Rotator Cuff Tear
Article by John Miller
What is a Rotator Cuff Tear?
A rotator cuff tear is quite simply a tear within your shoulder’s rotator cuff tendons. A rotator cuff tear can occur in two ways:
Traumatic rotator cuff tears occur quickly or under heavy load eg a fall or lifting a heavyweight. However, the most common cause of a rotator cuff tear is repeated microtrauma, which can occur over several weeks months or years.
Repeated rotator cuff injury from straining or pinching the rotator cuff tendons will injure the soft tissue resulting in bruising or swelling. Since there are only a few millimetres separating your rotator cuff tendons from a bony hood (acromion), the additional swelling causes a quicker impingement, catching or squeezing of the rotator cuff tendons.
What are the Symptoms of a Rotator Cuff Tear?
Your rotator cuff tears may be partial or full thickness tears.
You will notice that your shoulder pain and weakness increases with the severity of your rotator cuff tear. More importantly, it is a reduction in your shoulder function that is important.
Partial rotator cuff tear may only present with mild shoulder pain, clicking during shoulder elevation and mild shoulder weakness lifting your hand above shoulder height or reaching behind your back.
Full thickness rotator cuff tear will normally present with severe shoulder pain and an inability to lift your elbow away from your body. However, in some cases, the rotator cuff tear is so severe that a significant number of your pain fibres are also torn, which can make them less painful but very weak.
When you have a small rotator cuff tear you can often still raise your arm with or without pain. Moderate tears are usually very painful and you’ll have difficulty moving your arm. Most patients can’t sleep due to the relentless pain. When a large rotator cuff tear occurs you may find that you are unable to lift your arm at all.
What is the Rotator Cuff?
Your shoulder’s rotator cuff is a very important group of four small shoulder muscles that stabilise, control and move your shoulder joint. When your rotator cuff muscles work in isolation they exhibit rotational motion at the glenohumeral (shoulder) joint, which is why they are termed the rotator cuff. Your subscapularis, supraspinatus, infraspinatus and teres minor muscles are the four muscles collectively known as the rotator cuff.
How is a Rotator Cuff Tear Diagnosed
Your physiotherapist or sports doctor will suspect a rotator cuff tear based on your clinical history and the findings from a series of clinical tests.
A diagnostic ultrasound scan is the most accurate method to diagnose the size and location of your rotator cuff tear. MRI’s may show a rotator cuff tear but have also been known to miss a tear. X-rays are of little diagnostic value when a rotator cuff tear is suspected.
What is the Best Treatment for Rotator Cuff Injury?
Small and medium-sized rotator cuff tears usually heal successfully with appropriate conservative management and rotator cuff physiotherapy treatment. Physiotherapy is normally one of the first treatment options suggested by your doctor or shoulder specialist.
If conservative treatment methods have failed to settle your symptoms, or you have an added shoulder bursitis, you may be recommended a corticosteroid injection. These injections may improve your pain while sleeping or allow you to perform your rotator cuff exercises. Corticosteroid injections are known to potentially weaken your tendons, so prescription of an injection will be judicious.
Unfortunately, larger rotator cuff tears may require rotator cuff surgery (arthroscopic or open) if physiotherapy treatment fails to assist. Massive rotator cuff tears may require shoulder replacement or reverse shoulder arthroplasty to restore some of your shoulder function. Post-operative physiotherapist guided rehabilitation will be required to safely regain your shoulder function.
Early rotator cuff tear treatment is important. Delay will result in retraction of your rotator cuff tendon, which can make healing or rotator cuff repair surgery more difficult and less successful. The best rotator cuff tear treatment results occur when the rotator cuff injury is fresh.
Rotator Cuff Tear Treatment
Rotator cuff tears are a common problem. Rotator cuff injury deteriorates further if you return to sport or work too quickly – especially if a thorough rehabilitation program is not completed. They are also regularly poorly treated by inexperienced shoulder practitioners.
Your rotator cuff is an important group of control and stability muscles that maintain “centralisation” of your shoulder joint. In other words, it keeps the shoulder ball centred over the small socket. This prevents other shoulder injuries such as rotator cuff impingement or shoulder dislocation.
Researchers have concluded that there are essentially 7 stages that need to be covered to effectively rehabilitate rotator cuff tears and prevent recurrence.
Your physiotherapist will discuss your goals, time frames and training schedules with you to optimise you for a complete return to sport or work.
The perfect outcome will have you performing at full speed, power, agility and function with the added knowledge that a thorough rehabilitation program has minimised your chance of future injury.
There is no specific time frame for when to progress from each rotator cuff treatment stage to the next. Your rotator cuff injury rehabilitation status will be determined by many factors during your physiotherapist’s clinical assessment.
You’ll find that in most cases, your physiotherapist will seamlessly progress between the rehabilitation phases as your clinical assessment and function improves. It is also important to note that each progression must be carefully monitored as attempting to progress too soon to the next level can lead to re-injury and frustration.
For more specific advice about your rotator cuff injury, please contact your PhysioWorks physiotherapist.
What about a Corticosteroid Injections?
Corticosteroid injections are often administered to relieve pain and promote tendon healing. Cortisone’s primary function is to increase blood sugar, suppress your immune system, and aid in fat, protein and carbohydrate metabolism.
There are side effects and corticosteroid injections should be used cautiously especially with diabetics. It also decreases bone formation and leaves you vulnerable to future tendon rupture.
Researchers generally find that there is a good short-term benefit from corticosteroids but there are some long-term side effects, which may be less desirable. Some patients report good initial relief before a recurrence of symptoms. As with all medications, a discussion with your doctor regarding the pros and cons should always apply to corticosteroid injections.
Rotator Cuff Repair Surgery
Rotator cuff repair surgery is considered for full thickness and partial thickness tears that do not heal with physiotherapy. Most shoulder surgeons will recommend at least six weeks of physiotherapy prior to contemplating rotator cuff repair surgery.
They do this due to the high percentage of success under the guidance of a shoulder physiotherapist and the knowledge that the recovery from rotator cuff repair will commonly take between six to twelve months of postoperative physiotherapy rehabilitation.
During rotator cuff repair surgery, your surgeon will attempt to sew your torn tendon back together. The best results occur when the tear is fresh rather than older tear.
Most rotator cuff repairs take approximately six months of rehabilitation to regain as full as possible range of motion, shoulder strength and function.
It is important to follow your physiotherapist and surgeon’s post-operative guidelines for your best outcome. In our experience, about 90% have an excellent outcome at 12 months postoperatively.
As with all surgery, there are associated risks or complications. These can include infection, stiffness, blood clot formation, and nerve injury. The risks of significant joint stiffness are less than 5% and the risk of nerve injury is very low - approximately 1 in 10000.
Shoulder Replacement Surgery
Some massive rotator cuff tears will be irrepairable using a normal rotator cuff repair. In these instances, a total shoulder replacement may be recommended by your shoulder surgeon.
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