Rotator Cuff Tears
The rotator cuff is a group of muscles that arise from the scapula and insert into tuberosities of the upper humerus. Four muscles (subscapularis, supraspinatus, infraspinatus and teres major) form the rotator cuff.
Subscapularis arises from the front surface of the scapula. It runs across the shoulder and attaches to the front of the humerus. Its function is to rotate the shoulder inwards. Supraspinatus originates from the back of the shoulder blade above the scapular spine. It attaches to the top of the greater tuberosity. Supraspinatus initiates lifting the arm out to the side until the stronger deltoid takes over. Infraspinatus arises from the back of the scapula below the scapular spine and attaches to the lower part of the greater tuberosity. Along with the teres major muscle, they are a powerful external rotator of the shoulder. The rotator cuff tendons also work in conjunction to stabilise the shoulder joint.
With ageing, the rotator cuff tendons undergo degenerative changes. The cause of degeneration is multifactorial. Degeneration occurs as the tendon rubs against the acromion. Over many years tendon degeneration worsens and may lead to tearing. The rotator cuff tendons also have a relatively poor blood supply. This lack of blood supply also contributes to degeneration and lack of healing.
There are two types of tendon tears. The most common variety is a degenerative tear that is the result of ageing or progressive “wear and tear”. Often these tears are present but don’t cause symptoms. 30% of people over the age of 70 years have a rotator cuff tear. The majority of these tears are asymptomatic or only cause mild problems. These tears often only become painful after a seemingly minor injury, a fall or sometimes after overuse of the shoulder. The second type is an acute or fresh tear that occurs after a specific injury. It tends to occur in younger people, especially under the age of 50 years. They also commonly occur after a shoulder dislocation in people over the age of 40 years.
Diagnosis & treatment
If you have a rotator tear, you may experience shoulder pain, weakness and loss of shoulder function. Often your GP may have ordered an ultrasound that demonstrates a rotator cuff tear. However, if you’ve had an injury, it’s also necessary to get a shoulder X-Ray. An X-ray can exclude a fracture, which is common after a fall. An X-ray can also provide evidence of previous damage or degeneration of the rotator cuff.
Management of your rotator cuff tear depends on several factors. Important factors include your age, your activity level, the type of work you perform and your symptoms. Other significant findings include how your shoulder moves, the presence of any weakness and the presence of any muscle wasting. In determining the best treatment for your rotator cuff tear, it’s essential to know two things. The first is that a rotator cuff tear cannot heal itself. The second is that not all rotator cuff tears need surgery. Pain from a rotator cuff tear may be due to several factors, and often the pain resolves without surgery. As discussed above, depending on your age, you may have already had rotator cuff damage that has not caused any symptoms. So there is a good chance that your pain will settle with nonoperative treatment.
Therefore in considering the treatment of chronic tears, the most crucial ingredient is time. In my experience, there is an excellent chance that your pain will resolve or improve in the first three months. You must avoid aggravating activities to give your shoulder a chance to settle. Because the tissues around your shoulder are usually inflamed, a cortisone (an anti-inflammatory medication) injection may be helpful. Performing the cortisone injection under ultrasound guidance ensures they are delivered into the correct place and have a higher chance of success. Physiotherapy can also be beneficial. A physiotherapist can facilitate a home exercise program. Initially, this will comprise exercises to improve your movement. As the pain improves, you can start a gentle strengthening program.
Surgery may be required for acute traumatic tears in younger people or for more chronic ones that have failed to settle with treatment outlined above. An MRI scan of your shoulder is helpful to plan surgical repair. An MRI gives additional information including the size of the tear (from front to back), the thickness of defect (whether partial thickness or complete) and how far the tendon has retracted from the bone. The MRI will also look at the muscles of the rotator to see whether they are still in good condition. This additional information will help with surgical planning and will determine if the tear is repairable. Chronic large tears that have retracted a long way from their bony attachment, particularly if they are associated with muscle wasting, may be irreparable.
Surgery involves an arthroscopy of your shoulder to confirm the presence of a tear, its size and the general condition of the rotator cuff. These findings determine whether the tendon is suitable for a repair. Arthroscopic inspection of the shoulder determines the presence of other pathology. I repair smaller tears arthroscopically. More extensive damage is fixed openly, with a small incision placed on the outside part of your shoulder. The repair technique involves placing stitches into the tendon and then the use of small plastic anchors placed into the bone. These firmly hold the tendon in place to allow healing. Healing has usually occurred by three months from surgery, but the repair will be even more robust by six months. Though the tendon will take three months to heal, it may take longer for your movement to return and for you to get back to your usual activities.
Dr Brown has successfully treated many patients with rotator cuff injuries and is knowledgeable in the latest non-surgical and surgical treatments.