The rotator cuff is a group of four tendons and four muscles that work together and form a “cuff” over the upper end of the arm. The four muscles are the subscapularis, the supraspinatus, the infraspinatus and the teres minor. The muscles start on the shoulder blade (scapula) and are connected to the upper part of the arm bone (humerus) by the tendons that attach directly into the bone.
The rotator cuff helps a person raise and rotate the arm and stabilize the shoulder within the joint. A rotator cuff tear occurs most often when one or more of the tendons are torn. When this happens, a person usually suffers significant pain and weakness in the shoulder.
What causes the rotator cuff to become damaged?
Rotator cuff tears most often occur in adults over the age of 40 but also can happen in younger people. The injury can occur gradually or suddenly.
- Chronic or degenerative rotator cuff tear: A chronic rotator cuff tear is most common. In this case, the rotator cuff injury develops gradually in people who have a history of shoulder pain and shoulder tendonitis. Eventually the tendon is worn to the point that eventually it just gives way. This chronic injury likely occurs when someone performs repetitive overhead work (painting, stocking shelves, sheetrock workers) or when someone is an athlete who uses repetitive arm motions (swimmer, pitcher, tennis player). It also occurs as people age. The natural wear and tear breaks down the strength and flexibility of the tendons.
- Acute rotator cuff tear: An acute rotator cuff injury happens to those who have no history of shoulder pain. This may occur when a person tries to lift something that is too heavy, for example. When the tear occurs, the individual may experience immediate pain, a popping sound or snapping sensation and immediate arm weakness. This sudden rotator cuff tear also can occur in conjunction with another injury to the shoulder, such as a dislocation, a fall onto the shoulder or a fracture.
How is a rotator cuff tear treated?
Once a diagnosis has been made, an orthopedic surgeon recommends the best treatment option. There are both surgical and non-surgical options.
Not all rotator cuff tears need to be fixed with shoulder surgery as long as there is still reasonably good function and little pain. So possible therapies include:
- avoidance of activities that worsen pain (overhead activity, heavy lifting, repetitive motions).
- cold therapy.
- anti-inflammatory medication.
- steroid/cortisone injection.
- physical therapy to regain motion, which normally includes exercises to strengthen the non-injured muscles of rotator cuff to help compensate for the injured muscle.
Some patients have tears that leave them with limited movement, weakness, and pain. Surgery may be the best option.
The main goal of surgery is to re-attach the healthy tendon of the torn rotator cuff muscle to the location on the arm bone from which it was torn. If the tendon cannot reach this spot with the arm at the side of the body, the surgeon will release the tendon from the surrounding tissues. If the rotator cuff is repairable, a groove or trough is fashioned in the normal attachment site for the cuff. Sutures bring the edge of the tendon into the groove where it normally attaches.
If the tendon still doesn’t reach the attachment site or the tendon itself is in poor condition, the re-attachment may not be possible and the cuff tear is deemed irreparable. In this situation, the useless tendon is cut out and the shoulder is again examined to assure smooth and full motion. In some cases, a cadaver tissue graft (allograft) can be used to span the gap and repair the tendon.
Whichever the case, the objective is to relieve shoulder pain, improve strength and increase the function of the shoulder.
Some possible surgical techniques include the following:
- Debridement: A partial tear or a tear where there is not enough tendon or the tendon is in poor shape may only require a trimming or smoothing procedure called a debridement.
- Smooth and Move: Another surgical technique that may be used when the tear is not able to be corrected is the “smooth and move” technique. This is when the upper surface of the rotator cuff and the arm bone are smoothed by the removal of scar tissue, bony protrusions and irregular tendons. The surgery is followed by immediate post-operative motion to prevent the reformation of scar tissue.
- Acromioplasty: This procedure occurs when the surgeon makes an incision over the shoulder and detaches the deltoid muscle to gain access to the torn cuff. The surgeon then removes bone spurs from the underside of the top of the shoulder bone and attempts to reattach the tendon.
Depending upon the surgeon’s preference and the injury, the rotator cuff surgery may take one of three forms: open, mini-open or all arthroscopic.
- Open surgical repair is required if the tear is large or complex or if additional reconstruction such as tendon transfer has to be done. In some severe cases when there is substantial trauma or arthritic degeneration, a shoulder replacement is an option.
- Mini-open repair is possible using new techniques and instruments so that the incision for the surgery is considerably smaller than the incision of the open surgical repair.
- Arthroscopic repair makes use of a fiberoptic scope connected to a video camera and small, specialized instruments. In this surgery, the scope and instruments are inserted into small puncture-type incisions rather than through a larger open incision.
It is important to know that surgery can improve the mechanics of the shoulder but cannot make the joint as good as it was before the tear. In addition, complete recovery may take several months and include extensive physical therapy.