Rotator Cuff Tears
The rotator cuff is an important group of muscles in the shoulder. It comprises muscles called Teres Minor, Infraspinatus, Supraspinatus and Subscapularis. Like all muscles, the rotator cuff acts as a motor for the main ball and socket or “glenohumeral joint” of the shoulder. In addition, it has an important role in maintaining the shoulder’s stability. Tears in the cuff muscles can be painful and weaken the shoulder.
The degree of weakness varies but it is typically related to the size of the tear and the number of tendons involved. Pain associated with the tear varies greatly and depends on whether there is an associated inflammatory reaction. Tears can be long standing degenerate tears which happen over time or acute and related to significant trauma.
Rotator cuff tears are common, even in people who have no shoulder pain. In fact, over the age of 50, over 50% of us have small tears visible on MRI. While MRI is an important part of your assessment, the clinical examination of people with rotator cuff disease is also essential. Your shoulder pain may not necessarily relate to the tear seen on your MRI. Several other sources of pain such as the acromioclavicular joint, frozen shoulder or biceps tendon problems may be the real source of your problem and the MRI finding of a cuff tear may be incidental. In short, not all cuff tears need surgery and an MRI finding of a cuff tear does not necessarily mean your pain is coming from it.
While some tear patterns require early surgery, thankfully the majority of small tears can be managed without surgery. An injection to dampen the associated inflammation and pain with physiotherapy to strengthen the remaining muscles often will solve the problem. While this will not cause the tendon to heal, the above “active conservative management” for 6-12 weeks deals with the symptoms well and most patients are happy with the outcome.
It is important to engage with physiotherapy to maximise this effect as simply relying on the injection alone will not be enough. There is sometimes a concern that steroid injections will prevent the tendon from healing. This is not really relevant as without surgery the tendon will not heal anyway. The question is whether rehabilitation of the residual cuff will be enough to deal with the pain and improve function.
Where symptoms are persistent, surgery may be required. In addition, if severe lack of function and weakness, or an acute tear with significant size or retraction (the tendon pulling back into the joint) is involved, then earlier surgery may be necessary.
A repair involves releasing the retracted tendon and bringing back to its natural position and using anchors or special stiches to keep it there while it heals back to the bone. Some bone underneath the shoulder tip is often shaven away to give the repaired muscle more space in which to move (subacromial decompression). It is thought that this also allows some healing factors in the bone to be released and that this may promote tendon healing. The healing process usually takes 12-15 weeks to complete.
Most of the time, cuff repairs can be completed arthroscopically (through keyhole surgery) but in some situations, the size or configuration of the tear may be best managed through a small open incision. This decision is often made on table but usually we have enough information from the pre-op MRI to be able to predict which tears may need an open procedure.
In broad terms, post-operative management is much the same with each type. Open repairs are slightly slower to rehabilitate in the first three months, but the outcomes are the same at 6 months. Getting over a rotator cuff repair, especially for large retracted tears, can take a long time. The goal is to get you similar function to the opposite arm at a year but some deficits may remain. Adherence to the rehabilitation program is key. The surgery is really only the first step on the journey.
In the first 12 weeks, it is important that you engage with your physio. There will be a period during which you will need to wear a sling and limit your activities to protect the repair. The duration of these limitations depends on the type of surgery involved. Initially gentle passive motion (where you use the opposite arm to move the post-operative arm or your physio/partner moves it for you) is allowed. This then progresses to more active movements over time. I can discuss this with you at your consultation and post operatively. In addition, your physiotherapist can give you guidance.
Physios: see our therapy guidelines for post-operative care