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Treatment Arthroscopic Rotator Cuff Repair video Recovery Rotator Cuff and Shoulder Rehabilitation Exercises handoutIn many areas, nonessential orthopaedic procedures that were postponed due to COVID-19 have resumed. For information:Questions and Answers for Patients Regarding Elective Surgery and COVID-19. For patients whose procedures have not yet been rescheduled:What to Do If Your Orthopaedic Surgery Is Postponed.
A rotator cuff tear is a common cause of shoulder pain and disability among adults. Each year, almost 2 million people in the United States visit their doctors because of rotator cuff tears.
A torn rotator cuff may 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: the upper arm bone (humerus), the shoulder blade (scapula), and the collarbone (clavicle). The shoulder is a ball-and-socket joint: The ball, or head, of the upper arm bone fits into a shallow socket in the shoulder blade.
This illustration of the shoulder highlights the major components of the joint.
Your arm is kept in your shoulder socket by the 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 the 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 becomes partially or completely detached from 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 does not completely detach the tendon from the bone. It is called partial because the tear goes only partially through the thickness of the tendon. The tendon is still attached to the bone, but it is thinned.
- Full-thickness tear.With this type of tear, there is detachment of part of the tendon from the bone.
- When only a small part of the tendon is detached from the bone, it is referred to as a full-thickness incomplete tear.
- When a tendon is completely detached from the bone, it is referred to as a full-thickness complete tear.With a full-thickness complete 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 supraspinatus tendon.
Cause
There are two main causes of rotator cuff tears: injury and wear (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 injuries, such as a broken collarbone, a dislocated shoulder, or a wrist fracture.
Degenerative (Wear-Related) 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 and in most cases is relatively painless.
Rotator cuff tears are more common in the dominant arm — the arm you prefer to use for most tasks. 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 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.
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.
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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 a crackling sensation, when moving your shoulder in certain positions
Tears that happen suddenly, such as from a fall, usually cause intense pain. There may be a snapping sensation and immediate weakness in your upper arm.
Tears that develop slowly due to overuse may also cause pain and arm weakness. You may have pain in the shoulder when you lift your arm, or pain that moves down your arm.
- At first, the pain may be mild and present only when lifting your arm over your head, such as reaching into a cupboard. Over-the-counter medication, such as aspirin, ibuprofen, or naproxen, may relieve the pain.
- Over time, the pain may become more noticeable at rest and no longer goes away with medications. You may have pain when you lie on the painful side at night. The pain and weakness in the shoulder may make routine activities, such as combing your hair or reaching behind your back, more difficult.
It should be noted that some rotator cuff tears are not painful. These tears, however, may still result in arm weakness and other symptoms.
Doctor Examination
Medical History and Physical Examination
After discussing your symptoms and medical history, your doctor will examine your shoulder.
- They will check to see whether it is tender in any area or whether there is a deformity.
- They will have you move your arm in several different directions to measure the range of motion of your shoulder.
- They will test your arm strength.
Your doctor will test your range of motion by having you move your arm in different directions.
Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.
- They will check for other problems with your shoulder joint.
- They may also examine your neck to makesure that the pain is not coming from a pinched nerve, and to rule out other conditions, such as arthritis.
Imaging Tests
Other tests which may help your doctor confirm your diagnosis include:
- X-rays.The first imaging tests performed are usually X-rays. Because X-rays do not show the soft tissues of your shoulder like the rotator cuff, plain X-rays of a shoulder with rotator cuff pain are usually normal and may show a small bone spur, which is a normal finding. The reason X-rays are done is to make sure you don't have other reasons for your shoulder pain, such as arthritis.
- Magnetic resonance imaging (MRI) or ultrasound.An MRI can better show soft tissues, like the rotator cuff tendons, than an X-ray. It can show the rotator cuff tear, as well as where the tear is located within the tendon and the size of the tear. An MRI can also give your doctor a better idea of how old or new a tear is because it can show the quality of the rotator cuff muscles.
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If you have a rotator cuff tear and 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 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
- Your activity level
- Your general health
- 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 to 85% of patients, nonsurgical treatment relieves pain and improves function in the shoulder.
Nonsurgical treatment options may include:
- Rest.Your doctor may suggest rest and limiting overhead activities.
- Activity modification.Avoid any activities that cause shoulder pain.
- Nonsteroidal anti-inflammatory drugs (NSAIDs).Anti-inflammatory drugs like ibuprofen, aspirin, and naproxen can 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 combined with cortisone may be helpful. Cortisone is a very effective anti-inflammatory medicine; however, it is not effective for all patients. And if it is effective for you, there is no way to know how long the effects will last; it may be weeks, months, years, or possibly the rest of your life. On average, injections can be expected to provide pain relief in about two-thirds of patients for a period of at least 3 months.
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:
- The size of the tear may increase over time.
- You may need to limit activities.
Surgical Treatment
Your doctor may recommend surgery if your pain does not improve with nonsurgical methods. Continued pain is the main indication for surgery. However, your doctor may also suggest surgery if you are very active and/or use your arms for overhead work or sports.
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.
Continue to next page:Rotator Cuff Tears: Surgical Treatment Options
To assist doctors in the management of rotator cuff tears, the American Academy of Orthopaedic Surgeons has conducted research to provide some useful guidelines. These are recommendations only and may not apply to every case. For more information: Rotator Cuff Injuries - Clinical Practice Guideline (CPG) | American Academy of Orthopaedic Surgeons (aaos.org)
Information on this topic is also available as an OrthoInfo Basics PDF Handout.
For more information:
Basics Handouts
FAQs
What are 2 warning signs of a rotator cuff tear? ›
- Be described as a dull ache deep in the shoulder.
- Disturb sleep.
- Make it difficult to comb your hair or reach behind your back.
- Be accompanied by arm weakness.
Diagnostic imaging is considered to be the gold standard for rotator cuff injuries, particularly MRI, but it has also proven to be highly expensive. The incidence and prevalence of rotator cuff tears increase with age.
What is the best treatment for a torn rotator cuff? ›Conservative treatments — such as rest, ice and physical therapy — sometimes are all that's needed to recover from a rotator cuff injury. If your injury is severe, you might need surgery.
What is the difference between a Type 1 and Type 2 rotator cuff tear? ›Grade 0 represents a normal rotator cuff, grade 1 is superficial fraying less than 1 cm in size, grade 2 involves fraying 1 to 2 cm in size, grade 3 is tissue disruption in 2 to 3 cm of tendon, and grade 4 is a substantial cuff tear that involves a sizable flap and more than one tendon.
What exercises aggravate rotator cuff? ›- Deadlifts. “These heavy weights are basically pulling your arm out of your socket,” says Kinsey. ...
- Shrugs. Another example of weight pulling down on your shoulder.
- Squatting. Resting the bar across your shoulders and your arm positioning stresses the rotator cuff.
MRI scans are most commonly used to diagnose partial rotator cuff tears. However, just because an MRI scan shows a tear doesn't mean it is the cause of your shoulder pain. The most common condition that mimics a rotator cuff tear is shoulder stiffness or a frozen shoulder.
Does a 5mm rotator cuff tear require surgery? ›Most patients with a partial thickness rotator cuff tear can be treated without surgery. During this time, non-invasive treatments, most importantly physical therapy, can allow shoulder function to return to normal.
What is the most sensitive test for rotator cuff tear? ›The first special test I perform to diagnose a rotator cuff tear is the shoulder shrug sign. During this test, the key to check if they can actively elevate their arm if you help them past their shrug arc.
Is 70 too old for rotator cuff surgery? ›In conclusion, arthroscopic rotator cuff repair in patients over 70 years of age showed good clinical results and high satisfaction rate and can thus be considered a valid option of treatment after failure of conservative approach.
Can you fix a rotator cuff tear without surgery? ›Rotator cuff tears do not heal on their own without surgery, but many patients can improve functionally and decrease pain with nonsurgical treatment by strengthening their shoulder muscles. Just because there is a tear, does not necessarily mean a surgery is needed.
How long can you go with a torn rotator cuff without surgery? ›
You may be able to stop or reverse early rotator cuff damage without surgery. Try using rest, ice and heat, anti-inflammatory medicines, and physiotherapy. If you have symptoms that don't get better after 3 to 6 months, you may need surgery.
What is an alternative to rotator cuff surgery? ›“Shoulder pain in the context of rotator cuff disorders is a frequent source of medical consultation. A wide range of therapeutic options is reported in the literature. Non- or minimally invasive treatments include physiotherapy, anti-inflammatory medication, and infiltration of corticosteroids or platelet-rich plasma.
What size rotator cuff tear requires 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 tendon tissue is good. You have significant weakness and loss of function in your shoulder.
Do most rotator cuff tears require surgery? ›Most rotator cuff tears don't require surgery to heal. This is because most people with rotor cuff tears don't have any problem with their shoulders. Even if the torn rotator cuff causes shoulder pain, you can get relief without surgical treatment.
Can you leave a rotator cuff tear untreated? ›If left untreated, a rotator cuff tear can severely restrict function and range of motion. The tear can also increase over time. This may cause partial rotator cuff tears to progress to total tears.
What not to do with torn rotator cuff? ›During the recovery phase of a rotator cuff injury, avoiding overhead lifts with any weight is highly recommended. Movements that require the shoulders to be put under intense pressure or performing complex motions will put more strain on the muscles and potentially cause more significant injury.
Should I exercise my rotator cuff if it hurts? ›You may experience some mild soreness with muscle-toning exercises — ice applied to the shoulder should help relieve it — but if you develop sharp or severe pain, stop the exercises for a few days. Sit or stand holding a 5- to 10-pound weight in the hand of the affected shoulder.
Is it OK to exercise with a torn rotator cuff? ›Bodyweight exercises such as a push up can also be performed if you have rotator cuff related pain. It is a great exercise that can challenge the rotator cuff muscles, shoulders, chest, and triceps.
Can you walk around with a torn rotator cuff? ›Over time, the tissue can split, resulting in a partially or fully torn rotator cuff. Less than half of patients with full rotator cuff tears report pain, and some may walk around with a torn rotator cuff for 20 years or longer without issues. Then, one day, they wake up with disruptive pain, day and night.
Should I wear a sling for rotator cuff injury? ›Rotator cuff repair can reduce pain and improve shoulder function, although there is a risk of repeat tears or incomplete healing. Patients are often advised to wear an immobilizing sling or brace for the first few weeks after rotator cuff surgery.
Is 75 too old for rotator cuff surgery? ›
However, older patients (aged 75 years or older) with repairable, full-thickness rotator cuff tears can experience a significant clinical benefit from arthroscopic rotator cuff repair, according to midterm data from a study performed at the Rothman Orthopaedic Institute that was presented by Michael Stone, MD, of the ...
Will a cortisone shot help a torn rotator cuff? ›Injections around the rotator cuff are helpful in providing relief, restoring function, and facilitating rehabilitation. However, partial and complete rotator cuff tears will not heal with cortisone injections and can make them worse. In fact, injections may compromise healing after surgery.
Can a full thickness rotator cuff tear heal on its own? ›In most rotator cuff tears, the muscle partially or fully tears away from the bone. Rotator cuff tears won't heal on their own. You'll need rotator cuff repair to restore your shoulder joint. A shoulder surgeon is the perfect physician to see for rotator cuff injuries.
Can you diagnose a torn rotator cuff without an MRI? ›Yes. In most cases, a skilled shoulder physiotherapist or doctor will diagnose a rotator cuff tear without an MRI.
Can a rotator cuff tear not show up on an MRI? ›[Dr. Lewis] While both MRI and ultrasound can reliably diagnose rotator cuff tears, no test is perfect, so there are some cases of "false negatives" (reported normal when actually there is a missed tear), and even "false positives" (called a tear when the tendon is in fact not torn).
Is rotator cuff surgery minor or major? ›The rehabilitation, however, may be quicker if the procedure is done arthroscopically. An arthroscopic Rotator Cuff repair is a fairly major operation which has a six month rehabilitation period. The results are generally very good but even an excellent result does not give you a normal shoulder.
At what age should you not have rotator cuff surgery? ›Those aged ≥ 65 years have a larger tear size, which is associated with greater tendon degeneration and potentially increased repair difficulty. Elderly patients frequently have comorbidities that may weaken the healing response and complicate surgical management.
What is the average age of rotator cuff tears? ›Rotator cuff tendon tears are very common and are found in around 15–20% of 60-year-olds, 26–30% of 70-year-olds, and 36–50% of 80-year-olds (Tempelhof et al.
What happens if a rotator cuff tear Cannot be repaired? ›An untreated rotator cuff tear can eventually cause weakness and disability of the shoulder. That is why it is so important to seek the expertise of an experienced orthopedic doctor for your shoulder pain.
What happens if you leave a rotator cuff tear untreated? ›If left untreated, a rotator cuff tear can severely restrict function and range of motion. The tear can also increase over time. This may cause partial rotator cuff tears to progress to total tears.
Can a rotator cuff tear heal with physical therapy? ›
While physical therapy itself cannot heal a torn rotator cuff tendon, it does strengthen the shoulder muscles and restoring shoulder mechanics. By strengthening all the surrounding muscles, therapy can help compensate for the damaged tendons and improve the mechanics of the shoulder joint.