The shoulder is a complex, ball-and-socket joint that rotates through a greater range of motion than any other joint in the body. The shoulder is made up of: the upper arm bone (humerus), shoulder blade (scapula), and collarbone (clavicle). The ball, or head of the upper arm, fits into a shallow socket (glenoid) in the shoulder blade. The ends of these bones, where they touch, are covered with articular cartilage, a smooth substance that protects the bones and enables them to move easily. The glenoid is ringed by the labrum, a strong, fibrous cartilage that forms a gasket around the socket, adding stability and cushioning the joint.
The arm is held in the shoulder socket by the rotator cuff—a network of four muscles that come together as tendons to form a covering around the head of the humerus. The rotator cuff attaches the humerus to the shoulder blade and helps to lift and rotate your arm. Between the rotator cuff and the bone on top of your shoulder (acromion) is a lubricating sac (bursa). The bursa allows the rotator cuff tendons to glide smoothly during movement. When rotator cuff tendons are injured or damaged, the bursa can also become inflamed and painful.
When one or more of the rotator cuff tendons is torn, the tendon no longer fully attaches to the head of the humerus. Most tears occur in the supraspinatus muscle and tendon, but other parts of the rotator cuff may also be involved. In many cases, the tear begins with fraying. As the damage progresses, lifting a heavy object or other similar action can result in a complete tear of the tendon. A torn rotator cuff weakens the shoulder, making it painful and difficult to perform simple daily activities such as getting dressed or combing your hair.
Injury (acute tear) and degeneration (chronic tear) are the primary causes of rotator cuff tears.
Although most common in the dominant arm, a degenerative tear in one shoulder increases the risk of a similar tear in the opposite shoulder, even if there is no pain. Other risk factors include advancing age and performing repetitive activities over time.
Common symptoms of a rotator cuff tear include: pain at rest and at night, particularly when lying on the affected shoulder; pain when lifting and lowering the arm, or with specific movements; weakness when lifting or rotating the arm; and experiencing a crackling sensation (crepitus) when moving the shoulder in certain positions.
Sudden rotator cuff tears, such as from an injury or fall, usually cause intense pain. There may be a snapping sensation, immediate weakness in the upper arm, and pain when lifting the arm out to the side.
Tears that develop gradually due to overuse also cause pain and arm weakness. At first, pain may be mild, present only when lifting your arm above your head, and relieved by over-the-counter medication, such as aspirin or ibuprofen. Over time, symptoms become pronounced. You may have shoulder pain when you lift your arm to the side, or pain that moves down your arm. A torn rotator cuff may become more noticeably painful at rest or when you lie on the injured side at night. Medications may no longer provide relief. Increasing pain and weakness in the affected shoulder may make routine activities such as combing your hair or reaching behind your back more difficult.
During the physical examination, your physician will look for tenderness and deformity, and measure arm strength and range of motion in the shoulder. Your exam will also include ruling out other problems of the shoulder joint, and conditions such as a pinched nerve in the neck or arthritis.
Continued use of a torn rotator cuff, despite increasing pain, may result in further damage and cause the tear to get larger over time. It is important to see your doctor if you have chronic shoulder or arm pain. Early treatment can prevent your symptoms from getting worse, and help you get back to your normal routine more quickly.
The goal of any treatment is to reduce pain and restore function. There are several options for treating a rotator cuff tear. In planning your treatment, your doctor will consider your age, activity level, general health, and the type of tear you have before determining the best treatment option for you.
Although nonsurgical treatment relieves pain and improves shoulder function for approximately half of all patients, shoulder strength does not usually improve without surgery. As with any treatment, there are advantages and disadvantages to nonsurgical options.
In addition to rest, protecting the shoulder and limiting motion by using a sling, and avoiding overhead and other painful activities, other nonsurgical treatment options may include:
Your orthopaedic surgeon may recommend surgery if you have continued pain that does not improve with nonsurgical methods, or if you are very active and use your arms for overhead work or sports. Other indications that surgery may be a good option for you include: symptoms lasting for 6 to 12 months, a large tear, significant weakness and loss of shoulder function, your tear was caused by a recent, acute injury.
Surgery to repair a torn rotator cuff most often involves re-attaching the tendon to the head of humerus (upper arm bone). A complete tear within the thickest part of the tendon is repaired by stitching the two sides back together. A partial tear may need only a trimming or smoothing procedure called a debridement. There are several surgical options for repairing rotator cuff tears and advancements in surgical techniques include less invasive procedures. Each method has its own advantages and disadvantages, however all have the same goal: getting the tendon to heal. Many surgical repairs can be done on an outpatient basis and do not require you to stay overnight in the hospital. Your orthopaedic surgeon will discuss with you the best procedure to meet your individual health needs.
The three techniques most commonly used for rotator cuff repair include traditional open repair, arthroscopic repair, and mini-open repair. Most repairs are done arthroscopically.
Rehabilitation plays a vital role in getting you back to your daily activities. After surgery, you will have a specific program of physical therapy program to follow. Your therapy during recovery and rehabilitation will progress in stages to help you steadily regain shoulder strength and motion.
You should expect a complete recovery to take several months. Most patients have a functional range of motion and adequate strength by 4 to 6 months after surgery. The process may seem slow, but your commitment to rehabilitation is key to experiencing a successful outcome.
The majority of patients report improved shoulder strength and less pain after surgery for a torn rotator cuff. Each surgical repair technique offers similar results in terms of pain relief, improvement in strength and function, and patient satisfaction. The expertise of your orthopaedic surgeon 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 or tissue quality, large or massive tears, poor patient compliance with rehabilitation and restrictions after surgery, patient age of older than 65 years, smoking and use of other nicotine products, and workers' compensation claims.
After rotator cuff surgery, a small percentage of patients experience complications. In addition to general risks associated with surgery, such as blood loss, infection or anesthesia-related problems, complications of rotator cuff surgery may include: