Rotator Cuff Tear of the Shoulder

Shoulder is one of the most mobile joints in the human body, allowing us to perform a wide range of activities. However, this free mobility comes at the cost of stability, making the shoulder prone to injuries.

Shoulder problems are common amongst not only young, active individuals but also elderly people with limited mobility. One of the most common and disabling problems of the shoulder in middle and old age is a rotator cuff tear. It may vary in severity and can significantly impair the quality of life.

Let's try to understand some basics about rotator cuff tears, including their structure, causes, treatment options, and ways to prevent them.

What is a 'Rotator Cuff' ?

The rotator cuff is a group of four muscles and their tendons that form an envelope (cuff) around the ball of the shoulder joint (head of the humerus), allowing various movements of the arm and keeping it stable.

These muscles are:

1. Supraspinatus- keeps the ball pushed down and well-centred against the socket

2. Infraspinatus- responsible for outward or external rotation of the arm (e.g. reaching out the back of the head while combing hair)

3. Teres minor- assists with external rotation

4. Subscapularis- allows inward or internal rotation of the arm (e.g. reaching out the lower back)

How does a tear occur ?

The muscles of the rotator cuff are attached to the ball of the shoulder through tendons. With the ageing process, these tendons undergo ‘tendinosis’, i.e., degeneration, and become weak, eventually developing a tear near their attachment to the bone. The tear may be:

• Partial Thickness Tear: involves only a part of the entire attachment

• Full-Thickness Tear: involves the entire tendon, leading to weakness

What are the causes ?

Tendinosis of rotator cuff tendons is a weak link due to poor tissue quality and is hence prone to develop a tear quite easily. They can develop suddenly after a fall or slowly over many years.

1. Post Traumatic

• Lifting something heavy with a jerk

• Falling on an outstretched arm

• Sudden impact or dislocation of the shoulder

2. Degenerative Wear and Tear

• Common in individuals over 50 years of age

• Due to repetitive overhead activities, reduced blood supply to the tendon, and impingement by an acromial spur

• Common in occupations or sports involving overhead motions (e.g., painters, swimmers, tennis players)

• These individuals commonly suffer through ‘external impingement of the rotator cuff’ for many years before developing a noticeable tear

3. Poor Posture and Biomechanics

• Forward stooping posture with rounded shoulders can increase the risk of impingement of the rotator cuff

• Muscle imbalance around the shoulder girdle, e.g. dyskinesia of the shoulder blade (scapula)

  
  

How to know that you have developed a tear of the rotator cuff ?

The severity of symptoms can vary depending on the size and extent of the tear. Common  symptoms include:

• Shoulder pain - especially when lifting or reaching overhead

• Weakness in the arm - inability to lift the arm, comb hair, reach the back

• Limited range of movements due to weakness

In chronic tears, the pain and weakness worsen gradually. In contrast, acute tears are often accompanied by sudden, sharp pain and loss of strength immediately after the trauma.

How is it diagnosed?

1. Clinical Evaluation

• Thorough history (onset, occupation, activities).

• Physical examination: checking range of motion, strength, and special tests (e.g. Full can / empty can test, Jobe’s test, Lift-off test, Drop arm test ).

  
  

2. Radiology

• X-ray: Rules out arthritis, detects the type of acromion & bone spur

• Ultrasound: A Dynamic and cost-effective way to visualise a tear, but challenging to notice minor details

• MRI: Gold standard for confirming the diagnosis, assessing the extent of the tear and muscle atrophy

  

  Schematic representation of a tear & its repair on MRI film

What happens if a rotator cuff tear is left untreated?

• Partial tears typically progress to full-thickness tears with continued use or persistent activities. Once a complete tear occurs, the tendon slowly starts to retract away from its insertion site on the bone. The rate of retraction is faster in acute post-traumatic cases.

• As the particular muscle is not being used, the muscle belly undergoes ‘disuse atrophy’ (shrinking) and eventually, irreversible fatty degeneration occurs. With a disturbed fulcrum of the joint, the ball of the shoulder joint starts migrating upwards, leading to ‘cuff tear arthropathy’ (arthritis).

• Clinically, the weakness gradually increases to reach a stage of ‘pseudo-paralysis’, i.e., even though there is no true neurological paralysis of the arm, complete loss of arm movements mimics it. Pain begins to increase once joint biomechanics are disturbed and arthritis develops.

What are the treatment options available?

There is no one easy solution to this. Treatment depends on multiple factors, such as the patient’s age, activity level, severity of symptoms, size and extent of the tear, level of retraction, fatty degeneration, and level of arthritis.

A) Conservative Management:

Not every rotator cuff tear needs surgery. Most of them can be managed non-operatively, especially when the tear is partial thickness or small, and pain is the more prominent symptom without significant weakness.

It includes:

• Rest and Activity Modification: Avoid overhead, strenuous & painful activities

• Physical therapy: Correcting scapular rhythm, strengthening the deltoid, scapular muscles and remaining intact muscles of the rotator cuff

• Anti-inflammatory medications: To reduce pain and inflammation in the acute stages

• Intra-articular steroid injections: For temporary relief from inflammation and pain, when the patient is not fit or willing for surgery.

Many patients recover well as the remaining intact part of the tendon compensates for the torn portion.

B) Surgical Management:

It is ideally recommended for:

• Full-thickness tears

• Tears not improving with conservative treatment (decompensated tear)

• Acute traumatic tears, tears associated with shoulder dislocation

Choice of surgery is time bound as chronic tears that have progressed to Patte’s grade 3 retraction of the tendon (upto the glenoid socket) and more than Goutallier grade 3 fatty degeneration of muscle belly (>50%) are not amenable for primary repair and need more advanced procedures like tendon transfer or superior capsular reconstruction.

Arthroscopic Rotator Cuff Repair 

It is a minimally invasive key-hole surgery carried out with the help of an arthroscope and fine arthroscopic instruments.

Surgery involves reattaching the torn tendon to its native insertion site on the bone using suture anchors. These anchors are embedded within the bone and can be made of metallic, plastic, or even bioabsorbable materials. They don’t need removal in future.

Hospital stay is usually for a couple of days. Arthroscopy offers less post-operative pain, a lower risk of bleeding, infection and a faster recovery compared to an open surgery.

Recovery after surgery

The repaired tendon needs adequate time for healing. Hence, recovery from rotator cuff surgery is a gradual process and includes:

• Immobilisation: Sling support is necessary for the initial 4 to 6 weeks to protect the repair.

• Rehabilitation: can be roughly divided into-

• Phase I (0–6 weeks): Passive range of motion, scapular strength

• Phase II (6–12 weeks): Active-assisted and then active motion.

• Phase III (12+ weeks): Strengthening and functional training.

The time frame of these phases may vary depending on the size of the tear, the chronicity of symptoms and the amount of muscle atrophy. Most of the patients achieve a complete range of movements by 4 to 6 months and significant strength by 6 to 9 months.

Can you prevent a tear of the rotator cuff tendons?

While all tears are not preventable, certain precautions can reduce the risk

1.   Regular shoulder strengthening exercises, focusing on rotator cuff and scapular stabilisers

2.   Warm-up before sports or physical activities

3.   Ergonomic workspace adjustments to avoid repetitive overhead movements

4.   Postural correction to minimise crouching and protraction of the scapula

5.   Avoid lifting heavy weights with a jerk (e.g. taking luggage off a conveyor belt at the airport, lifting a bucket)

When to see an Orthopaedic Surgeon?

Seek medical attention at the earliest if you are facing:

• Sudden onset of shoulder pain post-fall or lifting weights

• Slow-onset shoulder pain persisting beyond a week

• Weakness or difficulty lifting the arm

• Night pain affecting sleep

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To summerise

Rotator cuff tears are a common, debilitating, but treatable cause of shoulder pain and weakness. Whether you're an athlete or someone doing routine chores, shoulder health is essential for leading an active daily life.

If you're experiencing persistent shoulder discomfort, don’t ignore it! Early evaluation and treatment can prevent long-term disability and ensure a quicker return to normalcy.

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