Rotator Cuff Tear: It is one of the nightmares for an athlete, especially for those involved in sports like baseball, football, tennis and volleyball. The rotator cuff tear in severe case often jeopardizes a player’s entire sporting profession.
The article answers following questions:
- What Exactly Is A Rotator Cuff Tear?
- What Are The Causes of Rotator Cuff Tear?
- Describe The Symptoms of Rotator Cuff Tear?
- What Are The Treatment Options For Rotator Cuff Tear?
What Is A Rotator Cuff Tear?
Common Cause Of Injury-
- It is one of the commonest causes of shoulder pain in athletes.
- Torn or ruptured rotator cuff results in weak shoulder joint.
- Individual is unable to perform activities like combing, brushing or getting dressed.
Anatomy of Shoulder Joint-
- To understand a Rotator Cuff Tear, one needs to understand the anatomy of the shoulder and the rotator cuff muscles.
- The shoulder is constituted of three bones, the humerus, the scapula, and the clavicle.
- The shoulder joint is a ball-and-socket joint in which the ball or the humerus fits into a shallow socket of the clavicle.
The Function of the Rotator Cuff-
- Function of rotator cuff tendon and muscle is to keep the ball of the humerus firmly gripped inside the socket or glenoid cavity of scapula.
- The rotator cuff muscle becomes tendon near the shoulder joint and covers the head of humerus and glenoid cavity. The cuff of the rotator cuff tendon prevents dislocation between head of humerus and glenoid cavity, which is shallow.
- The rotator cuff is made up of four muscles joined together by tendons. The muscles are as follows-
- Supraspinatus Muscle
- Infraspinatus Muscles
- Teres Minor
- Subscapularis Muscle
Bursae Between Rotator Cuff And Bones-
- There is also a fluid filled sac (bursa) between the rotator cuff muscles and the bone called the acromion, which allows free movement of the arm.
- Bursa prevents friction between tendon and solid bone. Friction could cause tear or laceration of the tendon or cuff.
- The tear or rupture of one of the four muscles or tendon is known as a Rotator Cuff Tear.
Types Of Rotator Cuff Tear
There Are Basically Two Types Of Rotator Cuff Tears:
- Partial Tear of the Rotator Cuff: This type of rupture usually damages soft tissues but does not completely tear it.
- Full Thickness Tear of the Rotator Cuff: it is also called as a complete tear. It basically tears the soft tissues into two parts.
Causes Of Rotator Cuff Tear
- Fall- This type of tear can occur if an individual suffers an injury to the shoulder as a result of fall on outstretched hands.
- Weight Lifting- It can also occur with repetitive heavy lifting while using shoulder joint.
- Shoulder Dislocation- This type of tear can occur with injuries like a fractured collarbone or shoulder dislocation.
Osteoarthritis and Degenerative Tears:
- Wear and Tear- Patient suffering with chronic disease like osteoarthritis of the shoulder joint often suffers with gradual wear and tear of rotator cuff muscles resulting in tear or inflammation of the rotator cuff.
- Elderly Patient- The lax rotator cuff secondary to degenerative changes in fibrous tissue often results in tear and dislocation of shoulder joint.1
- Sports Injury- Repetitive stress injury is observed in athletes who are involved in sports like tennis, baseball and football (quarterback).
- Work Injury- Even people who are employed in jobs, which require frequent lifting, pushing, and pulling may also be prone to degenerative tears of the rotator cuff.
Lack of Blood Supply:
- Ischemia- Atherosclerotic disease may compromise blood supply to rotator cuff muscles.
- Traumatic Ischemia- Sports or work injury may result in rupture of arteries and vein resulting in decreased blood supply to shoulder joint and rotator cuff. Ischemia causes weakness in tendon fibrous tissue; and tendon as well as rotator cuff is prone to injury resulting in tear or rupture.
- Spurs- Degenerative Bone overgrowth or spur formation is also a cause of degenerative tear of the rotator cuff and this usually develops on the underside of acromion.
- Shoulder Movement and Friction- Spurs are often sharp and cause friction injury of the tendon. Shoulder joint movement like lifting, flexion, extension, abduction and adduction causes continuous rubbing or friction between rotator cuff and bone spurs resulting in tear or rupture of the tendon.
Risk Factors Of Rotator Cuff Tears
- Age- Older patient are at high risk of injuring rotator cuff
- Smoker- Chronic smoker are at risk of rotator cuff inflammation, tear and delayed healing.2
- Degenerative Disease- Degenerative joint disease affects tendon and joint resulting in weakness of fibrous tissue of rotator cuff.
- Rheumatoid Arthritis- Inflammatory disease like rheumatoid arthritis cases inflammation of rotator cuff and also dislocation of shoulder joint, which often follows rotator cuff tear.
- Sports- Athletes are at risk of fall or direct impact of shoulder joint, which may result in shoulder joint injury as well as rotator cuff tear.
- Manual Work- Repetitive shoulder joint movement and use of heavy equipment causes rotator cuff tear.
Symptoms Of Rotator Cuff Tear
- Activities- Pain is intense with shoulder joint activity,
- Pressure on Diseased Shoulder- Pain is often severe in the morning because of lying on painful shoulder
- At Rest- Pain is less severe at rest
- Forceful Activities- Shoulder joint pain is severe while lifting heavy object and continues to be severe later for several hours.
Shoulder Joint Weakness
- Patient is unable to lift the shoulder because of pain and weakness
- Patient is unable to carry object, often light object.
Crackling Sound And Sensation
- Shoulder joint movement often causes crackling sound.
- Patient complaints of crackling sensation while moving the shoulder joint.
Shoulder Joint Swelling-
- Shoulder joint bruising and swelling is observed following fall or injury.
- Shoulder tear resulting from acute trauma or fall tend to cause excruciating pain in the shoulders.
Diagnosis of Rotator Cuff Tear
Patient complaining of shoulder joint pain is seen in either in ER or physician’s office. Physician will conduct a detailed history and physical examination. While examining the shoulder, the physician will look for tenderness or deformity. The physician may also ask the individual to move the arms in certain directions to assess the range of motion. The physician will also check the strength of the arm.
Apart From A Physical Examination, Radiological Studies Will Also Be Done To Include:
X-rays: This is the first radiological study that a physician would request. The X–ray is performed in ER or physician’s office. X-Ray is used to rule out fracture and dislocation. Soft tissue image like muscle or tendon tear or rupture is not observed to conclude diagnosis.
MRI Scan: An MRI scan is the diagnostic test. MRI will show the details of rotator cuff and tear. It also gives the extent of damage to the tendons.
Shoulder Joint Ultrasound- Ultrasound study shows hematoma (blood collection) and tear.
Treatment For Rotator Cuff Tear
The aim of the treatment is to decrease pain and regain lost function. A treatment plan will be designed by the treating physician based on the age, activity level, overall health of the individual, and the degree of tear. Basically, Rotator Cuff Tear can be treated both conservatively as well as surgically. The treating physician first tries the conservative approach for treatment of symptoms.
Conservative Treatments For Rotator Cuff Tear:
Nonsurgical Treatment Options For Rotator Cuff Tear
- Rest: It is imperative that the shoulder gets adequate rest from activities to allow the tendons to heal up. For this, a sling may also be prescribed to promote immobilization
- Activity Modifications: The physician may also recommend alteration of activities to promote speedy recovery.
- NSAIDs: Medications like ibuprofen may be given to decrease pain and swelling.
- Physical Therapy (PT): This is the most important aspect of treatment for Rotator Cuff Tear. The physical therapist will give exercises that will strengthen the shoulder and also restore lost range of motion.
- Steroid Injections: In case the symptoms are not relieved by the above mentioned modalities, then a steroid injection may be given for control of symptoms.3
Advantages of Nonsurgical Approach To Treat Rotator Cuff Tear
Some of the advantages of nonsurgical treatment are that it prevents inherent risks of surgery like
- Anesthetic complications
- Prolonged recovery phase
Disadvantages of Nonsurgical Approach To Treat Rotator Cuff Tear:
There are certain disadvantages of nonsurgical treatments for Rotator Cuff Tear and they include:
- Strength does not improve
- The tear may increase with time
- Activities may remain limited
Surgical Treatment For Rotator Cuff Tear:
If the symptoms of rotator cuff tear are not relieved by conservative approaches mentioned above then a surgical route is taken. Some of the indications for surgery to treat rotator cuff tear are:
- Presence of symptoms for about a year
- The tear is significantly large
- Extreme loss of function of the shoulders
There are various surgical approaches for repair of a Torn Rotator Cuff.
Some Of The Surgical Procedures To Treat Rotator Cuff Tears Are:
Open Repair: In this type of procedure an incision is made and then the shoulder muscles are detached in order to look at the torn tendon. The surgeon then removes any bone spurs if they are present. The surgeon then repairs the torn tendon.
Arthroscopic Repair 4: In arthroscopic repair, the surgeon will insert an instrument called arthroscope via a small incision in the shoulder. This arthroscope has a minature camera through which the surgeon will look at the shoulder for damaged tendon and repair them under direct visualization.
Reverse Shoulder Arthroplasty (RSA) 5- RSA were found to be giving superior results in patients with rotator cuff tear. Reverse Shoulder Arthroplasty or RSA surgery has also indicated improved joint function.
Recovery And Rehabilitation Phases Post-surgery For Rotator Cuff Tear
Rehabilitation postsurgery plays a vital role in the affected individual getting back to normal activities at the soonest possible time.
Immobilization: The rehabilitation starts with immobilization of the shoulder postsurgery to allow for the tendon and wounds to heal. The patient may be placed in a sling to prevent motion for about a month postsurgery.
Passive Exercise: This is started when the surgeon feels it is safe to move the shoulder to an extent. The physical therapist will be giving exercises to improve range of motion and strength of the shoulder. In passive exercises, the therapist will move the arm slowly in different directions.
Active Exercise: After introduction to passive exercises, the patient then progresses to active exercises. In this, the patient will be allowed to move the arm without the support of the therapist.
A complete recovery generally takes some months. Usually an individual gains adequate strength and range of motion within six months postprocedure.
Complications From Rotator Cuff Surgery
Some Of The Complications Of Rotator Cuff Surgery Are:
- Injury to the nerves
- Deltoid detachment
- Persistent stiffness
- Retear of the tendon
1. Instability and rotator cuff tear.
Porcellini G1, Caranzano F, Campi F, Paladini P.
Med Sport Sci. 2012;57:41-52.
2. The impact of preoperative smoking habit on rotator cuff tear: cigarette smoking influences rotator cuff tear sizes.
Carbone S1, Gumina S, Arceri V, Campagna V, Fagnani C, Postacchini F.
J Shoulder Elbow Surg. 2012 Jan;21(1):56-60. doi: 10.1016/j.jse.2011.01.039. Epub 2011 Apr 27.
3. Corticosteroids injection in rotator cuff tears in elderly patient: pain outcome prediction.
Gialanella B1, Bertolinelli M.
Geriatr Gerontol Int. 2013 Oct;13(4):993-1001.
4. Arthroscopic rotator cuff debridement without decompression for the treatment of tendinosis.
Budoff JE1, Rodin D, Ochiai D, Nirschl RP
Arthroscopy. 2005 Sep;21(9):1081-9.
5. Short and midterm results of reverse shoulder arthroplasty according to the preoperative etiology.
Wellmann M1, Struck M, Pastor MF, Gettmann A, Windhagen H, Smith T.
Arch Orthop Trauma Surg. 2013 Apr;133(4):463-71.