Managing Rotator Cuff Tears

Anatomy

The shoulder consists of 3 main joints: The glenohumeral joint, the acromioclavicular joint and the sternoclavicular joint. Together with a “floating” joint – the scapulothoracic joint, the shoulder is formed to be one of the most mobile joints in the human body. However the range of motion of the shoulder comes at the cost of joint stability.

The main shoulder joint is a ball and socket joint between the shoulder blade and the humerus (upper arm bone). It is the major joint that connects the upper limb to the trunk. To reduce friction in the shoulder joint, several synovial bursae are present. A bursa is a fluid filled sac, which acts as a cushion between tendons and other joint structures to stop rubbing and irritation.

Stabilising the bones of the shoulder joint are a number of ligaments and muscles. The main shoulder joint ligaments are:

  • The glenohumeral ligaments (superior, middle and inferior) are the main source of stability for the shoulder. They help to hold the shoulder in place and keep it from dislocating.
  • The coracohumeral ligament supports the superior part of the shoulder joint capsule.
  • The transverse humeral ligament holds one of the tendons of the bicep in place.
  • The coraco–clavicular ligaments play an important role in keeping the shoulder blade attached to the collarbone. They carry a huge load and are extremely strong.
  • The other major ligament is the coracoacromial ligament that lies over the shoulder joint, preventing the humerus from displacing upwards.

Contributing to the shoulder joints stability are muscles. The rotator cuff is a group of four muscles that surround the shoulder joint. The four muscles of the rotator cuff are supraspinatus, subscapularis, infraspinatus and teres minor.

Description

There is not an exact definition of what constitutes a rotator cuff tear. Sometimes the severity is determined by the number of tendons that are torn and sometimes the severity is classified by the size of the tear itself.

Most commonly, rotator cuff tears are described as partial or full thickness tears.

A partial tear goes only part of the way into the tendon, it does not completely sever it. It’s usually described in terms of how deep the tear is in the tendon and doesn’t refer to length, width or other dimensions. A full-thickness tear is when the wear in the tendon goes all the way through the tendon, separating the tendon from the bone.

A commonly cited classification system for full-thickness torn rotator cuff tears was developed by Cofield (1982) and is as follows:

  1. Small tear: less than 1cm
  2. Medium tear: 1-3cm
  3. Large tear: 3-5cm
  4. Massive tear: greater than 5cm

Secondly, according to Collin et al. Rotator cuff tears can be divided into the following 5 categories:

  • Type A: supraspinatus & superior subscapularis tears
  • Type B: supraspinatus and entire subscapularis tears
  • Type C: supraspinatus, superior subscapularis and infraspinatus tears
  • Type D: supraspinatus and infraspinatus tears
  • Type E: supraspinatus, infraspinatus and teres minor tears

Cause

Rotator cuff tears are the most common cause of shoulder-related disability. The cause of a rotator cuff tear can be divided into two categories; acute tear and degenerative tear.

Most commonly, an acute rotator cuff tear is caused by a traumatic injury such as a fall onto an outstretched arm or by an unexpected pushing or pulling force. An acute rotator cuff tear can also be caused by a broken collarbone or dislocated shoulder.

Degenerative tears of the rotator cuff occur due to wear and tear of the tendon over a long period of time. This degeneration occurs naturally with age and can be contributed to repetitive movements, lack of blood supply and bone overgrowth in the shoulder joint.

Treatment

If you have been diagnosed with a rotator cuff tear, it is important to understand the number of treatment options available to you. Early diagnosis and treatment is important to prevent the rotator cuff tear from increasing in size and symptoms worsening.

How to Treat Rotator Cuff Injuries With Easy Exercises

The goal of treatment is to return you to a level of function that will allow you to participate in the things that you love to do. The best treatment option varies from person to person but your Physiotherapist or Osteopath at Pillar Health will take into consideration your age, activity level, general health and the type of rotator cuff tear that you have when recommending treatment options.

Simply, treatment options for a rotator cuff tear can be divided into nonsurgical treatment options and surgical treatment options. Below I will outline both considerations.

Nonsurgical Treatment options:

  • Rest
  • Activity modification: Avoiding activities that cause discomfort in the shoulder
  • Nonsteroidal anti-inflammatory medications (NSAIDs) – Medications like Nurofen to help reduce pain and swelling.
  • Strengthening exercises and specific stretches. The correct exercises and stretches will restore movement and strengthen the muscles around the shoulder joint. In turn, this will help relieve pain and prevent further injury.
  • Corticosteroid injection. If rest, NSAIDs and Physiotherapy or Osteopathy do not relieve your discomfort, an injection of a local anesthetic and a corticosteroid injection may be recommended. Cortisone is an effective anti-inflammatory medication however should not be considered a quick fix. Once administered, it is important to follow the advice of a Physiotherapist or Osteopath to ensure the best outcome.

The main disadvantage of nonsurgical treatment is that the size of the rotator cuff tear may increase over time and activity may need to be limited.

Surgical treatment option:

If your discomfort does not improve with nonsurgical treatment or if the size of the rotator cuff tear is large, surgical treatment may be indicated.

Other signs that surgery is indicated:

  • You have had your symptoms for 6 to 12 months
  • Your rotator cuff tear is large (more than 3cm)
  • You have significant weakness and loss of shoulder function
  • Your tear was caused by an acute injury

Surgery to repair a torn rotator cuff can be performed a number of different ways:

  1. Open repair: Often recommended if the tear is large or complex.
  2. All arthroscopic repair – Where a small camera is inserted into the shoulder joint to display a picture of the joint on a television screen. The surgeon uses this image to guide small surgical instruments.
  3. Mini open repair: The repair is performed through a smaller incision than an open repair.

Arthroscopic repair of the rotator cuff in the shoulder | Joint-surgeon.com

Rehabilitation

Rehabilitation post surgery is vital to getting you back to your normal level of function. A Physiotherapy guided program will include the following:

  • Period of immobilisation. This period allows the initial healing of the tendon to take place.
  • Passive exercise. Once your surgeon has given you the green light to do so, you may begin passive movement exercises to improve the range of motion in the shoulder joint. This will normally begin 4-6 weeks post surgery.
  • Active exercise. After 4-6 weeks you will begin moving your muscles on your own to gradually increase the strength in the shoulder joint and improve control.
  • A complete recovery takes approximately 7 months. Although it is a slow process, rehabilitation is key for a successful outcome.

Symptoms

The most common symptoms of a rotator cuff tear include:

  • Pain or discomfort when lifting and lowering the arm with specific movements.
  • Pain or discomfort at rest or at night, particularly when lying on the affected arm.
  • Weakness in the shoulder or arm
  • Dull achy pain deep in the shoulder.

Risk factors

People who perform repetitive lifting or overhead activities are at greater risk of sustaining a rotator cuff injury. These are known as overuse or degenerative tears as repeating the same shoulder motion (serving in tennis or bowling a cricket ball) can stress the rotator cuff muscles and tendons. Additionally, wear and tear injuries to the rotator cuff tendons occur more commonly in people over the age of 40. This increased risk with age can be attributed to two main factors: lack of blood supply and bone overgrowth in the shoulder. As we age, the blood supply to the rotator cuff tendons lessens and with poor blood supply, the ability of the body to naturally repair a damaged tendon is reduced. Bone overgrowth develops commonly throughout the body with age. When this occurs in the shoulder joint, the rotator cuff tendons rub on the bone overgrowth and reduces the space in which the tendons have to move which weakens them over time, making them more likely to tear.

Complications

Without assessment and treatment, rotator cuff tears may lead to permanent loss of range of motion and or weakness. This may result in degeneration of the shoulder joint over time. Although it is important to rest the shoulder for a period of time for recovery, keeping the shoulder immobilised for an extended period of time can cause secondary issues.

Prevention

Below are a couple of strategies to prevent a rotator cuff injury.

  • Exercise and target both the small and large muscles of the shoulder.
  • Maintain good posture
  • Practice low resistance exercises and introduce more repetitions to gradually strengthen the shoulder globally.
  • Perform a balanced warm up before performing any activity requiring the shoulder joint specifically, sport or exercise that places your arm above your head.

Professional Examination

If you would like to have your shoulder assessed, make an appointment with our Physiotherapist or Osteopath at Pillar Health today. Call 03 8899 6277 or visit us online at pillarhealth.com.au to book.