How much does rotator cuff surgery cost

Rupture of the rotator cuff: Shoulder tightness (impingement) damages the supraspintus tendon

The human shoulder is largely suspended freely movable by ligaments and muscles. The most important tendon is the torn supraspinatus tendon in this illustration. © Viewmedica

Why is the rotator cuff, especially the supraspinatus tendon, particularly prone to wear and tear? The supraspinatus tendon encloses the head of the humerus from above. Tears in the rotator cuff can possibly be treated very conservatively. We also want to explain to you when a rupture of the supraspinatus tendon has to be operated on. In most cases, the tendon can be repaired through an arthroscopic suture.

Sometimes the damaged supraspinatus tendon cannot be sutured again because it is completely torn or worn out. In order to avoid a permanent, painful narrowing of the space under the roof of the shoulder (acromion) as a result of the supraspinatus rupture, we work with a self-dissolving implant.

Fig. 1: The human shoulder (from behind) with its complex apparatus of bones, ligaments and muscles is suspended freely movable on 4 muscles or tendons. The most important one is the supraspinatus tendon. It connects the head of the humerus with the supraspinatus muscle and ensures that the arm can be raised. When the rotator cuff is defective, the humerus moves up towards the roof of the shoulder (acromion). The increasing tightness leads to pain and movement disorders. © bilderzwerg - Fotolia.com

Terms relating to the rupture of the rotator cuff

  • Rotator cuff
    Four tendons and muscles as a guide structure for the shoulder joint
  • Acromion:
    Shoulder roof over the shoulder joint
  • "rotator cuff" "
    English for rotator cuff
  • Impingement
    Movement blockage in the shoulder joint
  • engl. "to impinge"
    nudge
  • Supraspinatus tendon
    The most commonly damaged rotator cuff tendon; surrounds the humerus head like a hood
  • Rupture: Crack

In this case, with the Inspace ™ system, we offer a surgical replacement for the placeholder function of the supraspinatus tendon: This minimally invasive implant can center the shoulder again. It enables shoulder-centering physiotherapy to stabilize the rotator cuff.

How common are rotator cuff and supraspinatus tendon disorders?

Shoulder pain and movement disorders of the shoulder are common orthopedic problems. 25% of all people have shoulder pain that requires treatment at some point in their life. The incidence of tears or partial tears in one of the shoulder tendons, especially the supraspinatus tendon, is well over 30% in those over 60 years of age. Shoulder pain is therefore one of the most common reasons for inability to work.

Aging process of the rotator cuff or supraspinatus tendon

What promotes the rupture of the supraspinatus tendon?

  • Increasing age
  • Frequent overhead movement during work and sports (swimming)
  • Shape of the shoulder roof: A hook-shaped acromion loads the supraspinatus tendon
  • Accident affecting the hand, elbow or shoulder

After the 40th birthday, the rate of shoulder diseases increases sharply in both men and women. The rotator cuff of the shoulder goes through a normal aging process: the stability and mobility of the shoulder decrease with age. The probability of injuries, on the other hand, increases significantly. On average, patients are 55 years old when they first start orthopedic treatment for a rotator cuff disease. Men and women are equally affected. In addition to the aging process, a narrowing under the roof of the shoulders can mechanically weaken the supraspinatus tendon through friction. This degeneration of the supraspinatus tendon is a chronic process that often progresses unnoticed for years.

How do damage (ruptures) of the rotator cuff occur?

Fig. 2: The human shoulder joint can move freely and is centered in the shoulder joint by the rotator cuff. When the supraspinatus tendon is torn (running above the head of the humerus), the upper arm rises up under the roof of the shoulder. One then speaks of shoulder impingement. © Prof. Dr. Sven Ostermeier

In contrast to the hip joint, for example, the shoulder is not firmly anchored in a joint socket that tightly encloses the joint head. The joint socket is very flat in the shoulder. It does not encompass the joint head: it just rests on it. The shoulder can move freely - it has a greater range of motion than any other joint in the human body. The joint head and socket of the shoulder are only held together by the muscles and tendons. That is a dynamic muscle balance.

This muscular apparatus that guides the shoulder and keeps it in place through its balance is also known as the rotator cuff (rotator = responsible for turning, cuff = wide tube) of the shoulder.

Balance means: All muscles and tendons must always work together and can only perform their function together. As soon as one of the participants is disturbed, the shoulder loses its precise guidance in the shoulder joint socket. The head of the humerus is pulled by the strong deltoid muscle from above out of the socket under the roof of the shoulder.

Shoulder tightness (shoulder impingement) is stress for the rotator cuff and supraspinatus tendon

Damage to the rotator cuff

  • Inflammation of the tendons (or the supraspinatus tendon)
  • Calcification of the tendons
  • Bursitis under the roof of the shoulder
  • Shoulder impingement: upper arm rubs against the acromion
  • Rupture of the supraspinatus tendon

There is a specific reason why rotator cuff tears are so common. This is due to the special structure of the rotator cuff of the shoulder (see Figure 1).

The center of attention is the space between the shoulder joint and the shoulder roof.

Whenever the arm is raised above the head, this space narrows under the shoulder roof. The supraspinatus tendon runs exactly between the head of the humerus and the roof of the shoulder. It is particularly affected by every overhead movement of the arm: When the upper arm rises, the supraspinatus tendon is pressed against the roof of the shoulder. When the arm is hanging down in a relaxed manner, the supraspinatus tendon ensures that the humerus head lies precisely in the shoulder socket (glenoid) and is not pulled under the roof of the shoulder by the strong muscles of the deltoid.

Rupture of the rotator cuff or supraspinatus tendon

Symptoms of rupture of the supraspinatus tendon

  • Tearing sound at the moment of the rupture
  • Shoulder pain
  • Muscle weakness
  • Shoulder pain in the side and front of the shoulder joint
  • Shoulder is not resilient
  • Overhead movements such as combing or reaching into a high shelf are no longer possible
  • Movement backwards such as apron grip or putting on trousers are disturbed
  • Night pain in the shoulder
  • Neck pain as other muscles try to do the job of the supraspinatus

The tear in the rotator cuff leads to a narrowing of the joint space under the roof of the shoulder (Acromion). The humerus head is comparable to a ball. The supraspinatus tendon surrounds them like a dense hood.

If the hood is damaged, the size of the rotator cuff tear increases and the humerus head penetrates upwards under the canopy.

The head of the humerus comes into contact with the roof of the shoulder and shows increasing changes.

The resulting pathological changes of the humerus head are called so-called. "rotator cuff arthropathyThe disorder of the shoulder depends on the damaged tendon - however, the supraspinatus tendon is mostly affected.

Adjacent tendons and muscles try to compensate for this function. Therefore, tension in the shoulder and neck can result from a rotator cuff rupture. The rotator cuff does not normally heal itself.

Shoulder tendon tears and insurance reports

After accidents, tendon tears are often found that are of an older date, but have so far been symptom-free. This is of legal importance: Compensation for pain and suffering only arises for the immediate causes of the accident.

Using computed tomography, however, the orthopedic surgeon can see the state of the muscles connected to the torn tendon.

If muscles are severely receded (atrophied), the tear was a long time ago. If the rotator cuff has new defects, the muscles are still well developed and not fatty. Defects in the rotator cuff can therefore be dated relatively easily.

Diagnosing defects in the rotator cuff of the shoulder

Clinical examination of the rotator cuff

  • Patient survey
  • Ask about night pain
  • Examination of mobility (active and passive)
  • Check for regressed muscles
  • Test for impingement
  • Muscle function test for loss of strength

The number of tendon tears and partial tears of the rotator cuff, which occur completely unnoticed by the patient, is astonishing. An estimated 30-50% of those over 60 years of age have detectable rotator cuff tears and are still painless in everyday life.

However, many patients are already significantly painfully impaired with partial tears and require targeted pain therapy. In the case of defects in the rotator cuff, the symptoms do not clearly indicate the extent of the damage.

Nevertheless, the anamnesis (diagnostic patient survey) plays a major role in the diagnosis of rotator cuff defects. In many cases, the patient can associate the symptoms with a fall or accident.

The role of ultrasound examination (sonography) in assessing the rotator cuff

X-ray examination of the supraspinatus tendon

  • X-ray: sclerosis, osteophytes
  • X-ray: Distance between humerus head and shoulder roof reduced?
  • X-ray shows differential diagnosis e.g. shoulder arthrosis
  • MRI shows defects in the supraspinatus tendon

An ultrasound examination of the shoulder can make a very important contribution to the assessment of the rotator cuff. The main advantage of this method: the orthopedic surgeon can assess the damage in real time with active and passive movement of the arm. The effect of a torn tendon on shoulder movement can be viewed directly. All other diagnostic methods (X-ray and MRT - magnetic resonance tomography) do not have this advantage. They only allow an indirect assessment of the rotator cuff because they represent static images.

Conservative treatment of a rotator cuff defect of the shoulder

Primarily and in most cases, the defective rotator cuff is treated conservatively.

Pain Therapy:

Before a meaningful therapy can begin, pain relief must be achieved through targeted pain relief. This can be achieved with nonsteroidal anti-inflammatory drugs in the form of tablets or ointments (NSAIDs), e.g. Ipuprofen. If there is no improvement, cortisone injections into the joint capsule can be used for a short time. However, cortisone injection is not a long-term therapy. More 2-3 repetitions of the injections spread over several weeks are not recommended.

Role of physical therapy in the treatment of the rotator cuff in elderly patients

Expert in conservative shoulder therapy

Martina Wetzel is the head of the Joint rehabilitation physiotherapy in the orthopedic joint clinic in Gundelfingen. The conservative treatment is planned together with the team of physiotherapists and closely monitored.

Fig. 4: Manual therapy for degenerative rotator cuff ruptures aims to increase the mobility of the shoulder joint. This enables the shoulder to be centered through an improved muscle balance. Manual therapy also aims to re-center the head of the humerus in the joint. © Jointreha.de

Physiotherapy exercises in the event of a rupture of the rotator cuff are aimed at restoring the full function of the shoulder joint. This includes free shoulder mobility, strength and coordination.

Manual rotator cuff therapy has several goals:

  1. Mobility of all shoulder joints: In addition to active mobilization exercises, the Manual therapy a major role. Passive techniques improve the elasticity of the capsule-ligament apparatus, the muscles and the muscle fasciae.
    The shoulder should be fully mobile again. This mainly affects the shoulder blade, the Glenohumeral joint (i.e. the actual shoulder joint) the AC joint and the SG joint.
  2. Centralization of the humerus head ("caudalization of the humeral head"):
    The head of the humerus, which often wandered upwards under the pull of the strong deltoid muscle in shoulder impingement (Humeral head) should move back down to create more space in the space under the shoulder roof. the humerus head should again lie centrally in the joint socket. During manual therapy, this is also achieved through active pressure on the head of the humerus.
  3. Perception:
    The shoulder consists of a total of 5 movable components. In order to fully perceive this mobility again, the patient must be freed from his evasive movements and the natural sequence of movements must be made aware again. Otherwise, for example, the shoulder is always brought to the ear before the upper arm is lifted.
  4. Exercises for Muscle strengthening are only added later, when mobility and freedom from pain have already been achieved through manual therapy. The strengthening of the external rotators is essential in order to achieve good guidance of the humerus head in the shoulder joint. The main thing here is the training of the so-called External rotators at. Above all, these are the Infraspinatus muscle and the Teres minor muscle. Strengthening them increases the space under the shoulder roof (subacromial space). By enlarging this space after Centering the humeral head the painful movement blockage (impingement) is eliminated.
View of the external rotators of the infraspinatus and teres minor muscles, which are important for the centralization of the shoulder. © Grays Anatomy

Also Exercise baths are gladly performed if the rotator cuff is defective.

Case I: Degenerative rupture of the supraspinatus tendon in a 64-year-old male patient

Anamnese: The patient has complained of shoulder pain and loss of strength in the right shoulder for about 3 months. He does not remember a fall or an accident.

Clinical examination: Soreness on pressure at the insertion of the supraspinatus tendon on the head of the humerus. Pain sensation when lifting the arm painful arc) between 70 ° and 120 °; Tension pain with isometric contraction

Sonography: The ultrasound examination shows a partial rupture of the supraspinatus tendon.

Roentgen: X-ray shows the head of the humerus (humerus head) raised under the roof of the shoulder due to reduced function of the supraspinatus tendon.

Conservative therapy: Prescription of 6 weeks of physiotherapy and manual therapy. After performing the physiotherapy, the patient is presented again.

MRI (magnetic resonance imaging): The shoulder pain persists when the patient is presented again. The radiological findings of the MRI image show a mass tear in the supraspinatus tendon and severe atrophy (regression) of the supraspinatus muscle.

OP decision: After the unsuccessful physiotherapy of the supraspinatus rupture, the patient expresses the desire for surgical treatment. The radiological findings suggest this decision, because in the case of a complete rupture of the supraspinatus tendon, further conservative treatment is not promising.

Surgery (supraspinatus suture and acromioplasty): Arthroscopic refixation (suturing) of the supraspinatus tendon was no longer possible because anchoring was no longer possible. Hence the prepared one Inspace ™ balloon implanted in order to restore at least the function of the rotator cuff centering the humerus head in the shoulder joint. Simultaneously performing a Acromioplasty: This is a partial removal of the shoulder roof with a small burr to create more space for the upper arm and the supraspinatus tendon. Removal of the inflamed Bursa under the roof of the shoulders. The duration of the operation was 40 minutes.

Rehabilitation: Physiotherapy to strengthen the rotator cuff.

Follow-up after 3 months: Shoulder is now painless. The arm raise is also painless. The painful point (painful arc) between 70 ° and 120 ° is no longer available. There is no longer any tenderness to pressure on the shoulder. With isometric contraction of the shoulder muscles, the patient is also pain-free. "Apron grip" (grip backwards as when tying an apron) is possible without pain. The atrophy of the supraspinatus muscle is no longer present: the muscle has been trained again. The patient also no longer has any signs of impingement (signs of tight shoulders).

When do you recommend conservative therapy for the supraspinatus tendon?

The clinical picture - painfulness, actual mobility impairment - is so different in the individual patients. In older patients in particular, conservative therapy is more likely to be used. These patients usually already suffer from several diseases of the shoulder joint: shoulder arthrosis and shoulder impingement.Here, surgical suturing of the supraspinatus tendon (rotator cuff) is not superior to conservative treatment.

In these patients, even with conservative therapy, a comparably good or even better result for shoulder mobility and stability can be achieved.

Conservative therapy should have brought about a significant improvement in shoulder pain within 6 weeks. If this does not work, an arthroscopic inspection and suturing of the supraspinatus tendon is recommended, even in older patients. Sometimes it turns out during the operation that the rotator cuff is irreparably damaged. This is often one of the reasons for an Inspace ™ implant surgery. This is a self-dissolving implant that can compensate for the lack of function of the supraspinatus tendon.
Read more about the Inspace ™ implant ...

Rotator cuff surgery: arthroscopic and minimally invasive

Minimally invasive suture of the supraspinatus tendon

A minimally invasive operation of the supraspinatus tendon can be performed with shoulder arthroscopy. © Prof. Dr. med. Sven Ostermeier

When making a decision about rotator cuff surgery, both doctor and patient have many treatment options. The extent of the pain and impaired movement, age, demands on athletic performance and analysis of the professional demands on the function of the rotator cuff are included in the therapy decision. In an open and detailed consultation, the patient and doctor have to work out a therapy plan.

Advantages of a quick suture in the case of a ruptured rotator cuff

A tendon suture is the more successful, the faster it is sewn after the tear. We recommend the rapid operation of a supraspinatus rupture, especially for younger patients and athletes under 40 years of age with a high load on the shoulder who are striving to restore their ability to exercise quickly.

© Prof. Dr. med. Sven Ostermeier

The most commonly used method is Suture anchor technology (Tight rope). Anchors are attached in the area of ​​the humerus head: this is where the tendons attach. These threads are looped through the tendons. This reattaches the tendon fragments.

After this operation, the upper arm must be immobilized for 6 weeks. A special pillow is used for this.

If the suture is not carried out, long-lasting painful complaints can arise in the shoulder joint, including a "frozen shoulder".

Such chronic exacerbation of rotator cuff rupture worsens the prospects of a suture.

The operation is then often simply unnecessary. Then you have to wait for the connective tissue inflammation of the joint capsule or the "frozen shoulder" syndrome to recede before a decision can be made again about a tendon suture.

Suture of a supraspinatus tendon after a fall

Fig. I: Arthroscopic view of a torn rotator cuff with holding sutures already in placeFig. II: The suture of the supraspinatus tendonFig. III: Rotator cuff closed again after arthroscopic suturing

© Prof. Dr. med. Sven Ostermeier

Concomitant operations on the shoulder: acromioplasty and bursa

In addition, all aspects of the situation can be dealt with during an operation Concomitant surgery be taken into account:

  1. For example, an inflamed or scarred bursa can be removed from under the shoulder roof to relieve the shoulder from pain.
  2. If the special shape of the roof of the shoulder (acromion) increases the friction of the supraspinatus tendon, it can be partially removed to create more space (acromioplasty).
  3. Suturing the supraspinatus tendon in a timely manner also avoids atrophy (regression) of the supraspinatus muscle. Rehabilitation after the operation can be made much easier by taking a timely approach: because the supraspinatus muscle must be well trained in order to be able to perform its function.

When should an operation be performed if the supraspinatus tendon ruptures?

If the conservative treatment of the rotator cuff does not improve mobility and freedom from pain after about 6 weeks, surgery is definitely considered.

In younger or sporty patients, a rupture of the rotator cuff is 100% indicated for surgery to suture the supraspinatus tendon.

The suture of the rotator cuff is increasingly being performed arthroscopically, i.e. as a minimally invasive procedure. In the case of arthroscopic surgery, major damage or complete ruptures of the rotator cuff can also be sutured in a minimally invasive manner.

This shoulder arthroscopy is usually performed under general anesthesia. The minimally invasive tendon suture of the rotator cuff is a very demanding procedure. A good technical equipment and arthroscopic experience of the shoulder specialist is a prerequisite for a successful procedure.

"Acromioplasty" - the partial removal of the roof of the shoulder

The friction between the humerus and the roof of the shoulder (Acromion) can be reduced by bone removal. A part of the shoulder roof can be removed with a minimally invasive procedure. With the smallest of milling machines and saws, space can be created for the shoulder joint. This acromioplasty can be carried out as a minimally invasive procedure together with the closure of the rotator cuff by suturing, if the assessment of the humerus and shoulder under arthroscopic view suggests.

Prognosis: outlook after treatment of the rotator cuff

At conservative therapy the symptoms usually improve within a few weeks or months. Even without sutures or surgery, an acute defect (tendon rupture) can be transformed into a painless, stable state in which the patient is sufficiently mobile.

The overwhelming majority (80% -90%) of the patients have a significantly more pain-free and more mobile shoulder after surgical treatment - acromioplasty and rotator cuff suturing. Acromioplasty greatly reduces the likelihood of a relapse. With rotator cuff sutures without acromioplasty (= removal of part of the shoulder roof to remove the tightness in the shoulder joint), the relapse rate is significantly higher.

If the supraspinatus tendon has been completely destroyed: Inspace ™ implant

If the rotator cuff is irreparably destroyed or has torn over a large area, it can no longer be repaired by suturing. These patients can be helped with a new type of balloon implant. This implant, called the Inspace® balloon, forms an elastic, mechanical barrier for the head of the humerus. The natural freedom of movement is retained. The patient has less pain after the operation of the implant and can rehabilitate normally again through physiotherapy. The Inspace ™ implant does not remain permanently in the body but gradually dissolves again - completely within 2 years. For a few months, however, the patient has the option of exercising the remaining rotator cuff muscles with the head of the humerus centered (pressed down) by the implant in order to achieve permanent centering of the head of the humerus through physiotherapy.

Read more about the operation rotator cuff rupture ...Fig. 5: If the supraspinatus tendon is so destroyed that it can no longer be sutured, conservative treatment is usually no longer possible. Then there is a risk of osteoarthritis of the shoulder and permanent instability of the shoulder. The humerus head can be centralized again in the shoulder socket through a self-dissolving (bioabsorbable), saltwater-filled implant over the course of a few months. This enables physiotherapeutic treatment of the rupture. © Exactech