Rotator cuff tear

Tears to the rotator cuff tend to occur when the wide rotator cuff tendons that surround the shoulder pull away from the bone, much like a carpet pulling away from its grippers on the floor.

The rotator cuff covers a large area and is made up of multiple tendons and muscles. Tearing can be of a small area through to the entire cuff, and range from painless tears you may be unaware of to tears causing significant pain and weakness.

Overall tears can be put into three main categories.

• Acute tears – sudden tearing from injury on a previously good tendon.
• Acute on chronic tears – sudden tearing from injury on a tendon already damaged or torn.
• Chronic tears – wearing through of the tendons over time from wear and tear or repeated minor injuries.

As you get older your risk of tears increases. In those over 70 a large number of people will have some tearing of the tendons although it may not cause problems, as the other muscles and tendons around the shoulder will compensate.

Causes of rotator cuff tear include:

• An injury, such as a fall or sudden accident, that has directly torn one or more of the tendons.
• Jobs that involve using your arms above your head regularly, such as painting and decorating or construction. This wears the tendons through over time.
• Sports that involve repetitive arm movements, such as tennis, archery or basketball.
• Shoulder dislocation if you are about 40 years or over.
• Previous shoulder injury that has partially torn a tendon.
• Simply getting older with tendons that have thinned and weakened.

Symptoms that could indicate a rotator cuff injury include:

• Pain on moving or lifting the arm. This may be felt (radiate) down the outside of the arm or up the shoulder blade where the rotator cuff muscles lie.
• A dull ache in your shoulder which may feel worse if you try to sleep on the affected side.
• Weakness in the affected arm.
• Loss of movement and flexibility, for example, you may be unable to reach behind your back or brush your hair.

A number of different approaches may be used to diagnose a rotator cuff injury, including:

• Physical examination, which may test for loss of movement and strength in your shoulder and arms.
• X-ray to rule out other possible causes of pain, including arthritis or the formation of bony spurs. This also shows any change in position of the ball and socket due to big tears.
• Ultrasound to check the condition of the soft tissues and assess your shoulder joint as it moves.
• MRI scan to build up a detailed image of the shoulder joint.

Ultrasound and MRI are good teats to look for tears but are not 100% accurate.

There are a number of possible treatments for rotator cuff injuries, depending on how serious the injury is and what the tendon quality is like.

The treatment of a tear that has occurred directly from injury (acute) may need quicker treatment or repair, with best results seen if tendons are repaired within a few months of the injury. However, chronic tears may not need repair.

The size of the tear may not relate to the degree of pain or the need for treatment and expert guidance can help clarify options for a condition where management can be confusing.

If the tear is relatively minor (minimal pain and good function), you may benefit from:

• Painkillers and anti-inflammatories.
• An exercise program to help increase the range of motion in your shoulder and improve muscle strength and flexibility. This may be guided by physiotherapists.
• Injections of corticosteroids into the joint to relieve pain and reduce inflammation in the short-term.

For more serious tear, some of the treatments may be important but you may also require surgery. There are a number of possible approaches, including:

• Arthroscopy – this is a minimally invasive (keyhole) surgical procedure to repair the affected tendon. It involves making a small incision in the skin and inserting an arthroscope, which is a tiny, flexible tube with a camera at one end that allows the surgeon to see inside the joint. Tiny surgical tools are inserted through further incisions in the skin and used to reattach torn tendons to the bone.
• Open surgery – to reattach damaged tendons to the bone when this cannot be achieved keyhole.
• Tendon grafts – these are false tendons used to replace or reinforce damaged areas. They may be derived from human donor skin which allows the most ‘biological’ healing.
• Tendon transfer involves using a tendon from another part of the body to replace the damaged rotator cuff.
• Joint replacement surgery may be required if there is substantial damage to the rotator cuff that cannot be repaired. Reverse shoulder arthroplasty involves creating a ball joint within the shoulder blade and a socket in the arm bone to improve movement and flexibility.