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, torn tendons begin by fraying. As the damage progresses, the tendon can completely tear, sometimes with lifting a heavy object or falling on an outstretched hand.
Different types of rotator cuff tears
A rotator cuff tear most often occurs within the tendon.
The four muscles and their tendons that form the rotator cuff and stabilize the shoulder joint
A rotator cuff tear is a common cause of pain and disability among adults. The prevalence of shoulder pain has been estimated to be 7% – 25% and the incidence 10 rotator cuff tears per 1000 people per year (peaking at 25 per 1000 per year among individuals’ ages 42 – 46 years). The overall number of individuals with rotator cuff impingements and tears are expected to grow coincident with an aging population that is increasingly active and less willing to accept functional limitations.
A large proportion of patients with rotator cuff tears remain asymptomatic. MRI scans of people without shoulder pain revealed partial- and full-thickness rotator cuff tears in 4% of individuals 40 years old and in more than 50% of individuals 60 years old. Furthermore, autopsy studies have demonstrated a 6% prevalence of full-thickness rotator cuff tears in subjects < 60 years old and 30% prevalence in >60 years old (it was unknown how many of these subjects had shoulder pain). A torn rotator cuff will weaken your shoulder. This means that many daily activities, like washing/combing your hair or getting dressed, may become painful and difficult to do.
The most common symptoms of a rotator cuff tear include:
Acute tears, such as from a fall, usually cause intense pain. There may be a snapping sensation and immediate weakness in your upper arm.
Rotator cuff tears that develop slowly due to overuse will also cause pain and arm weakness. You may have pain in the shoulder when you lift your arm to the side, or pain that moves down your arm. At first, the pain may be mild and only present when lifting your arm over your head, such as reaching into a cupboard. Over-the-counter medication, such as aspirin or ibuprofen, may relieve the pain at first.
Over time, the pain may become more noticeable at rest, and no longer goes away with medications. You may have pain when you lie on the painful side at night. The pain and weakness in the shoulder may make routine activities such as combing your hair or reaching behind your back more difficult.
There are two main causes of rotator cuff tears: injury and degeneration.
Several factors contribute to degenerative, or chronic, rotator cuff tears.
Your doctor will test your range of motion by having you move your arm in different directions.
After discussing your medical history and symptoms, your doctor will examine your shoulder. He will check to see whether it is tender in any area or whether there is a deformity. To measure the range of motion of your shoulder and arm strength, your doctor will have you move your arm in several different directions and do several specific tests.
Your doctor will also examine your neck to make sure that the pain is not coming from a pinched nerve or rotator cuff impingement; and to rule out other conditions, such as arthritis.
The following imaging tests may be done to guide diagnosis:
(Left) Normal outlet view x-ray.
(Right) Abnormal outlet view showing a large bone spur causing impingement on the rotator cuff.
Important: If you have a rotator cuff tear and you keep using it despite increasing pain, you may cause further damage. A rotator cuff tear can get larger over time. Chronic shoulder and arm pain are good reasons to see your doctor. Early treatment can prevent your symptoms from getting worse. It will also get you back to your normal routine that much quicker.
The goal of any treatment should be to reduce pain and restore function. There are several treatment options for a rotator cuff tear, and the best option is different for every person. In planning your treatment, your doctor will consider:
Ultrasound view of rotator cuff tear
In about 50% of patients, nonsurgical treatment relieves pain and improves function in the shoulder. Shoulder strength, however, does not usually improve without surgery and thus your orthopaedic surgeon may advise rotator cuff repair surgery instead.
Nonsurgical treatment options may include:
A cortisone injection may relieve painful symptoms.
The disadvantages of nonsurgical treatment are:
Arthroscopic Rotator Cuff Repair Surgery - http://www.youtube.com/watch?v=lKk0B8_gD80
Your doctor may recommend repair surgery for a torn rotator cuff if:
There are a few options for repairing rotator cuff tears. Your orthopaedic surgeon will discuss with you the best procedure to meet your individual health needs.
Surgery to repair a torn rotator cuff involves re-attaching the tendon to the head of humerus. A partial tear, however, may need only a trimming or smoothing procedure called a debridement. A complete tear within the thickest part of the tendon is repaired by stitching the two sides back together.
There are a few options for repairing rotator cuff tears. Advancements in surgical techniques for rotator cuff repair include less invasive procedures. While each of the methods available has its own advantages and disadvantages, all have the same goal: getting the tendon to heal.
You may have other shoulder problems in addition to a rotator cuff tear, such as osteoarthritis, bone spurs, or other soft tissue tears. During the operation, your surgeon may be able to take care of these problems, as well.
The three techniques most used for rotator cuff repair include:
Dr van den Berg does most of his rotator cuff repair surgeries arthroscopically which leads to less pain, shorter hospital stay and the ability to address all underlying conditions of the shoulder with minimal soft tissue damage.
During arthroscopic surgery for a rotator cuff repair, your surgeon inserts a small camera, called an arthroscope, into your shoulder joint. The camera displays pictures on a television screen, and your surgeon uses these images to guide miniature surgical instruments.
Because the arthroscope and surgical instruments are thin, your surgeon can use very small incisions (cuts), rather than the larger incision needed for standard, open surgery. All-arthroscopic repair is the least invasive method to repair a torn rotator cuff.
During arthroscopy, your surgeon inserts the arthroscope and small instruments into your shoulder joint.
(Left) An arthroscopic view of a healthy shoulder joint. (Center) In this image of a rotator cuff tear, a large gap can be seen between the edge of the rotator cuff tendon and the humeral head. (Right) The tendon has been re-attached to the humeral head with sutures.
During surgery, Dr. van den Berg also will remove any inflamed bursa or bone spurs that would delay tendon healing.
You will receive a general anesthesia and an injection of a local anesthetic around the nerve that goes to the shoulder. This lasts 4-24 hours and will help decrease your pain after the surgery.
During shoulder arthroscopy, a small camera, called an arthroscope, is inserted near the shoulder joint through a small (usually 5-10mm) incision. The arthroscope is attached to a video monitor to allow Dr. Van den Berg to look inside your joint.
Instead of making a large incision, Dr. Van den Berg uses three small (5-10mm) incisions. Through one incision, he inserts the arthroscope to look inside your shoulder. He inserts special instruments that allow the removal of scar tissue and bone through the other two incisions. Dr. Van den Berg will then insert small plastic/metal screws (called "suture-anchors") into the shoulder.
There are sutures attached to the eyelets of the screws. Dr van den Berg uses special instruments to weave the sutures through the torn tendon. The screws are inside the bone and you cannot feel them. They do not have to be removed. The screws will not set off airport sensors.
(Left) The rotator cuff muscles and their tendons.
(Right) Typical location for a rotator cuff tendon tear.
(Left) The suture anchors are inside the bone. The green and white sutures are ready for the repair.
(Right) The sutures have been placed through the torn tendon. The sutures hold the tendon in position while it heals to bone.
Following repair surgery, you will awaken in the recovery room with your arm in a sling. You will remain in the recovery room for 30-40 minutes until fully awake and will stay overnight in the hospital to ensure no medical problems develop. Most patients go home the next morning.
Your first post-operative visit is 2 weeks after surgery so that Dr van den Berg can examine the surgical incision. He will give you additional instructions for exercises, show you some pictures and videos taken during surgery (you are welcome to bring a USB Memory Stick for a copy of the pictures and videos) and discuss your allowed activity level.
You will need to wear a shoulder sling full-time for 6 weeks. During this time, you can come out of the sling three times a day to do your physiotherapy exercises. You are not to raise your arm without help for six weeks after surgery. This allows the tendon to heal in the best possible position.
After 6 weeks – you can come out of the shoulder sling and you can perform usual gentle activities of daily living and physiotherapy will commence. The goal is to slowly but surely achieve a normal range of motion, usually 3-6 months after surgery. Driving is not permitted until you come out of your sling, i.e. after 6 weeks.
Returning to Work: For most sedentary jobs, Dr van den Berg recommends taking 2 weeks off from work. When you return to work your arm will be in a sling (for 6 weeks after surgery), but you should be able to manage if you do no lifting, pushing, pulling or carrying. You may begin light duty work involving no lifting, pushing, pulling or carrying, within two weeks after surgery; you may work at waist/desk level. Most patients can tolerate occasional work at shoulder level 3-6 months after surgery, but a return to heavy lifting or overhead use may require 6-12 months.
Physiotherapy plays a vital role in getting you back to your daily activities. A personalized physiotherapy program will help you regain shoulder strength and motion. You will be referred to a dedicated shoulder physiotherapist with years of experience in treating all kinds of shoulder problems.
After surgery, therapy progresses in stages.
Surgery to repair a torn rotator cuff is almost always successful in alleviating shoulder pain. Returning strength to the shoulder is more difficult to guarantee. This type of surgery is successful about 85-95% of the time. No shoulder surgery is 100% successful in every individual but the procedures we perform are reliable and will help restore the potential function in your shoulder. Rotator cuff repair for a tear from an acute injury works best if it is done within a few weeks of the injury. Because of the many variables involved, I can make no guarantees other than to assure you I will deliver the very best medical care possible.
Factors that can decrease the likelihood of a satisfactory result include: