By Erik C. Johnson, M.D.
The rotator cuff is one of the most important structures of the shoulder. It is composed of four muscles and their tendons that hold the shoulder joint in place. The “cuff”, or the tendon portion of the rotator cuff, inserts onto the upper arm. The rotator cuff helps to elevate and rotate the arm away from the body.
Rotator cuff tears are most common in individuals over the age of 40. Younger patients may sustain tears with acute trauma or repetitive overhead activities. Common examples include factory workers who perform the same overhead activity throughout the day or baseball pitchers.
Symptoms of a torn rotator cuff may develop quickly after trauma or may have a more gradual onset. Acute tears usually occur with activities of heavy lifting or falls onto the affected shoulder. Usually, the pain starts slowly with overhead activities and is relieved by rest. The pain runs down the side of the arm toward the elbow. At first, the pain is activity related and is only present with overhead activities such as reaching into the kitchen cabinet for a dish.
Over time the pain may become constant especially at night while trying to go to sleep. Other symptoms include weakness and loss of motion. You may have difficulty reaching overhead to comb your hair or placing your arm behind your back. When tears occur with sudden trauma, a sudden “pop” may be felt in the shoulder with the inability to raise the arm.
The diagnosis of a rotator cuff tear is based on the patient’s history, a thorough physical examination, and imaging studies such as x-rays and MRI (magnetic resonance imaging). Your doctor will examine the shoulder for both active and passive range of motion, muscle strength, and tenderness. Some of the common signs of a torn rotator cuff include wasting of the muscles of the shoulder, pain when you lift the arm, and weakness with lifting. Plain x-rays of the shoulder are usually normal or may show a bone spur. An MRI is a more sensitive test for detecting a rotator cuff tear. It can distinguish between a partial versus a full-thickness tear.
Once the diagnosis of a rotator cuff tear has been made, several treatment options exist. In many cases, non-surgical treatment can provide pain relief and improve the function of the shoulder. Usually treatment starts with an anti-inflammatory medication as well as rest from the offending activity. Often physical therapy is instituted to improve the strength of the surrounding musculature of the shoulder. Steroid injections are occasionally given to help reduce the inflammation as well as pain in the shoulder. It may take weeks to months to reduce the pain and improve the function of the shoulder with these non-operative measures.
If non-operative treatment does not relieve the symptoms, surgery may be necessary. Surgery may be indicated in the acute situation when the dominant arm is involved for persons involved in overhead work or activities. The type of surgery required depends on several factors including tear size, surgeon experience, and location of the tear. In general, three approaches are used to repair the tendon back to the bone; open repair, mini-open repair, and arthroscopic repair. During an open repair, a 10-centimeter or larger skin incision is made to repair the rotator cuff. A mini-open repair is done through a 4-6 centimeter incision. During arthroscopic repair, a fiber optic scope and small instruments are inserted through small puncture incisions. The scope is connected to a television monitor and the rotator cuff repair is performed under video control. Your surgeon will determine which technique is best for you.
After surgery, the shoulder is immobilized in a sling to allow the rotator cuff tendon to heal. The sling is worn from 4 to 6 weeks depending on the size of the tear. Physical therapy is often performed to help regain motion as well as strength in the shoulder. Complete recovery may take several months. Return to recreational activities such as golf oftentimes takes 6 months or more.
Future developments in the treatment in rotator cuff tears include newer arthroscopic surgical techniques that allow for smaller incisions and quicker recovery times.
Dr. Erik Johnson is an orthopaedic surgeon with Carolina Orthopaedic & Sports Medicine Center, P.A. in Gastonia, NC. He is on staff at Gaston Memorial Hospital.