Rotator Cuff Tear

Knowledge that empowers

What is it?

The rotator cuff is a group of four muscles (supraspinatus, infraspinatus, teres minor and subscapularis) and their tendons that surround the shoulder joint.

These four muscles work together to keep the head of the humerus bone positioned in its socket (glenoid) as you move your arm and hand in space. They also play a very important role in rotating the arm. The terminology rotator cuff tear typically refers to a tear in the tendon portion of the rotator cuff.

Rotator cuff tears are categorised and described by certain characteristics of the tear, including but not limited to:

  • which tendons are involved
  • the thickness of the tear, being full or partial
  • the size of the tear – small, medium, large or massive
Dr Sumit Raniga - Shoulder and Elbow Surgeon - Sydney

Who is affected?

Rotator cuff tears are more commonly seen in patients older than 30. They can be caused by a traumatic incident such as a fall onto an outstretched hand, a biking accident or heavy lifting.

But most of the tears of the rotator cuff are degenerative and occur without injury (atraumatic). These are seen with increasing age, even in people who do not have a history of shoulder pain or injury – the older you are, the more likely you are to have one.

There is a type of tear called PASTA (partial articular supraspinatus tendon avulsion). It is usually seen in athletes under the age of 45, as a result of a twisting and/or traction (pulling) injury of the shoulder. It can present with pain when lifting outwards, overhead and throwing. Fatigue at the shoulder brought on by overhead activities is common.

Like other soft tissues in the body, as age increases, the tendons follow a degenerative process where the strength and resilience of the rotator cuff tendon lessens, and thus it becomes increasingly prone to injury or irritation from increasing activity. Activities of daily living and recreational activities that someone may previously have been able to take part in, can cause too much stress on the tendon, and eventually the tendon can tear.

A number of factors are associated with weakening of tendons including increasing age, overuse, genetics, hormones, diabetes, high cholesterol, repeated steroid injections, increased alcohol intake and smoking. Addressing any modifiable lifestyle factors can help tendon health.

What are the symptoms?

Pain, reduced range of motion and a feeling of weakness are the most common symptoms of a rotator cuff tear.

The pain is usually felt in the upper arm, in the anterolateral region of the shoulder and can refer to the mid upper arm to the deltoid muscle insertion.

Typically, the larger the size of the tear, the more weakness someone might experience. Holding onto, or lifting objects at arm’s length are common positions to feel pain or weakness with a small to medium sized rotator cuff tear. In some large and massive tears of the rotator cuff, where there is more than one portion of the tendon completely torn, the weakness can be so severe that it is impossible to elevate the shoulder or move it in certain directions.

Function of the shoulder depends also on the tear nature, so that acute tears are more impairing and chronic tears are usually better compensated.

Small, age-related tears of the rotator cuff can become increasing painful over time, and if the stresses placed on the shoulder over time are great enough, or are in high enough volumes, these small tears can progress in size.

Pain at night is commonly experienced after injuring the rotator cuff tendon, however many other shoulder conditions can cause night pain or difficulty sleeping.

How is the diagnosis made?

Diagnosis of a rotator cuff tear is usually suspected with a thorough examination of the strength and movement of the shoulder. 

The imaging investigations begin with plain radiographs of the shoulder which gives information about the bony architecture that can help diagnose rotator cuff tears and also have prognostic implications. An ultrasound scan can be useful to help confirm the presence of a rotator cuff tear, although an MRI is much more accurate giving greater detail related to the size, shape and location of a tear. In cases caused by a traumatic incident, an x-ray or CT scan may also be required if there is any suspicion of an injury to any of the bony structures of the shoulder.

What is the prognosis?

Rotator cuff tears usually progress with time, what means they become larger. The progression can vary related to which tendon is affected, the thickness and size of the tear.

Other factors including age, general health and desired activity levels can also affect prognosis. Some tears can be managed effectively without surgery with only occasional flare ups of pain with over-activity. 

Larger, and more complex tears are associated with poor function and ongoing pain and these may take longer to recover or eventually require surgery to improve. Some traumatic tears need early surgery for best recovery of function.

Acute tears of the rotator cuff, caused by a traumatic incident, may require urgent attention from a shoulder specialist as there can be a short window of opportunity for a successful surgical repair.

Non surgical treatment

Not all tears require surgery. For small, atraumatic, isolated, supraspinatus tears in older patients, the outcome of non-surgical treatment (physiotherapy) can be similar to surgery for up to 75% of patients.

Often a period of three to four months of physiotherapy can successfully reduce your symptoms and improve your function. This improvement is due to rebalancing of the muscles groups around the shoulder which compensate for the torn tendon.

An injection of cortisone, into the subacromial space above the rotator cuff, may be indicated in some rotator cuff tears to help settle pain that is thought to be driven by inflammation. Then institution of an intensive shoulder physiotherapy program is necessary for a good outcome.

One of the most important factors in success of non-operative treatment is having a good understanding of your shoulder condition, and reducing pain by avoiding, or managing activities that provoke it, combined with specific rehabilitation from your physiotherapists.

In the majority of cases, we advocate for initial non-surgical management of small partial or full thickness tears of the rotator cuff as first line treatment. Should someone not improve greatly with rehabilitation, surgery may indicated. For other tears, including traumatic tears in younger patients, or larger tears involving multiple tendons with good healing potential, surgery may in fact be required soon after the injury.

Surgical Management of Partial Thickness Tendon Tears

For small partial thickness tears of the supraspinatus tendon, surgery is typically completed arthroscopically (keyhole technique).

Depending on your circumstances, and the exact location of the tear, surgery may involve tear completion and repair or insertion of a collagen implant known as the REGENETEN bioinductive implant.

Arthroscopic in situ repair:

This procedure is suitable for the so called PASTA lesions, (partial articular supraspinatus tendon avulsion). It involves fixing the torn tendon arthroscopically through the intact tendon. This means that the remaining intact fibers attached to the bone are preserved. Recovery from this surgery requires use of a sling for 6 weeks. Total recovery time can take upwards of 6 months in total.

Arthroscopic tear completion and repair:

This procedure is suitable for high-grade degenerative partial tears. It involves surgically “completing” the tear so that the tear becomes full thickness. This then enables A/Prof. Raniga to repair the tendon back down to its bony attachment with bone anchors and a special suturing technique. Recovery from this surgery requires use of a sling for 6 weeks. Total recovery time can take upwards of 6 months in total.

Arthroscopic insertion of REGENETEN bioinductive implant

This procedure is particularly suitable for lowgrade or medium grade degenerative partial tears, not for traumatic tears. It involves attaching a specially designed bovine collagen patch over the top of the torn tendon. Over time, this patch act as a biological scaffold for cells to allow healing of the partially torn tendon. Imaging studies have shown that the original tear heals, and the tendon becomes thicker. Recovery from this surgery is shorter than a surgical repair; a sling is only required for approximately 1 week and there are only a few minor limitations on what movements are allowed in the first month after surgery.

Surgical Treatment for Full Thickness Tears of the Rotator Cuff

A complete rotator cuff tear will not heal. Complete ruptures usually require surgery if your goal is to return your shoulder to optimal function.

Full thickness tears of the rotator cuff can, in most cases, be repaired arthroscopically. A rotator cuff repair involves stitching the torn tendon back onto its attachment to the arm bone (Humerus). The tendon is repaired back down to its bony attachment with bone anchors and a special suturing technique. Some massive tendon tears though require use of an open technique, where a larger incision is made to access the torn tendon.

Rehabilitation following rotator cuff repair surgeries typically involve wearing a sling or specially designed shoulder brace for 6 weeks in order to protect the tendon repair. 

In this time it is important to complete some very gentle passive range of motion exercises to reduce stiffness. These exercises will be taught to you by an experienced physiotherapist. After the 6 week mark, you will start to work on restoring normal movement to the shoulder and begin to elevate the arm without assistance. After 12 weeks you will usually be able to start lifting light weights and gradually build up your strength.

Return to work and recreational activities will be dependent on what duties are involved in your work life or the demands of your chosen sport. Your surgeon and physiotherapist will be able to give you advice on return to work and sport. Evidence clearly demonstrates that compliance with physiotherapy after surgery leads to better outcomes.

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