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ROTATOR CUFF TEARS

What is a Rotator Cuff  Tear?

Side view of normal rotator cuff

Side view of normal rotator cuff anatomy. (click image to enlarge)

To understand rotator cuff tears, we first need to understand the rotator cuff itself. The rotator cuff is a group of 4 small muscles and their tendons that control the shoulder joint and help balance the ball of the joint on the socket. The muscles are attached to the shoulder blade and their tendons extend across the joint and attach to the ball of the shoulder (humeral head). At the front there is the large subscapularis muscle, at the top is the supraspinatus muscle, and at the back there are infraspinatus and teres minor.

What causes rotator cuff tears?

There are two main causes of rotator cuff tears: trauma and degeneration. Traumatic rotator cuff tears are less common, usually occur in younger patients, and can result from high energy injuries such as shoulder dislocations, and injuries from sports such as skiing and rugby. Degenerative tears are much more common and usually occur because of wear and tear as we age. From the age of about 25 our tendons start to wear. By age 60 if you scan patients who report their shoulder as normal half of them would have a rotator cuff tear and not know it.

What are the types of rotator cuff tear?

We already described traumatic vs degenerate rotator cuff tears. But we can further describe degenerate tears by their size. Most tears include a single tendon, and we often measure the size of the tear in cm. If a rotator cuff tear involves two or more tendons, we describe it as a massive tear.

Another type of degenerate tear is a chronic tear. These are tears that have existed for years, are often massive, because of the pull of the muscle the tendon is retracted from the bone, and in prolonged cases because the muscle can’t pull on the bone, the muscle undergoes fatty degeneration where muscle fibres are irreversibly replaced by fat.

In this video we describe the types of rotator cuff tears:

What is a partial thickness rotator cuff tear?

Bursal sided partial thickness tear

Bursal sided partial thickness tear. (click image to enlarge)

Degenerate rotator cuff tears happen slowly over time. As we load or overload our tendons, microdamage occurs to the tendon fibres. If we don’t heal or repair this damage, over time the fibres of the tendon start to fail and slowly the tendon starts to become detached from the bone. Partial thickness rotator cuff tears can start on the underside or joint side of the tendon (articular partial thickness tear) or the topside or bursal side of the tendon (bursal partial thickness tear). Partial thickness tears can eventually progress to full thickness tears as more and more of the tendon fibres fail and become detached from the bone.

Partial thickness tears can sometimes be responsible for shoulder pain, and they are considered under the umbrella term subacromial shoulder pain.

In this video we describe partial thickness rotator cuff tears:

Do all rotator cuff tears need a repair?

As mentioned above degenerate rotator cuff tears are most common, and half of people over 60 years old would have a tear and not know it. This is because most degenerate rotator cuff tears occur slowly over time and as they occur, the other muscles of the rotator cuff and the deltoid muscle can compensate for the weakened tendon. As a result, most degenerate rotator cuff tears do not cause any symptoms (asymptomatic). Degenerate tears can become painful if the rest of the rotator cuff and the deltoid lose their ability to compensate. This can be triggered by overuse or some minor injuries.

The first principle in symptomatic rotator cuff tears is to get the rest of the rotator cuff compensating again and so the first line of treatment in these patients is physiotherapy for 3 months. Only if non-operative management fails do we recommend a rotator cuff repair.

Traumatic rotator cuff tears are often acute and cause a sudden loss of function. The rest of the rotator cuff and the deltoid don’t have the time it takes to learn to compensate for the sudden tear. Traumatic rotator cuff tears have the best potential for healing and so to get patients the best result and recovery we recommend surgery within 6 months to repair their traumatic rotator cuff tears.

Most partial thickness tears can be managed without an operation but those partial thickness tears that are so thinned that they are almost full thickness, and don’t respond to physiotherapy, may require a rotator cuff repair.

Finally, chronic tears with large retraction of the tendon away from the attachment on the ball of the shoulder may not be repairable as the muscle may be contracted. If there is fatty change in the muscle, then we do not recommend a repair as the muscle will not be strong enough to work effectively anyway.

How Do I Repair a Tear?

Side view of rotator cuff repair

Side view of rotator cuff repair. (click image to enlarge)

I repair most cuff tears using keyhole surgery passing sutures through the tendon and securing them to the bone with plastic anchors. This short video demonstrates the technique. Most of these operations are done with the patient awake after discussing whether awake surgery is right for that patient.

The video below explains how an arthroscopic rotator cuff repair is done:

Rotator cuff repair cross section

Rotator cuff repair cross section. (click image to enlarge)

What are the Risks of Arthroscopic Rotator Cuff Repair?

It is important that before surgery you understand what is involved in the procedure and what to expect after the surgery. In this video we discuss the procedure of an arthroscopic rotator cuff repair, the post-operative rehabilitation, and risks of the procedure. In clinic prior to deciding on surgery we would discuss any risks that may be specific to you. On the day of surgery we then complete the consent process by discussing these risks again before you sign a consent form.

Further patient information about rotator cuff surgery can be found at aboutmyhealth.org.

Post-Operative Care

After a rotator cuff repair you will most likely be in a shoulder sling. This video explains how to put on a shoulder sling as some patients often struggle with this:

This video explains the exercises you can do after rotator cuff surgery while in your sling. Please consult with your surgeon before doing these exercises to ensure they are correct for you.

Patient Testimonials

After a journey of 2 years Mr Ferran immediately understood my situation and offered a solution. He explained everything very clearly in a way that I could understand and feel very relaxed about. On the day of the Operation he again explained everything that was going to happen. The Operation was fascinating to watch and Mr Ferran took me through everything that he was doing. This week I went for my follow up with Mr Ferran and the stitches were out in a minute and the next follow up will be in January. I am very pleased with Mr Ferran’s work and all is looking good for the future.

Verified Patient

Nick Ferran @ Shoulder & Elbow London Ltd

Clinics in:

Chiswick – Harley Street – Harrow – St. Johns Wood