A rotator cuff tear occurs when the muscles around the shoulder (rotator cuff) sustain a tear.
This may be the result of trauma or as a natural consequence of the ageing process. Although the tear itself won’t heal, in the majority of cases, the pain settles over time and the other parts of the rotator cuff are able to strengthen and compensate for the tear.
The rotator cuff refers to a group of tendons and muscles in the shoulder which attach the scapula (shoulder blade) to the humeral head (upper arm bone). When activated the rotator cuff muscles provide significant tension across the joint and thereby:
- Stabilise the humeral head (ball of the shoulder joint) in the centre of the glenoid (socket of the shoulder joint). This helps to prevent dislocation to the joint.
- Allows more powerful muscles around the shoulder to provide the tension needed to move the shoulder.
- Provide movement and control into rotational positions for the shoulder.
The rotator cuff is formed from four muscles and tendons that attach your arm to the top of your shoulder blade. Injury, inactivity and ageing can cause these tendons become compressed and tear, which can lead to severe pain and limit your shoulders range of motion. Rotator cuff repair surgery fixes the torn tendons.
Most commonly, there is shoulder pain and weakness. Commonly, individuals may suffer from referred pain radiating down the upper arm to the elbow. Weakness may result in an inability to lift the arm and affect activities of daily living such as dressing.
Pain on movements of the arm above the head, behind the back and across your body are the main aggravating activities. Lifting any significant weight with these movements will normally increase symptoms further.
If there is a significant rotator cuff tear then there may be significant weakness to shoulder movements resulting in an inability to move the shoulder in the direction of the affected muscle.
A rotator cuff tear can be diagnosed by your doctor or physiotherapist by taking a history of your condition and by conducting a physical examination.
The main features on examination are often pain and weakness when resisting rotational movements and movements of the arm away from the side.
An ultrasound scan may be required to assess the extent of any rotator cuff tear. This may guide future management including a possible surgical repair.
In the event of a rotator cuff tear being sustained through injury a period of watchful waiting may be appropriate to assess the degree of spontaneous recovery prior to deciding on any necessary intervention.
Exercises. A rotator cuff tear can be managed effectively by following a regular exercise routine to optimise strength and coordination of the affected shoulder joint:
5×30 second holds, 2x per day
3×10 repetitions, 3-4x per week
5×15 repetitions, 2x per day
Using painkillers when needed. Over-the-counter analgesia is available through pharmacies when needed. Paracetamol is most commonly prescribed. Anti-inflammatories, such as Ibuprofen, are also used, but as there is little or no inflammation involved in osteoarthritis these are best avoided without discussing with your GP. Side effects are even more common than with paracetamol so please ensure to take appropriate medical advice. There is a good booklet on the Arthritis Research UK website with information about the various drug options.
Corticosteroid injection therapy. These are best avoided in the presence of a rotator cuff tear but may be considered by your clinician in specific circumstances.
Surgical rotator cuff tendon repair is a highly invasive operation which normally requires 4-8 weeks’ immobilisation of the operated shoulder and extensive, prolonged rehabilitation following surgery. As such, many individuals may opt to manage the condition non-surgically even if there is some reduction in their ability to use the arm.
For patients who are willing to consider a surgical repair this decision is best discussed with your clinician as the effectiveness of this operation varies greatly according to individual characteristics:
- Patients age; Outcomes after rotator cuff repairs worsen with increasing age. Your clinician will discuss the implications of this at your consultation
- The exact location and size of the tendon tear (partial thickness tears will need to have trialled at least 3 months of non-surgical management before considering surgery
- Whether the tendon tear was traumatic (through an injury) or degenerative (age-related) in nature
Rotator cuff repair surgery fixes torn and damaged tendons in the shoulder to alleviate pain and improve power, strength and movement.
Rotator cuff repair surgery is suitable for people who have tears in the shoulder tendons as the result of the normal degenerative ageing processes with or without an additional injury and where the tendon tear is not so big or so longstanding that a repair operation is unlikely to help.
After rotator cuff repair surgery, you should have considerable less pain and your shoulder will function much better, although the amount of strength that is restored depends upon the quality of the muscles and tendons before surgery.
Rotator cuff repair surgery is carried out in hospital under general anaesthetic with local anaesthetic also used to numb the nerves in the whole of the arm. This technique is called a regional block and is similar to the idea of an epidural anaesthetic frequently used in childbirth.
This regional block not only means that a lighter general anaesthetic is required, reducing postoperative sickness and nausea, but also provides excellent pain relief afterwards. The operation usually takes around an hour and a half.
You will not be able to eat for eight hours prior to surgery although you will be able to drink small amounts of water up to four hours before. You would normally be admitted the evening before the operation and normal checks will be carried out.
A small incision will be made at the front of your shoulder, or arthroscopically through a number of small incisions around the shoulder. The first step is to remove the bone at the front of the shoulder (the acromion) and additionally to sometimes remove the very end of the collarbone if the joint between it and the acromion is part of the problem (the acromio-clavicular joint). This helps create a better view of the damaged tendons and means the tendons will no longer be under pressure once the repair is completed.
The damaged tendons are then freed and mobilised to allow them to be repositioned back on the edge of the shoulder joint where they have detached. The area of bone to which they need to be attached is then roughened to create an environment in which healing of tendon to bone can occur. Stitches are then inserted into the tendon and secured down through the bone through drill holes or using special little harpoons. The stitches are tightened to firmly hold the tendon against the bone and hold everything in the right place while natural healing occurs.
The incisions in the skin are closed with stitches that need removing after one or two weeks and waterproof dressings are applied.
Rotator cuff repair surgery requires a one night stay in hospital and your arm is placed into a special shoulder immobilising sling. Exercises and physiotherapy start on the day of surgery and your physiotherapist will teach you all you need to know for the first couple of weeks of recovery after discharge.
As a general guideline, your tendons take six weeks to start to securely heal to the bone and during this time they need to be protected from significant forces being passed through them. If your shoulder repair surgery is overloaded in the early stages, the stitches can pull out of the tendon and the repair can fail. Most people need to retain the sling for six weeks but some exercises during this time are essential to stop the whole arm becoming very stiff.
After six weeks, people wean themselves out of the sling and increased exercises and movements are encouraged. Most people can return to driving a car at around eight weeks and have regained good ordinary use of the shoulder by three to four months.
Physiotherapy and exercises continue for six to nine months. The long recovery period reflects not only time spent getting over the operation but also time spent getting muscles that have done little for a prolonged period of time to start working well again.
Activities such as running and swimming can generally start between two and three months. Golf can be resumed at four to five months but more vigorous activities such as racquet sports and sailing are rarely undertaken earlier than six months.
In addition to regular treatment with a physiotherapist, follow up is required with your surgeon. This is to monitor and guide progress and to look out for complications which are fortunately uncommon. The success rate of rotator cuff repair surgery very much depends on the initial size of the tear in the tendons and the quality of the tendons and muscles. A good assessment of this can be usually obtained preoperatively with a careful examination and the use of scans.