A Patient's Guide to Rotator Cuff Tears
Introduction
The shoulder is an elegant and complex piece of
machinery. Its design allows us to reach and use our hands
in many different positions. However, while the shoulder
joint has great range of motion, it is not very stable. This
makes the shoulder vulnerable to problems if any of its
parts aren't in good working order.
The rotator cuff tendons are key to the healthy
functioning of the shoulder. They are subject to a lot of
wear and tear, or degeneration, as we use our arms.
Tearing of the rotator cuff tendons is an especially painful
injury. A torn rotator cuff creates a very weak shoulder.
Most of the time patients with torn rotator cuffs are in
late middle age. But rotator cuffs tears can happen at any
age.
This guide will help you understand
- what the rotator cuff is
- how it can become torn
- what treatments are available for a torn rotator cuff
Anatomy
What is the rotator cuff, and what does it do?
The shoulder is made up of three bones: the scapula (shoulder blade), the
humerus (upper arm bone), and the clavicle
(collarbone).
The rotator cuff connects the humerus to the
scapula. The rotator cuff is formed by the tendons of four
muscles: the supraspinatus, infraspinatus, teres
minor, and subscapularis.
Tendons attach muscles to bones. Muscles move the bones
by pulling on the tendons. The rotator cuff helps raise and
rotate the arm.
As the arm is raised, the rotator cuff also keeps the
humerus tightly in the socket of the scapula. The upper part of the scapula
that makes up the roof of the shoulder is called the
acromion.
A bursa is located between the acromion and the
rotator cuff tendons. A bursa is a lubricated sac of tissue
that cuts down on the friction between two moving parts.
Bursae are located all over the body where tissues must rub
against each other. In this case, the bursa protects the
acromion and the rotator cuff from grinding against each
other.
Related Document: A
Patient's Guide to Shoulder Anatomy
Causes
What causes the rotator cuff to tear?
The rotator cuff tendons have areas of very low blood
supply. The more blood supply a tissue has, the better and
faster it can repair and maintain itself. The areas of poor
blood supply in the rotator cuff make these tendons
especially vulnerable to degeneration from aging.
The degeneration of aging helps explain why the rotator
cuff tear is such a common injury later in life. Rotator
cuff tears usually occur in areas of the tendon that had low
blood supply to begin with and then were further weakened by
degeneration.
This problem of degeneration may be accelerated by
repeating the same types of shoulder motions. This can
happen with overhand athletes, such as baseball pitchers.
But even doing routine chores like cleaning windows, washing
and waxing cars, or painting can cause the rotator cuff to
fatigue from overuse.
Excessive force can tear weak rotator cuff tendons. This
force can come from trying to catch a heavy falling object
or lifting an extremely heavy object with the arm extended.
The force can also be from a fall directly onto the
shoulder. Sometimes injuries that tear the rotator cuff are
painful, but sometimes they aren't. Researchers estimate
that up to 40 percent of people may have a mild rotator cuff
tear without even knowing it.
The typical patient with a rotator cuff tear is in late
middle age and has had problems with the shoulder for some
time. This patient then lifts a load or suffers an injury
that tears the tendon. After the injury, the patient is
unable to raise the arm. However, these injuries also occur
in young people. Overuse or injury at any age can cause
rotator cuff tears.
Symptoms
What does a rotator cuff tear feel like?
Rotator cuff tears cause pain and weakness in the
affected shoulder. In some cases, a rotator cuff may tear
only partially. The shoulder may be painful, but you can
still move the arm in a normal range of motion. In general,
the larger the tear, the more weakness it causes.
In other cases, the rotator cuff tendons completely
rupture. A complete tear makes it impossible to move the arm
in a normal range of motion. It is usually impossible to
raise the arm away from your side by yourself.
Most rotator cuff tears cause a vague pain in the
shoulder area. They may also cause a catching sensation when
you move your arm. Most people say they can't sleep on the
affected side due to the pain.
Diagnosis
What tests will my doctor run?
Your doctor will ask questions about your medical
history, your injury, and your pain. Your doctor will then
do a physical examination of the shoulder. The physical exam
is most helpful in diagnosing 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 can't move
the arm yourself, you most likely have a torn rotator
cuff.
X-rays won't show tears in the rotator cuff. However,
your doctor may want you to have a shoulder X-ray to see if
there are bone spurs, a loss of joint space in the shoulder,
or a down-sloping (hooked) acromion. These findings are
associated with tears in the rotator cuff. An X-ray can also
show if there are calcium deposits in the tendon that are
causing your symptoms, a condition called calcific
tendonitis.
Related Document: A
Patient's Guide to Calcific Tendonitis
Your doctor will probably also want to do an
arthrogram test. An arthrogram involves injecting dye
into the shoulder joint and taking several X-rays. If the
dye leaks out of the shoulder joint, there is probably a
tear in the rotator cuff.
Your doctor may ask you to have a magnetic resonance
imaging (MRI) scan.
An MRI scan is a special imaging test that uses magnetic
waves to create pictures of the shoulder in slices. The MRI
scan shows tendons as well as bones. This test is painless
and requires no needles or injections.
Treatment
What treatment options are available?
Nonsurgical Treatment
Your doctor's first goal will be to help control your
pain and inflammation. Initial treatment is usually rest and
anti-inflammatory medication, such as aspirin or ibuprofen.
This medicine is used mainly to control pain. Your doctor
may suggest a cortisone injection if you have trouble getting
your pain under control. Cortisone is a very effective
anti-inflammatory medication.
Your doctor will probably have a physical or occupational
therapist direct your rehabilitation program. At first,
treatments such as heat and ice focus on easing pain and
inflammation. Hands-on treatments and various types of
exercises are used to improve the range of motion in your
shoulder and the nearby joints and muscles.
Later, you will do strengthening exercises to improve the
strength and control of the rotator cuff and shoulder blade
muscles. Your therapist will help you retrain these muscles
to keep the ball of the humerus in the socket. This will
help your shoulder move smoothly during all of your
activities.
You may need therapy treatments for six to eight weeks.
Most patients are able to get back to their activities with
full use of their arm within this amount of time.
Surgery
A complete rotator cuff tear will not heal. Complete
ruptures usually require surgery if your goal is to return
your shoulder to optimal function. The exception is in
elderly patients or patients who have other diseases that
increase the risks of surgery. There is some evidence that
repairing the rotator cuff within three months of the injury
results in a better outcome. You will need to work with your
surgeon to determine when is the best time to do the
surgery.
Partial tears may not require surgical repair. If you
have a partial tear, your surgeon will most likely want to
give your rotator cuff a chance to heal on its own. But if
you can't stand the pain, or if you can't use your arm, you
may need to consider surgery.
The next step would be an arthrogram or MRI scan to help
your surgeon plan the procedure. Your surgeon will be
looking for details of your rotator cuff tear and checking
for other problems. As mentioned earlier, a tear usually
doesn't occur unless the rotator cuff is already weakened by
some other problem. Other potential problems include acromioclavicular (AC) joint osteoarthritis and
impingement syndrome. Your surgery may need to
address these conditions as well.
Related Document: A
Patient's Guide to Osteoarthritis of the Acromioclavicular
Joint
Related Document: A
Patient's Guide to Impingement
Syndrome Arthroscopic Debridement
Small tears can be sometimes be treated with a smaller
operation. The surgeon may simply use an arthroscope to see and remove (debride)
torn or degenerated fibers within the tendon. An arthroscope
is a tiny TV camera that can be inserted into a very small
incision. It allows the surgeon to see the area where he or
she is working on a TV screen. No sutures (stitches)
are sewn into the tendon. Instead, the small tear is allowed
to heal by itself. Acromioplasty
For minor partial tears on the undersurface of the
rotator cuff tendon, surgery may include arthroscopic
debridement (described above) and acromioplasty. In
acromioplasty, the end of the acromion is cut and shaped to
take pressure off the rotator cuff beneath the acromion.
This is a simpler method than repairing the tear, and the
results are generally excellent. The tear will probably
require sutures if it is in the top surface of the
tendon. Arthroscopic Repair
Surgeons usually get excellent results using an
arthroscope (mentioned earlier) to repair a torn rotator
cuff. The first step involves careful removal of any
unhealthy, degenerated rotator cuff tissue. Then, the area
of the humerus bone where the tendon tore away is prepared
for reattaching the tendon. To do this, the surgeon removes
the soft tissue to form a raw bony area. Drill holes are
made in the humerus for attaching sutures. The tendon is
then sewn together and stitched to the humerus by looping
sutures through the drill holes. The tendon heals to the
bone over time, reattaching itself. Suture Anchor
Repair
Surgeons also use special fasteners to anchor the rotator cuff to the
humerus. During the procedure, the surgeon makes small drill holes into the humerus. A suture
anchor is punched down inside the drill hole. By tugging
on the suture, the fastener becomes anchored to the bone.
The tendon is then sewn together and stitched to the humerus
by looping sutures over the edge of the rotator
cuff. Open Repair
In some instances, open surgery is necessary. In
open surgery, the surgeon gets to the rotator cuff tendon by
cutting through muscles and tissues on the front of the
shoulder. After repairing the tendon, the muscle on the
front is reattached to the bone. Graft Method
It is not possible to repair all rotator cuff tears.
Sometimes the tendon has been torn for too long a period of
time. The tendons and muscles become contracted and can't be
stretched enough to be reattached. In these cases, the
surgeon may use a length of tendon graft to span the
distance from the tendon stump of the torn rotator cuff to
the humerus. Salvage Procedure
In other cases, the tendon tissue has simply worn away,
and the remaining tendon is not strong enough to hold the
necessary stitches. In these instances, simply removing all
the torn tissue and fixing any other problems in the
shoulder may reduce your pain. But this will probably not
increase the strength or motion of your shoulder. It may
actually decrease your range of motion.
Rehabilitation
What should I expect after treatment?
Nonsurgical Rehabilitation
Even if you don't need surgery, you may need to follow a
program of rehabilitation exercises. Your doctor may
recommend that you work with a physical or occupational
therapist. Your therapist can create an individualized
program to help you regain shoulder function. This includes
tips and exercise for improving posture and shoulder
alignment. It is also very important to improve the strength
and coordination in the rotator cuff and shoulder blade
muscles. Your therapist can also evaluate your workstation
or the way you use your body when you do your activities and
suggest changes to avoid further problems.
After Surgery
Rehabilitation after rotator cuff surgery can be a slow
process. You will probably need to attend therapy sessions
for two to three months, and you should expect full recovery
to take up to six months. Getting the shoulder moving as
soon as possible is important. However, this must be
balanced with the need to protect the healing tissues.
Your surgeon may have you wear a sling to support and
protect the shoulder for a few days after surgery. Ice and
electrical stimulation treatments may be used during your
first few therapy sessions to help control pain and swelling
from the surgery. Your therapist may also use massage and
other types of hands-on treatments to ease muscle spasm and
pain.
Therapy can progress quickly after arthroscopic
procedures. Treatments start out with range-of-motion
exercises and gradually work into active stretching and
strengthening. You just need to be careful about doing too
much, too quickly.
Therapy goes slower after surgeries where the front
shoulder muscles have been cut. Exercises begin with passive
movements. During passive exercises, your shoulder joint is
moved, but your muscles stay relaxed. Your therapist gently
moves your joint and gradually stretches your arm. You may
be taught how to do passive exercises at home.
Active therapy starts three to four weeks after surgery.
You use your own muscle power in active range-of-motion
exercises. You may begin with light isometric strengthening
exercises. These exercises work the muscles without
straining the healing tissues.
At about six weeks you start doing more active
strengthening. Exercises focus on improving the strength and
control of the rotator cuff muscles and the muscles around
the shoulder blade. Your therapist will help you retrain
these muscles to keep the ball of the humerus firmly in the
socket. This helps your shoulder move smoothly during all
your activities.
Some of the exercises you'll do are designed to get your
shoulder working in ways that are similar to your work tasks
and sport activities. Your therapist will help you find ways
to do your tasks that don't put too much stress on your
shoulder. Before your therapy sessions end, your therapist
will teach you a number of ways to avoid future
problems.
If all of these efforts to improve your shoulder
condition fail, there are a few other options. Tendon grafts
and muscle transfers, for example, may help you regain use
of your shoulder. However, these procedures are very complex
and are rarely necessary. |