Rotator Cuff Tears
What Is The Rotator Cuff?
The rotator cuff is a group of four muscles that come together to form a large tendon “cuff” that allows our shoulders to move normally. These muscles start on the scapula (shoulder blade) and connect to the humerus (upper arm bone). The rotator cuff allows smooth overhead movements of the shoulder and provides stability to the joint. Tears of the rotator cuff disrupt this balance and cause dysfunctional movement, weakness, and pain.
What Causes A Rotator Cuff Tear?
Tears of the rotator cuff are often the result of either a traumatic shoulder injury (such as a fall), or gradual (chronic) breakdown over time. Evidence of both can often be seen in older individuals with a long history of shoulder pain. Rotator cuff tears can also be partial, and their location can clue us in to what the causative factor might be.
What Are Some Symptoms Of A Rotator Cuff Tear?
The most common symptom of a rotator cuff tear is shoulder pain that is associated with weakness in overhead activities. The pain can also radiate to the neck and upper arm, but rarely travels below the elbow. Pain radiating below the elbow to into the hand is often caused by nerve injuries or herniated discs in the cervical spine (neck). A classic sign of rotator cuff injury is relentless night pain and difficulty sleeping, with pain that seems to be worse at night than it is during the daytime.
How Do You Diagnose A Rotator Cuff Tear?
With an appropriate history and physical exam findings suggesting an injury to the rotator cuff, the gold standard for diagnosing a rotator cuff injury is with a non-contrast (no injected dye) MRI scan of the shoulder. Most rotator cuff tears can be visualized with high-quality MRI imaging and a experienced musculoskeletal radiologist.
How Are Rotator Cuff Tears Treated?
Most tears of the rotator cuff are small, partial-thickness tears that do not need surgical treatment. If, however, a large partial tear or a complete tear is found, most shoulder surgeons would recommend surgical repair, depending on your symptoms. The reason for this is that most complete rotator cuff tears will progress over time and can lead to worsening shoulder function and possibly arthritis. Furthermore, chronic and large tears have unpredictable healing rates, and repair of these tears become more difficult as time goes on.
Non-surgical treatment of a rotator cuff tear or tendon inflammation usually consists of a short period of rest, anti-inflammatory medications and a short course of physical therapy. This often allows patients to regain their shoulder motion and recruit other muscle groups to help alleviate the stress on the injured tendon.
Surgical management of rotator cuff injuries, when needed, is most often done through a minimally invasive (arthroscopic) technique. Use of the arthroscope provides a full diagnostic tour of the joint, and allows for treatment of any other abnormalities seen. After a full inspection, the torn rotator cuff is repaired back to bone using suture anchors and varying stitching techniques. Other abnormalities identified during the visual inspection are also addressed including removal of bone spurs, resection of an arthritic acromio-clavicular joint (AC joint), shaving of frayed ligaments, and addressing an injured biceps tendon (biceps tenotomy or tenodesis).
What’s The Recovery Like After A Rotator Cuff Repair?
Recovery after arthroscopic rotator cuff repair is prolonged and somewhat painful in comparison to many other surgical procedures; however, day-to-day improvements in pain, motion, and function can be expected. Full recovery (return to sports and normal activities at full strength) can be expected by 8-9 months. Patients are required to wear a sling for 5 weeks after surgery, both day and night, except for times of rest when we like the arm to be removed to maintain motion of the elbow, wrist and fingers. After the first 5 weeks, the sling is discontinued and physical therapy is started. This progresses over 3 phases, and takes approximately three months. By this time (4 months after surgery), most patients begin to return to sport-specific activities at a slow pace. A gradual return to full activity is encouraged, and by six months, the shoulder is nearly back to normal except during strenuous sporting activity. By 8 months, you should no longer realize that you had surgery on your shoulder as long as your rotator cuff successfully healed and you regained full motion. You can expect improvements for up to a year after surgery.
I Think I May Have A Rotator Cuff Tear. What’s The Next Step?
Many of us will develop shoulder pain over the course of our lives, and most times this resolves with rest and occasionally therapy. If, however, your pain is associated with an injury, weakness, or has not improved with rest or directed therapy, we would recommend a formal evaluation. In addition to physical examination, most shoulder problems can be accurately diagnosed with plain x-rays and MRI. X-rays should always be obtained prior to MRI to rule out the possibility of fractures, end-stage arthritis, and dislocations.
For further, in-depth information regarding rotator cuff tears, we have provided links to the American Academy of Orthopaedic Surgeons patient portal, as well as the University of Washington’s Department of Orthopaedic Surgery and Sports Medicine website.
Massive Rotator Cuff Tear
What Is A Massive Rotator Cuff Tear?
A massive rotator cuff tear refers to a tear that prevents normal repair of the torn tendon back to bone. For a review of rotator cuff tears and their treatment, please visit our rotator cuff tear section here. Patients with massive tears often exhibit signs and symptoms that have been associated with poor outcomes after attempting standard rotator cuff repair. These characteristics include the inability to raise the arm (pseudoparalysis), atrophy of the rotator cuff musculature, elevation of the ball part of the joint (humerus) in it’s relationship to the socket part of the joint (glenoid), and retraction of the rotator cuff tendon past the level of the joint socket on MRI. Massive tears have also been classified as those involving three or more of the four rotator cuff tendons, or a tear more than 2cm in length.
Why Is A Massive Tear A Bigger Problem Than A Normal-Sized Rotator Cuff Tear?
Massive rotator cuff tears are associated with much worse outcomes in comparison to standard rotator cuff repair. This is due to multiple factors including the quality of the remaining cuff tendon, the degree of muscle atrophy, the degree of arthritis in the joint, as well as the tension required to repair a retracted tendon back to it’s place on the humerus bone.
How Do Massive Tears Occur?
These tears are often the result of full-thickness rotator cuff tears that have been present for months to years. Over time, the torn tendon retracts away from the ball of the shoulder towards the scapula. The muscles around the shoulder atrophy because they are not being used. Eventually one of two things happens – either the surrounding muscles of the shoulder are strong enough to allow near-normal motion (we call these patients “cuff-independent”), or the shoulder becomes weak and eventually painful.
How Are Massive Tears Treated?
Similar to most injuries, the mainstay of our first-line treatment is rehabilitation of the shoulder to maintain strength, mobility, and flexibility. Many patients with massive tears, especially the “cuff-independent” group, will recover to an acceptable status through rehabilitation alone. If rehab and therapy fail, surgical treatment varies widely. The quickest surgical intervention is a procedure called the “smooth and move,” in which a small incision is made over the shoulder and any thickened scar tissue and bone spurs are removed to allow smooth and immediate shoulder motion. The biggest surgery is a type of shoulder replacement called a “reverse” shoulder arthroplasty. This is becoming more and more common recently with the success of this relatively new implant. We often reserve this procedure for our older patients with lower physical demands and in patients who have already developed significant arthritis of the shoulder. The middle ground is a rotator cuff reconstruction or replacement. This is where an acellular (no donor cells) skin graft from a donor is transplanted into the shoulder to “bridge” the gap missing between the retracted rotator cuff tendon stump and it’s connecting point on the humerus bone. We are able to do this surgery arthroscopically, and will typically recommend it for younger patients with higher physical demands.
A variation of the rotator cuff reconstruction or “bridge” technique is the rotator cuff augmentation. Augmentations are used for tears that exhibit some signs of a massive tear, or in tears that have already failed a previous repair. The rotator cuff is repaired, similar to a typical rotator cuff tear. However, after repair, the same acellular graft is sewn over the repair, augmenting the questionable tissue underneath. This has resulted in significantly-improved healing rates when compared to repair alone.
I have been told I have an irreparable (non-repairable), massive rotator cuff tear, or I have re-torn my rotator cuff after a previous repair. What is the next step?
We would be happy to meet with you to hear your story, examine your shoulder, and review any imaging and operative information you have. Depending on the findings, we will be able to counsel you as to whether or not a graft reconstruction of your rotator cuff is an option.