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Rotator cuff tears can cause significant pain and impair shoulder function, affecting daily activities and quality of life. If you are dealing with a rotator cuff tear or seeking information on the topic, you have come to the right place. In this comprehensive guide, we will provide you with valuable insights and expert advice on rotator cuff tears, their causes, symptoms, diagnosis, and treatment options. Written by an experienced orthopaedic specialist, this guide aims to empower you with the knowledge you need to make informed decisions about your shoulder health.

Understanding the Rotator Cuff

An overview of the rotator cuff: Its anatomy and function in shoulder stability and movement.

The rotator cuff is a group of four tendons that surround the shoulder joint, working together to stabilise and move the shoulder. These tendons connect the muscles of the rotator cuff to the bones of the shoulder, allowing for smooth and coordinated movement. Here is an overview of the four tendons that make up the rotator cuff:

Supraspinatus Tendon

  • Location: It runs along the top of the shoulder blade (scapula) and passes underneath the acromion, a bony prominence of the scapula.
  • Function: The supraspinatus tendon helps with the initiation of shoulder abduction (lifting the arm away from the body) and plays a crucial role in arm elevation.

Infraspinatus Tendon

  • Location: It is located on the back of the shoulder blade, below the spine of the scapula.
  • Function: The infraspinatus tendon is responsible for external rotation of the shoulder, which involves rotating the arm outward.

Subscapularis Tendon

  • Location: It is situated on the front side of the shoulder blade.
  • Function: The subscapularis tendon allows for internal rotation of the shoulder, facilitating movements such as reaching behind the back.

Teres Minor Tendon

  • Location: It is located on the back side of the shoulder blade, below the infraspinatus tendon.
  • Function: The teres minor tendon assists with external rotation of the shoulder joint, working in conjunction with the infraspinatus tendon.

These tendons are made up of strong, fibrous connective tissue that attaches the corresponding rotator cuff muscles to specific areas of bone in the shoulder joint. Together, the tendons provide stability to the shoulder joint and enable various movements, including lifting, reaching, throwing, and rotating the arm.

Signs and Symptoms of Rotator Cuff Tears

Due to their role in shoulder movement and the stresses they endure, the rotator cuff tendons are susceptible to injury. Rotator cuff tears can occur as a result of trauma, degenerative changes, overuse, or a combination of these factors. When a rotator cuff tendon is torn, it can lead to pain, weakness, limited range of motion, and functional impairment.

Common causes of rotator cuff tears

Exploring factors that contribute to rotator cuff injuries, such as trauma, overuse, and degenerative changes.

  1. Overuse or repetitive strain: Repetitive overhead arm motions, such as those involved in sports (e.g., baseball, swimming), occupation-related activities (e.g., painting, construction), or certain exercises, can lead to wear and tear on the rotator cuff tendons over time, increasing the risk of injury or tears.
  2. Traumatic injury: Acute injuries, such as falls, direct blows to the shoulder, or lifting heavy objects with jerking motions, can cause sudden tears in the rotator cuff tendons. Road traffic accidents where the patient’s car is rear-ended can also result in rotator cuff tendon tears.
  3. Degenerative changes: As we age, the tendons of the rotator cuff can degenerate and become weaker, making them more susceptible to injury or tears, even with minimal trauma.
  4. Impingement syndrome: When the space between the bones in the shoulder joint narrows, it can lead to impingement of the rotator cuff tendons. Over time, this impingement can cause irritation, inflammation, and potential tears in the tendons. I always tell patients that when the hard bone spur rubs against a tendon, eventually the tendon will rupture. The bone will never fracture off by rubbing against the tendon.
  5. Age: The risk of rotator cuff injuries and tears tends to increase with age, as the tendons naturally become weaker and more susceptible to damage.
  6. Shoulder Dislocation: Shoulder dislocation in the older folks (people above 50) can result in torn rotator cuff tendon. It is always necessary to get an MRI scan of the reduced shoulder in these vulnerable patients to rule out a con-comitant tendon tear resulting from the shoulder dislocation. 

Recognizing the red flags: Common symptoms associated with rotator cuff tears, including pain, weakness, limited range of motion, and difficulty with everyday activities.

When to seek medical attention

common shoulder surgeries

Identifying the signs that indicate it is time to consult an orthopaedic specialist for an accurate diagnosis and appropriate treatment.

  1. Severe or persistent pain: If you are experiencing severe shoulder pain that does not improve with rest, home remedies, or over-the-counter pain medications, or pain that disturbs sleep, it is recommended to consult a specialist.
  2. Limited range of motion: If you notice significant limitations in the movement of your shoulder joint, such as difficulty raising your arm or reaching overhead, For women, they usually experience difficulty in hooking their bra due to limitation in shoulder internal rotation. it is advisable to seek a specialist’s evaluation. 
  3. Shoulder instability: If your shoulder feels unstable, gives way, or if you have experienced recurrent dislocations or subluxations (partial dislocations), it is important to consult a specialist to assess the underlying cause and discuss appropriate management options. Untreated recurrent shoulder dislocations can result in secondary injuries such as shoulder cartilage injuries and nerve injury (axillary nerve palsy).
  4. Shoulder deformity or swelling: If you notice visible deformity, swelling, or bruising around your shoulder joint following an injury, it is recommended to seek immediate medical attention, as it could indicate a fracture, dislocation, or other serious injury.
  5. Inability to perform daily activities: If your shoulder pain significantly affects your ability to perform daily activities, work, or participate in sports or hobbies, it is advisable to see a specialist for a comprehensive evaluation and appropriate treatment. Early intervention via medications, steroid injections or physiotherapy can help to prevent need for surgery if the condition was left to fester and worsen.
  6. Prior unsuccessful treatments: If you have already tried conservative treatments like rest, physiotherapy, or medication without experiencing significant improvement in your shoulder pain, a specialist can provide a more in-depth assessment and explore alternative treatment options.
  7. Recurrent or chronic shoulder pain: If you have a history of recurring shoulder pain or chronic shoulder pain that persists for several weeks or months, it is prudent to consult a specialist to determine the underlying cause and develop an appropriate management plan.
  8. Presence of other symptoms: If your shoulder pain is accompanied by other concerning symptoms such as fever, unexplained weight loss, weakness, or numbness in your arm, it is important to seek medical attention promptly. These symptoms could be due to malignant growth around the shoulder. 

Diagnosis and Evaluation

Clinical examination: A step-by-step guide to the orthopaedic examination used to assess the shoulder and identify rotator cuff tears.

Imaging techniques: Understanding the role of X-rays, ultrasound, MRI, and other imaging modalities in diagnosing and evaluating rotator cuff tears.

Treatment Options

Non-surgical approaches: Exploring conservative treatments such as rest, physical therapy, medications, and corticosteroid injections for managing rotator cuff tears.

CAVEAT for Non-Surgical Treatment – This is meant for very minor tears of the rotator cuff tendon or small partial tears where surgery is not indicated.

If there is a sizable full thickness tendon tear, surgery IS needed and recommended. If left alone, the tendon will tear further over time and it might become irreparable. This can eventually result in cuff arthropathy (osteoarthritis of the shoulder joint) or in pseudoparalysis of that arm.

Rest and activity modification: Avoiding activities that exacerbate symptoms and modifying daily activities to reduce strain on the shoulder can promote healing. 

Physical therapy: A structured physical therapy program can help strengthen the surrounding shoulder muscles, improve range of motion, and alleviate pain. Therapeutic exercises, manual therapy techniques, and modalities like ultrasound or electrical stimulation may be employed.

Medications: Nonsteroidal anti-inflammatory drugs (NSAIDs) or pain-relieving medications may be prescribed to reduce pain and inflammation associated with the rotator cuff injury.

Corticosteroid injections: In some cases, corticosteroid injections may be recommended to provide temporary pain relief and reduce inflammation.

Surgical interventions: A detailed look at various surgical techniques, including arthroscopic repair, open repair, and other advanced procedures for rotator cuff tears.

Partial-thickness tears: If the rotator cuff tear is partial thickness and causing persistent symptoms despite non-surgical treatment, arthroscopic debridement may be performed. This involves removing the damaged tissue and smoothing the remaining tendon. Surgical application of an allograft patch of tissue on the tendon can also help with tendon healing in partial tears.

Full-thickness tears: Surgical repair is often recommended for full-thickness rotator cuff tears. The specific surgical technique will depend on factors such as tear size, location, tissue quality, and patient characteristics.

Arthroscopic repair: Small incisions are made, and an arthroscope is inserted to visualise and repair the torn tendon using sutures or anchors.

Open repair: A larger incision is made to directly access and repair the torn tendon. This technique may be preferred for larger or more complex tears. This is now uncommonly performed. 

Mini-open repair: A hybrid approach that combines aspects of both arthroscopic and open surgery.

In cases of irreparable tears, where the tendon cannot be repaired, alternative procedures like tendon transfers or superior capsular reconstruction may be considered.

Rehabilitation and Recovery

The importance of post-operative rehabilitation: Explaining the role of physical therapy and exercise programs in restoring strength, range of motion, and function after rotator cuff surgery.

Recovery timeline and expectations: A guide to the expected recovery process, including potential challenges and milestones.

Over 95% of the conditions that I treat involving the shoulder joint can be done via arthroscopic approach.  This is a minimally invasive procedure that can at times lead to less pain and faster recovery for the patient.

Most of my shoulder surgeries are done in the hospital under general anaesthesia. I will usually request my anaesthetist to perform a nerve block so that the patient has no pain during and for a period of time after the surgery.

This helps to reduce the need for oral pain killers that sometimes can result in nausea and vomiting.

Most forms of keyhole shoulder surgeries will necessitate the patient to use a shoulder sling for about 2 days post-surgery to rest the shoulder joint.

For those that had undergone shoulder rotator cuff tendon tears, they will need to avoid excessive active movements of the operated shoulder as it takes about 6 weeks for the repaired tendon to mend back to the bone of the humeral head. These patients will be taught a passive range of motion exercises for the first 6 weeks. They start an active range of motions of the operated shoulder from the 7th week onwards.

Most patients tell me that the operated shoulder is most painful at night and for the initial 2 to 3 nights after the surgery. There is usually minimal pain in the daytime. Most of these pains can be well controlled with simple medications.

Patients will also need to undergo physiotherapy of their shoulders. These can be started soon after surgery for certain conditions and at 7th weeks onwards for patients with cuff tendon repairs.

Preventing Rotator Cuff Tears

rotator cuff repair treatment

Proactive measures: Practical tips and strategies for reducing the risk of rotator cuff tears and maintaining shoulder health.

While it may not be possible to completely eliminate the risk of a rotator cuff tendon tear, there are steps you can take to reduce the likelihood of injury. Here are some preventive measures that can help:

  • Maintain Shoulder Strength and Flexibility:
      1. Regular exercise: Engage in exercises that strengthen the muscles of the shoulder, including the rotator cuff muscles. Focus on both strengthening and stretching exercises to maintain flexibility and improve stability.
      2. Cross-training: Incorporate a variety of activities into your fitness routine to avoid overuse of specific muscles and tendons. This can help prevent repetitive strain on the rotator cuff tendons.
  • Practice Proper Posture and Body Mechanics:
      1. Maintain good posture: Avoid slouching and rounded shoulders, as this can place increased stress on the shoulder joint and rotator cuff tendons.
      2. Lift and carry objects properly: Use proper lifting techniques, such as bending at the knees and lifting with the legs instead of the shoulders. When carrying heavy loads, distribute the weight evenly and avoid overloading one shoulder.
  • Warm-Up and Stretch:
      1. Before engaging in physical activities or sports, warm up your shoulder joint with gentle movements, such as arm circles or pendulum swings. This helps increase blood flow and prepare the muscles and tendons for activity.
      2. Stretching exercises: Incorporate shoulder stretches into your warm-up and cool-down routines. Focus on gentle stretches for the rotator cuff muscles to improve flexibility and prevent muscle imbalances.
  • Modify Activities and Take Breaks:
      1. Avoid repetitive overhead activities: If your work or sports involve repetitive overhead motions, take regular breaks and modify your technique to minimize stress on the rotator cuff tendons.
      2. Listen to your body: Pay attention to any warning signs of overuse or fatigue in your shoulder. If you experience pain or discomfort, take a break and allow your shoulder to rest and recover.
  • Gradually Increase Intensity and Load:
      1. When starting a new exercise program or increasing the intensity of your workouts, progress gradually. This allows your shoulder muscles and tendons to adapt and become stronger over time, reducing the risk of injury.
  • Use Proper Equipment and Technique:
      1. Ensure that any sports or exercise equipment you use, such as racquets or weights, is properly sized, fitted, and suited to your body and skill level.
      2. Seek guidance: If you are participating in sports or activities that involve repetitive shoulder movements, consider seeking guidance from a coach or trainer who can teach you proper technique and form to minimize the risk of injury.
  • Maintain Overall Health and Well-being:
    1. Adopt a healthy lifestyle: Eating a balanced diet, maintaining a healthy weight, and avoiding smoking can contribute to overall musculoskeletal health.
    2. Stay hydrated: Proper hydration helps maintain tissue health and flexibility.
    3. Get sufficient rest and recovery: Allow your body enough time to rest and recover between workouts or strenuous activities.

Remember, prevention is key, but accidents and injuries can still occur despite taking precautions. If you experience persistent shoulder pain, weakness, or limited range of motion, it’s important to seek medical evaluation and guidance from an orthopaedic specialist. They can provide an accurate diagnosis and recommend appropriate treatment options based on your specific condition.

Empowered with the knowledge shared by an orthopaedic specialist, you now have a comprehensive understanding of rotator cuff tears, their diagnosis, treatment options, and rehabilitation. Remember, early intervention and proper care are vital in achieving optimal outcomes. By taking proactive steps to protect your shoulder health and seeking timely medical attention, you can overcome the challenges posed by rotator cuff tears and regain your active lifestyle.

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