacuated with a procedure called lithoclasis or ultrasound imaging-guided percutaneous lavage Dr. Lisai explains:

“This procedure is performed under ultrasound guidance, under local anesthesia and lasts about 20 minutes: at the end the patient has immediate relief and does not need any immobilization with a shoulder brace”.

“If the rupture of the tendon is complete, the patient is active and symptomatic, we opt for surgery which consists of arthroscopic repair of the tendons (3-4 small incisions). The anesthesia is loco-regional or mixed, the hospitalization is only one night long,” clarifies Dr. Lisai.

In a few cases in which the lesion of the rotator cuff reaches an advanced degree of retraction and degeneration and the patient shows functional limitations, repair is no longer possible and, therefore, a prosthesis is implanted, defined “reverse”, which allows the patient to resume normal activities of daily life after 4-6 weeks.

“Rehabilitation is an important pillar in the treatment of a shoulder. It must be performed by specialized personnel, because the shoulder is a very complex joint and experience is required. In this regard, at the San Siro Clinical Institute we have significantly speeded up our rehabilitation protocols relating to the repair of the rotator cuff and shoulder prostheses, in such a way as to allow a rapid return to work and sports activities, also limiting the onset of post-surgical stiffness. Our patients no longer wear a brace during the day (vice versa at night) and are empowered and instructed to perform exercises from the first day after surgery,” says Dr. Lisai.

Therefore, no more wearing braces for 30-40 days, but an early and responsible use of the shoulder in compliance with the operation performed.

At the San Siro Clinical Institute, patients with rotator cuff pathologies have a tailor-made diagnostic path, starting from entering the facility and finishing at the discharge.