What is a rotator cuff tear?
The 'rotator cuff' is a collective term for the four tendons in your shoulder that control the movement and help with the stability of the shoulder joint.
Tendons are connections between muscle and bone which allow the muscle to move a joint when it contracts. The blood supply to the shoulder tendons is not particularly good so, over time, the tendons generally become a bit weaker and frayed and can eventually tear.
The tendon most commonly affected is the one in the top of your shoulder known as the 'supraspinatus' tendon and it pulls away from its bony attachment.
What causes a rotator cuff tear?
Tears can be 'acute', 'chronic' or a combination of both. An acute tear of the rotator cuff usually happens after an injury such as a fall when the shoulder is wrenched or suffers a direct blow.
Acute tears are usually very painful and you will notice an immediate loss of function in your shoulder that varies depending on the size of the tear.
A chronic tear happens as a result of the gradual weakening of the tendon described above and typically affects older patients. The loss of function can be quite subtle as the rest of the rotator cuff tends to compensate for the torn part.
How is a rotator cuff tear diagnosed?
The first step is to make the correct diagnosis. Rotator cuff tears can be confused with impingement, frozen shoulder, labral lesions and acromioclavicular joint pain. The diagnosis is made by taking a careful history, particularly around the onset of the symptoms and the sorts of activities which cause the pain.
A thorough examination is very important assessing the range of movement of the joint, strength of the individual tendons and the manoeuvres which cause pain. The strength of the torn tendon is usually reduced but small tears can be difficult to detect.
An x-ray is helpful to exclude conditions such as underlying arthritis and to see if the head of the humerus has ridden up which you see in a chronic large tear.
Our preferred diagnostic investigation is ultrasound. We have a superb group of specialist radiologists at the Montefiore with a state of the art ultrasound machine who can pick up small or even partial thickness (incomplete) tears. Occasionally an MRI scan is required if you have a large tear to assess the state of the muscles.
What are the treatment options?
Treatment will depend on your degree of pain, loss of function, activity level, how your tear occurred and its size. If you are active and have a relatively acute tear that is causing you pain and difficulty with activities such as dressing or lifting your arm then it is probably best to repair the tendon.
If, on the other hand, your tear is more chronic, is not causing you too much pain and you are managing the activities you wish to, then the tear can be treated 'conservatively' with physiotherapy and occasionally a steroid injection.
Sometimes the tear is so large and chronic that direct repair of the tendon is not possible. There are other options to address this problem if it proves to be the case.
What does surgery involve?
The operation for a rotator cuff tear aims to reattach the tendon to the bone. This is usually performed as a 'key hole' procedure but occasionally larger tears or 'delaminating' (layered) tears require an open approach.
The tendon is reattached using small, screw in anchors with sutures attached which are passed through the tendon to tie it down onto the bone. Sometimes, during an open approach, the tendon is reattached with stiches directly through the bone and anchors are not needed.
The operation is typically performed as a day case under a general anaesthetic with a nerve block (which helps the pain for the first 12-16 hours) and takes about 60-90 minutes, depending on the size of the tear. You will usually be admitted to the hospital early in the morning and be home by late afternoon.
What can I expect after surgery?
You will wake up from surgery with your arm in an abduction sling (there will be a cushion under your sling to protect the repair). Your arm will feel numb and 'heavy' whilst the nerve block is working during the first night.
The shoulder will become quite sore after that but you will be provided with painkillers which you should take regularly for the first few days. It is important to rest you arm in the abduction sling, day and night, for the first 6 weeks.
You should only remove the sling to perform your exercises and carefully when in the shower. You will be provided with an Exercises sheet showing you the appropriate exercises or you can download the instructions from the Exercises section of this website. Your physiotherapist will closely monitor your exercises and progress.
During the first 6 weeks you will be performing elbow and 'passive' shoulder exercises only. It is important not to try and lift your arm up by itself during these first six weeks to protect the repair. From 6-12 weeks you will perform 'active assisted' exercises. This means using your good arm to help lift the operated arm upwards.
During this time you will gradually progress to moving the operated arm on its own. From 12 weeks after surgery you will be able to start gentle strengthening exercises. You should be able to return to driving at around 8 weeks post surgery, to swimming (breaststroke) at around 4 months, to light duties around 8 weeks and to heavier duties around 4 months. You can expect the shoulder to continue to improve for 6-9 months after surgery.