Condition
Rotator cuff tear
A rotator cuff tear is the detachment of one or more of the four cuff tendons from the humeral head. Causes weakness and pain in the shoulder, often worse at night, and is one of the most common reasons adults over 40 see a shoulder surgeon.
Anatomy
What the rotator cuff is and what it does
The shoulder is a ball-and-socket joint, but the ball (the humeral head) is relatively large compared to the socket (the glenoid). That gives the shoulder a large range of motion compared to other ball-and-socket joints in the body, like the hip.
Attached to the humeral head is a group of four tendons that rotate the humeral head on the glenoid and so move the arm. Together these four tendons are called the rotator cuff.
- Supraspinatus attaches to the top of the humeral head and elevates the arm. It is the most commonly torn cuff tendon.
- Subscapularis attaches to the front of the humeral head and internally rotates the shoulder.
- Infraspinatus attaches to the back of the humeral head and externally rotates the shoulder.
- Teres minor also attaches to the back of the humeral head and contributes to external rotation.
Pathology
What a rotator cuff tear looks like
A rotator cuff tear is the detachment of one or more of the cuff tendons from their insertion into the humeral head. Tears can be described by how much of the tendon is involved and by how many tendons are torn.
- Partial tear. Some of the tendon fibres are torn, but the tendon is not completely detached.
- Full-thickness tear. The entire thickness of the tendon is torn, leaving a hole in the cuff.
- Massive tear. More than one tendon is torn, usually with significant retraction of the tendon ends away from the bone.
When a tendon is completely torn, the tendon end retracts away from the bone insertion because the muscle attached to the other end of the tendon is still pulling on it. A massive, retracted tear that has been present for a long time may not be repairable, in which case other treatment options including reverse shoulder replacement are considered.
Symptoms
How a rotator cuff tear feels
Symptoms vary from patient to patient, but usually include weakness of the shoulder and pain. The pain is often felt during attempted elevation of the shoulder, while lifting, while driving, or with overhead activity.
Pain at night is very common. Patients often describe being unable to sleep on the affected side.
Weakness is more obvious with larger tears. A small partial tear may be more painful than weak; a massive tear may cause profound weakness with relatively less pain.
Causes
How rotator cuff tears happen
A tear can result from an injury such as a fall onto the shoulder or a heavy lift, but many tears develop slowly over time and patients cannot recall any specific event. The tendon weakens with age, and that weakened tendon is then more vulnerable to a tear with what would otherwise be a minor strain.
Rotator cuff tears are very common and usually occur in patients over the age of 40. Tears in patients younger than 40 are usually traumatic.
Diagnosis
How a rotator cuff tear is diagnosed
A clinical examination may suggest a rotator cuff tear, but the diagnosis is usually confirmed with imaging.
- X-rays are usually the first investigation. They do not show the tendon directly but rule out other causes of shoulder pain such as arthritis, fracture, or calcification.
- MRI scan is the most accurate way to image the rotator cuff. It shows the size of the tear, how far the tendon has retracted, the quality of the tendon and muscle, and any associated injuries.
- Ultrasound can also be used to diagnose a rotator cuff tear, but it is not as accurate as MRI and is not as useful for planning surgery.
Associated conditions
Other shoulder problems that often go with a cuff tear
Rotator cuff tears are commonly associated with other conditions of the shoulder. Treatment of the cuff tear usually addresses these at the same time.
- Damage to the long head of biceps. The biceps tendon enters the joint adjacent to the supraspinatus and is often damaged or inflamed with a cuff tear. It usually causes pain radiating down the front of the upper arm, into the biceps muscle.
- Subacromial impingement. Once the cuff is torn, the torn end and humeral head can rub on the undersurface of the acromion (the bone above the shoulder), causing pain, pinching or catching when elevating the arm.
- AC joint arthritis. Common in patients with a cuff tear though usually not directly related to the development of the tear itself. It causes pain on top of the shoulder.
Treatment
Treatment options for rotator cuff tears
The right treatment depends on the size of the tear, the retraction of the tendon, how long the tear has been present (chronicity), the patient's age, and the functional demand on the shoulder.
- Non-operative treatment. A period of rest, anti-inflammatories, and physiotherapy. Many small partial tears settle with conservative management.
- Injections. Corticosteroid or platelet-rich plasma injections may be used for pain control and to support a course of physiotherapy.
- Arthroscopic rotator cuff repair. Keyhole surgery to re-attach the torn tendon to the bone with suture anchors. Used for tears that are repairable and where non-operative treatment has not resolved symptoms.
- Reverse shoulder replacement. For massive, irreparable tears with cuff-tear arthropathy or pseudoparalysis. The reverse design restores overhead function without needing the cuff.
Recovery
Recovery from rotator cuff repair
Recovery from a rotator cuff repair depends on the size of the tear and the strength of the repair. A sling is usually worn for six weeks to protect the repair while the tendon heals back to the bone. Passive exercises start within the first week or two under physiotherapy guidance.
Active movement out of the sling progresses through weeks six to twelve, with strengthening introduced at around three months. Most patients can drive at six weeks once out of the sling and with safe two-handed control of the steering wheel, and return to office work within two to four weeks. Manual work is later, depending on the demands. Strength continues to improve for six to twelve months after surgery.
Complications and risks
Risks of rotator cuff repair
As with any surgery, there are risks. Dr Piper will discuss surgery risks with you during your consultation and answer any questions you may have. The general risks of arthroscopic rotator cuff repair include (but are not limited to):
- Re-tear of the repair. A repaired tendon is never as strong as a healthy tendon. Re-tear rates depend on the size of the original tear and the quality of the tendon and muscle. For larger tears, re-tear rates can be significant.
- Stiffness. A period of stiffness after sling removal is normal and improves with physiotherapy. A small number of patients develop significant stiffness that needs further treatment (frozen shoulder).
- Persistent pain. Some patients have ongoing pain after surgery, particularly if there are other associated shoulder problems.
- Infection. Very rare with arthroscopic shoulder surgery.
- Complex regional pain syndrome (CRPS). A rare condition that causes pain and stiffness in the hand.
- Anaesthetic complications. Discussed separately with the anaesthetist before surgery.
- DVT. Very rare with surgery of the upper limb.
FAQ
Frequently asked questions
- How is a rotator cuff tear diagnosed?
- A rotator cuff tear is diagnosed with a combination of clinical examination and imaging. Plain x-rays rule out other causes of pain. MRI is the most accurate way to image the tear and shows its size, the retraction of the tendon, the quality of the tendon and muscle, and any associated injuries. Ultrasound can also identify a tear but is less useful for surgical planning.
- Will a rotator cuff tear heal on its own?
- A torn rotator cuff tendon does not reattach to the bone on its own. Pain and symptoms can settle with non-operative treatment, particularly for partial tears, but the tear itself does not heal. Some patients live well with a torn cuff if the tear is small and the symptoms are manageable. Others, particularly those with full-thickness tears or weakness, benefit from surgical repair.
- How long is recovery after rotator cuff repair?
- A sling is worn for six weeks to protect the repair while the tendon heals back to the bone. Active movement out of the sling progresses through weeks six to twelve. Strengthening starts around three months. Most patients can drive at six weeks once out of the sling and with safe two-handed control of the steering wheel, and return to office work within two to four weeks. Strength continues to improve for six to twelve months.
- When should I see a shoulder surgeon for shoulder pain?
- If shoulder pain has not settled with two to four weeks of rest, anti-inflammatories, and physiotherapy, or if there is significant weakness, night pain that disrupts sleep, or pain after a fall or injury, it is worth seeing a shoulder surgeon. Earlier review is sensible for traumatic tears in younger patients, where earlier surgery improves the chance of tendon healing.
- Is rotator cuff repair covered by Medicare and private health funds?
- Most consultations attract a Medicare rebate when a current GP referral is provided. Surgery at Lakeview Private Hospital is usually covered by private health funds with appropriate hospital cover, though there may be out-of-pocket gaps that reception can quote in advance. Workers compensation and CTP claims are also accepted with insurer-approved details.
Concerned about a rotator cuff tear?
Book an appointment with Dr Piper
Consultations at Lakeview Private Hospital, Norwest. Bring a referral and any imaging you have.