Rotator cuff tears may be the most publicized of all shoulder problems. They are relatively common in those over the age of 40. There are many types and levels of tears from small partial thickness tears to full thickness tears involving one or more of the rotator cuff tendons. When caused traumatically, the pain, discomfort, and weakness is profound and leads to early evaluation and treatment. More insidious onset tears are often ‘dealt’ with for many weeks or months before treatment is sought. A full thickness tear will not heal on its own because the rotator cuff tendon does not have a good blood supply to help it heal. If the tendon is not repaired the tear will get bigger over time.
These tears can be from repetitive overuse or from a single traumatic event. The former is more common in older individuals and overhead athletes while the latter occurs with falls or contact athletic activities.
- Pain with some or all motions
- Aching pain at night and after use
- Weakness with activities, especially overhead
- Trouble sleeping due to pain
- Limited motion secondary to pain or weakness
- Clicking or popping
- Unable to lift arm
The diagnosis of a rotator cuff tear can often be made through physical examination. An MRI will help to determine the location and extent of the injury. In most cases, once the diagnosis is made, therapy is begun to regain better motion and function of the shoulder. It is not uncommon that partial or small tears be treated conservatively depending on work and athletic interests. Exercises begin simply to reduce pain, and then establish motion. Strengthening and a return to functional work or sport occur only after the first two steps – pain reduction and improved motion – are achieved. Anti-inflammatories and Tylenol are often helpful during the early stages. A tear that is full thickness will get larger overtime. At some point surgery will be needed to fix the tear.
Surgical care involves the reattachment of the torn tendon to the top of the arm bone, to their anatomic location. The repair can be performed often arthroscopically. A larger tear may require a larger skin incision. Repairs are successful when both the tendon quality is good and the repair is done without significant tension. When the tendon has been torn for a long period of time or the tissue is of poor quality the success rate decreases.
Rotator cuff tendon surgery is common and techniques are improving. The success rates are high. However, any repair will fail if appropriate rehabilitation after the surgery is not performed. This includes immobilizing the shoulder until the surgeon tells you to remove it. Following instructions such as no pushing, pulling of lifting of the arm in the early postop period. Once the repair is healed then you will be allowed to return to your normal activities.
Rotator cuff arthropathy is an end-stage, painful condition that develops slowly over the course of time after a massive tear in the rotator cuff. At first, these tears are often asymptomatic and may not become symptomatic until the occurrence of secondary destructive changes. Radiographically, cuff tear arthropathy is characterized by superior migration of the humeral head, which is often in contact with the acromion. Erosive changes in the humeral head, accompanied by sclerosis of the humerus, glenoid, and acromion are also present. In advanced cases, the humeral head may actually appear to have formed a secondary “socket” in the acromion. The MRI will often reveal a large fluid filled space extending under the anterior deltoid. Portions of the subscapularis and teres minor are usually all that remain of the rotator cuff mechanism.
Treatments for rotator cuff arthropathy consist of physical therapy to strengthen the deltoid and retraining the deltoid to help you lift your arm, cortisone injections as needed for the pain, tens unit to help decrease the pain, and pain medications and anti- inflammatories as needed. When the patient can no longer lift the arm, then a reverse shoulder replacement can be scheduled. This procedure, replaces the shoulder with medical and plastic, and is made in such a way, to help you lift your arm again. Many patients will regain good range of motion after this procedure, but some patients are only able to get 90 degrees of overhead motion, so this procedure is not usually done, if you can lift your arm above 90 before surgery. There can also be some loss of external rotation due to the implant, but most patients will accept this to be able to lift the arm overhead again.