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Doctor Joël MIRBEY

Tel: +33 (0)3.80.30.26.03


Doctor Frédéric GIVRY

Tel: +33 (0)3.80.30.99.15

Epaule douloureuse

Tendons' rupture

It is the next stage after the tendons’ disease, when it develops without a suitable treatment. The rupture may be spontaneous, or provoked by a slight trauma (a fall or a little lifting effort) since there are previously degenerative injuries which have weakened the tendons.

The tendons’ ruptures are of two kinds:

  • complete rupture
  • partial rupture

Anatomy

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050223031639.jpg

The shoulder joint or glenohumeral joint is a synovial joint between the humeral ball and the glenoid cavity, strengthened by the fibro-cartilaginous ring, the glenoid ring. The joint’s capsule is reinforced by 2 or 3 ligaments. It is wide and loose on its lower part.

Most of the joint’s stability is ensured by the muscles of the head:

  • The sub-scapula muscle at the front
  • The over-spinal muscle at the top
  • The sub-spinal and little round muscle at the back
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01_050223031707.jpg

They are inserted into the proximal part of the humerus via their tendons which form a fibrous tissue blade difficult to separate from the joint capsule below: the head of the rotators.

Above the head, but separated from the latter by the sub-acromial purse, lies the arc constituted by the acromion ( a bone structure of the scapula located just above the humeral head ) and the coraco-humeral ligament.

Clinical Symptoms

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041211061303.jpg

Total rupture is easily diagnosed with a patient who suffers and complains from a weakness in the arm, without a limitation of any passive mobility of the shoulder (even if the move is painful), but with a serious limitation of active mobility.

The diagnosis of a partial rupture is more difficult: the persisting pain plus a decrease of strength to resistance may evoke a partial rupture.

When your surgeon is in doubt as to the rupture of tendons, he will carry out various clinical tests and each one of them will explore the tendons of the 4 muscles of the shoulder.

 

The various tests are the following:

Job's Test
Job's Test

 

Job’s manoeuvre: the arm at 90° of abduction, in inside rotation (the thumb facing downwards), brought back to 30° forward (level with the shoulderblade), specifically tests the sub-spinal tendon.

 

« Palm-up » test
« Palm-up » test

The ‘palm-up’ test: the arm in antepulsion at 60°, in outside rotation (palm upwards), tests specifically the long biceps, the tendon of the long biceps and the sub-scapula tendon.

 

Patte's Test
Patte's Test

The “patte” test: in external rotation, the elbow flexed at 90°, the arm at 90° abduction, specifically tests the tendons of the small round and of the sub-spinal.

These ruptures of the tendons can be supported by X-rays. Besides the X-rays which show indirect signs, the echography and mainly the arthroscanner or the MRI will not only confirm the rupture but also show its size and its location, which will be of course of primary importance for the treatment.

Evolution without any Treatment

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01_050223034637.jpg

If no reparation of the tendons is carried out, the pains will of course persist and increase, the loss of strength will not be recovered and what is more, the evolution towards arthrosis in the short term will jeopardize the shoulder’s joint requiring then the implantation of a prosthesis of the shoulder.

Surgical Treatment

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050223034949.jpg

The rupture of tendons is a very serious problem and requires surgical repair under arthroscopy. 3 or 4 incisions, less than 1cm long, will be necessary so as to carry out an effective repair of the tendons ruptured.

After the surgery, your upper limb will be immobilized or not, for a period of one month, according to the seriousness of the rupture repaired.

Over this period, sessions of passive re-education will be prescribed.

Sometimes it is impossible to repair, especially for aged patients who have a historical rupture of the tendons, and in this case, a cleaning of the tendinous bridles and of the inflammation under arthroscopy will relieve the patient most of the time.

Complications

Anaesthetic complications:

They are not specific to arthroscopic surgery. The anaesthetist will provide you with all relevant information during the pre-operation consultation.

local complications:

Vascular complications:
The main blood vessels: (arteries, veins) can exceptionally be affected, which may have serious consequences; with less serious consequences, other little veins may be hurt, which will lead to a haematome of the shoulder called haemarthrosis.

Complications of the nerves:
It may be possible to have an area of skin anaesthesia round the scar and even localized itches because of small nervous ramifications under the skin being affected. Generally, these unpleasant sensations diminish with time.

Arthritis:
It is a post-op infection of the joint. It is not so frequent: -0.4% of all arthroscopies. The treatment requires another operation with an arthroscopic cleansing of the joint and a suitable antibiotics treatment.

Haemarthrosis:
It is a serious and painful blood flow in the joint.

A stiffness (retractable capsulitis) of the shoulder may appear.

A swelling or a serious oedema may appear and usually regress during the first post-op night without any serious consequences.

Rare problems of the scar.

Algodystrophy:
This complication in surgery may also occur outside of all operation gesture. It often seems to affect women over 40. Its symptoms are a decalcification of the shoulder joint along with invalidating pains. We often observe a redness of the skin, a rising of the sweating, heat, a stiffness in the joint. It requires a functional and medical treatment by easy re-education. It can also be provoked by unadapted physiotherapy. It usually disappears spontaneously. The recovery can be achieved over a few weeks but can also take up to 2 years.

Stay in Clinic

You will leave the clinic the same day as the operation, your shoulder immobilized for a month.

Pain care will be shared between the anaesthetists, your surgeon and the nurses on duty.

When you leave the clinic, your surgeon will give you the prescriptions for painkillers, dressing, re-education, work-leave if necessary and your next appointment. Of course your GP will receive an account of the operation as well as a mail explaining the therapeutic act carried out and the operating consequences to foresee.

On leaving, you will have to make quickly an appointment with your physiotherapist. Your surgeon will give you a prescription with a re-education protocol; the latter will have to be easy, done with care and progressive.

Incapacity

You may consider resuming your activity only after a minimum of 2 to three months, depending of course on the degree of your physical activity.

Everyday gestures will be possible only after the removal of the immobilization that is to say after about a month or a month and a half.

Strenuous tasks can only be considered after several months.
 

Results

The first results concerning strength will only be visible around the third month. If the rupture of the tendons was serious and the repair difficult, a small decrease of the strength must be expected.

On the other hand, if the rupture was a slight one and of easy repair, a total recovery of the strength can be expected.

As for pains, they will rapidly disappear during the first few weeks.