What is the rotator cuff?

The rotator cuff corresponds to a musculo-tendinous complex that surrounds and covers the joint between the humerus and the scapula. This musculo-tendinous cap hermetically closes the glenohumeral joint in physiological conditions.

The cuff is composed of four tendons that attach to the humeral head, allowing the different movements of the shoulder and arm in all directions of space. It is thanks to it that the shoulder joint is the most mobile in the human body.

Anatomy of the four tendons

The four tendons

Subscapularis, supraspinatus, infraspinatus and teres minor form the rotator cuff

Function and physiology

The tendons of the rotator cuff allow the different movements of the shoulder and arm in all directions of space:

• Anterior elevation movements
• Lateral elevation movements (abduction)
• Internal or external rotation movements

This great mobility will also be at the origin of the fragility of these different structures and in particular of the rotator cuff.

Types of lesions

Lesion classification

Cracks and ruptures

Lesions in the axis of the fibers (cracks) or perpendicular (ruptures), partial or transfixing

Extent of lesions

Isolated

Single tendon affected (Supraspinatus in more than 80% of cases)

Multiple

Several tendons affected simultaneously, or even all simultaneously in case of complete rupture

Causes of lesions

Subacromial impingement

It is the repeated friction of the different tendons of the shoulder against the acromial bone that will cause progressive weakening of the rotator cuff. The evolution of this friction will cause a tendon lesion, which can range from superficial partial lesion to complete rupture.

Upper limb trauma

Traumatic rupture most often occurs in the context of a fall, either directly on the shoulder stump, or on the elbow or arm. Shoulder dislocations are also responsible for sometimes massive tendon lesions.

Symptoms and manifestations

Pain

They are often very important during the acute phase at the time of trauma with sensation of cracking or tearing. These pains will be constant throughout the day, without real fluctuation between day and night.

Immobilization and rest, with the arm in elbow-to-body position, best calms these painful phenomena.

Functional impairment

This is the inability to normally mobilize the affected limb. In some cases, a temporary picture of paralyzed shoulder may appear with total inability to actively mobilize the shoulder.

Lack of strength is often associated with functional impairment and may persist even after recovery of mobility.

Diagnosis and evaluation

Clinical examination

• Specific tests: Jobe test, Patte test, Belly press test, Lift off test, Bear-hug test
• Mobility assessment: Active and passive
• Strength assessment: Tests against resistance
• Pain assessment: Location and intensity

Imaging examinations

X-ray

Routine examination to evaluate bone structures and look for indirect signs

Ultrasound

Minimally invasive examination to explore tendon and muscle structures

Arthro-CT/MRI

Reference examination to confirm and assess a rotator cuff lesion

Therapeutic options

Conservative treatment

The choice of conservative treatment will most often be made in people over 80-85 years old or in people with low functional needs.

• Drug treatment: Level 1-2 analgesics, anti-inflammatories
• Immobilization: Orthopedic vest maximum 1 week to 10 days
• Cryotherapy: Multiple daily cold applications
• Cortisone infiltration: Injection into the glenohumeral joint
• Physiotherapy: Fundamental role in conservative treatment

Surgical treatment

The choice of surgical treatment most often addresses young patients with important functional needs. It will be particularly favored for active people, exercising a professional activity or regular sports activities.

Arthroscopic repair

Video surgery intervention with 2-3 centimeter incisions. Tendon repair using anchor systems inserted into the bone.

Acromioplasty

Shaving of the anterior tip of the acromion often at the origin of tendon lesions, performed at the same time as the repair.

Post-operative rehabilitation

Physiotherapy is a fundamental element of functional recovery after rotator cuff repair. This physiotherapy must progressively adapt to tendon healing according to three defined phases.

Phase 1: Passive mobilization (D0 to D45)

Immobilization by abduction pillow 24h/24. Only strict passive mobilization will be performed to regain good joint flexibility.

Phase 2: Active mobilization (D45 to M3)

Active mobilization of the arm and shoulder in all directions without work against resistance. Stop immobilization by abduction pillow.

Phase 3: Progressive strengthening (M3 to M6)

Progressive work against resistance with stabilization and shoulder centering work to avoid inflammatory phenomena.

Possible complications