Solutions to a massive shoulder problem

NE OF THE most common shoulder problems is a progressive wear of the tendon that covers the head of the humerus, the bone in the upper arm. This tendon is similar to a cuff, or a swimming cap. It stabilises the joint firmly but at the same time allows huge freedom of movement (the biggest in the human body).

The tendon can be damaged during strenuous activity, as well as by trivial movements if its quality is poor.

The rotator cuff, as it is known, is actually made up of four tendons that join to form a single large hat on the humeral head. “Massive” tears are greater than 5cm and involve at least two of these tendons (the supraspinatus and infraspinatus, if you want to get technical).

A massive tear, unfortunately, is more common in older people. The cause may be genetic, smoking, overuse of the shoulder or age-related degeneration. A minor fall or injury can lead to final failure of the cuff, with weakness, pain and restriction of the range of movement of the shoulder.

Direct tendon repair of these massive degenerative tears has a high failure rate, in excess of 50 per cent.

The decision on which treatment to use depends on age, general health, time from injury, functional requirements, surgeon’s expertise and available facilities. Treatments available are:

Deltoid rehabilitation: training the deltoid muscle so that it takes over the functions of the failed rotator cuff muscles, sometimes with steroid injections for pain relief.

Tendon repair: many new materials have been developed to augment healing and strengthen the weak tendon tissue. These materials can be human, synthetic or animal-derived and can be combined with growth tendon factors (substances that stimulate healing).

Muscle transfer: for example, a normal tendon is harvested from the armpit and transferred to the upper arm to increase the shoulder power, using keyhole surgery.

Arthroscopic debridement and biceps tenotomy: this technique consists of cleaning out damaged tissues from the joint and eliminating a small tendon trapped between two bony surfaces. This is effective in resolving pain but not strength.

Inspace balloon: an absorbable spacer — like a balloon — is inserted between opposing surfaces on top of the shoulder, reducing painful clashing. This is very effective against pain; less effective on strength. Recovery and rehab are usually quick and easy.

Non-stemmed reverse shoulder replacement: a new form of joint replacement, which has “inverse geometry”, a ball in place of the socket and a socket where normally there is a sphere, to compensate for the loss of muscle and stability in the shoulder. Giuseppe Sforza is a consultant orthopaedic surgeon at Highgate Private Hospital, north London