Rotator Cuff Tear
What is the rotator cuff?
The rotator cuff is made up of four (4) muscles and their tendons. These muscles originate on the shoulder blade (scapula) and extend out to form a cuff around the shoulder joint and insert on the ball of the upper arm. (humerus). These four muscles are called the supraspinatus, subscapularis, infraspinatus, and teres minor.
These four muscles help to elevate and rotate the arm. In addition, these muscles help to stabilize the ball of the shoulder joint (humeral head) in the shallow socket of the shoulder blade (glenoid). The rotator cuff works especially hard to stabilize the shoulder when the arm is in the overhead position.
What are the causes of rotator cuff tears?
A rotator cuff tear is a common cause of pain and disability among adults age 50 and older, and in people who play sports or work with their hands overhead. Degenerative tears usually occur with repetitive use, where the rotator cuff weakens and begins to fray. In a tendon that is already weak, a small amount of pressure or trauma, like a pulling injury, can lead to a full tendon tear. Occasionally, there is an acute traumatic even that causes the rotator cuff to tear, such as an accident or fall.
Tears are typically classified as partial thickness or full thickness. A partial-thickness tear means the tendon is still attached to the humerus, but some fibers have torn. A full-thickness tear means the tendon has been completely torn off the humeral head.
Symptoms
Injuries to the rotator cuff most typically cause pain, especially with overhead activities. In addition, rotator cuff injuries or tears cause shoulder pain at night and lead to difficulty sleeping. With large rotator cuff tears, people notice weakness, especially in doing overhead activities. Difficulty with activities of daily living, such as dressing, bathing, and reaching outward, is also a common complaint.
Diagnosis
Diagnosis of a rotator cuff tear is base on the physical exam, x-rays, and an MRI.
Although we cannot see a tear on x-ray, a set of x-rays is usually ordered to evaluate the bones around the shoulder. The bone above the rotator cuff, called the acromion, can be have a bone spur, which leads to pinching and irritation of the rotator cuff. The x-rays are also used to evaluate for arthritis of the shoulder joint and acromio-clavicular joint (AC joint). A MRI may be ordered if a rotator cuff tear is suspected, or if a patient is not improving with conservative treatment.
Treatment
Nonsurgical
Many patients with a rotator cuff injury improve with conservative treatment. The treatment includes exercises, use of anti-inflammatory medications (NSAIDs), and possibly an injection of steroid. The rehabilitation may include a program you can do at home or formal physical therapy. A steroid injection is commonly used in patients who do not get better with therapy, or in severe cases. Many patients get better with these treatments and do not require surgery.
If patients do not get better with conservative therapy, or have a large tear or acute rotator cuff tear, surgery may be necessary.
Surgical
Rotator cuff tears are usually repaired with arthroscopic techniques. The arthroscope is a fiber optic instrument (narrower than a pen) which is put into the joint through small incisions. A camera is attached to the arthroscope and the image is viewed on a TV monitor. This allows for full evaluation of the entire shoulder joint, including the ligaments, the rotator cuff, and cartilage surface.
Once any degenerative tissue and bone spurs are removed, the torn rotator cuff tendon can be reattached to the bone. The bone is prepared for the tendon to be re- attached, and then plastic screws (suture anchors) are placed in the bone which contain sutures. These sutures are then weaved through the tendon, and the tendon is sewn back to bone.
On rare occasions, if the tear is severe or longstanding, the surgery needs to be performed with an open incision. This incision is placed in the area of the rotator cuff on the side of the shoulder, and the repair is performed in the same way that is described above. This is called a “mini-open” rotator cuff repair.
