Shoulder Rotator Cuff Tears

Updated 02/23/2015
Written and edited by Aruna Seneviratne, M.D.

Shoulder rotator cuff tears are painful condition that leads to dysfunction of the shoulder.

Symptoms:
Shoulder pain and dysfunction - the inability to use the shoulder, are the hallmarks of a rotator cuff tear. The shoulder will be painful, and will have markedly limited range of motion. Frequently patients report pain at night. Activities of daily living are difficult.

Biology: Why does it occur?
The rotator cuff is a group of 4 tendons that coalesce together to form a cuff. A tendon connects a muscle to bone and is made up primarily of collagen. The four muscles of the rotator cuff are the subscapularis in the front of the shoulder, the supraspinatus on the top of the shoulder, the infraspinatus at the back of the shoulder, and the teres minor - also in the back of the shoulder. Together the tendons of these muscles forms a cuff and hence its called the rotator cuff. The most commonly torn rotator cuff tendon is that of the supraspinatus.

Tears can occur due to trauma such as falls, or over time due to degeneration of the tendon or an external bone spur. Rotator cuff tears usually occur in patients in their 60s and above. Younger patients can tear their rotator cuffs, but it's usually traumatic in nature. Natural history of a rotator cuff tear is for it to get larger. Rotator cuff tears do not heal over time. If neglected, the muscle can atrophy, followed by fatty infiltration of the muscle. This is an irreversible condition, and does not bode well for restoration of normal function, and can lead to development of arthritis. Arthritis in the setting of a rotator cuff tear is called rotator cuff tear arthropathy. Treatment options for this condition is limited and includes such procedures as reverse shoulder replacement. Non surgical treatment comprise of a particular form of exercise called the Reading protocol.

Common Diagnostic Techniques:
History: Diagnosing the problem begins with a detailed history that your surgeon will obtain from you.
Physical Exam: A thorough physical examination is then conducted by your surgeon.
X-Rays: Plain radiographs (X-Rays) are the most important diagnostic study that is performed initially. Several views will be obtained to diagnose the condition.
MRI: Allows the visualization of the damage to the soft tissues about the shoulder.

Treatment:

Non -operative:
Small tears of the rotator cuff can be treated non-operatively if the patient becomes symptom free with physical therapy. A home exercise program can also be done.
Operative:
Dr. Seneviratne treats the vast majority of rotator cuff tears with arthroscopic repair. A small camera is inserted into the shoulder via keyhole incisions, and arthroscopic instruments are used to repair the rotator cuff tendon back down to the bone where it belongs using suture anchors.
There are two types of repair that can be performed - the double row repair and the single row repair. Both types yield good to excellent results, and Dr. Seneviratne with customize your treatment based on a variety of factors. Most tears are treated using the double row technique to provide improved biomechanical fixation strength to the healing rotator cuff tear. Dr. Seneviratne has studied this problem extensively and was involved in basic science research about double row vs. single row repairs

The postoperative course
Rotator cuff surgery is an ambulatory procedure and the patient goes home the same day.

After Surgery
Pain after surgery of this nature is not very severe, and most patients manage the pain with Tylenol after a few days of narcotic pain medicine use. NSAID medications are discouraged for six weeks after the operation as it can impede rotator cuff healing. A sling is used for about 3-6 weeks. Physical therapy starts about 4-6 weeks after surgery. Early healing occurs at 6 weeks post operatively. Full healing takes 4-6 months. Most patients will be quite pain free by 6 weeks, and very functional by 3 months. Keep in mind that each patient is different and return to normalcy will be guided by Dr. Seneviratne.

FAQ's
What is the re-tear rate after surgery?
In Dr. Seneviratne's experience the re-tear rate after arthroscopic rotator cuff repair is about to 10%. The peer reviewed literature shows higher re-tear rates. There are many factors that predict re-tear rates, and Dr. Seneviratne pays careful attention to choosing the right operation for the right patient depending on patient factors, level of sports participation/activity, and findings on diagnostic studies.

Can I get arthritis after shoulder rotator cuff tear?
Yes - especially if there is fatty infiltration of the muscle.

What are the risks of arthroscopic rotator cuff repair surgery?
Infection, bleeding, damage to nerves and blood vessels, re-tear of the rotator cuff and shoulder stiffness.

Will I have hardware in my shoulder?
The rotator cuff is repaired using tiny suture anchors that are drilled into the the greater tuberosity of the humerus bone. These are usually made of suture material, and patients do not feel them.

How soon after surgery:
  1. Can I drive?
    Usually in 6 weeks, but as early as 3 weeks if it's the non dominant arm.
  2. Can I return to work?
    About 1-2 days depending on your occupation, but a week off is recommended.
  3. Can I shower?
    Yes - in 48 hours.
  4. Can I resume sexual activity?
    Yes - within a day or two.

Can I fly in an airplane?
In about 1 week - you must arrange for an aisle seat, have your bags handled by someone else, and you MUST do ankle pumps every 15minutes, as DVT is a major concern. You must also take Aspirin to prevent DVT.