Rotator Cuff Tear - Rotator cuff tendon tearWhat is a Rotator Cuff Tear?

A tear of a tendon that connects muscles on the shoulder blade to the proximal humerus (the ball of the shoulder). It is a common source of shoulder pain.

About the Rotator Cuff

The rotator cuff tendon is a connection of three shoulder blade muscles to the proximal humerus. The muscles are the supraspinatus, the infraspinatus, and the teres minor. These three muscles blend together to form one continuous tendon that attaches to the proximal humerus (the ball of the shoulder) at an area of the proximal humerus called the greater tuberosity. Many popular anatomy drawings depict the rotator cuff tendon as if it is three separate tendons. This is not the case. This tendon is not distinguishable as three distinct components by either direct inspection or microscopic inspection.

My experience with inspecting the rotator cuff tendon at surgery is that in most males it is about 2-1/2 or 3 inches wide and about 3/16 inch thick. The thickness varies with the overall stature of the patient. The thickness also varies with age.

What is the purpose of the rotator cuff tendon?

The rotator cuff tendon plays a vital role in properly centering the ball of the shoulder in the shoulder socket during arcs of movement of the shoulder. A normal shoulder is a very flexible joint. I find that the ball of the shoulder will usually rotate in the socket about 3/8 to a half an inch in each direction. The rotator cuff tendon helps “fine tune” the position of the ball in socket during movements. When one uses the arm in a throwing motion, the rotator cuff is very important in its role to slow down the arm. Without the rotator cuff to decelerate the arm, a baseball pitcher’s arm might follow the ball to the plate.

The rotator cuff tendon acts in concert with many other muscles that work around the shoulder. These include, but are not limited to, the deltoid, biceps muscle, the teres major muscle, and the subscapularis muscle. Because the deltoid is able to do a lot of work around the shoulder, it can often lift the arm even in the setting of a complete tear of the rotator cuff tendon.

How can one tell if they have a rotator cuff tendon problem?

The most prominent symptom I see in my practice related to rotator cuff problems is pain. Another common symptom is weakness and trouble participating in activities that involve raising the hand higher than shoulder height. Certain arcs of movement are consistently very bothersome and other arcs of movement barely bother the shoulder at all. Nighttime pain is a prominent component of rotator cuff disorders. Patients will generally have difficulty getting a good night’s sleep if the rotator cuff tendon is generating a lot of pain. Your physical exam will be done by me. I do not utilize non-physician providers such as nurse practitioners or physician assistants.

What’s going on when the rotator cuff tendon hurts?

It appears that pain coming from the rotator cuff tendon originates from inflammation of the tendon. The tendon can become inflamed without any tearing. This may be the situation when one has overworked the shoulder on a hard day of sports activity or yard work. A tear of the tendon can also generate inflammation.

How can I tell if there is a tear?

I usually begin my evaluation with a careful history and physical exam. There are many characteristics of the pattern of pain that help me diagnose shoulder pain. The physical exam is very helpful. An experienced examiner can often reach a diagnosis of rotator cuff pain without any imaging studies. It is very appropriate to initiate treatment for rotator cuff pain without sophisticated imaging studies. There is almost never a rush to do an imaging study such as an MRI scan.

Rotator Cuff Tear - Rotator cuff tear as viewed from top sideA tear of the rotator cuff tendon is a very common cause of shoulder pain. When I use the terminology “tear” I’m referring to a spectrum of disease that can include a very tiny amount of tearing (think of a piece of cloth that has a little bit of fraying) to a tendon completely torn in two.

It’s important to understand that rotator cuff tendon tears are very common in people that have no shoulder pain or dysfunction. If I gathered a group of 100 people age 60 or older and performed an MRI scan on each one of them it is likely that at least one in five would have a rotator cuff tear. Most of the patients in this group would have no shoulder pain or dysfunction. Not all rotator cuff tears require treatment. Rotator cuff tendon tears warrant treatment when they cause pain or dysfunction for a person.

How are rotator cuff tears treated?

The treatment of rotator cuff problems should be tailored to the individual. Treatment may be as simple as abstaining from certain arcs of movement of the shoulder.

Physical therapy and strengthening of certain muscle groups will often resolve a rotator cuff problem.

Medication is sometimes used as an adjunct to treatment for a rotator cuff problem. There is no medication that will make or help the tendon heal. Medication is used to lessen the pain until natural healing takes place. It is common for anti-inflammatory medicine to be utilized in the care of rotator cuff problems. Sometimes strong pain medication is used. Injectable medication is a very effective treatment for rotator cuff pain.

I do not have any personal experience with the use of acupuncture for treatment of rotator cuff problems. It seems that massage therapy makes a painful shoulder feel better, but it is unclear whether it actually affects healing in a favorable way.

High intensity ultrasound treatment is commonly used in other parts of the world for certain rotator cuff problems.

There is a role for surgery in the treatment of some rotator cuff problems. If the patient has tried nonoperative treatment and has failed to gain the level of pain relief and function to meet their needs, it would be appropriate to consider surgery.

There are several different surgeries that might be done for rotator cuff pain. For a partial rotator cuff tear, arthroscopic surgery can often lessen that pain. If one has a complete tear of the rotator cuff either arthroscopic or open surgery is effective in lessening the pain.

Open Rotator Cuff Repair FAQs         Arthroscopic Rotator Cuff Repair FAQs

Open Rotator Cuff Repair FAQs

What surgery are you suggesting?

I am suggesting that we operate on your shoulder to repair your torn rotator cuff tendon.

 

Pre-op Instructions    Post-op Instructions

Is it done in an operating room?

Yes.

Will I be anesthetized?

One can have this surgery under a general anesthetic. The surgery can also be done with the shoulder anesthetized. That method involves numbing nerves to the shoulder. It is called an interscalene block. It is common to be sedated if the surgery is done with an interscalene block. The sedation is such that most patients will take a nap during the procedure.

Do I have to stay in the hospital?

No. This procedure is done on an outpatient basis most of the time.

What are the alternatives to surgery?

This surgery is done to improve function and decrease pain. If you find that your pain and function are acceptable, it is reasonable to decline surgery. There is not clear evidence that ignoring a rotator cuff tear of the shoulder will do damage to the shoulder over the long run. There is some evidence to show that over very long time frames, perhaps two decades or so, a rotator cuff deficient shoulder will wear out sooner than one with a working rotator cuff tendon.

Will my shoulder get stiff?

Almost all patients will lose a little flexibility.

What is a rotator cuff repair?

Rotator Cuff Tear - Rotator cuff reapir, after completionA rotator cuff repair is a method of reattaching a tendon to the ball of the shoulder. Generally they tear away from the attachment point.

About Your Doctor

How many of these have you done?

I do not have an exact total. I have been performing surgery since 1981. I usually perform operations on the shoulder at a rate in excess of 250 per year. I am a Board Certified Orthopaedic Surgeon. I have been in practice at Piedmont Orthopaedics since 1986. I subspecialize in my practice, and most of what I take care of relates to problems of the shoulder.

Risks

What are some of the things that could go wrong?

The anesthesia carries risks with it. The person who evaluates you for your anesthetic will discuss those risks with you. In general, complications from anesthesia are very, very rare, but they do exist.

How often does infection occur?

Approximately 1% of shoulder surgeries become infected soon after surgery.

What happens if there is an infection?

Infection will sometimes require that another operation be done on the shoulder. During that surgery the infection is washed out and intravenous antibiotics are often begun. Intravenous antibiotics may be necessary for 6 weeks, and sometimes oral antibiotics are needed for long-term use.

Could I die?

No surgery is absolutely safe. It is possible that one could die from any type of operation. The death rate from rotator cuff repair is profoundly low. I would estimate that it is less than 1 in 10,000. Other major events such as heart attack or stroke are extremely rare following this type of surgery.

Will it relieve my pain satisfactorily?

I find that about 90% of patients are very happy with the result after they have completely recovered from this type of surgery. Of the remaining 10%, most are improved, but some have reservations such as some mild pain or weakness. About 1 in 20 patients feel like the surgery was not worth doing.

Will I need a blood transfusion?

Almost certainly, no.

Will I have limitation on what I can do after it is healed?

No. It is safe to pursue all activities without restriction once completely healed.

A Common Sequence of Recovery

When will the sutures or staples be removed?

I use surgical glue. No sutures or staples require removal.

What is involved in this type of surgery?

In preparation of surgery, you will be asked to not eat or drink for at least 8 hours prior to surgery. Specific times to stop all food and drink will be given to you by your anesthesia professional. If you are on a drug that causes blood thinning such as Plavix or Coumadin, be sure to mention that to me. It may be important that those drugs be stopped well in advance of surgery.  If you have rheumatoid arthritis or lupus and are on certain drugs for those conditions, they too may need to be stopped prior to surgery.

The anesthesia personnel who evaluate you for surgery will determine what lab work, if any, is needed. On the day of your surgery, you will be asked to arrive about two hours prior to your surgery time.

After surgery is over, you will need to remain at the facility for at least one hour. It is okay to eat or drink as soon as you feel like it. Your pain can be controlled by using the pain medication pills that I will prescribe for you. Pills will not eliminate all of the pain, but they will make it tolerable. Pain may be severe in the first few days. Pain can also be helped by the use of ice on the shoulder, sitting in an upright position as in a recliner and resting the arm in a position of maximal comfort to the side. I will probably recommend that exercises to your shoulder begin about two weeks after the operation.

When can I get it wet?

The surgical glue is waterproof, so it is okay to take a bath or a shower from the very first day.

Will I have to wear a sling?

Yes. The sling is worn until several weeks have passed from surgery, at your discretion. It can be removed to perform daily exercises and can also be removed when the arm is resting in a safe position while sitting. Whenever there is a risk where you might fall or trip, the sling should be on.

Is any special wound care required?

You will have a prettier scar if you protect it from sunlight for one year. That is easily done with a sunscreen applied along the scar. It is also okay to rub Vitamin E into the scar. The contents of a Vitamin E gel capsule can be expressed onto one’s fingertip, rubbed into the wound twice a day, and continued for about 2 months.

Arthroscopic Rotator Cuff Repair FAQs

What surgery are you suggesting?

Rotator Cuff Tear - Biceps tendon, torn rotator cuff tendon at 2 o'clockI am suggesting that we operate on your shoulder to repair your torn rotator cuff tendon with an arthroscopic technique. At least three incisions around the shoulder area will be made. Each is about ⅜ inch long.

Pre-op Instructions     Post-op Instructions

Is it done in an operating room?

Yes.

Will I be anesthetized?

This is usually done under a general anesthetic. The surgery can also be done with just the shoulder anesthetized. That method involves numbing nerves to the shoulder. It is called an interscalene block. It is common to be sedated if the surgery is done with an interscalene block. The sedation is such that most patients will take a nap during the procedure. You and your anesthesia professional will decide which anesthetic is best for you.

Do I have to stay in the hospital?

No. This procedure is done on an outpatient basis.

What are the alternatives to surgery?

This surgery is done to improve function and decrease pain. If you find that your pain and function are acceptable, it is reasonable to decline surgery. There is not clear evidence that ignoring a rotator cuff tendon tear of the shoulder will do damage to the shoulder over the long run. There is some evidence to show that over very long time frames, perhaps two decades or so, a rotator cuff deficient shoulder will wear out sooner than one with a working rotator cuff tendon.

Will my shoulder get stiff?

Almost all patients will lose a little flexibility.

What is a rotator cuff repair?

A rotator cuff repair is a method of reattaching the tendon to the ball of the shoulder. (Generally, they tear away from the attachment point.)

About Your Doctor

How many of these have you done?

I do not have an exact total. I have been performing surgery since 1981. I do operations on the shoulder at a rate in excess of 250 per year. I am a Board Certified Orthopaedic Surgeon. I have been in practice at Piedmont Orthopaedics since 1986. I subspecialize in my practice, and most of what I take care of relates to problems of the shoulder.

Risks

What are some of the things that could go wrong?

The anesthesia carries risks with it. The person who evaluates you for your anesthetic will discuss those risks with you. In general, complications from anesthesia are very, very rare, but they do exist. I find that about one out of 15 of my patients develops significant but temporary stiffness after this operation.

How often does an infection occur?

Approximately 1% of shoulder surgeries become infected soon after surgery.

What happens if there is an infection?

Infection will sometimes require that another operation be done on the shoulder. During that surgery the infection is washed out and intravenous antibiotics are often begun. Intravenous antibiotics may be necessary for 6 weeks. Oral antibiotics may be needed indefinitely.

Will my shoulder get stiff?

It takes about 8 months to gain maximal flexibility and strength of the shoulder after this operation. Some patients will take as long as a year to gain that maximum flexibility. Almost all patients recovering from this operation feel very tight in the first couple of months after the operation.

Could I die?

No surgery is absolutely safe. It is possible that one could die from any type of operation. The death rate from this surgery is profoundly low. I would estimate that it is less than 1 in 10,000. Other major events such as heart attack or stroke are extremely rare following this type of surgery.

Will I need a blood transfusion?

Almost certainly, no.

Will it relieve my pain satisfactorily?

I find that about 80% of patients are very happy with the result after they have completely recovered from this type of surgery. Of the remaining 20%, most are improved, but some have reservations such as mild pain or weakness. About one in 20 patients feel like the surgery was not worth doing.

Will I have limitations on what I can do after it is healed?

No. It is safe to pursue all activities without restriction once completely healed.

A Common Sequence of Recovery

What is involved in this type of surgery?

In preparation of surgery, you will be asked to not eat or drink for at least eight hours prior to surgery. Specific times to stop all food and drink will be given to you by your anesthesia professional. If you are on a drug that causes blood thinning such as Plavix or Coumadin, be sure to mention that to me. It may be important that those drugs be stopped well in advance of surgery. If you have rheumatoid arthritis or lupus and are on certain drugs for those conditions, they too may need to be stopped prior to surgery.

The anesthesia personnel who evaluate you for surgery will determine what lab work, if any, is needed. On the day of your surgery, you will be asked to arrive about two hours prior to your surgery time. After surgery is over, you will need to remain at the facility for at least one hour. It is okay to eat or drink as soon as you feel like it after surgery. Your pain can be controlled by using the pain medication pills that I will prescribe for you. Pills will not eliminate all of the pain, but they will make it tolerable. Pain may be severe in the first few days. Pain can also be helped by the use of ice on the shoulder, sitting in an upright position as in a recliner and resting the arm in a position of maximal comfort to the side. I will probably recommend that exercises to your shoulder begin about two weeks after the operation.

What about the overall recovery from this operation? How long does it take to completely recover?

Approximately 8 months is common.

Will I be hurting that long?

No. Generally within a week or two a person notices a significant diminution in their pain. They continue to gain further improvement after that.

How long will I need prescription pain medication?

Most patients will use it regularly in the first week and periodically until about three weeks following surgery. Often by week three, it is needed only at night.

When are the sutures removed?

I use surgical glue. No sutures or staples require removal.

When can I get it wet?

The surgical glue is waterproof, so it is okay to take a bath or a shower from the very first day.

Will I have to wear a sling?

Yes. A sling is provided at the time of surgery and the patient is instructed to use it for the first 6 weeks following surgery. It can be removed in certain environments such as the safety of your home. It is important that you are confident that no one will bump into you and that you will not trip if your sling is off. When the sling is off, it is important not to move the shoulder beyond the safe arc of motion.

Is any special wound care required?

Your scars will look prettier sooner if you rub vitamin E into them.