The physicians of Muir Orthopaedic Specialists believe good medical care is a result of mutual understanding, respect and trust.  In today's fast paced world, we recognize the importance of communication and spend as much time as possible to provide information explaining condition and treatment options so that our patients can make informed decisions about their care.

ROTATOR CUFF TEAR

Introduction
The shoulder is a very elegant and complex piece of machinery. The design of the shoulder gives us the ability to do many useful things by allowing the shoulder to help us reach and use our hands in many different positions. This design gives the shoulder great range of motion but not much stability. As long as the parts of this elegant machine are in good working order, the shoulder can move freely and painlessly. The rotator cuff tendons are one of the key reasons that the shoulder is so useful. The tendons can be subject to a considerable amount of wear and tear, or degeneration, as we used our arms, especially overhead activities. This wear and tear can lead to weakening of the rotator cuff tendons, through a condition known as impingement. The rotator cuff tendons are also subject to degeneration as we age. An injury to these tendons can result in a weak, painful shoulder, due to tearing of the rotator cuff tendons. Let’s look at how this occurs.

Causes
Many studies have shown that the rotator cuff tendons have areas where there is a very poor blood supply. In the human body, the better the blood supply a tissue has, the better and faster that tissue can repair and maintain itself from day to day wear and tear. These areas of poor blood supply in the tendon make the rotator cuff tendons especially vulnerable to degeneration with aging. This simple condition of aging may help explain why the rotator cuff tear is such a fairly common injury later in life. Rotator cuff tears usually occur through areas of the tendon that were not normal to begin with and have been weakened by degeneration and impingement.

The weakened rotator cuff tendons can be injured, and torn, by an excessive force, such as trying to catch a falling heavy object, or lifting an extremely heavy object with the arm extended. This can occur even in a young person. Typically, a rotator cuff tear occurs in a middle-aged person who has been having problems with the shoulder for some time before the acute event. That person starts a lifting activity which exceeds the strength of the tendons, and the tendon tears acutely, leaving an inability to raise the arm. There may, or may not be pain associated with the event.

Symptoms
Rotator cuff tears cause two main problems- pain and weakness. In some cases, a rotator cuff may be only a partial tear of the tendons, and you may have pain but can continue to move the arm in normal range of motion. In other cases, a complete rupture of the tendons occurs, and you are unable to move the arm in a normal range of motion. A complete rotator cuff tear usually results in an inability to raise the arm away from the side under your own power.

Most rotator cuff tears cause a vague pain in the shoulder area, and may result in a “catching” sensation when the arm is moved. The larger the tear in the tendon, the more weakness there is when trying to move the arm. Most people report an inability to sleep on the affected side, due to pain.

Treatment
Initial treatment for a suspected rotator cuff tear is rest and anti-inflammatory medication, mainly to control pain. While a true rotator cuff tear will not heal, some partial tears will become very tolerable and may not require a surgical repair.

As soon as pain tolerance permits, physical therapy to regain motion is begun.

A cortisone injection may be suggested if you are still having pain after several weeks of conservative care. After a reasonable time, if the pain is not tolerable or the motion of the arm is not acceptable, an arthrogram of MRI scan may be suggested to plan for surgery

Surgery to repair a tear in the rotator cuff tendons is usually necessary if there is a complete tear in the tendons resulting in an inability to raise the arm. Surgery may also be necessary for a partial tear of the tendons – if the tear results in more discomfort and weakness than you are willing to tolerate. The timing of surgery is variable. In a complete tear of the rotator cuff, there is evidence to suggest that repairing the tendons within 3 months of the injury results in a better outcome.

Repairing the tendons can be difficult. The surgery is usually done through a 4-5 inch incision on the side of the shoulder. In most cases, repairing the tendons involves first removing any degenerative rotator cuff tissue that does not appear healthy. Then, an area of the humerus (the upper arm bone) where the tendon was torn from is prepared for reattachment of the tendon. The soft tissue is removed on an area of the humerus to form a raw bony area for attachment of the torn tendon. Drill holes are made in the humerus to allow sutures to be placed through the bone to attach the tendon. The tear in the tendon is then sewn together. Other sutures are used to attach the tendons to the bone of the humerus by looping the sutures through drill holes. The tendon heals to the bone over time and reattaches itself.

Following surgery, you may spend one or two nights in the hospital. There is a trend towards smaller incisions for repair of the rotator cuff tendons, and in some cases repair with the aid of the arthroscope. If you are a candidate for this type of repair, you may go home the same day.

Expect to begin physical therapy fairly soon after surgery. The repair must be protected, mainly to keep the sutures from pulling free, but early range of motion exercises will lead to a quicker recovery. During the period of three to six weeks following surgery, the therapist will begin more active exercises to begin regaining the strength in the rotator cuff muscles. Recovery from shoulder surgery can be a slow process. Getting the shoulder moving as fast as possible is important, but this must be balanced with the need to protect the healing muscles and tissues. You can expect the process of recovery to take several months.

Finally, not all rotator cuff tears are repairable. Sometimes, the tendon has been torn for too long of a period of tine. This can lead to the tendon and muscle contracting. The muscle and tendon cannot be stretched enough to be attached back to where it was torn from. In other cases, the tendon tissue has simply worn away, and what tendon remains is not strong enough to hold the stitches necessary to attach the tendon to bone. In these circumstances, simply removing all the torn tissue and fixing any other problems in the shoulder (such as acromioclavicular (AC) joint arthrosis and impingement syndrome) may reduce your pain. It will probably not increase the strength or motion of the shoulder. It may actually decrease the motion.

Copyright 2003 Muir Orthopaedic Specialists