Rotator Cuff Tears

Introduction

Rotator cuff tears are extremely common. It is estimated that 21% of the population have rotator cuff tears, although the incidence is much higher in the older population. Another interesting fact is that many people with rotator cuff tears may not be symptomatic at all! In fact, the incidence of asymptomatic rotator cuff tears appears to be higher in older patients. It is estimated that up to 2/3 of patients in their 60s with rotator cuff tears may not be symptomatic. The remaining 1/3 of patients seek help because of pain in their shoulders, especially during movements of their arms at their shoulders. In order to understand this topic, some knowledge of anatomy is required.

Anatomy of the Shoulder Joint

Bony anatomy of the shoulder
Bones that make up the shoulder joint

The shoulder joint is made up of 3 bones: the shoulder blade (scapula), the humeral head and the collar-bone (clavicle).

Shoulder joint
The scapula and humerus in their natural position behind the ribcage

Movements around the shoulder involve 3 separate articulations: the glenohumeral joint, the acromioclavicular joint and the scapulothoracic articulation. When the arm is raised, the majority of movement occur at the glenohumeral joint and the scapulothoracic articulation.

Shoulder with bursa
The size of the bursa is greatly exaggerated for illustration

4 muscles are attached to the scapula and send their respective tendons across the glenohumeral joint and attach to the humerus just beyond the humeral head. These 4 tendons are collectively known as the rotator cuff. You can think of the muscles as motors and their tendons as pulleys. Contractions of the muscles will hence bring about movement at the joint that their tendons cross.

How does a rotator cuff tear occur?

Occasionally, patients will find that they have lost significant strength in their shoulders. Some may not even be able to lift their arm. Sometimes, patients may develop rotator cuff tears and not be able to remember any inciting event or injury!

Rotator cuff tears can present in a wide variety of ways.An injury to the shoulder is a common way that patients may present. The injury is often not a direct one (where the patient is struck directly over the shoulder), but rather an indirect one. Breaking a fall with his/her outstretched arm is a common mechanism of injury. Often times, patients will feel a sharp and immediate pain in the shoulder. Some may even feel a snapping or popping sensation as the rotator cuff tears. In other cases, patients may feel sudden pain in the shoulder when they attempt to lift a heavy load (eg heavy bag of rice or pail of water). They will often ignore it, assuming that it is a simple sprain, but will eventually seek help when the pain does not resolve with rest and time.

It is thought that due to the process of aging, the blood supply to the part of the rotator cuff where it attaches to the humerus diminishes, hence resulting in weakening of the attachment and eventually progressing to a tear. Some patients also seem to be particularly prone to developing rotator cuff tears. I find that many of my younger patients (in their late forties and early fifties).

What symptoms may I have?

As you might have already guessed, pain is the shoulder is the most common symptoms that patients experience. The pain is often aching in nature and felt around the entire shoulder region extending down to the upper arm, rather than in a specific point. It is also usually aggravated by trying to lift heavy loads or lifting their arms or loads overhead. Most patients will also notice that they have lost power in their arms. Power of elbow bending (using the biceps) will not be affected. The weakness occurs with movements around the shoulder joint only. This is especially marked if the affected side is their master hand because suddenly they will notice that their non-master hand will is now the stronger side!

Many patients are surprised when I tell them that they have a complete or full thickness rotator cuff tear. Their assumption is that if they have a full thickness tear of the rotator cuff, they will not be able to move their arms at all. This, however, is not true. As mentioned above, the rotator cuff is not one single muscle with its tendon, but rather 4 muscles and their accompanying tendon. Most times, there is a full thickness tear of one or two, but almost never all 4! The other tendons which are not torn will often be able to compensate for the tear to a certain extent. In addition, the overlying deltoid muscle will also be able to provide some movement at the shoulder joint.

Finally, some patients may also experience clicking and crackling sounds and sensations in their shoulders as they lift their arms.

What will the doctor do?

Your doctor will chat with you and ask you more about the. A careful examination of the shoulder is then carried out. He (I will use “he” to refer to the doctor to simplify the discussion although clearly, there are many female doctors out there!) will need to visually inspect your shoulders, looking out for any asymmetry or wasting of the muscles. He then feels around the shoulder looking for any tender spots which may give a clue as to the source of the problem. This may be particularly hard in large or muscular patients.

He then tests your shoulder movements. Rotator cuff tears often do not cause any restriction of range of movement unless the tear has been there for a certain amount of time, and the patient’s reluctance to move the shoulder fully due to pain has resulted in a stiffness of the joint (secondary frozen shoulder).

Your doctor will then test the strength in each of the rotator cuff muscles. The most commonly torn tendon is the supraspinatus tendon and many patients with rotator cuff tears will have decreased power in the supraspinatus. However the patient may also have tears of the other rotator cuff muscles and weakness will then correspond to the whichever tendon is torn.

What tests can be done to confirm the diagnosis?

This section will briefly discuss the common investigations that doctors carry out to identify the problem. For a more detailed discussion regarding investigations, please go to the page on investigations.

Many doctors may begin their investigations with x-rays for the shoulder. X-rays are excellent investigations for viewing bony and joint problems. To me, x-rays provide me with a “bird’s eye view” of the problem. X-rays, however are often not terribly informative in cases of rotator cuff tears. Occasionally bone spurs may suggest presence of an underlying rotator cuff tear, but other tests will be required to confirm the diagnosis and allow your doctor to assess its severity.

Ultrasound scans are generally more useful in the diagnosis of rotator cuff tears than x-rays. In the hands of an experienced ultrasonographer, it is possible to accurately diagnose rotator cuff tears and shed light on its severity. However, ultrasound examinations may not yield enough information for the surgeon to assess the chances of a re-tear of the tendon even after successful surgical repair. As such, I have encountered patients who have opted initially for an ultrasound scan, had the presence of a tear confirmed, and required an MRI scan for further evaluation and prognostication!

An MRI (magnetic resonance imaging) scan is by far, the most informative scan, and it is my investigation of choice for rotator cuff tears. It gives excellent information with regards to the rotator cuff, presence of any tears of the rotator cuff tendons, state of the rotator cuff muscles etc.

I am told I have a rotator cuff tear. How can it be treated?

Intact cuff vs partial cuff tear vs full thickness cuff tear
Comparison of rotator cuff tears

Rotator cuff tears can range in severity greatly. Treatment depends very much on how bad the tear is. We usually classify tears into the following: partial tears, small full thickness tears, medium tears, large tears, massive tears and finally, cuff tear arthropathy (where the joint is permanently damaged due to the presence of severe rotator cuff tears). The attached pictures show what an intact cuff versus partial cuff tear versus full thickness cuff looks like. Exact details of each are too complicated to describe here (entire books have been written on rotator cuff tears and their treatment). But basically, partial tears may be treated with simple physiotherapy and activity modification. Complete tears usually require surgical fixation unless the patient is asymptomatic (which begs the question, why would the patient have sought help from a doctor in the first place?). Massive tears may require more controversial forms of surgery like tendon transfers, insertion of “spacers” or balloons or soft tissue reconstruction. Finally, cuff tear arthropathy will require a special type of joint replacement.

How is rotator cuff surgery performed?

Double row rotator cuff repair
Rotator cuff repair
Suture anchor

The tendon tear almost always occurs at the area where the tendon joins the bone. An analogy would be the “glue” holding the tendon to the bone has weakened and the tendon comes off the bone. The aim of the surgery is thus to reattach the tendon to the bone. This is done via keyhole surgery or minimally invasive surgery. For a more detailed description of shoulder surgery, please refer to the page on Keyhole Surgery.

There are many ways to repair the tendon tear. A detailed discourse of tendon repairs is beyond the scope of this article. Basically, as tendons are somewhat rubbery in texture, it is easy to pass stitches through the tendon to pull the torn and sometimes retracted tendon back to place. To hold it fast to the bone so that it can eventually heal up and reattach itself to the bone, it is necessary to use suture anchors. Suture anchors are small implants made of either metal (often titanium) or medical grade plastics. They measure about 0.5 cm in diameter and 1 cm in length. A hole just big enough to insert the suture anchor is made in the bone the suture anchor is screwed in. The sutures are then passed through the tendon and tightly tied in place, firmly securing the torn tendon to the bone. These anchors are designed to be permanent and will not cause any problems like rejection or corrosion. They do not need to be removed.

What kind of anaesthesia will I require?

I often do these surgeries under general anaesthesia. An anaesthetist will be present throughout the surgery to not only anaesthetize the patient, but also to monitor the patient throughout the duration of the surgery to ensure safety of the patient. Please read the section on anaesthesia for more information.

How long does the surgery take?

The surgery usually takes slightly over an hour. But complicated cases can take up to 2 hours.

Is this surgery very dangerous?


Not at all. Risks of any procedure can usually be divided into anaesthetic risks and surgical risks. For most patients, the risk of any serious adverse event happening is less than 1-2%. However, as every patient is different, it is important that you have a detailed chat with your doctor with regard to your risk.

Can I return home on the same day as the surgery?

Yes, certainly you can return home on the same day. Many patients, however, find it more convenient to stay overnight. This is because you may be feeling rather drowsy and tired after you wake up from the anaesthesia.

How long will I take to recover?

Full recovery can take anything from 6 months to a year. Physiotherapy is very important after the surgery because patients will always develop temporary stiffness of the shoulder after the surgery. But with physiotherapy, most patients can expect to recover full functionality of the shoulder. For more details about physiotherapy, please refer to the section on Physiotherapy.

What should I do now?

If you have managed to get to this part of this long article, your shoulder must be bothering you significantly! Consult your family doctor or see an orthopaedic specialist and he/she should be able to advise you accordingly.

Disclaimer:

The above information is meant to be used as a guide and for patient education purposes. This article is not meant to be a used for self diagnosis or a substitute for professional medical evaluation or advice. As patients may be differing symptoms, please see your family doctor or orthopaedic specialist if you have any symptoms or worries.

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