Rotator Cuff Tear

What is a Rotator Cuff Tear? How is it diagnosed?

What is a Rotator Cuff Tear?

A rotator cuff tear is a tear or rip in one or more of the tendons of the four rotator cuff muscles that work to stabilize the shoulder joint. Rotator cuff tears can occur through direct trauma to the arm, dislocation of the shoulder, quick, forceful movement of the arm, or as a result of degeneration over time (think of a fraying rope). 

Rotator cuff tears can either be partial, causing a rip in only a portion of a tendon, or complete (full-thickness), in which the tendon is completely torn off from where it attaches to the humerus bone of the arm. Because rotator cuff tears can be partial or full-thickness and can affect one or more than one tendon, the severity of a rotator cuff tear can vary greatly between people.

How is it diagnosed?

History & Physical Exam

A thorough history and physical examination by your healthcare provider can help determine whether you have a rotator cuff tear. Your healthcare provider will ask you questions about your symptoms and how and when your symptoms began to get a clearer picture of how your injury occurred. 

In addition to discussing your medical history, your healthcare provider will perform a physical examination to assess your shoulder for pain, swelling, mobility, and instability. Your healthcare provider will palpate, or feel the soft tissues around your shoulder to see if anything is tender to the touch, and move your arm in different directions to see if your range of motion is affected or if a particular motion is painful.

Your healthcare provider will also test the strength of your shoulder muscles and examine your ability to move your shoulder joint. If a rotator cuff injury is suspected, your healthcare provider will likely perform specialized tests to examine the integrity of your rotator cuff tendons and overall shoulder stability. These tests include:

• Empty Can Test: While sitting, you will lift your arm out straight up to shoulder height with your elbow extended and your thumb facing down in the scapular plane, a plane of motion about halfway between your arm out directly in front of your body and your arm out to the side of your body. You will then try to maintain this position and resist as your healthcare provider applies downward pressure on your arm. A positive result on this test occurs when you experience pain with resisting and/or weakness and inability to maintain resistance against the external force applied by your healthcare provider, indicating injury to the rotator cuff, specifically the supraspinatus muscle.
• Hornblower’s Sign: While sitting, your healthcare provider will lift your arm out to the side to shoulder height while maintaining a 90 degree bend in your elbow so that your palm faces the floor. You will then try to externally rotate your arm so that the back of your hand moves up and back while your healthcare provider resists this motion. A positive result on this test occurs when you experience pain with resisting and/or weakness and inability to maintain resistance against the external force applied by your healthcare provider, indicating injury to the rotator cuff, specifically the infraspinatus muscle.
• Bear Hug Test: While sitting, you will place the hand of your injured arm across your body and onto your opposite shoulder. You will then try to maintain your hand on your shoulder and resist as your healthcare provider attempts to pull your hand away from your shoulder. A positive result on this test occurs when you experience pain with resisting and/or weakness and inability to maintain resistance against the external force applied by your healthcare provider, indicating injury to the rotator cuff, specifically the subscapularis muscle.

Imaging 

While a thorough medical history and physical examination can provide useful information to suggest that one or more of your rotator cuff tendons is torn, imaging studies may be performed to ultimately confirm a diagnosis of a rotator cuff tear, especially if your pain is severe or if your symptoms do not improve after several weeks of physical therapy. Different imaging methods can be used to examine the tissues and structures of your shoulder, which include:

• X-Ray: An x-ray is a type of image produced by radiation that examines the structure of your bones. Your healthcare provider may order an x-ray to make sure that you do not have a broken bone or to check for signs of arthritis. Because x-rays only clearly produce images of bones, they cannot be used to diagnose a rotator cuff tear.
• MRI: An MRI, or magnetic resonance imaging, is a 3-dimensional imaging scan that is produced by magnetic fields. MRIs more clearly illustrate soft tissues of the body and can be used to assess the integrity of your rotator cuff tendons and surrounding structures like ligaments, cartilage, and the labrum of the shoulder. An MRI is needed to confirm the full extent of your rotator cuff tear.

Rotator Cuff Tear Treatment Options (Surgical vs Non-Surgical)

Not every rotator cuff tear requires surgery, especially if you have a partial rotator cuff tear. In the end, the decision will depend on your individual symptoms, age, health of your tendons, and overall activity level.

Surgery – Rotator Cuff Repair

Full-thickness rotator cuff tears almost always require surgical repair as the torn tendons tend to retract away from the shoulder joint and cannot reattach back to the humerus properly. Without surgery, full-thickness rotator cuff tears result in chronic shoulder instability, pain, and decreased range of motion, limiting the functional use of your arm and increasing the risk of further complications to your shoulder joint such as the development of another rotator cuff tear, labrum tear, frozen shoulder (adhesive capsulitis), or osteoarthritis. 

A rotator cuff repair is performed through a shoulder arthroscopy, a minimally invasive surgical procedure to repair or remove damaged structures within the shoulder joint. During your rotator cuff repair, your surgeon will use an arthroscope, a tool the size of a pencil with a camera and light attached, to view the inside of your shoulder joint while using surgical tools to reattach and anchor your torn rotator cuff tendon(s) to the humerus bone.

If you are generally healthy, the surgery will likely be performed in the outpatient surgical setting, so you will not have to stay overnight at a hospital. 

Non-Surgical Management of Rotator Cuff Tear

Non-surgical management for a rotator cuff ear involves carefully structured and progressive physical therapy to rehabilitate your shoulder to decrease pain and swelling, restore normal shoulder joint range of motion, and improve the strength of the rotator cuff muscles to stabilize your shoulder.

While full-thickness rotator cuff tears almost always require surgery, partial rotator cuff tears may recover with a specialized physical therapy program to rehabilitate your shoulder.

Resting your shoulder from physical activity and use of ice, elevation, and compression can also be used to help alleviate pain and swelling. Your healthcare provider may prescribe you medication like nonsteroidal antiinflammatory drugs (NSAIDs) to help control your pain initially after injury, and may consider giving you a cortisone injection into your shoulder to decrease pain and inflammation.

Rotator Cuff Tear FAQs

General

How common is a Rotator Cuff Tear?

A rotator cuff tear is one of the most common shoulder injuries, affecting approximately two to four million people in the United States each year. 

Treatment Decision

Who is not a good candidate for surgery?

People with significant comorbidities such as heart and lung problems and bleeding disorders may not be healthy enough to undergo any type of surgery and are usually not good candidates for rotator cuff repair. 

While full-thickness rotator cuff tears often require surgery, especially if you are very active with work, sports, or exercise requiring overhead movements, people with partial rotator cuff tears, low pain levels, and generally sedentary lifestyles may be able rehabilitate their rotator cuff tear with physical therapy alone and may not necessarily be candidates for surgery. 

For cases of full-thickness rotator cuff tears that cannot be repaired due to poor quality of the tendon fibers and/or presence of significant shoulder arthritis, a reverse shoulder replacement may be performed instead to replace the damaged joint and rely on the deltoid muscle of the shoulder to move and stabilize the arm.

Can I wait to have surgery?

Most surgeons will recommend trying physical therapy for several weeks if you are presenting with signs of a rotator cuff tear since partial rotator cuff tears have good potential to heal with structured rehabilitation. If your symptoms do not improve after one month or more of physical therapy, you will likely have an MRI of your shoulder performed, if you haven’t had one already, to determine the full extent of the damage to your shoulder. 

If an MRI reveals that you have a full-thickness tear in one or more of the rotator cuff tendons and you continue to experience significant pain, limited range of motion, and shoulder instability, surgery for a rotator cuff repair will generally be scheduled within the following few weeks. Because rotator cuff tears can cause significant pain limiting your ability to move your arm, complications like a frozen shoulder (adhesive capsulitis) can develop, so surgery should not be put off for too long in order to restore your shoulder to as much normal functioning as possible.

After Surgery

Can I shower or take a bath?

You should avoid taking a bath or shower for the first two to five days after surgery to protect your incions. Avoid submerging your arm in water during the first two to three weeks after surgery to decrease the risk of your incisions reopening. 

Will I need a shoulder sling? What other supplies will I need?

You will need to keep your arm immobilized and supported in a shoulder sling after surgery to prevent active use of your shoulder and to support the weight of your arm as your rotator cuff repair heals. In the initial weeks after surgery, your repaired rotator cuff is too weak to stabilize your shoulder with movement or at rest. You will also need extra pillows to help support your arm and prop yourself up when you sit or sleep. 

How long will I need to use a shoulder sling? Do I have to sleep with it on?

You will need to wear a shoulder sling at all times of the day, including when you sleep, after your rotator cuff repair. The only time you will be allowed to remove your sling is during physical therapy so that your physical therapist can stretch your shoulder and so that you can perform passive range of motion exercises, both in physical therapy and at home. You may also remove your shoulder sling briefly to shower or get dressed.

Depending on the speed of your recovery and extent of your rotator cuff repair, you will be able to discontinue the use of the sling after 4-6 weeks under the guidance of your healthcare provider,

When can I return to work?

Return to work will greatly vary depending on the nature of your job. Many jobs will require 3-8 months of recovery before returning to full work duties.

How can I minimize scarring?

You can minimize scarring by avoiding picking at your surgical incisions and leaving your stitches or steri-stris in place until they naturally come off. Keeping your incisions clean and dry will also help avoid infection which can delay healing and worsen scarring.

Can I re-injure my rotator cuff? If so, how can I prevent re-injury?

Re-injuring your rotator cuff is possible if you try to return to too much activity too soon without strengthening your rotator cuff muscles enough or not allowing your repaired rotator cuff tendon(s) enough time to heal. To prevent re-injury, precise adherence to your post-operative protocol and consistent physical therapy visits and progressive exercises over several months are crucial to maximize the strength and stability of your rotator cuff repair.