Rotator Cuff Tear

What is the Rotator Cuff?

Rotator Cuff is a term which refers to four tendons that pass through the sub-acromial space of the shoulder. Each component tendon has its own name:

  • Supraspinatus
  • Infraspinatus
  • Subscapularis
  • Teres Minor

They are collectively called “The Rotator Cuff”. They blend into a hood-like structure that that is attached to the front, top and back of the head of the humerus. The direction that the head of the humerus moves within the shoulder joint socket is determined by which component of the rotator cuff is pulling the most. They, along with the bursa that lines their upper surface, pass backwards and forwards through the small space between the head of the humerus and acromion. This is called the Sub-Acromial Space.

What Causes Rotator Cuff Tears?

Rotator cuff tendon tears develop in a number of ways. Multiple factors may be involved. Mechanisms include:

  • Acute Injury such as a fall
  • Repetitive Low Grade Injuries
  • Chronic Shoulder Impingement
  • Secondary to Shoulder Dislocation
  • Occupational Tasks
  • Sporting Activities
  • Degeneration of Tendons with age
  • Soft tissue Inflammatory Conditions
  • Weakening effect of some Medications
  • Any Combination of the above

What are the Symptoms of Rotator Cuff Tears

The symptoms of acute rotator cuff tear may be obvious. The patient may describe a specific injury such as a fall. The pain at the time of the incident may be severe. Some patients notice an actual tearing sensation. If the tear is relatively small it may still be possible to lift the arm overhead but with a sharp catching pain with the arm at shoulder height. Large tears may result in obvious shoulder weakness and an inability to lift the arm overhead at all. Bruising at the front of the shoulder and upper arm some days after the injury may indicate a serious tear. Sleep disturbance due to pain is common.

The symptoms of chronic rotator cuff tears may emerge slowly. Their source may not be obvious at the outset. It is not unusual for older patient to gradually develop rotator cuff tearing without any symptoms at all. This may be part of the normal aging process. Symptoms may emerge only after the tearing reaches a greater extent. It is also very common in mature patients for extensive tearing to occur after a seemingly trivial injury. This will be a reflection of already compromised tissue quality. It might also be an indicator of tissue that cannot be repair. The degree of shoulder weakness will give a clue to the extent of the tear. Sleep disturbance is also a feature of chronic tears.

How is a Rotator Cuff Tear diagnosed?

Mr Lyons will listen to the problems you have noticed with your shoulder. He will then examine your shoulder to assess the integrity of the individual rotator cuff tendons. If certain movement reproduce your pain it will help to localise the problem.

Special Diagnostic Tests will be helpful:

  • X-rays will rule out a fracture after an acute injury. X-rays may reveal an acromial spur or bony irregularity at the point of attachment of the rotator cuff the upper humerus in chronic cases. These bony changes may indirectly provide clues about the quality of the tendons
  • Ultrasound may demonstrate the actual tear. The location and size of the tear can be assessed. It may also provide a guide as to whether the tear is partial or full thickness in nature. The tendons can be observed in real time as they pass under the acromion to assess the degree of the impingement. Associated thickening of the sub-acromial burs and excess fluid in the bursa is assessed.
  • MRI may demonstrate the location and extent of the tear. It may give additional information about the quality of the tendon tissue. This is in turn an indicator of whether the tendon tissue has sufficient quality to be repaired
  • Arthrogram is a test wear the radiologist injects an X-ray dye in to the shoulder joint. If there is a tear through the full thickness of the rotator the dye will leak from the shoulder joint through the tear in to the sub-acromial bursa. It is a much less common test but one that Mr Lyons uses when it is critical from a surgery planning standpoint to know whether the tendon is torn part way or fully through.
  • Acromial Spur
    Acromial Spur

    Irregularity on Upper Humerus
    Irregularity on Upper Humerus

    Rotator Cuff Tear Treatment Options

    Not all rotator cuff tears require surgery. Small acute tears may cause minimal symptoms. Rest, activity modification and a period of observation may be appropriate. Even larger chronic tears, especially in older patients, may causes symptoms that are quite manageable with simple measures. An occasional cortisone injection may be helpful in avoiding a surgery in much older patients with significant background medical issues.

    If symptoms remain unacceptable despite trying all conservative options there may be a case for surgery. Surgery ideally involves Rotator Cuff Decompression and repair of the torn tendon. Arthroscopic and Ope Surgery techniques may be appropriate depending upon the extent of the tearing and the judgement of your surgeon. Regardless of technique the goal is return of the best possible shoulder comfort and function. Large chronic rotator tears may not be completely repairable. However a decompression and debridement (clearance of the irreparable tendon tissue) can be effective in restoring at least better comfort and fuction.