Rotator Cuff Tear

Introduction

Your rotator cuff is made up of the muscles and tendons in your shoulder. These muscles and tendons connect your upper arm bone with your shoulder blade. They also help hold the ball of your upper arm bone firmly in your shoulder socket. The combination results in the greatest range of motion of any joint in your body.

A rotator cuff injury includes any type of irritation or damage to your rotator cuff muscles or tendons. Causes of a rotator cuff injury may include falling, lifting and repetitive arm activities — especially those done overhead, such as throwing a baseball or placing items on overhead shelves.

About half of the time, a rotator cuff injury can heal with self-care measures or exercise therapy.
 

When is Rotator Cuff Tear Surgery recommended?

Rotator cuff injury signs and symptoms may include:

  • Pain and tenderness in your shoulder, especially when reaching overhead, reaching behind your back, lifting, pulling or sleeping on the affected side

  • Shoulder weakness

  • Loss of shoulder range of motion

  • Inclination to keep your shoulder inactive

The most common symptom is pain. You may experience it when you reach up to comb your hair, bend your arm back to put on a jacket or carry something heavy. Lying on the affected shoulder also can be painful. If you have a severe injury, such as a large tear, you may experience continuous pain and muscle weakness.

You should see your doctor if:

  • You're experiencing severe shoulder pain

  • You're unable to use your arm or feel weak in the arm

  • You have shoulder pain that's lasted more than a week

What are the causes?

Four major muscles (subscapularis, supraspinatus, infraspinatus and teres minor) and their tendons connect your upper arm bone (humerus) with your shoulder blade (scapula). A rotator cuff injury, which is fairly common, involves any type of irritation or damage to your rotator cuff muscles or tendons, including:

  • Tendinitis. Tendons in your rotator cuff can become inflamed due to overuse or overload, especially if you're an athlete who performs a lot of overhead activities, such as in tennis or racquetball.

  • Bursitis. The fluid-filled sac (bursa) between your shoulder joint and rotator cuff tendons can become irritated and inflamed.

  • Strain or tear. Left untreated, tendinitis can weaken a tendon and lead to chronic tendon degeneration or to a tendon tear. Stress from overuse also can cause a shoulder tendon or muscle to tear.

Common causes of rotator cuff injuries include:

  • Normal wear and tear. Increasingly after age 40, normal wear and tear on your rotator cuff can cause a breakdown of fibrous protein (collagen) in the cuff's tendons and muscles. This makes them more prone to degeneration and injury. With age, you may also develop calcium deposits within the cuff or arthritic bone spurs that can pinch or irritate your rotator cuff.

  • Poor posture. When you slouch your neck and shoulders forward, the space where the rotator cuff muscles reside can become smaller. This can allow a muscle or tendon to become pinched under your shoulder bones (including your collarbone), especially during overhead activities, such as throwing.

  • Falling. Using your arm to break a fall or falling on your arm can bruise or tear a rotator cuff tendon or muscle.

  • Lifting or pulling. Lifting an object that's too heavy or doing so improperly — especially overhead — can strain or tear your tendons or muscles. Likewise, pulling something, such as a high-poundage archery bow, may cause an injury.

  • Repetitive stress. Repetitive overhead movement of your arms can stress your rotator cuff muscles and tendons, causing inflammation and eventually tearing. This occurs often in athletes, especially baseball pitchers, swimmers and tennis players. It's also common among people in the building trades, such as painters and carpenters.

How is Rotator Cuff Tear diagnosed?

If your injury appears to be severe or your doctor can't determine the cause of your pain through physical examination, he or she may recommend diagnostic imaging tests to better delineate your shoulder joint, muscles and tendons. These may include:

  • X-rays

  • A magnetic resonance imaging (MRI) scan

  • An ultrasound scan

What are the treatment options for Rotator Cuff Tear?

Most of the time, treatment for rotator cuff injuries involves exercise therapy. Your doctor or a physical therapist will talk with you about specific exercises designed to help heal your injury, improve the flexibility of your rotator cuff and shoulder muscles, and provide balanced shoulder muscle strength. Depending on the severity of your injury, physical therapy may take from several weeks to several months to reach maximum effectiveness.

Other rotator cuff injury treatments may include:

  • Steroid injections. Depending on the severity of your pain, your doctor may use a corticosteroid injection to relieve inflammation and pain.

  • Surgery. If you have a large tear in your rotator cuff, you may need surgery to repair the tear. Sometimes during this kind of surgery doctors may remove a bone spur or calcium deposits. The surgery may be performed as an open repair through a 2 1/2- to 4-inch (6- to 10-centimeter) incision, as a mini-open repair through a 1 1/4- to 2-inch (3- to 5-centimeter) incision, or as an arthroscopic repair with the aid of a small camera inserted through a smaller incision.

  • Arthroplasty. Some long-standing rotator cuff tears over time may contribute to the development of rotator cuff arthropathy, which can include severe arthritis. In such cases, your doctor may discuss with you more extensive surgical options, including partial shoulder replacement (hemiarthroplasty) or total shoulder replacement (prosthetic arthroplasty).

A unique treatment option now available involves the use of a reverse ball-and-socket prosthesis. This reverse shoulder prosthesis is most appropriate for people who have very difficult shoulder problems. These include having arthritis in the joint, along with extensive tears of multiple muscles and tendons (rotator cuff) that support the shoulder, or having extensive rotator cuff tears and a failed previous shoulder joint replacement.

What are the risk factors for Rotator Cuff Tear?

The following factors may increase your risk of having a rotator cuff injury:

  • Age. As you get older, your risk of a rotator cuff injury increases. Rotator cuff tears are most common in people older than 40.

  • Being an athlete. Athletes who regularly use repetitive motions, such as baseball pitchers, archers and tennis players, have a greater risk of having a rotator cuff injury.

  • Working in the construction trades. Carpenters and painters, who also use repetitive motions, have an increased risk of injury.

  • Having poor posture. A forward-shoulder posture can cause a muscle or tendon to become irritated and inflamed when you throw or perform overhead activities.

  • Having weak shoulder muscles. This risk factor can be decreased or eliminated with shoulder-strengthening exercises, especially for the less commonly strengthened muscles on the back of the shoulder and around the shoulder blades.

Can Rotator Cuff Tear be prevented?

If you've had a rotator cuff injury in the past, daily shoulder stretches and a shoulder-strengthening program can help prevent a recurrence. Especially important is a program of strength exercise to promote balanced strength about the shoulder. Most people exercise the front muscles of the chest, shoulder and upper arm, but it is equally important to strengthen the muscles in the back of the shoulder and around the shoulder blade.

If you are at risk of rotator cuff injuries — such as from having a job or hobby that requires repetitive shoulder motions — daily exercises can help prevent an injury. Your doctor or a physical therapist can help you plan an exercise routine.

To help prevent a rotator cuff injury:

  • Do regular shoulder exercises

  • Take frequent breaks at work if your job requires repetitive arm and shoulder motions

  • Rest your shoulder regularly during sports that require repetitive arm use

  • Apply cold packs and heat pads when you experience any shoulder pain or inflammation

How fast can you recover?

The first days after rotator cuff surgery are focused on ensuring that your pain control is adequate. Your doctor will prescribe medications to help with discomfort. Always try to prevent the pain from becoming severe by taking smaller doses of pain medication at the early signs of discomfort, rather than large doses when the pain is more severe. Trying different types of medication can also be helpful; many doctor recommend alternating prescribed narcotic medications with an anti-inflammatory medication. And don't forget about icing the shoulder. Ice application may be the most important part of pain control.

Sleeping at Night:

Sleeping after shoulder surgery can be a challenge. Even a moderate ache in the shoulder can prevent a good night's sleep. Many patients find it most comfortable to sleep in a semi-upright position after rotator cuff surgery; a recliner is perfect. If you don't have a recliner, just get a lot of pillows and create a back rest in bed to allow you to sleep in a seated position with the elbow pointing down. A sleep-aid medication may be as helpful as a pain medication, as getting a good night's sleep can do as much for pain control as anything else.

Recovery Phase 1: Passive Motion:

The first phase of recovery is passive motion only. This may last up to 6 weeks, depending on the size of the rotator cuff tear and the strength of the repair.

Passive motion means the rotator cuff muscles and tendons are not doing any work. When the rotator cuff muscles contract, tension is placed on the repair that was performed. Passive motion means that the shoulder moves without placing tension on the repair.

In order to perform passive motion, your therapist will move your shoulder for you. The therapist can also instruct you on how to move your own shoulder without contracting the rotator cuff muscles.

Recovery Phase 2: Active Motion:

Active motion is initiated when there is sufficient healing of the tendons to allow them to start moving the arm, but before any extra resistance is applied. You may be limited to active motion for up to 12 weeks from the time of surgery. Active motion means that you can move your own arm, but not against resistance.

Recovery Phase 3: Strengthening:

The strengthening phase of recovery is the most important. Because of the injury, surgery, and early phases of recovery, the muscles of the rotator cuff have become weak. Once the repair has adequately healed, it is important to begin strengthening the muscles to allow you to resume your normal activity level.

The rotator cuff muscles do not need heavy weights for effective strengthening. A skilled therapist can instruct you on techniques to isolate the proper muscles for strengthening such that only light resistance bands or weights can provide an excellent workout.

Recovery Phase 4: Full Activity:

Full recovery after rotator cuff surgery often takes 4 to 6 months and in some cases longer. The critical factors that determine the length of the recovery are the size of the rotator cuff tear, the ability to adequately repair the tendons, and the commitment to rehabilitation.

Knowing when to progress from one phase of rehab to the next is an art. Not all people will progress through rehab in the same way, and each individual must adhere to their prescribed rehab protocol. Discuss any specific questions you have about your rehab with your surgeon.

After Discharge?

Medicines:

  • Acetaminophen: This medicine decreases pain. Acetaminophen is available without a doctor's order. Ask how much to take and how often to take it. Follow directions. Acetaminophen can cause liver damage if not taken correctly.

  • NSAIDs: These medicines decrease swelling, pain, and fever. NSAIDs are available without a doctor's order. Ask your primary healthcare provider which medicine is right for you. Ask how much to take and when to take it. Take as directed. NSAIDs can cause stomach bleeding or kidney problems if not taken correctly.

  • Pain medicine: You may be given a prescription medicine to decrease pain. Do not wait until the pain is severe before you take this medicine.

  • Steroids: This medicine may be injected into the rotator cuff area to decrease inflammation and pain.

  • Take your medicine as directed: Call your primary healthcare provider if you think your medicine is not helping or if you have side effects. Tell him if you are allergic to any medicine. Keep a list of the medicines, vitamins, and herbs you take. Include the amounts, and when and why you take them. Bring the list or the pill bottles to follow-up visits. Carry your medicine list with you in case of an emergency.

Follow up with your primary healthcare provider or orthopedist as directed:

Write down your questions so you remember to ask them during your visits.

Physical therapy:

A physical therapist can teach you exercises to help improve movement and strength, and to decrease pain. These exercises may help you go back to your usual activities or return to playing sports.

Self-care:

  • Rest: Rest may help your shoulder heal. Overuse of your shoulder can make your injury worse. Avoid heavy lifting, using your arms over your head, or any other activity that makes the pain worse.

  • Put ice or heat on your shoulder: Use ice on your shoulder every few hours for the first several days. This may help decrease pain and swelling. After the first several days, a heating pad may help relax the muscles in your shoulder.

Contact your primary healthcare provider or orthopedist if:

  • The pain in your shoulder or arm is not improving, or is worse than before you started treatment

  • You have new pain in your neck

  • You have a fever

  • You have questions or concerns about your condition or care

What are the results of the surgery?

The majority of patients report improved shoulder strength and less pain after surgery for a torn rotator cuff.

Each surgical repair technique (open, mini-open, and arthroscopic) has similar results in terms of pain relief, improvement in strength and function, and patient satisfaction. Surgeon expertise is more important in achieving satisfactory results than the choice of technique.

Factors that can decrease the likelihood of a satisfactory result include:

  • Poor tendon/tissue quality

  • Large or massive tears

  • Poor patient compliance with rehabilitation and restrictions after surgery

  • Patient age (older than 65 years)

  • Smoking and use of other nicotine products

  • Workers' compensation claims

What are the complications?

After rotator cuff surgery, a small percentage of patients experience complications. In addition to the risks of surgery in general, such as blood loss or problems related to anesthesia, complications of rotator cuff surgery may include:

  • Nerve injury. This typically involves the nerve that activates your shoulder muscle (deltoid).

  • Infection. Patients are given antibiotics during the procedure to lessen the risk for infection. If an infection develops, an additional surgery or prolonged antibiotic treatment may be needed.

  • Deltoid detachment. During an open repair, this shoulder muscle is detached to provide better access to the rotator cuff. It is stitched back into place at the end of the procedure. It is very important to protect this area after surgery and during rehabilitation to allow it to heal.

  • Stiffness. Early rehabilitation lessens the likelihood of permanent stiffness or loss of motion. Most of the time, stiffness will improve with more aggressive therapy and exercise.

  • Tendon re-tear. There is a chance for re-tear following all types of repairs. The larger the tear, the higher the risk of re-tear. Patients who re-tear their tendons usually do not have greater pain or decreased shoulder function. Repeat surgery is needed only if there is severe pain or loss of function.

Cost of Surgery?

The cost of surgery for Rotator Cuff Tear depends on many factors. They include the cost of being in the hospital for several days. Unexpected events that result in an extended hospital stay will also increase the overall cost.

Costs also vary depending on the type of insurance coverage you have. Many insurance companies cover the cost of the surgery, the hospital stay, and the instruments to straighten the spine. You may owe a co-payment or you may be billed the balance of what your insurance does not cover.

Be sure to contact your insurance provider prior to surgery to discuss the extent of your coverage. Discuss with your surgeon, as well as the hospital billing department to make sure you understand all the costs involved.

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