About Rotator Cuff Tears
The most common symptom patients experience is pain with reaching away from the body or overhead. Patients also experience weakness with lifting, pain at night, and limited range of motion.
Cause and Anatomy of Rotator Cuff Tears
The shoulder joint is formed by an extension of the shoulder blade called the glenoid and the top of the arm bone called the humeral head. These bones form a ball-and-socket joint, which is the most mobile joint in the body. There are four muscles that attach the shoulder blade to the humeral head and are called the rotator cuff muscles. The two muscles in the back are called the infraspinatus and teres minor, the muscle on top is called the supraspinatus, and the muscle in front is called the subscapularis. The tendons of these four muscles form a cuff of tissue around the humeral head and help keep the head centered on the socket. They provide the ability to effectively lift and rotate the arm.
Diagnosis of Rotator Cuff Tears
Rotator cuff tears are typically diagnosed with an MRI because soft tissue structures like muscles and tendons do not show up on an X-ray. On MRI, a fluid gap is noted between the tendon and its normal attachment on the humerus. The size of the tear and amount of retraction can be measured on the MRI and help determine the best course of treatment. The normal length of the tendon attachment is 12-15 mm. The tendon can be partially torn, which means that part of the tendon is still attached.
Rotator cuff tears can be diagnosed with a clinical exam, but are confirmed with an MRI. On exam, patients demonstrate weakness when assessing the arm strength in certain positions to test the specific rotator cuff muscles. Range of motion is also limited due to pain with reaching away from the body or overhead.
It is important to distinguish between an acute and chronic rotator cuff tear. Acute tears occur from a fall or other trauma to the shoulder, while chronic tears occur from age-related degeneration without any specific trauma.
What Are My Options?
Physical therapy is the first-line treatment for patients with small tears (less than one centimeter), partial rotator cuff tears, and chronic tears. PT can help restore range of motion and is focused on strengthening the muscles around the one that is torn. Chronic rotator cuff tears are often associated with a condition called subacromial impingement, which is treated by rebalancing the muscles that attach to the shoulder blade. A trained physical therapist will be able to assess subtle muscular imbalances and can use different modalities such as massage, dry needling, and transcutaneous electrical stimulation to alleviate pain.
- Anti-inflammatory pain medication – Nonsteroidal anti-inflammatory drugs (NSAIDs) are helpful in reducing pain caused by rotator cuff tears. NSAIDs help to block the effects of inflammatory proteins, which results in less pain. These medications can be taken over the counter or by prescription. There are dozens of different NSAIDs, so often patients must try a couple of different types to see, which one works best. NSAIDs can have detrimental effects when taken long-term or over the recommended dose, such as kidney damage, ulcers, and even a small increased risk of heart attack or stroke. It is recommended that patients discuss the use of these medications with their doctor.
- The most common substance injected into the shoulder is steroids (often referred to as cortisone). Steroids are powerful anti-inflammatory medications, which turn off cellular signals that form inflammation. This results in reduced pain, but it usually takes 1-2 days for the steroid to take effect. Steroid injections result in 3 months of pain relief on average. In the case of a chronic rotator cuff tear, steroids can be injected into the subacromial space (above the rotator cuff). This is not recommended in acute rotator cuff tears or tears that require surgery because steroid injections within 3 months of surgery have been shown to decrease the healing rate for the rotator cuff repair. Repeat steroid injections around tendons have been shown to weaken the tendon over time, so should be avoided when possible.
- Toradol is an injectable type of nonsteroidal anti-inflammatory drug. This medication can be injected into the subacromial space and can help alleviate inflammation and pain like steroid injections. Toradol is often the preferred medication to inject in patients with diabetes because it does not elevate the blood sugar as is often the case with steroid injections.
- Platelet-rich plasma (PRP) is an emerging technique for treating partial rotator cuff tears. Blood is taken from a vein and spun in a centrifuge. This stratifies the blood into different layers. One of those layers is called platelet-rich plasma, which contains healing factors called cytokines. The PRP is isolated and injected around the tendon, which concentrates healing factors at the site of the tear and helps promote healing.
The primary treatment for acute rotator cuff tears as well as chronic and high-grade partial tears that have failed more conservative treatment is surgery to re-attach the torn tendon. This is typically done arthroscopically through 3-4 small (1-2 cm) incisions called portals. A 4 mm camera is inserted through one portal and small instruments are inserted through the other portals. The normal attachment site of the tendon is roughened to create bleeding bone. This is an important step because stem cells from inside the bone are released and migrate into the site of the rotator cuff repair to facilitate healing. Small anchors (4-5 mm) made of plastic or absorbable materials are inserted into the bone. The anchors contain sutures that are passed through the torn tendon. The sutures are then tied, which secures the tendon back to its anatomic position. The sutures simply hold the tendon in the correct position until the body reforms the connections between the tendon and the bone, which typically takes 3-4 months.
Frequently Asked Questions
Do I need to have my rotator cuff tear fixed?
Small (<1 cm) and partial tears are usually treated without surgery with physical therapy, activity modifications/rest, anti-inflammatory pain medication, and injections. If you have persistent pain despite more conservative treatment or if you have a tear larger than 1 cm, then you should consider having the rotator cuff surgically repaired.
How do I know if I have a rotator cuff tear?
If you fell and have difficulty lifting your arm, you should have your shoulder evaluated by a specialist. A clinical exam and X-rays will be performed. X-rays are important to look at the overall alignment of the joint and to assess for any fractures. An MRI will likely be ordered to evaluate for rotator cuff tear. Other symptoms that may indicate a rotator cuff tear are weakness and pain at night.