Shoulder pain is one of the most common reasons that people come to see me in my office. While many of the causes of shoulder pain are simply related to overuse or inflammation, some are more significant and are a result of tearing of the rotator cuff. The likelihood that your shoulder pain comes from a tear in the rotator cuff increases as you age. There are many treatment options available for rotator cuff tear, and since this topic generates a lot of questions I will try to briefly review some of the treatments options and answer some of the questions here. For a more complete discussion of rotator cuff tears, see the rotator cuff tears section on my website.
What exactly is the rotator cuff?
The rotator cuff is made up of four muscles that surround the shoulder and are responsible for much movement of the shoulder, especially the overhead and rotational movements of the shoulder. The tendons of these four muscles come together to form a cuff around the top of the shoulder and attach to the top of the humerus.
What causes a tear in the rotator cuff?
In young people, rotator cuff tears are uncommon and usually only occur with significant trauma to the shoulder. Occasionally, they may occur from overuse in throwing athletes such as baseball pitchers, or overhead athletes like tennis players.
In older people, rotator cuff tears can definitely still occur with trauma such as falls, but they also commonly can occur in a degenerative manner. Over time the rotator cuff tissue degenerates, which weakens it and makes it easier to tear. Conditions such as shoulder impingement and bone spurs on the acromion or clavicle can increase the wear on the rotator cuff tendons and lead to degenerative tears.
What are the symptoms of a rotator cuff tear?
Rotator cuff tears generally cause pain in the shoulder, especially at night. Many patients with tears tell me that falling asleep is difficult and sometimes the pain wakes them up at night. Large tears also cause weakness in the shoulder with overhead or rotational activities. Rotator cuff tears do not typically cause pain that radiates down the arm all the way to the hand – this may be a sign of a pinched nerve in the neck.
Can a rotator cuff tear be fixed? How is it done?
Yes, rotator cuff tendon tears can be fixed back to the bone. This can be done arthroscopically through small incisions. The tendon is held to the bone with small devices called suture anchors. Small holes are drilled or punched into the bone, and then the device is inserted and won’t back out, much like a drywall anchor. There is suture in the anchor that is then passed through the torn tendon and tied down. This will hold the tendon to the bone for the next few months while the body heals it back into place. The larger the tear, the more anchors that are required to fix it.
What about partial rotator cuff tears?
Many times a degenerative rotator cuff tear will begin as a partial tear. These can cause just as much pain as a full thickness tear, but typically do not have the symptoms of weakness. The treatment for partial tears is based on how much of the tendon is torn. For tears less than 50% of the tendon thickness, the initial treatment is non-surgical (anti-inflammatories, physical therapy, cortisone injections). Tears over 50% of the tendon thickness are treated more like full thickness tears, and if they are symptomatic can be repaired similarly to a full thickness tear.
Do all rotator cuff tears need surgery?
No, there are many instances for which surgery is not necessary or indicated for a rotator cuff tear. Small partial tears as discussed above are generally treated without surgery. Some patients with large partial tears or even small full thickness tears may improve with treatments and do not have much pain or weakness, so I do not recommend surgery for those patients. There are some tears that are so large they cannot be repaired, especially if it is a chronic tear where the rotator cuff muscles have atrophied to the point that they cannot recover. Large, irreparable tears like this will usually lead to severe arthritis of the shoulder joint over time and may eventually lead to shoulder replacement.
There are multiple factors to consider when treating a rotator cuff tear, and when I see patients in the office with these tears I try to go over all these factors. We will then discuss all available treatment options and come to a decision together on how it is best to proceed for that particular individual.