Rotator Cuff Tear
What is a Rotator Cuff Tear?
The rotator cuff tendons are the end parts of the rotator cuff muscles that attach to the bone of the humerus. They are involved in keeping the humeral head (ball) central in the glenoid (shoulder socket) whilst also coordinating all movements of the shoulder. The supraspinatus (lifts the arm out to the side) and Infraspinatus (rotates the arm to the side) tendons are most frequently involved in cuff tears.
Why do they occur?
Rotator cuff tears occur in the following situations
Acute tear – these happen as a result of a fall or trauma causing the tendon to pull off the bone or tear within its substance. This can be a complication of shoulder dislocations and other injuries.
Degenerate tear – these happen as a result of age and activity related wear and tear, especially where there have been spurs of bone catching on the tendons. Sometimes a fairly innocuous event can be the final straw which leads to a tear in an already weakened worn tendon.
What are the symptoms and signs?
Some rotator cuff tears occur as a normal part of ageing and remain asymptomatic. Those tears that occur after an accident or a fall tend to be very painful over the top and outside part of the shoulder. Movement makes the pain worse and some activities are no longer possible due to the pain. It is not uncommon to experience weakness on certain movements, especially when trying to lift the arm up or perform activities over shoulder height.
Degenerate rotator cuff tears often occur on a background of niggling and discomfort that could have been present for months or years. Pain is often associated with certain movements but it may be that no movement has been lost. Weakness is often felt with tasks above shoulder height and strenuous activities such as gardening. Pain from both types of tears can disturb your sleep especially when lying on the affected side. Clicking and cracking may be a feature of a rotator cuff tear although pain free clicking can occur in normal shoulders.
How do you diagnose a rotator cuff tear?
Diagnosing a rotator cuff tear requires a careful questioning about any accidents or events that may have brought on your shoulder symptoms. The location and timing of the pain can give clues as to any underlying damage as well as any weakness you may have noticed. A thorough examination testing all the muscles and tendons will often raise suspicions of a cuff injury.
When a tear is suspected, an x-ray will be requested to look for any associated injuries or arthritis. More definitively, an Ultrasound scan or an MRI scan will assess the tendons and soft tissues for any tears and muscle wasting.
Will it heal on its own?
In short, the answer is No. In many cases though the tear will cause minimal symptoms and symptoms can improve with simple measures.
Does it have to be repaired?
Many rotator cuff tears are asymptomatic and cause no problems. As such it is perfectly reasonable to “keep an eye on these” and not intervene unless pain or weakness arise.
For acute rotator cuff tears in high demand individuals such as people involved in heavy manual jobs, overhead occupations (joiners, electricians etc), and sportsmen, it is worth considering surgical repair. In these cases a better healing rate is seen if the tears are repaired early and before they can extend and get bigger.
For more chronic and degenerate tears, rest, pain killers and physiotherapy can be very effective in managing symptoms. If however you have lost strength, you have had symptoms for 3-6 months or have a large tear then it is worth discussing those issues with regard to further treatment options.
What does rotator cuff repair surgery entail?
The surgery can be done entirely using the latest keyhole techniques. It does however require either general anaesthesia (going to sleep for the operation) or a nerve block (the shoulder and arm are temporarily made numb for several hours).
Three to four small incisions are required to introduce the camera and instruments into the shoulder. A complete examination of the entire shoulder is made prior to repairing the torn tendons. The tendons are fixed back to the bone using special anchors which are inserted inside the bone of the humerus. Any other abnormalities can be dealt with at the same time e.g. shaving away any spurs of bone or dealing with other damaged tendons.
The surgery takes approximately 60 minutes and the majority of patients will be able to leave hospital on the same day of the surgery. Several small stitches are inserted and these can be removed by the nurse at your local GP practice at around 10 days post surgery.
What are the complications?
Complications from this type of surgery include pain and stiffness (5%). These generally improve over the course of time. Re-tears of the tendon can occur particularly if the tendon is very worn. These are more likely to happen with advancing age and in those who smoke or have diabetes or in the case of massive retracted tears. Rare complications include infection, blood clots in the legs or lungs, nerve injuries and strokes.
What rehabilitation is necessary?
It takes a minimum of 3 months for the rotator cuff to heal back to the bone of the humerus. As such you would be immobilised in a sling for the first 6 weeks. Physiotherapy is absolutely essential during the rehab period to help minimise the chances of stiffness but it is important to undertake only the exercises prescribed to avoid doing any damage to the underlying repair. Overdoing things in the first 6 to 12 weeks post surgery is a common cause for re-tears.
A successful outcome is dependent not only on a good surgical repair but also on your diligence and compliance with the correct physiotherapy.