Rotator cuff tear is one of the common problems in the elderly population but can be seen in any age group especially after injury. If you have a rotator cuff tear you will experience weakness and mild to extreme pain in your shoulder, especially when you try to raise your arm, lift things up or lie on it. Carrying out normal daily activities with your arm and shoulder may become difficult for you.

Shoulder Joint Anatomy

The shoulder joint is the most movable joint in your body primarily formed of three bones i.e. the upper arm bone (humerus), the shoulder blade (scapula) and the collarbone (clavicle).  The shoulder joint moves with the help of a ball and socket arrangement in which the head of the upper arm bone is fitted into the shallow socket of the shoulder blade.

The rotator cuff is a group of four shoulder muscles joined together as tendons. They form a covering ‘cuff’ around your humerus {FiG 1} so that it stays firm and stable into the shallow socket. It is with the help of your rotator cuff that you can rotate and raise your arm.

Explanation

Rotator cuff tears usually occur in people who are either actively involved in sports or in work that demands them to move their arms repeatedly. It can also happen to you if you suddenly fall on your arm or lift a weighted object.

You can experience a rotator cuff tear in two ways:

Partial tear- When anyone out of the four muscles that make up your rotator cuff wears out or torn (partially) but is not pulled off the bone.   There is also a term medically used “PASTA” which means Partial Articular Suraspinatus Tear which means supraspinatuspatial tear from joint surface.

Complete tear- When all the four muscles that make up your rotator cuff are completely torn off the bone, leaving the tendon hollow, it is a full-thickness tear.

Causes

Rotator cuff tear may happen suddenly or over a period of time. They can be caused due to:

Acute tears- They can also be called as the sudden tears or the traumatic tears. They occur when you fall on your outstretched arm without warning or when you are roughly lifting something too heavy.  You can sustain a tear in your rotator cuff with some other shoulder problems or injuries like a dislocated shoulder or a broken collarbone.

Chronic tears- Also known as degenerative tears, these are the more common ones that occur when your rotator cuff wears over a period of time due to age or repetitive strain on your shoulder. The several determinants that contribute to this are –

Using your shoulder and arm day after day may damage your rotator cuff. It is more likely to happen to sportsmen involved in tennis, badminton, rowing, weightlifting or swimming and to people doing jobs that demand the repetitive use of their shoulders.

Age lessens the blood supply without which a frayed rotator cuff tendon may not recover its strength and sustain a tear.

A condition called shoulder impingement can also cause the tendon to become weak and sustain a tear.

If you have a chronic rotator cuff tear in one shoulder then it is likely that your other shoulder will also be susceptible to it, even if there is no pain in it.

Risk Factors

You are at a greater risk to suffer from rotator cuff tears if:

• You are over 40 years in age
• Your shoulder has undergone a traumatic injury
• You are an athlete involved in sports that involve repeated use of your arm and shoulder
• You do overhead work such as painting or carpentering

Symptoms

Your symptoms will depend on the severity of the tear in your rotator cuff.  If you have a partial tear, you will feel mild pain and weakness in your shoulder, more so when you lie down at night or rest on the affected shoulder. The pain will aggravate when you raise your arm above your shoulder, rotate your arm or try to reach behind your back.

If your tear is a full-thickness tear you will feel excessive pain and weakness in your shoulder. Lifting your arm above your shoulder or lifting your elbow away from your body will almost be impossible.

If you obtain a tear because of a sudden injury to your shoulder, you may hear a crackling sound in your shoulder when you move your arm.

Some rotator cuff tears are painless, though weakness may still persist and your shoulder functionality may reduce.

Diagnosis

The diagnosis of rotator cuff tears is carried out in two parts i.e. doctor’s examination and imaging tests.

Doctor’s examination- After understanding your symptoms the doctor will ask you briefly about your medical history. He will then conduct a physical examination to test the mobility of your shoulder by rotating your arm and raising it above your shoulder height. All the while he will question you regarding pain, weakness or tenderness when he touches your shoulder on specific points.

Imaging tests- Besides the physical examination, the doctor may ask you to undergo a few diagnostic tests that include:

X-ray- Even though they do not show any soft tissues inside the shoulder, x-rays are the first imaging test the doctor will ask you to undergo. It helps him to gauge if your shoulder has a bone spur or is a normal image of your shoulder.

 MRI- Magnetic Resonance Imaging helps the doctor to accurately see the size, the location, and the quality of the tear on the rotator cuff.

Ultrasound- An ultrasound helps the doctor to probe into the muscles and the tendons in your shoulder.

Treatment

A rotator cuff tear can worsen over time, more so if you do not consult a specialist and keep using your shoulder despite the pain and the weakness. There are different ways your doctor may consider treating your tears.  The treatment method is carefully planned by the doctor after taking your age, your health, your lifestyle and the severity of your tear into account.

Non-Surgical Treatment Techniques:

The doctors usually begin with the non-surgical methods to relieve you from the aggravating pain. The non-surgical techniques may comprise of:

Non-steroidal anti-inflammatory medications- These are specially prescribed medicines that will bring down the swelling and the pain in your shoulder.

Steroid injections- The specialist may prescribe cortisone injections if NSAIDs do not give you the desired relief. Cortisone prepared injections are anti-inflammatory and extremely successful in providing relief.

Physical therapy- Besides NSAIDs or steroid injections, you may also have to undergo some strengthening exercises to restore your lost movability. The doctor may advise you to avoid some activities that can further damage your shoulder and put your shoulder in a sling to protect it.

If your specialist feels that your tear is not improving rather increasing in spite of the non-surgical treatment, he may advise you to undergo surgical treatment.

Surgical Treatment Techniques:

Your specialist doctor may suggest the course of surgical treatment if

• Your pain is not reducing in spite of medications and physical therapy
• You are an athlete or your work involves repeated use of your arm and shoulder
• Your tear was caused by a traumatic injury
• You have had pain and weakness for more than a few weeks
• Your tear is sizeable but the surrounding tissues are intact

There are several surgical invasive procedures to repair your torn rotator cuff.  The most appropriate method is decided upon by the surgeon after taking into account the condition of your tear, the quality of your tissues and several other factors.  A partial tear requires smoothening that is done by a procedure called debridement whereas for complete tears the surgical techniques include-

Arthroscopic Repair- Your surgeon will make a small cut on your shoulder and will repair your tear with the help of arthroscopy. This surgery is an outpatient and invasive technique.

Open Repair- If the tear is large or there are other complications the surgeon may perform open surgery. This method is the conventional method of treatment that has been gradually replaced by more invasive techniques.

Mini-Open Repair- As the name indicates, this technique is a combination of arthroscopic and open repair. After making a small incision, the tear is repaired arthroscopically and then the surgeon inspects the shoulder joint directly and takes action accordingly.

Reverse shoulder replacement arthroplasty– if there is chronic tear which is not reparable because retraction, poor tendon quality (friable) or Fatty deneration/atrophy which means muscle is not able to contract for proper function. In such cases in elderly patient sometimes surgeon decides to do reverse soulder replacement.