Rotator Cuff
Tears
A rotator cuff tear is a
common cause of pain and disability among adults. In 2008, close to 2 million
people in the United States went to their doctors because of a rotator cuff
problem.
A torn rotator cuff will
weaken your shoulder. This means that many daily activities, like combing your
hair or getting dressed, may become painful and difficult to do.
Anatomy:
Your shoulder is made up of
three bones: your upper arm bone (humerus), your shoulder blade (scapula), and
your collarbone (clavicle). The shoulder is a ball-and-socket joint: The ball,
or head, of your upper arm bone fits into a shallow socket in your shoulder
blade.
Your arm is kept in your
shoulder socket by your rotator cuff. The rotator cuff is a network of four
muscles that come together as tendons to form a covering around the head of the
humerus. The rotator cuff attaches the humerus to the shoulder blade and helps
to lift and rotate your arm.
There is a lubricating sac
called a bursa between the rotator cuff and the bone on top of your shoulder
(acromion). The bursa allows the rotator cuff tendons to glide freely when you
move your arm. When the rotator cuff tendons are injured or damaged, this bursa
can also become inflamed and painful.
This illustration more
clearly shows the four muscles and their tendons that form the rotator cuff and
stabilize the shoulder joint.
Description:
When one or more of the rotator cuff tendons is
torn, the tendon no longer fully attaches to the head of the humerus. Most
tears occur in the supraspinatus muscle and tendon, but other parts of the
rotator cuff may also be involved.
In many cases, torn tendons begin by fraying. As
the damage progresses, the tendon can completely tear, sometimes with lifting a
heavy object.
There are different types of tears:
Partial Tear:
This type of tear damages the soft tissue,
but does not completely sever it.
Full-Thickness Tear:
This type of tear is also called a complete
tear. It splits the soft tissue into two pieces. In many cases, tendons tear
off where they attach to the head of the humerus. With a full-thickness tear,
there is basically a hole in the tendon.
Cause:
There are two main causes of rotator cuff tears:
injury and degeneration.
Acute
Tear
If you fall down on your outstretched arm or lift something too heavy
with a jerking motion, you can tear your rotator cuff. This type of tear can
occur with other shoulder injuries, such as a broken collarbone or dislocated
shoulder.
Degenerative
Tear
Most tears are the result of a wearing down of the tendon that occurs
slowly over time. This degeneration naturally occurs as we age. Rotator cuff
tears are more common in the dominant arm. If you have a degenerative tear in
one shoulder, there is a greater risk for a rotator cuff tear in the opposite
shoulder -- even if you have no pain in that shoulder.
Several factors contribute to degenerative, or
chronic, rotator cuff tears.
Repetitive stress:
Repeating the same shoulder motions again and again can stress your
rotator cuff muscles and tendons. Baseball, tennis, rowing, and weightlifting
are examples of sports activities that can put you at risk for overuse tears.
Many jobs and routine chores can cause overuse tears, as well.
Lack of blood supply:
As we get older, the blood supply in our rotator cuff tendons
lessens. Without a good blood supply, the body's natural ability to repair
tendon damage is impaired. This can ultimately lead to a tendon tear.
Bone spurs:
As we age, bone spurs (bone
overgrowth) often develop on the underside of the acromion bone. When we lift
our arms, the spurs rub on the rotator cuff tendon. This condition is called
shoulder impingement, and over time will weaken the tendon and make it more
likely to tear.
Risk Factors
Because
most rotator cuff tears are largely caused by the normal wear and tear that
goes along with aging, people over 40 are at greater risk.
People who do repetitive
lifting or overhead activities are also at risk for rotator cuff tears.
Athletes are especially vulnerable to overuse tears, particularly tennis
players and baseball pitchers. Painters, carpenters, and others who do overhead
work also have a greater chance for tears.
Although overuse tears
caused by sports activity or overhead work also occur in younger people, most
tears in young adults are caused by a traumatic injury, like a fall.
Symptoms:
The most common symptoms of a rotator cuff tear
include:
- Pain at rest and at night, particularly if
lying on the affected shoulder
- Pain when lifting and lowering your arm or
with specific movements
- Weakness when lifting or rotating your arm
- Crepitus or crackling sensation when moving
your shoulder in certain positions
Tears that happen suddenly, such as from a fall,
usually cause intense pain. There may be a snapping sensation and immediate
weakness in your upper arm.
Tears that develop slowly
due to overuse also cause pain and arm weakness. You may have pain in the
shoulder when you lift your arm to the side, or pain that moves down your arm.
At first, the pain may be mild and only present when lifting your arm over your
head, such as reaching into a cupboard.
Over-the-counter medication, such as
aspirin or ibuprofen, may relieve the pain at first.
Examination:
Your MD or your therapist will test your range of
motion by having you move your arm in different directions.
Medical History and
Physical Examination
After
discussing your symptoms and medical history, your MD or your therapist will examine your
shoulder.
He or she will check to see whether it is tender in any area or
whether there is a deformity. To measure the range of motion of your shoulder,
your doctor will have you move your arm in several different directions. He or
she will also test your arm strength.
Your MD or therapist will check for
other problems with your shoulder joint. He or she may also examine your neck
to make sure that the pain is not coming from a "pinched nerve," and
to rule out other conditions, such as arthritis.
Imaging
Tests
Other tests which may help your doctor confirm your diagnosis include:
X-rays
The first imaging tests performed are usually x-rays.
Because x-rays
do not show the soft tissues of your
shoulder like the rotator cuff, plain
x-rays of a shoulder
with rotator cuff pain are usually normal or may show a
small bone spur.
Magnetic resonance imaging
(MRI) or ultrasound.
These studies can better show
soft tissues like the
rotator cuff tendons. They can show the rotator cuff
tear,as well as where the tear is located within the
tendon and the size of
the tear. An MRI can also give
your doctor a better idea of how "old"
or "new" a tear is
because it can show the quality of the rotator
cuff
muscles.
Treatment:
If you have a rotator cuff tear and
you keep using it despite increasing pain, you may cause further damage. A rotator
cuff tear can get larger over time.
Chronic shoulder and arm pain are
good reasons to see your MD. Early treatment can prevent your symptoms from
getting worse. It will also get you back to your normal routine that much
quicker.
The goal of any treatment is to
reduce pain and restore function. There are several treatment options for a
rotator cuff tear, and the best option is different for every person.
In
planning your treatment, your MD will consider your age, activity level,
general health, and the type of tear you have.
There is no evidence of better
results from surgery performed near the time of injury versus later on. For
this reason, many MD first recommend nonsurgical management of rotator
cuff tears.
In about 50% of patients, nonsurgical treatment relieves pain and
improves function in the shoulder. Shoulder strength, however, does not usually
improve without surgery.
Nonsurgical treatment options may include:
Rest:
Your doctor may suggest rest and and limiting overhead activities. He
or she may also prescribe a sling to help protect your shoulder and keep it
still.
Activity modification:
Avoid activities that cause shoulder pain.
Non-steroidal anti-inflammatory
medication:
Drugs like ibuprofen and
naproxen reduce pain and swelling.
Strengthening exercises and
physical therapy:
Specific exercises will
restore movement and strengthen your shoulder. Your exercise program will
include stretches to improve flexibility and range of motion. Strengthening the
muscles that support your shoulder can relieve pain and prevent further injury.
Steroid injection:
If rest, medications, and physical therapy do not relieve your pain,
an injection of a local anesthetic and a cortisone preparation may be helpful.
Cortisone is a very effective anti-inflammatory medicine.
The chief advantage of nonsurgical treatment is
that it avoids the major risks of surgery, such as:
- Infection
- Permanent stiffness
- Anesthesia complications
- Sometimes lengthy recovery time
The disadvantages of nonsurgical treatment are:
- No improvements in strength
- Size of tear may increase over time
- Activities may need to be limited
Surgical
Treatment
Your MD may recommend surgery if your pain does not improve with
nonsurgical methods. Continued pain is the main indication for surgery. If you
are very active and use your arms for overhead work or sports, your doctor may
also suggest surgery.
Other signs that surgery may be a good option for
you include:
- Your symptoms have lasted 6 to 12 months
- You have a large tear (more than 3 cm)
- You have significant weakness and loss of
function in your shoulder
- Your tear was caused by a recent, acute
injury
Surgery to repair a torn rotator cuff most often
involves re-attaching the tendon to the head of humerus (upper arm bone). There
are a few options for repairing rotator cuff tears. Your orthopaedic surgeon
will discuss with you the best procedure to meet your individual health needs.