Rotator Cuff Tears - Understanding the Anatomy of this injury
Approximately 1% of the adult population will have shoulder pain at some point in their lives.
While it is estimated that 65-70% of all shoulder pain involves the rotator cuff tendon, it has been estimated that 5 to 40 % of people without shoulder pain have full-thickness tears of the rotator cuff
The rotator cuff is made up of 4 muscles
The shoulder joint has “ball and socket” shape .
This type of joint is great for movement because it allows the arm to move freely in any direction ( 360 degree ) but it requires a lot of muscles to get it stable .
The main role of the rotator cuff as a whole is to guarantee stability to the glenohumeral joint by keeping the ball centered into the socket at all times.
Besides this compression and stability function of the rotator cuff , these muscles also participate in other more specific movements :
Supraspinatus: abduction (raising the arm up)
Teres minor and infraspinatus: external rotation (rotating the arm outward or away from the body)
Subscapularis: internal rotation (rotating the arm inward or toward the body)
Understanding the impact that cuff tears have on shoulder function can contribute to designing an exercise rehabilitation program.
Strengthening of the rotator cuff muscles is important to provide accurate positioning and stabilization of the humeral head in the glenoid fossa, preventing excessive elevation of the humerus, which may cause impingement and compression of the tendon against the coraoacromial arch.
An upward movement of the humeral head relative to the glenoid fossa occurs in healthy shoulders and is maintained within normal limits by the coordinated activity of the rotator cuff muscles.
However, when the rotator cuff is torn, this disrupts the glenohumeral fulcrum, leading to abnormal superior translation of the humeral head on the glenoid fossa during arm elevation as the destabilizing force generated by the deltoid muscle is unchallenged.
Pain is the main manifestation of a rotator cuff tear and can present acutely with a traumatic injury, or increase with overhead activity and intensify over time.
Pain is felt predominantly at night when lying on the shoulder.
The consequent impairment of the shoulder function causes the inability of the patient to:
Raise the arm, Painful Arc Sign * Raise arm above shoulder height
Work above head
Reach back of the head
Perform activities of daily living: washing, closing bra, dressing, shaving and makeup.
Individuals with a constant use of the upper extremities may suffer from chronic tendon inflammation (rotator cuff tendinopathy), which over time predisposes to the rupture of the tendon under heavy or repeated arm work.
Sports involving throwing activity such as tennis and basketball, contact team sports, swimming and weight lifting pose a significant risk for a rotator cuff tear.
Carpenters, painters and other professionals moving their arm with repetitive overhead activity or weight lifting are particularly vulnerable to this pathology.
In older patients poor muscle condition, presence of bony spurs on the acromion and tendon degeneration are significant risk factors to develop a rotator cuff tear.
Ultrasound and MRI are optimal diagnostic tools to localise any changes or injuries to the tendons forming the rotator cuff and their connecting muscles.
They also allow to measure the tears’ length and shape, which are parameters required for pathology classification and treatment.
In the long term, if not repaired, a rotator cuff tear can lead to fatty degeneration of the muscles of the shoulder joint.
Types of RC Tears
A rotator cuff tear consists in the rupture of one or more of the 4 tendons forming the rotator cuff of the shoulder.
It is mostly observed in the supraspinatus tendon.
This pathology is often associated with shoulder impingement of the subcoracoid and subacromial structures as well as shoulder dislocation and degenerative weakening of the tendons due to ageing.
Because of its role in stabilizing the shoulder joint , an injury to the rotator cuff impacts significantly on activities of daily living.
Classification of RCT
The classification of the torn rotator cuff depends on the anatomical location where the injury has occurred, either at the insertion of the tendon to the bone or within the tendon length.
The tear can also be classified based on its shape and severity, being a partial Tear when only a portion of the tendon is ruptured or a Complete Tear with full detachment of the tendon from the bone.
The size of a tear is divided into a small (0-1 cm), medium (1-3 cm), large (3-5 cm) and massive (above 5 cm).
Causes of RCT
A traumatic rotator cuff tear is more frequent in young individuals secondary to a shoulder dislocation, a fall or a forced overhead movement.
On the other hand degenerative cuff lesions occur predominantly in older people or those involved in prolonged repetitive activities that strain the rotator cuff.
Chronic Tears develop over time with overuse and is related to a gradual degeneration of the tendons.
Surgical Repair of RCT means a long recovery process
Surgery is recommended in the case of a complete rotator cuff tear, with concomitant pathologies such as acromioclavicular joint osteoarthritis, shoulder impingement or when the pain persists despite conservative treatment .
The rehabilitation of a rotator cuff repair may take up to 6 months to achieve a full recovery.
This includes a first phase of up to six weeks of controlled movement to avoid overstrain of the sutures with initial passive and some active movements together with treatment to reduce pain, inflammation and swelling.
These exercises strengthen the rotator cuff and the musculature of the shoulder and shoulder blades. Stretching is useful to restore flexibility and the range of movement of the shoulder joint.
Following surgery the patient wears a sling for about 3-6 weeks.
After this first 6 weeks patient will follow and comprehensive strengthening and mobility program similar to the non-operative treatment but with more emphasis on restoring rotator cuff strength.
Is Surgery always necessary in a Rotator Cuff Tear?
A tear in the Rotator Cuff it is not a sentence for Surgery, The hole in the blanket analogy
Having a Rotator cuff tear is more common that what you may think. In adults and older adults RC Tears are part of the aging process of our joints, like wrinkles on the skin.
In one study 75 % of the Rotator Cuff Tears were managed successfully with Physical Therapy and without Surgery.
So the 1st thing you have to do if you are diagnosed with a RC Tear is “ Do Not Panic”.
I see a lot of people with rotator cuff tendon tears, most of whom are scared and do not understand what this diagnosis means and many are left to believe that a torn rotator cuff is a sentence which means a life of shoulder pain and disability, or that it will need surgery to fix it. That’s not true.
First we need to consider is that not all tendons are the same and so not all tendon tears are the same.
Most tendons are like ropes, long and thin, but the rotator cuff tendon is broad and flat, more like a blanket.
Having a tear in a rope is very different than having a tear in a blanket therefore a lot of the rotator cuff tendon tears can be well managed by utilising and improving the rest of the blanket around the hole the tear has created to compensate for the injury.
Of course this does depend on the size and location of the Tear , but most tears of the rotator cuff occur in the supraspinatus tendon (top rotator cuff muscle) and in the crescent, which are easily managed without surgery and does not mean a life of pain or disability.
I have seen many many patients with RC Tears getting back to playing their favorite sports once the arm is strong and stable without surgery.
Non-Operative Treatment Rotator Cuff Tears
Recently, there has been increasing interest in exercise rehabilitation and physical therapy as a means to manage partial and full thickness tears of the rotator cuff by addressing weakness and functional deficits.
Recent studies have suggested that patients opting for physical therapy have demonstrated high satisfaction, an improvement in function, and success in avoiding surgery.
The management for a rotator cuff tear very much depends on the severity of the injury, its causes and patient age.In all cases a non-operative Treatment must be indicated first .
These are the guidelines for recovering from a RC tear without surgery:
1. Restore Full Motion
Pectoralis Minor Mobility drills associated with posterior capsule soft tissue techniques will help achieve full shoulder motion
2. Restore Thoracic Motion
Remember that the scapula “sits” on the rib cage and the ribcage orientation depends on the position of the thoracic spine. Almost all shoulder pain patients show a “Round shoulders posture “ which means that the thoracic spine is bent forward taking with it the ribcage and the Scapulas. Therefore, Restoring some degrees of Thoracic Extension is a very important component of any Shoulder program
3. Scapular Strengthening
The scapula is the base of the overhead movement. Without a stable base the arm can not move properly. Therefore, Exercises targeting the scapula are a must in order to assure pain free arm elevation
4. Overhead Movement Reeducation
You must earn the ability to reach or lift overhead. After a RC tear the fine balance between the arm and the scapula is lost and needs to be reeducated with coordinated arm elevation exercises
5. Return to Sport Rehabilitation
Finally when everything is tuned-up patient can start progressively returning to their sports fully or with modifications. Sport-simulation drills need to be included in the last part of the rehabilitation process.
Rotator Cuff Tears are very common, especially as we get older.
A tear in the cuff does not means a sentence for Surgery.
Many patient recover from a full tear without surgery
If after a good conservative Treatment of at least 8-12 weeks fails, then surgery can be considered as an option
Post-Surgical treatment is a long process than can take up to 3-6 months to recovery fully
Lionel Pannunzio is a Physical Therapist Certified in Sports Injuries.
With more than 20 years of experience helping athletes return to their sports after an injury.
He is the Owner of White Bay Sports Physical Therapy and Fitness, conveniently located in the beautiful City of Weston, where he treats Soccer Player, Runners and Athletes of all ages
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Board-Certified Sports Specialist
Owner of White Bay Physical Therapy