The rotator cuff can tear for a variety of reasons. The end of the muscle forms a tendon, which acts as a rope to attach the muscle to the bone. However, this tendon does not typically have a substantial blood supply, which can make it prone to damage over time, and limits its ability to heal on its own. The tendon is therefore the typical location for tears to occur. It can happen abruptly with a quick injury to the area, or it can happen slowly over a long period of time as the tissue breaks down from wear and tear. The wear and tear effect can be worsened by abrasion of the tissue between 2 bones that make up part of the shoulder (called the shoulder impingement syndrome). This is perhaps the most common reason for tears in middle age patients.
When the rotator cuff tears, it will typically cause pain and weakness. The pain can come from the tear itself, but also from the continued “pinching” or impingement. Weakness develops as a result of the pain and the decrease in muscle function as it detaches from its insertion into the bone. Often patients will present to their doctor with a partial tear, many of which will heal on their own with the appropriate protection and physical therapy. However, most will progress to a certain extent, becoming more painful and tearing more, leading to more dysfunction. This is typically when surgery will be indicated to either stimulate the tissue to heal or repair it.
Pain from a rotator cuff tear typically includes pain with any “overhead” activity (such as reaching above your head into cabinets, combing hair, lifting objects overhead, tennis serves, and throwing a ball). Also the associated weakness will make these activities simply difficult to perform, even if not terribly painful. The pain is typically at the top and side of the shoulder and may be felt to approximately the middle of the arm. Other common complaints include difficulty putting on clothes, especially reaching for shirts or fastening a bra, reaching into the back seat of the car or turning the steering wheel. Pain in the shoulder at night, pain awaking you from sleep or preventing sleep, and pain when lying on that side are also classic symptoms of a rotator cuff tear.
The diagnosis is made based on the presenting complaints, matched with a comprehensive physical exam of the shoulder. Xrays and an MRI are also used to document the extent of damage to the rotator cuff and the shoulder joint and help provide prognostic information, as well as plan for certain surgical techniques. Occasionally an injection into the area of the rotator cuff bursa (a fluid filled sack above the muscle that can be inflammed and cause additional pain) can be performed. This is done during the examination to help determine how much observed weakness is due to pain and how much is due to the extent of the tear. It can be helpful for decision making for treatment.
The treatment depends upon both the characteristics of the tear (size, location, and the effect on surrounding muscle tissue), as well as the severity of the symptoms. The treatment can include the combination of medications (either pills or an injection, or even both) and physical therapy, or surgery.
Physical therapy is designed to rebalance ALL the muscles of the shoulder and not just the rotator cuff. This can take pressure off of the rotator cuff muscle tissue, allow it to move correctly and safely and provide a healthy environment for the body to try to heal the tear. This can be augmented with anti-inflammatory medications. However, if this does not work, or if the tear is significant, then surgery may be indicated. Classically, the rotator cuff was repaired through an “open” surgery with an incision that had the risk of significant damage to the other structures in the shoulder, even though most of the results from this surgery were positive. However, currently the standard of treatment, and the method utilized by trained sports medicine surgeons is to perform the same surgery with an arthroscopy. This has far fewer risks involved and in trained surgeons hands, the results have been excellent overall. The results in general, regardless of the type of surgery, are highly dependent upon the health of the rotator cuff tissue that remains, the blood flow to the tissue, and the quality of the repair. Not all tears can be treated with arthroscopy. Not all tears can be repaired. These are (thankfully) rare situations, but they do occur. The likelihood of having one of these problems INCREASES with longer and longer time from the actual tear to treatment. This is due to the development of scar tissue, muscle atrophy, tissue breakdown and arthritis.
Common Questions:
“My shoulder really hurts, but how do I know if I have a tear in my rotator cuff?”
This can be difficult to determine for sure without being evaluated as certain other muscles may be partially capable of compensating for a lack of rotator cuff function. Warning signs for a tear include weakness with attempts to lift objects, especially overhead, pain with elevation of the arm, pain at night in the shoulder, pain that extends down the side of the shoulder and into the middle of the arm, and pain with reaching. The best method is simply to get a good physical exam by a trained physician. If a tear is suspected, an MRI will be obtained to further identify the extent of the injury.
“If I do have a tear in the rotator cuff, how do I know if I need surgery?”
This is only a decision that can be made by a discussion with your surgeon, taking into account your specific injury, and your functional requirements. Typically though, if the tear is “complete” then this will benefit from surgery and physical therapy will not be enough. However, many “partial” tears will benefit (atleast initially) from a trial of physical therapy. There are several clues on both the physical exam and MRI that will help make this decision somewhat easier as well.
“If I do need surgery, when should I have it done?”
The problem with complete rotator cuff tears is that the longer one waits to have surgery performed, the more potentially challenging the surgery becomes and there is an increased likelihood of having tissue that is not suitable for repair, or may require larger surgery. This typically only applies to more chronic tears and simply waiting a few weeks or more is not a problem. As there is a fair amount of rehabilitation to complete after the surgery, and certain temporary limitations will be imposed after the surgery to allow for healing, this should be done when it is convenient for you. This is a discussion to be had with your surgeon, taking into account several factors, including your schedule of events, plans to return to sports and work, etc.
For answers to any other questions or to schedule and evaluation, please contact my clinic at (408) 866-6651 and we will arrange for a convenient appointment for you and any necessary xrays or MRI.