Sports Medicine

Rotator Cuff Tear

Anatomy

The shoulder is a complex, ball-and-socket joint that rotates through a greater range of motion than any other joint in the body. The shoulder is made up of: the upper arm bone (humerus), shoulder blade (scapula), and collarbone (clavicle). The ball, or head of the upper arm, fits into a shallow socket (glenoid) in the shoulder blade. The ends of these bones, where they touch, are covered with articular cartilage, a smooth substance that protects the bones and enables them to move easily. The glenoid is ringed by the labrum, a strong, fibrous cartilage that forms a gasket around the socket, adding stability and cushioning the joint.

The arm is held in the shoulder socket by the rotator cuff—a network of four muscles that come together as tendons to form a covering around the head of the humerus. The rotator cuff attaches the humerus to the shoulder blade and helps to lift and rotate your arm. Between the rotator cuff and the bone on top of your shoulder (acromion) is a lubricating sac (bursa). The bursa allows the rotator cuff tendons to glide smoothly during movement. When rotator cuff tendons are injured or damaged, the bursa can also become inflamed and painful.

Description

When one or more of the rotator cuff tendons is torn, the tendon no longer fully attaches to the head of the humerus. Most tears occur in the supraspinatus muscle and tendon, but other parts of the rotator cuff may also be involved. In many cases, the tear begins with fraying. As the damage progresses, lifting a heavy object or other similar action can result in a complete tear of the tendon. A torn rotator cuff weakens the shoulder, making it painful and difficult to perform simple daily activities such as getting dressed or combing your hair.

• Partial tear—Soft tissue is damaged but not completely severed.
• Full-thickness tear, also called a complete tear—Soft tissue is split into two pieces, basically creating a hole in the tendon. In many cases, the tendon tears off where it is attached to the head of a humerus.

Causes

Injury (acute tear) and degeneration (chronic tear) are the primary causes of rotator cuff tears.

• Acute tear—Falling on an outstretched arm or lifting something too heavy with a jerking motion can result in a torn rotator cuff. These may occur with other shoulder injuries, such as a broken collarbone or dislocated shoulder.
• Chronic tear—Usually the result of a wearing down of the tendon that occurs slowly over time, chronic or degenerative tears may be the result of the natural aging process or repetitive stress caused by repeating the same shoulder motions again and again.

Risk Factors

Although most common in the dominant arm, a degenerative tear in one shoulder increases the risk of a similar tear in the opposite shoulder, even if there is no pain. Other risk factors include advancing age and performing repetitive activities over time.

• Age—People over 40 are at greater risk because most rotator cuff tears are caused by the normal wear and tear that goes along with aging. Also, as we get older, the blood supply to rotator cuff tendons lessens, impairing the body's natural ability to repair tendon damage. Bone spurs, or bone overgrowth, are another age-related risk factor. These often develop on the underside of the acromion bone as we grow older. When the arm is lifted, the bone spur rubs on the rotator cuff tendon, causing shoulder impingement, a condition that weakens the tendon over time, making it more likely to tear.
• Repetitive activities—Painters, carpenters, and others whose jobs require repeated activities, such as constant lifting or reaching to do overhead work, have a higher risk of tearing a rotator cuff. Tennis players, baseball pitchers, weightlifters, and many other athletes are also especially vulnerable. Overuse tears caused by sports or overhead work occur in people of all ages, however, tears in young adults are more often the result of a traumatic injury or fall.

Symptoms

Common symptoms of a rotator cuff tear include: pain at rest and at night, particularly when lying on the affected shoulder; pain when lifting and lowering the arm, or with specific movements; weakness when lifting or rotating the arm; and experiencing a crackling sensation (crepitus) when moving the shoulder in certain positions.

Sudden rotator cuff tears, such as from an injury or fall, usually cause intense pain. There may be a snapping sensation, immediate weakness in the upper arm, and pain when lifting the arm out to the side.

Tears that develop gradually due to overuse also cause pain and arm weakness. At first, pain may be mild, present only when lifting your arm above your head, and relieved by over-the-counter medication, such as aspirin or ibuprofen. Over time, symptoms become pronounced. You may have shoulder pain when you lift your arm to the side, or pain that moves down your arm. A torn rotator cuff may become more noticeably painful at rest or when you lie on the injured side at night. Medications may no longer provide relief. Increasing pain and weakness in the affected shoulder may make routine activities such as combing your hair or reaching behind your back more difficult.

Diagnosis

During the physical examination, your physician will look for tenderness and deformity, and measure arm strength and range of motion in the shoulder. Your exam will also include ruling out other problems of the shoulder joint, and conditions such as a pinched nerve in the neck or arthritis.

Additional imaging tests, such as X-rays, MRI or ultrasound, may be needed to help your doctor confirm your diagnosis.

• X-rays—Although X-rays do not show soft tissues like the rotator cuff, they may reveal a small bone spur or additional injury to the bone.
• Magnetic resonance imaging (MRI) and ultrasound—These imaging tests can reveal the size and exact location of the rotator cuff tear. An MRI can also provide an indication of how recent the tear is by showing the quality of the rotator cuff muscles.

Recommendation

Continued use of a torn rotator cuff, despite increasing pain, may result in further damage and cause the tear to get larger over time. It is important to see your doctor if you have chronic shoulder or arm pain. Early treatment can prevent your symptoms from getting worse, and help you get back to your normal routine more quickly.

The goal of any treatment is to reduce pain and restore function. There are several options for treating a rotator cuff tear. In planning your treatment, your doctor will consider your age, activity level, general health, and the type of tear you have before determining the best treatment option for you.

Nonsurgical Treatment

Although nonsurgical treatment relieves pain and improves shoulder function for approximately half of all patients, shoulder strength does not usually improve without surgery. As with any treatment, there are advantages and disadvantages to nonsurgical options.

• Advantages—With nonsurgical treatment, patients avoid the major risks of surgery, such as: infection, permanent stiffness, anesthesia complications, and a potentially lengthy recovery time.
• Disadvantages—Nonsurgical options provide no improvements in strength, the size of the tear may increase over time, and activities may need to remain limited.

In addition to rest, protecting the shoulder and limiting motion by using a sling, and avoiding overhead and other painful activities, other nonsurgical treatment options may include:

• Nonsteroidal anti-inflammatory medication—Drugs like ibuprofen and naproxen reduce pain and swelling.
• Strengthening exercises and physical therapy—A program of specific strengthening and stretching exercises can help improve flexibility, restore range of motion, relieve pain and prevent further injury.
• Steroid injection—If rest, physical therapies and other anti-inflammatories do not relieve your pain, an injection of local anesthetic and cortisone may be helpful to reduce inflammation and pain.

Surgery

Your orthopaedic surgeon may recommend surgery if you have continued pain that does not improve with nonsurgical methods, or if you are very active and use your arms for overhead work or sports. Other indications that surgery may be a good option for you include: symptoms lasting for 6 to 12 months, a large tear, significant weakness and loss of shoulder function, your tear was caused by a recent, acute injury.

Surgery to repair a torn rotator cuff most often involves re-attaching the tendon to the head of humerus (upper arm bone). A complete tear within the thickest part of the tendon is repaired by stitching the two sides back together. A partial tear may need only a trimming or smoothing procedure called a debridement. There are several surgical options for repairing rotator cuff tears and advancements in surgical techniques include less invasive procedures. Each method has its own advantages and disadvantages, however all have the same goal: getting the tendon to heal. Many surgical repairs can be done on an outpatient basis and do not require you to stay overnight in the hospital. Your orthopaedic surgeon will discuss with you the best procedure to meet your individual health needs.

The three techniques most commonly used for rotator cuff repair include traditional open repair, arthroscopic repair, and mini-open repair. Most repairs are done arthroscopically.

• Open repair—Traditionally, rotator cuff tears were treated with a large incision over the top of the shoulder. Now, most rotator cuff tears are treated arthroscopically or with a mini-open procedure. During an open repair, the surgeon makes the incision over the shoulder and detaches the shoulder muscle (deltoid) to better see and gain access to the torn tendon. The surgeon then typically removes bone spurs from the underside of the acromion (this procedure is called an acromioplasty). An open repair may be a good option if the tear is large, complex, or if additional reconstruction, such as a tendon transfer, is indicated.
• All-arthroscopic repair—During arthroscopy, your orthopaedic surgeon will make several very small incisions to introduce the arthroscope and other small instruments into your shoulder joint. The arthroscope provides a clear, illuminated view of structures inside your shoulder by projecting images onto a monitor. Your surgeon uses these images to guide miniature surgical instruments while making repairs. All-arthroscopic repair is usually an outpatient procedure and is the least invasive method to repair a torn rotator cuff.
• Mini-open repair—The mini-open repair uses newer technology and instruments to perform a repair through a small incision that is typically 3 to 5 cm long. This technique uses arthroscopy to assess and treat damage to other structures within the joint, such as bone spurs, without any need to detach the deltoid muscle. Once the arthroscopic portion of the procedure is completed, the surgeon repairs the rotator cuff through the mini-open incision while viewing the shoulder structures directly, rather than through the video monitor used for arthroscopy.

Rehabilitation

Rehabilitation plays a vital role in getting you back to your daily activities. After surgery, you will have a specific program of physical therapy program to follow. Your therapy during recovery and rehabilitation will progress in stages to help you steadily regain shoulder strength and motion.

• Immobilization—Use of a sling after surgery will protect the shoulder and prevent your arm from moving while the repair heals. A sling is often required for the first 4 to 6 weeks, or however long your orthopaedic surgeon recommends, depending on the severity of your injury.
• Passive Exercise—During this form of exercise, a therapist supports the arm while moving it in different positions to help improve range of motion in your shoulder. Passive exercise usually begins within 4 to 6 weeks after surgery, or whenever your orthopaedic surgeon decides it is safe for you to begin moving your arm and shoulder.
• Active exercise—As your healing and recovery progresses, you will be told when it is safe for you to begin doing active exercises without the help of your therapist. Moving your muscles on your own will gradually increase your strength and improve your arm control. At 8 to 12 weeks, your therapist will start you on a strengthening exercise program.

You should expect a complete recovery to take several months. Most patients have a functional range of motion and adequate strength by 4 to 6 months after surgery. The process may seem slow, but your commitment to rehabilitation is key to experiencing a successful outcome.

Outcome

The majority of patients report improved shoulder strength and less pain after surgery for a torn rotator cuff. Each surgical repair technique offers similar results in terms of pain relief, improvement in strength and function, and patient satisfaction. The expertise of your orthopaedic surgeon is more important in achieving satisfactory results than the choice of technique.

Factors that can decrease the likelihood of a satisfactory result include: poor tendon or tissue quality, large or massive tears, poor patient compliance with rehabilitation and restrictions after surgery, patient age of older than 65 years, smoking and use of other nicotine products, and workers' compensation claims.

Complications

After rotator cuff surgery, a small percentage of patients experience complications. In addition to general risks associated with surgery, such as blood loss, infection or anesthesia-related problems, complications of rotator cuff surgery may include:

• Nerve injury —Typically involving the nerve that activates your shoulder muscle (deltoid).
• Deltoid detachment—During an open repair, this muscle is detached to provide better access to the rotator cuff then stitched back into place at the end of the procedure. It is very important to protect this area after surgery and during rehabilitation to allow it to heal.
• Stiffness—Early rehabilitation lessens the likelihood of permanent stiffness or loss of motion. Stiffness usually improves with more aggressive therapy and exercise.
• Tendon re-tear—There is a chance for re-tear following all types of repairs, and the larger the tear, the higher the risk of re-tear. Patients who re-tear their tendons only require surgery if there is severe pain or loss