Rotator Cuff Tears

What is it?
Rotator cuff tears are very common. The rotator cuff muscles are 4 small but powerful muscles that lie deep inside your shoulder and function to keep the shoulder stable and move your upper arm. The supraspinatus muscle is one of more important of the rotator cuff muscles, and this muscle commonly tears right where it inserts into the top of the humerus. The tears can range from small (<1cm) to massive (>4cm) and can be chronic or acute. The symptoms most people experience typically include nagging and hard to localize pain in the shoulder that can radiate down the side of the upper arm or into the neck. People often experience pain when the arm is over head, such as when reaching for an object in the top of the cupboard. Many people have pain that is worse at night, often waking them from sleep or preventing restful sleep altogether. Weakness is generally associated with large rotator cuff tears. Some tears make moving the arm above the head almost impossible.

What causes it?
Rotator cuff tears may occur from an injury (even a very minor injury) or from repetitive wear and tear. A common scenario is for the tear to occur after a fall on an outstretched arm. It is also common to have a tear that happens with no identifiable cause. In these situations, the tear may have slowly progressed over several months or years from “micro-trauma” to the shoulder. It is important to realize that normal tendons don’t tear in this way, these tears happen because the tendons themselves are not normal, not unlike how tears in a pair of jeans happen when the jeans are worn out, not when they are new.

What is the conservative (first line) treatment?
The primary treatment is physical therapy, either with a therapist or on your own. The remaining rotator cuff muscles need to be strengthened so that they may work more efficiently and help stabilize your shoulder. These exercises can be very successful in treating this condition. It may take up to 3 months or longer to fully benefit from therapy, so stay with it as long as you can – it is worth it. Sometimes your inflammation can be so severe that an injection is done in addition to therapy. The injection is done with a very small needle, and it is a combination of a short-acting analgesic and a corticosteroid which helps control the inflammation. The injection may make your shoulder sore for a few days, but once the steroid starts to work (one week approximately) you should feel better. You may need several injections over a few months to calm down the inflammation. The injections will not help the tendons heal however.

What if that fails to relieve my condition?
The first step may be to get an MRI or MRI arthrogram which is an MRI with dye injected into your shoulder to improve the image quality. The MRI is ordered to find out how large a tear there is, and to determine if the tendon is repairable. Some tendons can not be repaired. If you have done physical therapy and have tried injections with no benefit, the next step is to consider surgery. Surgery is done either arthroscopically through 3 or 4 small (<1cm) incisions, or through an open approach which uses a small single incision. The decision to use one or the other methods depends upon the type of tear, your age, and other factors. The surgery is done to repair the torn tendon and to clear out any inflammation surrounding the tear. The surgery takes about an hour and a half and you typically can go home the same day, although some people may spend one night in the hospital. Complete recovery takes a few months. Most people have a sling for a month to 6 weeks. You can start doing motion exercises with the therapists after a week, and you will start doing “active” motion at 6 weeks. Strengthening starts at roughly 3 months. Most patients continue to heal for up to a year after surgery.

How successful is surgery for this?
The surgery (arthroscopic or mini-open) is generally successful. Approximately 90% of people get significantly better after the surgery. The tendons are not restored to their normal state however, and the repaired tendon may re-tear over time or with another traumatic event. If this does occur, the good news is that the pain usually does not come back to the same degree. After a successful repair, the pain you feel at night is usually gone, and overhead activities become much more tolerable.