Article

Rotator Cuff Tear: Causes, Symptoms, Treatment, and Prevention
January 30, 201901,059

Rotator Cuff Anatomy

Your shoulder is made up of the humerus (upper arm bone), scapula (shoulder blade) and clavicle (collarbone). The ball of the upper arm bone sits in a socket (space) in the shoulder blade to form the shoulder joint. The shoulder bone is kept in place by the rotator cuff.2

The rotator cuff is made up of four muscles that cover the head of the upper arm bone and attach it to the shoulder blade.2

The four muscles of the rotator cuff are,2:

  1. The supraspinatus muscle, which is located on top of the ball of the shoulder bone. A supraspinatus tear commonly occurs in a rotator cuff tear.
  2. The infraspinatus muscle, which is located at the back of the ball of the shoulder bone.
  3. The teres minor muscle, which is found at the back of the ball of the shoulder bone.
  4. The subscapularis muscle, which runs across the front of the ball of the shoulder bone.

These muscles and their tendons provide strength and support to your shoulder when it moves.1,2

A lubricating sac, called a bursa, is located between the rotator cuff and acromion (a bony ridge on the shoulder blade) to allow free movement of the rotator cuff.2

 

Figure 1: The muscles of the rotator cuff. (iStockphoto/JFalcetti)

 

What is rotator cuff tear?

A rotator cuff tear is when one or more tendons that link the rotator cuff muscles to the bones of the shoulder. The muscle and tendon most commonly affected in a rotator cuff tear is the supraspinatus muscle and its tendon. However, the tendons of other muscles in the group can also be involved in a rotator cuff tear.2

 

Statistics related to rotator cuff tear13

According to a study published in the Journal of Orthopedics, the prevalence of rotator cuff tear is 22.1% for the whole population, but it increases with age. Asymptomatic tears are two times more common than symptomatic tears.

 

Types of torn rotator cuffs

  • Partial tear in rotator cuff: the tendons are ripped, but are not fully separated from the shoulder bones.1,2
  • Full thickness tear or rotator cuff complete tear: the tendons completely tear and separate the muscle from the shoulder bones.1,2

 

What are the causes of a rotator cuff tear?

A torn rotator cuff can occur due to a traumatic injury, which is the cause most common in young people. Older people often experience a rotator cuff tear due to gradual weakening and breakdown of their rotator cuff tendons.1-3

 

Injury

A rotator cuff tear can occur due to a rotator cuff injury from an accident or a sudden rigorous arm motion.1-3 A rotator cuff tear can occur when you fall down on your arm while it is extended or when you lift a heavy object with a jerk.1

Rotator cuff tears often occur at the same time as dislocated shoulders and broken collar bones.2

 

Weakening of the tendons

A rotator cuff tear can occur due to slow degeneration (damage) of the tendons that hold the rotator cuff in place.1-3

Damage to these tendons may be caused by2:

  • Repetitive actions that put stress on your shoulder.

Athletes who perform activities such as rowing, weight lifting and playing tennis are prone to rotator cuff tears. Workers whose jobs involve lifting of heavy objects are also at greater risk.

  • Decrease of blood supply to the rotator cuff linked with aging.

Lack of blood flow reduces the ability of the body to heal and strengthen tendons, which gradually damages them, leading to a rotator cuff tear.

  • Developing a bony overgrowth on the acromion.

The rotator cuff tendons may be damaged by this bony overgrowth if it rubs on them when you move your shoulder. This damage can eventually result in a rotator cuff tear.

Who is at risk of developing rotator cuff injury?

  • Individuals over the age of 402,5
  • People who have jobs where they have to lift thins over their heads, such as painters and carpenters2,5
  • Athletes who perform rigorous activities with their arms, such as tennis players and baseball players2,5
  • People with a family history of rotator cuff injuries5,11

 

Rotator Cuff Tear Symptoms

 The following are the symptoms of a rotator cuff tear:

  1. Pain

One of the first torn rotator cuff symptoms is rotator cuff pain. The pain can range from mild to severe.3 It may become worse when you lay on your injured shoulder or when you lift your arm.2,3

If your rotator cuff tear is due to a traumatic injury, rather than general wearing out of the tendon, the pain is likely to be intense. It is likely to be accompanied by a feeling of weakness when you move your arm.2

If your rotator cuff tear is due to a general wearing out of the tendon, the pain usually starts out mild and worsens over time. It is also associated with weakness in the arm. Eventually, the pain may become severe enough to make it difficult to do activities such as combing your hair, wearing a coat, lifting shopping bags, or reaching behind your back.2

  1. Crackling sounds

A common symptom of a fully torn rotator cuff is an odd snapping or crackling sound or sensation. This may occur when moving your arm or lifting heavy things.3

  1. Swelling

If you have a torn rotator cuff, your shoulder may swell due to inflammation in and around the damaged tendons.2,3

  1. Difficulty sleeping

You may find it difficult to fall asleep if you are laying on the side with the affected shoulder. You may also wake in the night if you roll over onto your damaged shoulder.2,3

 

When should you see your doctor?5

 If you have short-term pain in your shoulder, you should consult a doctor who can evaluate your symptoms to find out if you have rotator cuff tear. If you are diagnosed with a rotator cuff injury, your doctor will likely refer you to a specialist.

If you experience long-term shoulder pain, you should contact a specialist.

If you experience severe pain and sudden loss of motion in your shoulder after an injury, you should contact your doctor as soon as possible. This is because some of the treatment options, like rotator cuff surgery, are time sensitive.

 

 Rotator Cuff Tear Diagnosis

 Your doctor will record your medical history, perform a physical examination and do diagnostic tests to determine if you have a rotator cuff tear.2,6

 

Medical History 

To record your medical history, your doctor will simply discuss your symptoms with you and ask about any recent injuries to your shoulder.2,6

Your doctor may ask questions regarding6:

  • the type of pain you are experiencing
  • the location of the pain
  • the frequency of the pain
  • the duration of the pain

Your doctor may also ask about other symptoms such as6:

  • weakness in your arm
  • popping or cracking sounds in your shoulder
  • changes in your range of motion

 

Physical examination

 After recording your medical history, your doctor will usually perform a physical exam. She will check for tenderness or deformity in your shoulder. She will ask you to move your hand in different directions to check your range of motion. Finally, she will test the strength of your arm.2,6

Your doctor may also perform so-called “provocative tests” during your physical exam. Provocative tests are intended to trigger your symptoms and confirm your diagnosis. Some of the provocative tests your doctor may perform include6:

  • Apley scratch test
  • Neer’s test
  • drop arm test
  • Hawkin’s test
  • apprehension test
  • relocation test
  • Sulcus test

 

Diagnostic tests

 Following your physical exam, your doctor may order diagnostic tests to rule out any other shoulder problems (such as arthritis) and to confirm your diagnosis. These tests may include:

X-rays

 X-rays are often the first tests ordered. X-rays can detect abnormalities in your bones, such as bone spurs, that may have caused a rotator cuff tear.2

Diagnostic Ultrasound

 Ultrasound uses sound waves to produce images of structures in your body. Shoulder ultrasounds have been reported to be a reliable technique to diagnose a rotator cuff tear.

Shoulder ultrasound allows imaging of your shoulder while it is in motion. Additionally, it can be used to compare your healthy shoulder with the one that has a rotator cuff injury.2,5,7

Partial rotator cuff tears can be easily diagnosed with diagnostic ultrasound.5,7

When compared to magnetic resonance imaging (MRI), ultrasound is more cost-effective and easier to use.7

Magnetic Resonance Imaging (MRI)

 An MRI uses magnetic fields and radio wave energy to produce images of structures in your body. MRI scans can provide detailed images of the muscles, tendons and cartilage of your shoulder joint.14

You may also be given a dye (through an IV) that can detect inflammation in your shoulder.14

A rotator cuff tear MRI can determine the location of your tear, its size, and how old it is. This information can be used to decide whether you need surgery.2,5,7,12,13

An MRI is more accurate at diagnosing rotator cuff tears than x-rays or diagnostic ultrasounds.2,5,7,12,13

Torn rotator cuff Treatment

The main goal of treatment is to reduce pain and help you lead a normal life by restoring normal function of your arm.2

When deciding on a treatment plan, your doctor will consider various factors, including2,4:

  • your age
  • your general fitness level and health
  • the amount of shoulder-stressing activities you perform every day
  • the type of tear you are suffering from

Initially, your doctor may recommend non-surgical treatment and physical therapy. If you do not recover from your rotator cuff tear with non-surgical treatment, your doctor may suggest surgery.2

Non-surgical rotator cuff treatment

The majority of people recover with non-surgical rotator cuff treatment.2

The non-surgical treatments are the same for both partial and full rotator cuff tears. A partial rotator cuff tear can usually be completely repaired with non-surgical treatments.2,5

A full rotator cuff tear may require surgery if there is no response, or only partial response, to non-surgical treatments.2,5

Non-surgical treatments include:

  1. Rest

 Your doctor may ask you to rest while treating rotator cuff tear without surgery so that you put less stress on your shoulder. He may suggest wearing a sling to avoid straining your shoulder. He may also suggest avoiding certain activities, such as lifting your arms or working on anything above your head. You should avoid all activities that make your shoulder pain worse.2,12

  1. Non-steroidal anti-inflammatory drugs (NSAIDs)

In order to reduce the inflammation and swelling in your shoulder, your doctor may suggest that you take an NSAID, such as ibuprofen or naproxen. They may help to provide relief from the pain. This not only boosts your quality of life, but can also help you to perform the exercises necessary to strengthen your shoulder.2,4,11,12

  1. Rotator Cuff Tear Exercises

Your doctor may recommend that you visit a therapist who will teach you rotator cuff tear exercises designed to2:

  • improve your mobility
  • stretch your shoulders
  • strengthen your shoulders
  1. Steroid drugs

If rest, exercise, and NSAIDs do not give you sufficient pain relief, your doctor may suggest an anesthetic or a steroid drug, such as cortisone.2,5

Steroids can, however, weaken your tendons. They are prescribed with caution and only to people that cannot perform their daily activities due to their shoulder pain, even with NSAIDs and therapy.2,5

 

Rotator cuff tear surgery

Surgery is recommended in the following cases2:

  • If you still experience shoulder pain after receiving non-surgical treatment
  • If you need to perform a lot of overhead activities daily
  • If you are an athlete
  • If you have been suffering from symptoms for more than 6 months
  • If the tear is new and large
  • If you have lost a lot of function in your arm

There are various surgical techniques available for repairing a rotator cuff tear. Some of the surgeries can be done in an outpatient facility.2 Your doctor will suggest the surgical technique with the greatest benefits for you.2,5

The following are some of the surgeries available for a torn rotator cuff:

  1. Open tendon repair

 Open tendon repair was the first form of surgery used to repair rotator cuff tears. It is recommended if the tear is large.2

In an open tendon repair, the surgeon makes an incision in the shoulder and removes the shoulder (deltoid) muscles for better access to the tendons. She then repairs the tear. Today, doctors usually chose less invasive techniques to repair rotator cuff tears.2

  1. Arthroscopic tendon repair

 In this procedure your surgeon first inserts an arthroscope, which acts like a camera, in to your shoulder joint. The arthroscope is used to guide the surgical instruments that repair your tendon(s). 2

Unlike the open tendon repair surgery, your surgeon only has to make small holes. This is because both the arthroscope and surgical instruments are very thin and small. 2

This surgery is less invasive and can be performed as an outpatient procedure.2

  1. Mini-Open repair

 In this technique, your surgeon inserts an arthroscope to look at your tear. If she finds any bone spurs or debris, she removes them. Afterwards, she makes a mini open incision to actually repair the tendon.2

There is no need to remove the shoulder muscle in order to see the tendon in this procedure.2

  1. Tendon transfer

 If your injured tendon is too damaged to be repaired, your surgeon may decide to replace the it with a healthy tendon from somewhere else in your body. This tendon is removed from its normal location and attached to the bone and muscle that had been disconnected by your rotator cuff tear.5

  1. Shoulder replacement

In case of severe injuries where the rotator cuff has been damaged beyond repair, shoulder replacement is required.5

  1. Debridement for partial rotator cuff tears

This is a “smoothening” procedure done to help partial rotator cuff tears heal. During debridement, your surgeon smoothes frayed edges of your damaged tendon and removes any tendon fragments or other tissue debris from your shoulder joint.2

 

Recovery from rotator cuff surgery

 After surgery you will be given drugs to relieve your pain. Your doctor may prescribe drugs such as opioids, NSAIDs and/or local anesthetics for this purpose. Opioids are used with caution as they have a potential to be abused.2

You will likely be sent home with a sling to immobilize your arm. In most cases, the sling is worn for 4 to 6 weeks. If your surgery was not very invasive, you may be able to wear it for a shorter time.2

After this initial immobilization period, you will be sent to a physical therapist to begin working to restore your shoulder mobility and strength. You will start with passive exercises. These exercises are done with your therapist supporting your arm.2,10

Active exercises are started after passive exercises when your therapist believes your shoulder is ready. During active exercises, you move your arm without assistance from your therapist. This helps build strength more quickly.2

Typically, after around 8 to 12 weeks after surgery, you will begin weighted strengthening exercises to improve the strength and stability of your shoulder further.2,10

A complete recovery time for rotator cuff tear requiring surgery is usually 6 to 12 months.10

Depending on the invasiveness of your surgery and the nature of your job, however, you may be able to return to work much earlier, sometime between 1 and 8 weeks post-surgery.8

 

Exercises for rotator cuff tear

The exercises recommended to help treat a rotator cuff tear fall into three main categories. They are described below:

  1. Mobility exercises

These exercises improve the mobility of your arm. Mobility exercises should be started as soon as your pain improves. If pain develops with any of these exercises, it is better to avoid them. These exercises can be done up to three times a day.9

  1. Stretching exercises

Stretching exercises are done after you are comfortable with your mobility exercises. These exercises are performed to stretch your muscles, which often spasm and shorten while trying to stabilize your shoulder when you have a rotator cuff tear.9

  1. Strengthening exercises

These are exercises that are performed to strengthen the muscles of your shoulder. You can start with static strengthening exercises and then progress to dynamic exercises with dumbbells or resistance bands. Eventually, you may be able to do functional strengthening exercises with medicine balls.9

  1. Exercises to avoid

You should avoid all weight bearing and weight lifting exercises until your injury has healed and/or you have approval from your doctor or surgeon. If you have had surgery, this may take around 3 months.1,2

 

How to Prevent a Rotator Cuff Tear?

A rotator cuff tear can be prevented by1,2:

  • avoiding movements that stress or hurt your shoulders
  • avoid lifting heavy weights above your head
  • avoid repetitive shoulder movements
  • not smoking

 

Rotator Cuff Tear FAQs

  • Is a torn rotator cuff tear painful?

Yes, a rotator cuff tear is a painful condition. In fact, pain is often the first symptom of a torn rotator cuff.2

  • Can a partially torn rotator cuff heal?

Yes, a partially torn rotator cuff can completely heal using non-surgical treatment methods.2

  • Can a torn rotator cuff heal on its own?

In some people, a torn rotator cuff can heal on its own. But, if the condition persists, surgery is recommended.2

  • How much does rotator cuff surgery cost?

A recent study in Florida estimated that the average cost of rotator cuff surgery is around $40,000.15 The price may vary widely, however, depending on where you live and how complicated your surgery is.

  • Why is rotator cuff surgery so painful?

Recovery from rotator cuff surgery can be a long and painful process because it takes time for the repaired tendon to heal and attach back strongly to the shoulder bone.10

  • What is rotator cuff tear arthropathy?

This is a painful condition in which arthritis is associated with a rotator cuff injury.11

  • What is rotator cuff tendinitis?

In rotator cuff tendinitis there is inflammation in the muscles of the rotator cuff and the associated bursa.12

 

References

  1. jblack03. Repair of Rotator Cuff Tears. UW Orthopaedics and Sports Medicine, Seattle. http://www.orthop.washington.edu/?q=patient-care/articles/shoulder/repair-of-rotator-cuff-tears.html. Published July 9, 2012. Accessed August 2, 2017.
  2. Rotator Cuff Tears-OrthoInfo – AAOS. http://orthoinfo.aaos.org/topic.cfm?topic=a00064. Accessed August 2, 2017.
  3. pmhdev. Rotator Cuff Tears – National Library of Medicine. PubMed Health. https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0022451/. Accessed August 2, 2017.
  4. John M. Eisenberg Center for Clinical Decisions and Communications Science. Treatment Options for Rotator Cuff Tears: A Guide for Adults. In: Comparative Effectiveness Review Summary Guides for Consumers. AHRQ Comparative Effectiveness Reviews. Rockville (MD): Agency for Healthcare Research and Quality (US); 2005. http://www.ncbi.nlm.nih.gov/books/NBK51223/. Accessed August 2, 2017.
  5. Print MCS. Rotator cuff injury – Symptoms and causes. Mayo Clinic. http://www.mayoclinic.org/diseases-conditions/rotator-cuff-injury/symptoms-causes/dxc-20126923. Accessed August 2, 2017.
  6. Woodward TW, Best TM. The Painful Shoulder: Part I. Clinical Evaluation. Am Fam Physician. 2000;61(10):3079-3088. https://physiomulpk.wordpress.com/deep-tendon-reflex-testing/the-painful-shoulder-part-i-clinical-evaluation/.
  7. Singh JP. Shoulder ultrasound: What you need to know. Indian J Radiol Imaging. 2012;22(4):284-292. doi:10.4103/0971-3026.111481.
  8. Return to Work Guidelines Shoulder – Return to Work Guidelines Shoulder copy.pdf. http://orthodoc.aaos.org/drmoola/Return%20to%20Work%20Guidelines%20Shoulder%20copy.pdf. Accessed August 2, 2017. PDF.
  9. Rotator Cuff Exercises. http://www.sportsinjuryclinic.net/sport-injuries/shoulder-pain/rotator-cuff-exercises. Accessed August 2, 2017.
  10. Rotator Cuff Surgery Recovery- Howard Luks, MD. http://www.howardluksmd.com/education/common-injuries/recovery-from-rotator-cuff-surgery/. Accessed August 2, 2017.
  11. jblack03. Shoulder Arthritis and Rotator Cuff Tears. UW Orthopaedics and Sports Medicine, Seattle. http://www.orthop.washington.edu/?q=patient-care/articles/shoulder/shoulder-arthritis-and-rotator-cuff-tears.html. Published July 9, 2012. Accessed August 2, 2017.
  12. Rotator Cuff Injury & Tendonitis. Cleveland Clinic. https://my.clevelandclinic.org/health/articles/rotator-cuff-tendonitis. Accessed August 2, 2017.
  13. Minagawa H, Yamamoto N, Abe H, et al. Prevalence of symptomatic and asymptomatic rotator cuff tears in the general population: From mass-screening in one village. J Orthop. 2013 Mar; 10(1): 8-12. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3768248/.
  1. Mayo Clinic. MRI. Last Updated: August 19, 2016. https://www.mayoclinic.org/tests-procedures/mri/home/ovc-20235698. Accessed September 17, 2017.
  1. Iyengar, JJ, et al. Current trends in rotator cuff repair: surgical technique, setting and cost. 2013;30(3):284-288. DOI: 10.1016/j.arthro.2013.

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