What Is Rotator Cuff Tear?

Overview

The rotator cuff is a group of muscles in the shoulder that allows movement while maintaining the stability of the glenohumeral joint.

The rotator cuff complex refers to the tendons of

• Subscapularis
• Infraspinatus
• Teres minor
• Supraspinatus.

These above muscles originate from the scapula, cross the glenohumeral joint and insert into the proximal humerus.

The glenohumeral joint is a ball and socket joint that consists of a large spherical humeral head and a small glenoid cavity and performs the following functions:

• It rotates the humeral head
• Stabilises the humeral head in the glenoid socket by compressing the humeral head into the socket.

The tendons of the rotator cuff muscles along with the joint capsule, create a musculotendinous collar and tendons around the posterior, superior, and anterior parts of the joint. However, the inferior part is not covered and remains unprotected.¹

Explanation of a rotator cuff tear

A rotator cuff tear is a common reason for shoulder pain in adults. In case of a rotator cuff tear, your shoulder can become weaker putting a toll on your daily chores.

The supraspinatus tendon is commonly affected. The tendon can completely tear if you put more pressure on the shoulder.²

Causes and Risk Factors

Injury and degeneration are common causes of rotator muscle tear. For example, a tear may occur suddenly when you fall on an outstretched hand and may develop over time due to repetitive activities. Another cause is the degeneration of the tissues due to ageing.³

In a case-control study, it was found that males with a higher body mass index (BMI) who are being diagnosed with carpal tunnel syndrome are at a higher risk of rotator cuff tears. Contrary to what some studies suggested before, smoking wasn't linked to rotator cuff tears.

Types

Partial tear (articular or bursal side) – the tear goes partially through the tendon and does not completely detach the tendon from the bone.

Complete tear- A part of the tendon detached from the bone and is referred to as full thickness incomplete tear whereas, when the tendon gets detached from the bone completely with no hole in it called full thickness complete tear.

Symptoms

The most common symptoms of a rotator cuff tear include:

• Pain at rest and increases at night when you lie on the affected shoulder.
• In case of a sudden fall, you may feel intense pain along with immediate weakness in your upper arm.³
• Lifting your arm may be painful, and you might experience pain moving down your arm.
• Initially, the pain might be mild and only happens when you lift your arm
• Sleeping on the affected side may cause discomfort at night. The shoulder's pain and weakness can make daily activities more challenging.

Diagnosis

During the examination, the healthcare provider will assess the affected shoulder including the strength of the muscles around your shoulder and in your arms.

Imaging tests may include X-rays which help to eliminate other pathologies like fracture or dislocation This can also be used to detect a differential diagnosis of arthritis.

Ultrasound utilizes sound waves to create images of structures inside your body, especially soft tissues like muscles and tendons in motion.

Magnetic resonance imaging (MRI) displays all structures of the shoulder and provides direct imaging of the rotator cuffs by demonstrating the size and degree of the tear.

Treatment approaches

Non-surgical approach for managing a rotator cuff tear:

Pain management

Reducing pain and swelling is the first step of pain management. The inflammation of soft tissues surrounding a rotator cuff tear can cause pain and discomfort in the shoulder, especially when you use your arm.

Rest and activity modification

Rest and activity modification to help reduce joint pain. You might need to modify your daily tasks and perform only those that do not put strain on your shoulder. As your shoulder heals and symptoms improve, you can slowly get back to your regular activities.

Your healthcare provider might recommend nonsteroidal anti-inflammatory drugs (NSAIDs) or muscle relaxants to lessen inflammation and pain. These medications can help manage pain and allow you to function better.

Icing the shoulder helps reduce pain and swelling.

Physical therapy

Physical therapy is an important part of rotator cuff treatment both conservatively and post-operatively. The conservative approach for reducing pain and swelling may include ultrasound therapy which uses soundwaves to facilitate soft tissue healing.

Exercises

Active exercises may include wall walking and Codman pendulum exercises. Passive range of motion exercises like shoulder flexion and extension, internal and external rotation may also be beneficial. Avoid assisted exercises, and abduction-rotation as that might re-create shoulder impingement.

You can carry sling immobilization for your comfort.

Muscle strengthening exercises like grip strengthening exercises may gradually progress to open-chain strengthening exercises.

Post-operative physical therapy treatment involves passive ROM only for about 6 weeks and immobilization for 3-8 weeks depending upon the size of the tear. Then progressing to shoulder motion exercises followed by muscle strengthening exercises.⁵

Corticosteroid Injections

If your pain worsens, corticosteroid injections help relieve intense pain. These injections have powerful anti-inflammatory effects and are usually advised when other medications haven't helped. However, these injections are carefully used as they can make the tendons in the shoulder weaker.

Surgical interventions and procedures 

The techniques used for rotator cuff repair are:

• Traditional open repair
• Arthroscopic repair
• Mini-open repair

A traditional open surgical repair is performed if the tear is large. During an open repair, the bone spurs are removed from the acromion and are called an acromioplasty.

An open repair may be a good option if:

• The tear is large or complex
• Additional reconstruction like tendon transfer is required
• Arthroscopically open repair fails.

Mini-open repair

Mini-open repair is performed through a smaller incision rather than a larger one. This method usually involves using arthroscopy to assess and treat damage to joint structures, like removing bone spurs and avoiding detaching the deltoid muscle. After the arthroscopic part, the rotator cuff is fixed through the smaller incision, allowing direct viewing of shoulder structures during tendon repair instead of using a video monitor.

All-arthroscopic repair

In arthroscopy repair, a tiny camera (arthroscope) is put into your shoulder joint and small tools are used for the procedure. Since the tools are thin, small cuts (portals) were made instead of a larger incision like the one for regular open surgery⁶

Complications

Complications after rotator cuff repair by operative and non-operative means:

• Chondrolysis
• Deep infection
• Deltoid injury
• Implant failure
• Osteonecrosis
• Complex regional pain syndrome
• Fracture
• Nerve injury
• Stiffness
• Venous thromboembolism⁶

Summary

A rotator cuff tear is a common and debilitating injury that affects the shoulder's joint. There are various causes involved including trauma, overuse, or degeneration over time. The symptoms of a rotator cuff tear typically include pain, weakness, and limited range of motion of the shoulder. Treatment approaches are based on the severity of the tear, ranging from conservative approaches like rest, physical therapy, and NSAIDs medications to surgical repair.

The recovery process for a rotator cuff tear can take a lot of time and requires patience and commitment to rehabilitation exercises.

Preventive measures, such as proper shoulder mechanics, strengthening exercises, and restricting repetitive overhead activities, can contribute to reducing the risk of rotator cuff tears. It can be concluded that understanding the causes, symptoms, and treatment options for a rotator cuff tear will enhance the chances of a successful recovery and long-term shoulder function.