Rotator Cuff Tear

Anatomy/Pathophysiology

The rotator cuff tendons are subject to a considerable amount of wear and tear as we use our arms, especially overhead activities. This wear and tear can lead to weakening of the rotator cuff tendons, through a condition know as impingement. The rotator cuff tendons are also subject to degeneration as we age. The tendons have areas where there is a very poor blood supply. These areas are especially vulnerable to degeneration with aging and may play a role in the evolution of a rotator cuff tear. Rotator cuff tears usually occur through areas of the tendon that were not normal to begin with and have been weakened by degeneration and impingement.

The weakened rotator cuff tendons can be injured, and torn, by an excessive force, such as trying to catch a falling heavy object, or lifting an object with the arm extended. Typically a rotator cuff tear occurs in a late middle-aged person who has been having problems with the shoulder for a period preceeding the acute event. That person starts a lifting activity which exceeds the strength of the tendons, and the tendon tears acutely, leaving an inability to raise the arm. There may or may not be pain associated with the event.

Symptoms

In some cases a rotator cuff may be only a partial tear of the tendons, and you may have pain but can continue to move the arm in a normal range of motion. In other cases, a complete rupture of the tendons occurs, and you are unable to move the arm in a normal range of motion. A complete rotator cuff tear usually results in an inability to raise that arm away from the side under your own power.

Most rotator cuff tears cause a vague pain in the shoulder area, and may result in a “catching” sensation when the arm is moved. The larger the tear in the tendon, the more weakness there is when trying to move the arm. Most people report an inability to sleep on the affected side, due to pain.

Diagnosis

The physical examination can be very suggestive of a rotator cuff tear. A complete tear is usually very obvious. If your doctor can move the arm in a normal range of motion, but you are unable to move the arm using your own strength, there is a high likelihood of a tear in the tendons.

Xrays may give clues as that there is a rotator cuff tear, but a test called an arthrogram is usually required. This test involves placing dye into the shoulder joint. Xrays are then taken to see if the dye leaks from the shoulder into the bursa. If it does, there is a rotator cuff tear present.

xray-shoulder-jointThe shoulder MRI Scan can also be used to actually look at the rotator cuff tendons and determine whether or not they are torn.

Treatment

Initial treatment for a suspected rotator cuff tear is rest and anti-inflammatory medication, mainly to control pain. While a true rotator cuff tear will not heal, some partial tears will become very tolerable and may not require a surgical repair.

As soon as pain tolerance permits, physical therapy to regain motion is begun.

A cortisone injection may be suggested if you are still having pain after several weeks of conservative care. After a reasonable time, if the pain is not tolerable or the motion of the arm is not acceptable, an arthrogram or MRI scan may be suggested to plan for surgery.

 

Surgery to repair a tear in the rotator cuff tendons is necessary if there is a complete tear in the tendons resulting in an inability to raise the arm. Surgery may also be necessary for a partial tear of the tendons if the tear results in more discomfort and weakness than you are willing to tolerate. The timing of surgery is variable. In a complete tear of the rotator cuff, there is evidence to suggest that repairing the tendons within 3 months of the injury results in a better outcome.

Repairing the tendons can be difficult. In the most straight forward instance, repairing the tendons involves first removing any degenerative cuff tissue that does not appear healthy. Then an area of the humerus is prepared with a surgical burr to form a raw bony areas for attachment of the torn tendon. Usually, drill holes are made in the humerus to allow sutures to be placed through the bone to anchor the tendon. The tear in the tendon is then sewn together and anchored to the humerus through the drill holes.

Following surgery, you may spend one or two nights in the hospital. There is a trend towards smaller incisions for repair of the tendons, and in some cases repair with the aid of the arthroscope. If your are a candidate for this type of repair, you may go home the same day.

Expect to begin physical therapy fairly soon after surgery. The repair must be protected, mainly to keep the sutures from pulling free, but early range of motion exercises will lead to a quicker recovery. During the period three to six weeks following surgery, the therapist will begin more active exercises to begin regaining the stregth in the rotator cuff muscles.

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