Ching-Yueh Lin
A rotator cuff tear is a common cause of pain and disability among adults. In 2013, almost 2 million people in the United States went to their doctors because of a rotator cuff problem.
A torn rotator cuff will weaken your shoulder. This means that many daily activities, like combing your hair or getting dressed, may become painful and difficult to do.
Anatomy
Your shoulder is made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle). The shoulder is a ball-and-socket joint: the ball, or head, of your upper arm bone fits into a shallow socket in your shoulder blade.
This illustration of the shoulder highlights the major components of the joint.
Your arm is kept in your shoulder socket by your rotator cuff. The rotator cuff is a group of four muscles that come together as tendons to form a covering around the head of the humerus. The rotator cuff attaches the humerus to the shoulder blade and helps to lift and rotate your arm.
The rotator cuff tendons cover the head of the humerus (upper arm bone), helping you to raise and rotate your arm.
There is a lubricating sac called a bursa between the rotator cuff and the bone on top of your shoulder (acromion). The bursa allows the rotator cuff tendons to glide freely when you move your arm. When the rotator cuff tendons are injured or damaged, this bursa can also become inflamed and painful.
Description
When one or more of the rotator cuff tendons is torn, the tendon no longer fully attaches to the head of the humerus.
In most rotator cuff tears, the tendon is torn away from the bone.
Most tears occur in the supraspinatus tendon, but other parts of the rotator cuff may also be involved.
In many cases, torn tendons begin by fraying. As the damage progresses, the tendon can completely tear, sometimes with lifting a heavy object.
There are different types of tears.
- Partial tear.This type of tear is also called an incomplete tear. It damages the tendon, but does not completely sever it.
- Full-thickness tear. This type of tear is also called a complete tear. It separates all of the tendon from the bone. With a full-thickness tear, there is basically a hole in the tendon.
(Left) Overhead view of the four tendons that form the rotator cuff. (Right) A full-thickness tear in the supraspinatus tendon.
(Left) The front view of a normal rotator cuff. (Right) A full-thickness tear in the upraspinatus tendon.
Cause
There are two main causes of rotator cuff tears: injury and degeneration.
Acute Tear
If you fall down on your outstretched arm or lift something too heavy with a jerking motion, you can tear your rotator cuff. This type of tear can occur with other shoulder injuries, such as a broken collarbone or dislocated shoulder.
Degenerative Tear
Most tears are the result of a wearing down of the tendon that occurs slowly over time. This degeneration naturally occurs as we age. Rotator cuff tears are more common in the dominant arm. If you have a degenerative tear in one shoulder, there is a greater likelihood of a rotator cuff tear in the opposite shoulder — even if you have no pain in that shoulder.
Several factors contribute to degenerative, or chronic, rotator cuff tears.
- 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 is called shoulder impingement, and over time will weaken the tendon and make it more likely to tear.
Risk Factors
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.
Symptoms
The most common symptoms of a rotator cuff tear include:
- 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
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Treatment
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. In planning your treatment, your doctor will consider your age, activity level, general health, and the type of tear you have.
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 management of rotator cuff tears with physical therapy and other nonsurgical treatments.
Nonsurgical Treatment
In about 80% of patients, nonsurgical treatment relieves pain and improves function in the shoulder.
Nonsurgical treatment options may include:
- Your doctor may suggest rest 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.
- Nonsteroidal 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; however, it is not effective for all patients.
A cortisone injection may relieve painful symptoms.
The chief advantage of nonsurgical treatment is that it avoids the major risks of surgery, such as:
- Infection
- Permanent stiffness
- Anesthesia complications
- Sometimes lengthy recovery time
The disadvantages of nonsurgical treatment are:
- 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) and the quality of the surrounding tissue is good
- You have significant weakness and loss of function in your shoulder
- Your tear was caused by a recent, acute injury
Surgery to repair a torn rotator cuff most often involves re-attaching the tendon to the head of humerus (upper arm bone). There are a few options for repairing rotator cuff tears. Your orthopaedic surgeon will discuss with you the best procedure to meet your individual health needs.