What structure is called rotator cuff?
The rotator cuff is a group of muscles and tendons that surround the ball of the shoulder (humerus). Their main function is to enhance the rotation of the shoulder. The video below demonstrates those tendons and muscles. It is a video about the anatomy of the shoulder
A tear of the rotator cuff usually involves one of these muscles. The tendon of the supraspinatus as indicated in the picture below can have a tear as a result of trauma or as a result of wear and tear or otherwise called degenerative tear. A traumatic tear is usually related to one big trauma to the shoulder. A degenerative tear is seen after progressive loss of the thickness of the rotator cuff tendon. In 2008, close to 2 million people in the United States went to their doctors because of a rotator cuff problem.
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What happens to my arm when the tendon/rotator cuff has a tear?
When the tendon is torn completely then it does not contribute to the rotational motion of your shoulder the other tendon will have to take more load and compensate for the loss. This can be painful and can lead to loss of motion or strength to the shoulder. Sometimes the tendon of the supraspinatus is just thinner due to wear a tear. In this case the intact remaining fibers which are still attached to the bone receive significant load and become painful. Overtime some partial thickness tears (incomplete) will become complete.
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. The arthroscopy (view through a telescope) picture below demonstrates the detached tendon
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As mentioned previously there are two main ways tearing the tendon. Injury and degeneration
Injury
This happens as a result of a fall on an outstretched arm or when he lift something heavy and you feel a pop in your shoulder. Remember that a pop in the shoulder can be also associated with other injuries such as other ligaments and even broken bones.
Degenerative Tear
The most common form of tear is the one aging or wear and tear. As a result of aging the tendon gets thinner over time and slowly tears. Studies show that after the age of 50 if you have one shoulder with wear and tear of the rotator cuff then you have high chances of having a tear in the other one too-- even if you have no pain in that shoulder.
To better understand the difference between the two the example of torn blue jeans is shown below. If a nail catches your blue jeans then the tear will look like this picture below. This similar to the traumatic tear of the tendon
If you wear the blue jeans over a long period of time the tear will look like the picture below. This is a degenerative tear and is the most common form of tendon tear.
What causes the tendon to tear?
The following factors are related to a tear of the rotator cuff
- 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 was thought to be the primary cause of tear of the tendons. IT IS NOT COMMON AS we used to believe in the past because 90% of the tendon degenerative tears start on the undersurface of the tendon WHICH DOES NOT COME IN CONTACT with bone spurs.
Which patients have higher risks of tearing the rotator cuff?
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.
What kind of symptoms or problems will I have if I have a torn rotator cuff?
It is important to understand that some patients have rotator cuff tears that we see on an MRI test and have no pain. Be aware that after the age of 60-70 the majority of patients will have a tear of the rotator visible on MRI but that tear of the cuff DOES NOT CAUSE pain. There is no clear explanation to this phenomenon. The theory is that these patients can compensate with the other tendons of their shoulder.
If the MRI shows a rotator cuff tear and you have symptoms to your shoulder your doctor can tell you if that torn tendon is the source of pain.
Those patients who cannot compensate for the torn tendon will experience all or some of the following symptoms:
- 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.
Over time, the pain may become more noticeable at rest, and no longer goes away with medications. You may have pain when you lie on the painful side at night. The pain and weakness in the shoulder may make routine activities such as combing your hair or reaching behind your back more difficult.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.
Your doctor will ask you questions about the duration of shoulder pain, if you have any neck problems, any numbness or tingling to your arms, weakness and how severe your pain is. He will ask about injuries and then examine the shoulder in several different positions. He will test the strength of your arm and may give you a numbing medication with an injection to see if the shoulder pain originates in the shoulder. The doctor will make decisions about your overall problem taking into consideration your age, activity level, smoking status, sport that you participate, other medical problem, presence of diabetes or medications that you already take. He will make also decisions based on the type of tear that you have as described above.
What tests will he order?
- X-rays. He will ask for an Xray to see if you have arthritis and any signs of severe loss of the tendons that can lead to movement of the ball upwards in relation to the socket.
- Magnetic resonance imaging (MRI) or ultrasound. This is an expensive test that will show the tendons and their condition. If you symptoms are recent and the onset was in the not too distant past he may try to treat you first with conservative treatment before ordering an MRI. He will do that if you have no loss of motion or strength to your arm.
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 doctor. 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.
There is no evidence of better results from surgery performed near the time of injury versus later on. For this reason, many doctors first recommend nonsurgical management of rotator cuff tears.
Nonsurgical Treatment
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.
A cortisone injection may relieve painful symptoms and also helps with the diagnosis. If the pain does not get any better then further examination is needed as to what the source of the pain may be.
- Infection
- Permanent stiffness
- Anesthesia complications
- Sometimes lengthy recovery time
- No improvements in strength
- Size of tear may increase over time
- Activities may need to be limited
Surgical Treatment
Your doctor 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
Examples of cases that were treated with surgery can be found by clicking here.
