A rotator cuff tear is a tear of one or more of the tendons of the four rotator cuff muscles of the shoulder. A rotator cuff ‘injury’ can include any type of irritation or overuse of those muscles or tendons
Many rotator cuff tears are asymptomatic. They are known to increase in frequency with age and the most common cause is age-related degeneration and, less frequently, sports injuries or trauma.
There are two main causes, injury (acute) and degeneration (chronic and cumulative), and the mechanisms involved can be either extrinsic or intrinsic or, probably most commonly, a combination of both.
The amount of stress needed to tear a rotator cuff tendon acutely will depend on the underlying condition of the tendon prior to the stress. In the case of a healthy tendon, the stress needed will be high such as a fall on the outstretched arm. This stress may occur coincidentally with other injuries such as a dislocation of the shoulder, or separation of the acromioclavicular joint. In the case of a tendon with pre-existing degeneration, the force may be surprisingly modest such as a sudden lift, particularly with the arm above the horizontal position.
Chronic tears are indicative of extended use in conjunction with other factors such as poor biomechanics or muscular imbalance. Ultimately, most are the result of wear that occurs slowly over time as a natural part of aging. They are more common in the dominant arm but a tear in one shoulder signals an increased risk of a tear in the opposing shoulder. Several factors contribute to degenerative, or chronic, rotator cuff tears of which repetitive stress is the most significant.
Another factor in older populations is impairment of blood supply. With age, circulation to the rotator cuff tendons decreases, impairing natural ability to repair, ultimately leading to, or contributing to, tears.
The final common factor is impingement syndrome, the most common non-sport related injury and which occurs when the tendons of the rotator cuff muscles become irritated and inflamed while passing through the subacromial space beneath the acromion. This relatively small space becomes even smaller when the arm is raised in a forward or upward position. Repetitive impingement can inflame the tendons and bursa, resulting in the syndrome.
Hooked, curved, and laterally sloping acromia are strongly associated with cuff tears and may cause tractional damage to the tendon.
Most common presentation is shoulder pain or discomfort. This may occur with activity, particularly shoulder activity above the horizontal position, but may also be present at rest in bed. Pain-restricted movement above the horizontal position may be present, as well as weakness with shoulder flexion and abduction.
The recommendations usually include:
- regular shoulder exercises to maintain strength and flexibility;
- utilizing proper form when lifting or moving heavy weights;
- resting the shoulder when experiencing pain;
- application of cold packs and heat pads to a painful, inflamed shoulder;
- strengthening program to include the back and shoulder girdle muscles as well as the chest, shoulder and upper arm.;
- adequate rest periods in occupations that require repetitive lifting and reaching.
Diagnosis is based upon physical assessment and history, including description of previous activities and acute or chronic symptoms. A systematic, physical examination of the shoulder comprises inspection, palpation, range of motion, provocative tests to reproduce the symptoms, neurological examination, and strength testing. The shoulder should also be examined for tenderness and deformity.
Diagnostic modalities, dependent on circumstances, include x-ray, MRI, MR arthrography, double-contrast arthrography, and ultrasound. Although MR arthrography is currently considered the gold standard, ultrasound may be most cost-effective. Usually, a tear will be undetected by x-ray, although bone spurs, which can impinge upon the rotator cuff tendons, may be visible. Such spurs suggest chronic severe rotator cuff disease. Double-contrast arthrography involves injecting contrast dye into the shoulder joint to detect leakage out of the injured rotator cuff and its value is influenced by the experience of the operator. The commonest diagnostic tool is magnetic resonance imaging (MRI), which can sometimes indicate the size of the tear, as well as its location within the tendon. Furthermore, MRI enables the detection or exclusion of complete rotator cuff tears with reasonable accuracy and is also suitable to diagnose other pathologies of the shoulder joint.
The three general surgical approaches are arthroscopic, mini open, and open-surgical repair. In the recent past small tears were treated arthroscopically, while larger tears would usually require an open procedure. Advances in arthroscopy now allow arthroscopic repair of even the largest tears, and arthroscopic techniques are now required to mobilize many retracted tears. The results match open surgical techniques, while permitting a more thorough evaluation of the shoulder at time of surgery, increasing the diagnostic value of the procedure, as other conditions may simultaneously cause shoulder pain. Arthroscopic surgery also allows for shorter recovery time.
MRI evidence of fatty atrophy in the rotator cuff prior to surgery is predicative of a poor surgical outcome. If the rotator cuff is completely torn, surgery is usually required to reattach the tendon to the bone.
Delaying the surgery increases the retraction of tear and fatty degeneration in muscle . Both of them decrease the chances of success of surgery and increase the difficulty
Patient is advised to move and do gentle pendular movements of shoulder immediately after surgery.
We follow a specific exercise protocol which makes the patient comfortable in 1 week and by 2-3 weeks patient is relatively pain free and cuff heals after which passive assisted movements are started .
- By 2 months all active movements and muscle strengthening is started
- By 3 months patient is allowed to do all his routine activities