 Hi, I am Dr. Ayyappan Meenayar, I am a Shoulder and Sports Injury Specialist at Manipal Hospital Whitefield. The shoulder as such is a ball socket joint and it is one of the most mobile joints of the body which gives us almost like an entire rotation expanding almost around 360 degrees and it has got varied movements like external rotation, internal rotation and so and so. So this helps us participate in different activities like basketball, volleyball, gymnastics, name it. The main rotators or the main movements of the shoulder are by a group of muscles called as the rotator cuff. It is a group of four muscles arranged from front to the back of the shoulder. In some cases you can have injuries to them resulting in severe pain and inability to move the shoulder. So as I said it is basically there is pain in lifting the shoulder with the movements of the shoulder and inability to move the shoulder. And some patients even have a condition called as pseudo-paralysis. So unlike the paralysis which is basically a brain problem or you have a stroke or something like that, it is not a true paralysis and that is why it is called as pseudo-paralysis. In pseudo-paralysis the hand is almost like flail and the patient is unable to lift the shoulder absolutely. These are the main complaints the patient comes to us with. The population who can or what kind of people have this kind of rotator cuff injuries, we see that there are two categories. One is in young people, in young people like in the 20s, 30s or maybe even the 40s, where you have a sudden fall, a fall from a bike or you are falling while playing. So what happens is you fall on an outstretched hand like this, you fall on your outstretched hand and suddenly the muscles contract and pull away from the bony attachments. So that is one group of patients and coming to the second group of patients, it is older age patients like who are in their 50s, 60s and even their 70s. In them, it is not because of a fall, it is not because of a trauma, it is because of something called as degeneration. So degeneration is basically part of an aging process that is wear and tear and gradually over a period of time there is rubbing of bones against each other and the muscle gradually tears off. So these are two risk categories of patients who have rotator cuff tears. The investigation, once a patient comes to me for a possible rotator cuff injury, which I make a clinical diagnosis first. So I see the patient first, listen to them and then we have a clinical examination where actually I test the patient, we move the patient's shoulder and see how much power they have, what kind of problems they have. And then once I come to a conclusion that this particular patient has got a rotator cuff injury, then what we do is we ask for a confirmatory radiological investigation. This could be an ultrasound scan or an MRI. When you compare an ultrasound to an MRI, MRI is much better because we have the films, we can actually see how much the tear is and we can actually plan the management very well. So if we do an ultrasound scan and if it comes as a positive test for it saying that there is definitely a rotator cuff tear, eventually we have to do the MRI. So to sum it up, the investigation of choice is an MRI scan for the rotator cuff injury. All patients have to be operated or all rotator cuff injuries have to be operated on. It is not like that. So it depends upon the amount of tear the patient has. So suppose the muscle is completely torn off or we say we call it as a full thickness tear where the complete thickness of the muscle is torn and those cases definitely require surgery. And then we have a particular category called as partial tears. So in partial tears, the entire muscle is not torn, only a part of the muscle is torn. And in this case, if it is, we have a criteria for that. If it is 50% torn, that is if the partial tear is there and if it is 50% torn, then you can avoid a surgery. If it is more than 50%, the tear, that is the thickness of the tear is more than 50%, definitely these patients require surgery. This is why, why do that, why is that these partial tears also require surgery? Because if we follow up these patients for a period of next two to three years, what we find is if it is more than a 50% partial tear, these patients progress to full thickness tears in three years and then becomes more difficult to treat and they have a difficult time for the next two to three years. So it is better to operate on these patients at an earlier time. Partial management is definitely yes for partial rotator cuff tears. So we are discussing about rotator cuff tears, like full tears and partial tears. So if the partial tear is less than 50% thickness of the tear of the muscle and the belly of the muscle of the thickness of the muscle, then these patients will definitely respond to an injection like I called as a PRP injection. So PRP is basically a platelet-rich plasma. So our blood is taken to blood, we have a particular group of cells in the blood called as a platelets and these platelets normal count is around two to three lakhs. So we have to concentrate it to five times. So take the, we take around 10 cc of blood, concentrate the blood so that we get around five times the normal count and these platelets have healing potential. So this platelets can be re-injected into the cuff that is the tone part of the muscle and then we allow it to heal. So the healing happens over a period of three to four weeks and it's got excellent results. So that is one conservative management protocol we can have. So another important thing is not only giving the PRP injection but definitely physiotherapy. Physiotherapy is very, very important in strengthening and getting the shoulder back to normal shape. So with or without surgery, the healing time of a muscle tear or rotator cuff tear is around 12 weeks. Complete healing happens only by 12 weeks. Most of the healing does happen by the six weeks. So what happens is over a period of 12 weeks, there are special fibers which form called as sharp-edge fibers. They attach the tone muscle back to the bone. So this appears only by the 12th week according to a scientific studies. So the healing time with surgery, without surgery, it takes 12 weeks. And out of that the first six weeks is extremely important. Coming to surgical options, so now our technology and medical science are so advanced that in shoulder surgery, any patient with rotator cuff tears, we treat them by an arthroscopic procedure. Arthroscopy basically stands for arthro is joint and scopi is putting a camera inside the joint. So arthroscopically we put a small camera, the size of the camera is around four millimeters. We put it inside the shoulder and through key holes, we make another two or three small holes in the shoulder called as the key holes or the portals through which we pass special instruments used for stitching the muscle back to the bone. There are some group of patients who have neglected their injury and this happens over a period of maybe two to three years. They have not taken care of it, they didn't want treatment and now they want treatment. So in those group of patients, we would require specialized procedures because now the problem is we don't have enough muscle to stitch back and they require a procedure called as superior capsular reconstruction. So basically what we do is, we take a muscle from the thigh and replace the muscle which is turned off in the shoulder and which is maybe not in a good shape. So this is called SCR or superior capsular reconstruction. There are some group of patients who eventually end up in severe arthritis of the shoulder when the rotator cuff tear is neglected. In them, we require a procedure called as reverse shoulder auto-plastic. Basically it's a shoulder replacement procedure. So it's an open procedure. So these are the options, surgical options we have in rotator cuff tears. If the rotator cuff is not repaired, that's what I was trying to emphasize earlier. So over a period of time, what happens is the muscle degrades. It shrinks in size and because it's not functioning anymore, because it is torn and it goes back from its original position and eventually it comes to a condition called as irreparable tear. What is irreparable tear? It is known first, it is when we can't actually repair the muscle back to its original position. So we have the position, there is a normal position on the head or the ball where the muscle comes in and attaches. So what happens is if you don't repair it, it goes back, it gets degraded. So we don't have enough muscle to replace it. So what we do is we have to take muscle from the thigh and fix it up or eventually if it becomes arthritic over a period of 2 to 3 years that the joint degrades very badly, it ends up in arthritus, it requires shoulder replacement. Postoperatively once the surgery is done, surgery takes us around 30-40 minutes to do to fix the muscle back to its original position and the patient requires a day in the hospital. You don't require actually more than that. One day 24 hours automation is more than enough and even in sometimes in young patients who don't have any other medical problems, we can actually send the patient home by evening. What happens is, so once the surgery is done and the patient is discharged, they come and they have to come back for a stitch removal at the end of 2 weeks. From 2 weeks, from the second week to the 8th week, we need to do the physiotherapy and it is mandatory, it is important and it is very, very important to do the physiotherapy correctly. So what we do is during the initial phases that is during the first 2-3 weeks, the physiotherapist moves the shoulder up and down but the patient is not supposed to move. At the end of 2-3 weeks, the patient can hold both hands together and start moving the shoulder. This is called as active assisted movement which we initiate by around 4th week after surgery and the patient lifting by himself or herself happens or is allowed only after the 6th week. When 50% of the healing has actually happened and suppose it is a very bad tear, it is a difficult tear, then we hold on this kind of active lifting or self lifting by the patients for another few more weeks. So normally the return to full power by around 3 months and the patient goes about a normal activity by around 3 months and you can go back to sports, that is overhead activities, overhead sports, volleyball, basketball etc, we can do definitely only after 6 months. So these are the average timelines of return to normal.