Rotator Cuff Tears

How does it typically present?

Pain in the shoulder and upper arm that comes on gradually. The pain can also be the result of an injury or a fall on the shoulder, in which case the symptoms appear suddenly and strongly (see the section on traumatic rotator cuff tears).

The pain appears especially:

• when raising the arm
• with rotation movements (mainly backwards)
• with throwing movements
• and at night

The pain lasts a long time, and it is common to get only temporary relief after injections or pain treatments.

The pain is accompanied by:

• difficulty using the arm
• and sometimes marked weakness of the shoulder
• mainly in activities with the arm raised

What is a rotator cuff tear?

The rotator cuff muscles are responsible for keeping the head of the humerus in place and for rotation movements of the shoulder. In particular, these muscles rotate the shoulder, mainly turning the arm outwards (external rotation). They attach to the humerus through tendons that form a broad band.

A tear usually means the tendon has been pulled off the bone where it attaches, not that the tendon itself has torn through. In many cases, even when there was an injury, the tendon had already been weakened by chronic wear, and the injury turned this into a larger tear.

What types of tears are there?

1. Partial-thickness tear

A partial-thickness tear is a tear that involves only part of the thickness of the tendon. The tendon is still continuous, but worn on one side, with some of its fibers torn. Partial tears are usually small and mainly cause pain.

2. Full-thickness tear

In a full-thickness tear there is an actual hole in the tendon through the full thickness of the fibers (a complete hole in the tendon from side to side). The tendon may still be continuous on either side of the tear, but at the site of the tear the fibers are torn through the full thickness of the tendon.

A full-thickness tear can be small, in which case it behaves like a partial tear, that is:

• function is mostly preserved
• and the main problem is pain

The larger the tear in width and length, the greater the loss of shoulder function and strength.

3. Massive tear

A very large tear, sometimes involving several tendons, with complete detachment of the tendons. In these cases the tendon is pulled back by the muscle.

A massive tear usually leads to:

• very severe limitation of shoulder function
• and sometimes, in fact, to less pain

Treating massive tears is more difficult and rehabilitation takes longer.

How is a rotator cuff tear diagnosed?

Diagnosis starts with the symptoms and the physical examination.

Imaging needed:

• Ultrasound or MRI – these are the main tests.
• To assess the size of the tear more accurately and to judge the quality of the muscles themselves – whether or not there is fatty degeneration – an MRI is needed.
• For some of the smaller tears, an ultrasound (US) is enough for diagnosis.

An important part of the initial work-up is an X-ray, whose purpose is to identify associated problems in the bones and joints of the shoulder, such as:

• cartilage wear in the shoulder joint
• cartilage wear in the acromioclavicular joint (AC joint)

A rotator cuff tear cannot be diagnosed from an X-ray.

How is a traumatic rotator cuff tear treated?

Rotator cuff tears do not heal on their own – only through surgical repair of the tear. That said, many people live and function fully despite having a tear, so the mere presence of a tear certainly does not mean surgery is required.

In some cases, physiotherapy can achieve:

• improved shoulder function
• less pain
• and a return to activity

This is despite the tear still being there. It is achieved by strengthening the remaining muscles so that they take over the role of the torn tendon (see the muscle-strengthening exercise protocol). In such cases it is advisable to monitor the tear to make sure it does not get worse over time.

Repairing the torn tendon requires surgery. The operation can be done open or arthroscopically; today it is standard to perform it arthroscopically (see arthroscopic rotator cuff repair). During the operation the tendon is repaired by stitching it back to the shoulder bone from which it tore.

After surgery there is a rehabilitation period lasting several months, which requires:

• the patient's cooperation
• and daily physiotherapy

Expect pain mainly in the first two weeks, although the pain sometimes lasts longer, even months.

There are situations in which a repair is not possible, and even if it is done, the chance of a re-tear is high. These are cases in which:

• the tear is too large
• or the quality of the muscles themselves is poor, because of prolonged disuse

In these cases, mainly in older people (there is no clear-cut rule, but certainly above age 70), a joint replacement can be performed with a special implant of the reverse shoulder type. This implant has a special design intended for this situation and allows the shoulder to function despite the torn tendons (see reverse shoulder replacement).

What are the chances that tendon repair surgery succeeds?

The chances of success depend on many factors, including: the size of the tear, the time from the onset of the tear to the repair, the patient's age, general health, the quality of the bone and tendons, the range of motion of the shoulder before surgery, the level of activity before the injury, and the patient's motivation.

The smaller the tear, the shorter the time since the injury, and the younger and more motivated the patient – the chances of success are very high.

For an accurate assessment, consult your treating physician.

What can happen if surgery is not done?

The tear will not heal and continues to get worse over time. The larger the tear, the greater the chance of:

• the tear continuing to grow
• and loss of function

Bear in mind that with large tears, and those accompanied by restricted movement, the longer surgery is postponed:

• the lower the chances that the operation succeeds
• the harder the rehabilitation
• and the less good the functional result at the end of the process

On the other hand, if the tear is partial or small and shoulder function is preserved, surgery can be postponed and physiotherapy can be tried.

Summary

When the tear is relatively small or partial, shoulder movement is good and there is no significant impact on quality of life, my preference is conservative treatment, mainly physiotherapy. If there is no improvement, or if things get worse with loss of function and/or quality of life, surgery should be considered.

In large tears, and especially with loss of function such as:

• restricted movement
• inability to raise the arm above shoulder height
• difficulty sleeping
• and especially if physiotherapy has already been tried

my recommendation is surgical repair of the tear, and sooner is better than later. In a massive tear that cannot be repaired, the different options should be discussed according to the current level of function and the degree of pain, and if needed a decision made on a reverse shoulder replacement.

This explanation is background and a general summary of the subject, from my professional point of view.

Every case is individual and requires a personal consultation and discussion with the treating physician.

Explanatory video

Rotator cuff tears – diagnosis and treatment – A detailed explanation of rotator cuff tendon tears: the types of tear, symptoms, diagnosis with MRI and the treatment options – from physiotherapy to minimally invasive surgery. The video is in Hebrew.