What is the Rotator Cuff?

The rotator cuff is a group of four muscles that envelope the shoulder blade, or scapula.  As those muscles travel to their insertion site, the upper part of the arm, they coalesce into a cuff of tendons.  This cuff inserts into the upper end of the arm (onto the head of the humerus).   The rotator cuff muscles help lift and rotate the arm.

What is a Rotator Cuff Tear?

The term "tear" gives one the impression that the muscle tears.  However, it is highly unusual for the actual muscle to tear.  Most commonly, tendinous part of the cuff- the part that inserts into the bone- detaches itself from the bone.  Generally speaking, rotator cuff tears occur in individuals over the age of 40, as the result of "wear and tear". People who do repetitive overhead work are at a higher risk for rotator cuff tears. 

Tears can also occur in the following scenarios:

• Traumatic tears in people younger than 40
• In overhead athletes
• In conjuction with a fracture or dislocation of the shoulder

Symptoms of a rotator cuff Tear

Pain is the most common symptom of a rotator cuff tear. It may develop acutely such as after a fall or a sudden lifting injury.  More commonly it occurs slowly over time.  The pain may present in the front of the shoulder and can even radiate down the arm.  As the condition worsens, the pain may be noticeable at rest.  Pain at night time, during sleep is also common.

It is also very common to develop stiffness and weakness in the shoulder.  You may notice that it is difficult to reach behind your back while grooming or fastening a seat belt.

Diagnosis of a Rotator Cuff Tear

The first step in making a diagnosis of a rotator cuff tear is a thorough review of your symptoms and a good physical exam.  Plain X-rays can often be very helpful to rule out other very common causes of shoulder pain.

If the index of suspicion for a rotator cuff tear is high, your doctor may order an MRI.  Magnetic Resonance Imaging (MRI) is very sensitive in diagnosing rotator cuff tears, and may reveal other possible sources of shoulder pain.

If you are not a candidate for an MRI scan, it may be necessary to use an arthrogram or an ultrasound to help confirm the diagnosis.

Treatment of rotator cuff tears: Non-Surgical

Treatment depends on a variety of factors.  Often, a rotator cuff tear is only a "partial tear".  In this situation, some of the fibers of the rotator cuff have frayed and torn, but there is still some structural integrity to the rotator cuff.  Partial tears are usually treated with:

• Rest and activity modifications
• Anti-Inflammatories
• Physical Therapy
• Occasionally injections

The process of wear and tear on the rotator cuff occurs slowly over time.  Associated weakness and stiffness also develops slowly over time. Thus, it may take weeks or months for your pain to improve with the above treatments.

Treatment of rotator cuff tears: Surgical

Surgery may be recommended in the following circumstances:

• Acute, traumatic tears
• Partial tears that fail to improve with appropriate attempts at non-surgical care
• Symptomatic, full thickness tears in active individuals

Surgery to repair a torn rotator cuff is usually done on an outpatient basis.  The goal of surgery is to re-attach the torn tendon to the bone.  This may be done through a small incision (a mini-open repair) or entirely with the use of an arthroscope (using several incisions that each measure less than a centimeter).  Often times, your surgeon will need to address other conditions that may be contributing to your pain, such as bone spurs or arthritis.  To read more about surgical options, Click Here .

Regardless of the surgical technique used, the "biology" of soft tissue healing to bone is the same.  The surgeons job is to re-attach the tendon to the bone in a mannar that provides good, secure fixation so that your bone and tendon can grow back together.  This process can take months.  Thus, the patient's and physical therapist's role are as critical in the success of the surgery as the surgeon's.  

Rehabilitation

Rehabilitation after a rotator cuff repair depends on the nature of the repair and the particular philosophy of your treating surgeon.  But, most rehab protocols follow the same principles:

• Early goals:  passive motion (someone moves your arm for you) prevents adhesions and scar tissue formation, but "protects" the repair from the stresses of active motion
• Intermediate goals:  active motion helps stimulate healing and allows for gradual return of muscle function
• Late goals:  Strengthening.  This is the last step in your rehab protocol.  It may takes several months to regain strength, and even up to a year to regain your endurance

Research on the Horizon

Work is constantly being done on minimizing soft tissue trauma during rotator cuff surgery.  Arthroscopic surgery has gained a lot of support, and techiques are continually being refined and improved.  However, the mini-open repair continues to lead to excellent and predictable results.

Research is also being done on growth factors that may enhance healing of the repair.

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