A diagram and MRI scan showing a torn rotator cuff tendon
Rotator Cuff Tears
Rotator cuff tears are a group of injuries in which one or more of the tendons in the shoulder are torn or ruptured. Tendons are dense tissue that allows muscles to anchor to the bone. When a muscle contracts, it moves the joint by transferring the force of the contraction through the tendon to the bone. Tendons are similar in structure to ligaments, which connect two bones together to stabilize them. Patients with rotator cuff tears complain of pain and an inability to raise their arm. They commonly have a "shrug sign" (see photo below). Rotator cuff tears can involve part of the tendon (partial thickness tears) or the tendon can tear completely and separate from the bone (full thickness tears). Most surgeons also classify tears as degenerative or traumatic. Degenerative tears happen slowly over time as a result of degeneration of the tendon from chronic inflammation and impingement ( a condition in which the tendon is pinched by bony spurs) while traumatic ruptures are commonly the result of an injury such as a fall. Both are treated the same, but I personally think the outcome for different types of tears tends to be different. Traumatic tears tend to heal more quickly because in these cases the tendon itself was otherwise normal before the injury whereas degenerative tendon tears have pre-existing abnormalities in the tendon tissue prior to the tear.
Photo of a patient with a "shrug sign"
Treatment depends on how badly the tendon is damaged. If I suspect a tear of the tendon, then I recommend an MRI because it is the test of choice to assess the extent and nature of rotator cuff tears. There are two main types of rotator cuff tears and each has a different treatment and recovery. Partial thickness tears involving less than 50% of the tendon thickness can be treated with injections and physical therapy and will heal in 6-12 months. Initial treatment involves relieving the inflammation first and the proceeding with physical therapy to strengthen the damaged tendons. THe following link contains a number of rotator cuff strengthening exercises that can be done as a home exercise program.
Rotator cuff exercise protocol
Full thickness tears or large partial thickness tears generally require surgical repair to reattach the tendon to the bone. Recovery is prolonged and most patients have 80% recovery at 3-4 months and complete recovery at 6-8 months. Many times the tendon can be reattached arthroscopically without large incisions. I typically repair smaller tendon tears using a 'double row' arthroscopic technique. In larger or more retracted tears, I use a mini-open approach in which the tendon is repair through a 2-3" incision on the upper part of the shoulder. The link below is a report on the outcome of patients who underwent rotator cuff repair using a double row technique.
Outcomes with double row repair
In cases of massive tears or in tears where the torn portion of the rotator cuff is retracted significantly, I will use a cadaveric tissue patch called a graft jacket to reinforce and augment the repair. Rehabilitation in patients with massive rotator cuff tears is more prolonged and often takes 8-12 months to reach maximal improvement.
I recommend surgical repair in most patients with full thickness tears because arthritis and chronic shoulder problems tend to develop in patients with untreated tears. This condition is known as rotator cuff arthropathy and leads to a very difficult problem of arthritis in the setting of a large rotator cuff tear. In these cases, the only surgical option for reconstruction is a reverse shoulder arthroplasty, a very difficult type of surgery. Rotator cuff repair also dramatically decreases the overall pain and discomfort associated with the torn tendon. For these reasons, I think that most patients who can tolerate surgical repair should have their tendons repaired.
To view my post-operative rotator cuff instruction sheet click of the link below
Rotator Cuff Repair - Post op Instruction Sheet