Rotator Cuff Tears and Rotator Cuff Surgery. Symptoms, Risk Factors, Diagnosis, Surgery Options
The rotator cuff symptoms, tears and surgery are referred to by many names and phrases including: rotator injury, rotator tear, rotator surgery, rotator repair and rotator cup. Doctors and surgeons refer to it as the rotator cuff. Injuries and rotator cuff symptoms can vary from rotator bursitis, rotator impingement, and bone spurs to a rotator sprain or strain to a rotator tear.
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Rotator Cuff Symptoms
- Recurrent, constant pain, particularly with overhead activities.
- Pain at night that prevents you from sleeping on the affected side.
- Muscle weakness, especially when attempting to lift the arm.
- Catching and grating or cracking sounds when the arm is moved.
- Limited motion.
Many patients’ rotator cuff symptoms can improve with rotator exercises but when there is a tear of the rotator cuff, it usually requires arthroscopic shoulder surgery.
Rotator cuff symptoms are very common in the U.S. and can affect individuals of all ages.
It is estimated that more than 4 million people in the U.S. seek medical care each year for shoulder problems. Although there are many reasons for shoulder pain, rotator cuff tears are a common problem for people over 40 years of age.
Those younger than 40 years old can also require rotator cuff treatment. However, this patient group is more likely to have another shoulder problem that leads to a rotator injury.
If the primary problem, usually loose shoulder ligaments, is not diagnosed and treated correctly then the patient will continue to have problems even if the rotator injury is treated.
What is the Rotor Cuff or Rotator Cup? (Correctly Called the Rotator Cuff)
Side view of shoulder anatomy
The rotator cuff is a group of muscles deep inside of the shoulder. Every muscle in the body normally attaches to a bone. This attachment occurs as the end of the muscle becomes a tendon which then inserts into the bone. Muscle is typically a red, beefy tissue while a tendon is a white, firm, grisly tissue.
The rotator cuff is made of 4 different muscles and shoulder tendons. These include the supraspinatus, infraspinatus, subscapularis and teres minor muscles. Each has a slightly different function but in general the combination of them function to hold the ball (humeral head) in the socket (glenoid) as you raise your arm above your head or take it back as if you are going to throw a ball.
Bones of the Shoulder
Rotator Cuff Tear Risk Factors
- Repetitive overhead motion, such as pitching or painting a ceiling.
- Heavy lifting.
- Excessive force, such as a fall.
- Degeneration due to aging, including a reduction in the blood supply to the tendon.
- Narrowing of the space (acromioclavicular arch) between the collarbone (clavicle) and the top portion (acromion) of the shoulder bone (scapula).
- Rubbing (abrasion) of the cuff surface by the top portion of the shoulder bone.
In addition to the rotator cuff, it is important to also understand the bones that are involved in the shoulder. The rotator cuff sits under two important bones on the top of your shoulder: collar bone (clavicle) and the acromion. The acromion protrudes from the shoulder blade onto the very top of the shoulder. Bones spurs pointing down from the clavicle or acromion can rub on the rotator cuff.
The rotator cuff attaches on the top outer part of the humerus (arm bone). As the muscles contract (squeeze) the humeral head is held in the glenoid and the arm raises overhead. In addition to the rotator cuff, the biceps tendon is another important structure within the shoulder. Even though the biceps muscle is in the front of your arm, the tendon attaches in the front part of the shoulder. The biceps tendon is very close to the rotator cuff and it is common to have injuries to this tendon is association with rotator injuries.
A tear of the rotator cuff can occur in three ways.
- First, a rotator injury from a fall, a lifting injury or a forceful pull on the arm. This is known as an acute rotator cuff tear.
For 99% of patients, I routinely perform the less-invasive arthroscopic shoulder surgery for rotator cuff injuries and tears regardless of size. In my experience, even the largest of tears can be repaired better with arthroscopic surgery than with open surgery.
- The second cause is from years of use. This is common in people that do a lot of overhead work or are heavy laborers. In these cases, the rotator cuff slowly tears over time and finally reaches a point where people begin to feel pain. In other situations patients suffer from impingement which is where the rotator cuff is pinched under bone spurs from the acromion and clavicle bones. Over time the spurs cause the cuff to tear.
- The third and final way the rotator cuff tears is from repetitive overuse. This sounds similar to the last category that I just described. However in this case I am referring to younger individuals that participate in overhead sports such as baseball or swimming. They commonly have loose ligaments in their shoulder. This makes it hard for the rotator cuff to hold the ball in the socket as they use their arms. In many cases their rotator cuff muscles will be weak from them not doing enough rotator exercises. Over time with extra stress on the rotator cuff, it slowly tears and causes pain.
Diagnosing a Rotator Injury and Tear at your Appointment. What to Expect.
ACL Knee Surgeon
This article has been written by me, Vic Goradia, M.D., a nationally recognized orthopedic sports medicine surgeon specializing in knee and shoulder surgery.
I am a master instructor in advanced arthroscopic shoulder surgery, teaching other surgeons around the United States.
See Dr. Goradia's bio.
During your consultation, I will ask you about your symptoms and any recent injuries. I will carefully examine the top and back of your shoulder to see if the muscles have begun to shrink (i.e. atrophy).
You may be asked to move your arm in several directions, or to hold it in various positions. X-rays can help me see problems with the bones, although other tests may be required to confirm a rotator cuff tear.
One such test is an arthrogram, in which a dye is injected into the joint before the X-ray is taken. This was a very common test prior to MRI.
Currently, it is more common for me to order an MRI which is better for showing the rotator cuff muscles as well as other structures such as the biceps tendon. In some cases I will order an arthrogram with an MRI which is known as a MR arthrogram.
Rotator cuff tears may be partial-thickness or full-thickness.
Partial-thickness tears do not completely sever the tendon but over time will often worsen and in many cases progress to full-thickness tears. Full-thickness tears fully sever the tendon and require surgery to correct.
In some cases, you may have already undergone some initial treatment such as:
- Rest. This will sometime help you feel better even with a full thickness rotator tear.
- Non-steroidal anti-inflammatory medications. This helps control rotator cuff symptoms such as pain.
- Strengthening and stretching rotator cuff exercises. As part of a rotator cuff therapy program.
- Cortisone injections. These injections can help reduce pain but cannot be repeated frequently because they can weaken the tendon.
Rotator Surgery Options
There are several surgical options to treat rotator cuff tears, depending on the size, depth, and location of the tear. If other shoulder problems are discovered during the surgery, they will be corrected as well.
- Arthroscopic shoulder surgery. Small instruments are inserted through small skin punctures, can be used to remove bone spurs, remove bursitis and repair rotator tears.
- A mini-open repair. This is a combination of arthroscopy and a 3-4 inch incision is used by most surgeons. They have to cut through your deltoid muscle in order to see and treat your rotator cuff tear.
- Open surgery. A larger incision is used and the deltoid muscle is detached from the bone.
My Preferred Rotator Surgery Treatment
In almost 99% of patients I routinely perform arthroscopic shoulder surgery for rotator injuries and rotator tears regardless of size. In my experience, even with the largest of tears it is advantageous to repair arthroscopically as opposed to open surgery. Typically, patients will consult me for a second opinion regarding a rotator tear where another surgeon has either told them they cannot repair the tear at all or they have been told it will require a large open incision. Again, in 99% of cases I will repair the tear arthroscopically.
Over the last 3 years I have also developed a new technique which I use for very bad tears that have poor tissue quality or are severely retracted and scarred. With this technique, I can reinforce a rotator repair with donor tissue. The donor tissue is a rotator cuff tendon that comes from a cadaver. I place the tissue into the shoulder arthroscopically and use it to strengthen the repair.
About Dr. Goradia
Vic Goradia, MD is a nationally known knee, shoulder and sports medicine specialist. Dr. Goradia has published and presented numerous medical articles related to shoulder arthroscopy. He also routinely teaches advanced arthroscopic shoulder surgery to other orthopedic surgeons around the U.S. at medial conferences.
Dr. Goradia is a member of the Arthroscopy Association of North America (AANA), the American Orthopedic Society for Sports Medicine and other societies. Dr. Goradia has served as chairman of the technology committee for AANA and on the editorial board for the Journal of Arthroscopy. He is also a consultant for orthopedic companies that develop new techniques and instruments for arthroscopic surgery.