Rotator Cuff Tendon Tears

 

Background

Rotator cuff tendon tears can be a considered to be part of a group of conditions that also affect the rotator cuff: subacromial/subcoracoid impingement, calcific tendonitis, rotator cuff tendinosis, and rotator cuff arthropathy (arthritis). Despite the myriad of names, all of the above cause pain within the shoulder and often prompt a visit to a family physician. Almost everyone will experience shoulder pain sometime within their lifetime – and we hope the following information will be useful for those who have been told they have a ‘rotator cuff tear’.

It should first be stated that not all rotator cuff tendon tears are structurally the same: they vary in size, width of the tear (partial thickness vs. full thickness), or tendons involved (i.e. subscapularis vs. supraspinatus). When adding in the complexity of dominant vs non-dominant hand, occupation, athletic activity, location of pain, and medical status – it is not surprising that patients often hear very different accounts from friends, acquaintances, or loved-ones about how their rotator cuff tendons tears were treated.

 

General Information

 

The rotator cuff often accumulates wear and tear as we age. If we were to MRI people without shoulder pain, we would find that almost 30% of people over 60 have a full-thickness tear, while 65% of patients over 70 have a full-thickness tear. This is to say that the presence of a tear on ultrasound or MRI does not mean you need an operation. The bulk of people with rotator cuff tears are able to recover without the need for surgery.

The majority of people seeking treatment for rotator cuff problems can be classified as ‘chronic’ in nature, that is the tendons have progressively torn (or degenerated) over time. A small subset of patients can be attributed to an ‘acute’ injury, such as a severe fall or a shoulder dislocation.  There is at times a combination of both chronic and acute pain, where someone describes a lengthy but mild pain within their shoulder that became severe after an injury.

It is unclear (even to shoulder surgeons) why some people develop rotator cuff tears and others do not. It is also unclear to us why some people with large rotator cuff tears have no pain, while others with very small tears do. Although research is currently looking at anatomic factors that may predict the chance of shoulder problems later in life, there is no iron-clad measurement or test to predict which tears will ultimately require surgery.

People often come to see us concerned that their tears will progress to arthritis later in life. Although there is a type of arthritis termed ‘rotator cuff arthropathy’ that is related to tendons which have been torn for a long period of time, the possibility of arthritis should not warrant immediate surgical management without first trying to improve with physical therapy. Similarly, people are also concerned that the tear will continue to increase in size if no surgery is performed. Although there is data to suggest that tears do get larger as we age, there is no evidence to suggest that they will be guaranteed to become painful if surgery is not done. Regardless of what the future may bring, the purpose of surgery is for relief of pain that persists in spite of attempts at non-operative treatments.

 

Treatment

Physical Therapy

Anyone with shoulder pain, regardless of cause, should be started on a shoulder conditioning program to maintain or improve range of motion while working on strengthening.  This is incredibly important for multiple reasons:

  • Therapy can help avoid shoulder stiffness. After an injury, there is a tendency of the shoulder to stiffen up during the healing processes. This will be made worse if a shoulder is not used. Even if therapy is unable to fully alleviate shoulder pain, it will help maintain motion. I often comment: ‘A painful shoulder I can help with, a stiff and painful shoulder is much more difficult to treat’.
  • Therapy can improve pain. By working on muscular strengthening, posture and shoulder kinematics (how the shoulder moves in space), therapy may be able to allow you to recover from injury or pain without the need for surgery or more invasive therapies.
  • Therapy is Time Dependent. It is intuitive that the quicker someone starts physical therapy, the faster they will recover. What most people realize is that delay in start of physical therapy leads to deconditioning, abnormal shoulder movements, and chronic pain. Immediate therapy can avoid a ‘downward spiral’, where a painful shoulder becomes a deconditioned shoulder, which in turn causes more pain (and so on). Shoulder specialists often cringe when a patient says the phrase “I didn’t want to start physical therapy until I was seen by a surgeon” as we know recovery will likely be longer because of it. With very few exceptions, therapy should be started as soon as a physician provides a prescription for it!

 

Cortisone Injection

Cortisone injections can provide short-term pain relief in most patients. It is important to note that cortisone is not a curative therapy. What this means is that once the injection wears off, the shoulder pain will return unless something is done in the meantime. With that said, I use cortisone in patients for one of three reasons:

  • To Help with Physical Therapy: pain prevents us from rehabilitating to our full potential. If cortisone is able to provide short-term relief of discomfort, therapy may be more successful.
  • To Help Establish a Diagnosis: pain around the shoulder may be caused by many things. It can occasionally be difficult to pinpoint the exact cause with certainty or to determine how painful one problem is relative to another. By targeting one potential source of pain with an injection, we may be able to achieve greater accuracy of diagnosis and thus a greater success rate with treatment.
  • To Predict Results of Surgery: the relief achieved with cortisone is often very similar to that obtained by surgery. These injections can serve as a guide regarding the outcomes of a given surgical procedure.

 

Surgical Rotator Cuff Repair

Surgery to reattach torn rotator cuff tendons can be performed through open or arthroscopic (i.e. minimally invasive) techniques. The tendon can be anchored to bone through sutures alone, or with suture anchors. If indicated, your surgeon will describe their preferred technique. Regardless of how the operation is performed, the following considerations are all the same:

  • No surgery is without discomfort – and is often worse within the first 2 weeks of a procedure. Discuss pain control with your surgeon prior to the operation. In our practice, we seek to limit post-operative pain through a multi-modal pain regimen.
  • Surgery only if needed – surgery is considered only in those that have failed attempts at physical therapy. Even if it comes to an operation, efforts with therapy beforehand (so called pre-rehabilitation) will help hasten your post-operative recovery.
  • Successful surgery requires post-operative therapy – To maximize your results with shoulder surgery, we consider formal physical therapy a must. Each surgeon has their own set of post-operative therapy instructions, and working with your own therapist following an operation is well worth the investment.

 

Irreparable Rotator Cuffs

Occasionally it is not possible to repair a rotator cuff using sutures or anchors as outlined above. A shoulder specialist can outline other options, including tendon transfer or shoulder replacement, based on a patients’ functional requirements and medical status.

 

Expected Follow-up and Recovery

Recovery with a rotator cuff tear is variable but can be accelerated by starting immediately on a physical therapy program. Should surgery be ultimately required, recovery follows a standardized post-operative ‘protocol’ with key stages along the way. Return to work is variable and depends on the type of job performed.  Likewise, return to sport depends on the activity and level of competition.

 

General Information

  • All slings should be kept clean and dry.
  • Swelling is common following an injury. To decrease swelling consider icing it 15 minutes at a time every 1-2 hours. Ice should be wrapped in a tea-towel to avoid frost-bite.
  • You may find it more comfortable to sleep in a reclining chair for the first 2-5 weeks following the injury. Ensure the chair is placed close to washrooms and away from any tripping hazards.

 

General Therapy Instructions

Please note: this alone does not constitute as a formal referral to a physical therapy. The following guidelines are for non-operatively treated shoulders. Therapy should be initiated, conducted and monitored by trained professionals.

  • Stage 1 – Motion: The first goal is to achieve and maintain the maximal amount of range of motion possible, ideally back to pre-injury state. Active and active assisted range of motion of the glenohumeral and scapulothoracic joints (along with neck, elbow, wrist and fingers) occurs at this stage.
  • Stage 2 – Light Strengthening: To start when 80% of expected range of motion is achieved. Recommend starting with light bands and progress to cables and finally free weights. Focus is on low weight with higher repetition.
  • Stage 3 – Strengthening and Conditioning: This stage involves increasing weight to regain pre-injury strength. Exercises are tailored towards job-specific or sport-specific tasks. Care should be taken to maintain proper form and avoid re-injury.
  • Stage 4 – Maintenance: An often forgotten or neglected component of the rehabilitation program. Exercises from Stage 3 should be incorporated into a weekly fitness regimen with the goal of avoiding re-injury.

Rotator cuff tears that undergo surgery progress through the above four stages of recovery at a pace that is dependent on the extent of surgery.

 

Expected Outcomes

Rotator cuff injuries have a good to excellent prognosis. Our goal for non-operatively treated shoulders is 90-95% return of function when compared to the pre-injury state.  The time to achieve this is variable but recovery is aided by an immediate start to physical therapy.

Operatively treated rotator cuff injuries also have a good to excellent prognosis. Our goal for operatively treated shoulders is a 90-95% reduction in pain. Strength and endurance return with time and physical therapy, but may not fully return to that of the pre-injury state.

 

Notable Challenges

  • Post-Operative Pain: Shoulder surgery is painful, especially in the first two weeks following an operation. We utilize a multi-modal pain management strategy to keep a patient comfortable while also decreasing narcotic medication consumption.
  • Shoulder Stiffness and Weakness: Stiffness around the shoulder is to be expected, especially in operatively managed shoulders requiring post-operative immobilization in a sling. It can take upwards of a year to maximize gains in shoulder range of motion and strength. Physical therapy and ongoing exercises are critical for recovery during this time.
  • Complex Regional Pain Syndrome: a challenging adverse pain response associated with some fractures. Requires time, physical therapy and occasionally medications to treat.

 

Summary of Common Treatment/Rehabilitation Pathway