By: Chris Bales, MD
A lot of my patients come to the office with shoulder pain and have been told they may have a tear in their rotator cuff. They may have heard this from a friend or may have already seen their primary care doctor and have an MRI that says they have a torn rotator cuff. Most think this means they need surgery. While arthroscopic rotator cuff repairs are one of the most common surgeries I do, not all tears need to be fixed. So, let’s talk a little more about the rotator cuff, what it is, what the spectrum of rotator cuff pathology consists of and then what some of the treatment options are.
Your rotator cuff consists of four muscles that arise from your scapula (the shoulder blade) and turn into a tendon as they insert on the greater tuberosity of your humeral head. They help elevate and rotate the arm. We will focus on the two most common tendons that are torn: the supraspinatus (elevates the arm) and the infraspinatus (externally rotates the arm).
How do people get rotator cuff tears?
A patient’s medical history is an important aspect of the initial evaluation as it can really help steer early treatment. Tears are either traumatic or non-traumatic.
The patient who slips on the ice and lands on their shoulder, elbow or outstretched hand and now can’t raise their arm up after the fall, typically have suffered an acute tear.
Non-traumatic tears typically present a gradual onset of worsening pain over months or may have acutely worsened after a change in activity level, such as starting a new work out program, house project that requires a lot of lifting, fall clean up in the yard, etc.
Traumatic tears make sense, but how exactly do you develop a non-traumatic tear? This often comes as a surprise to people when I tell them, but asymptomatic tears, which is a tear that doesn’t hurt, are very common.
Some suggest that rotator cuff pathology is part of the natural aging phenomenon. If you look at various cadaver and MRI/ultrasound imaging studies examining the incidence of rotator cuff tears, you’ll be surprised to learn that asymptomatic tears are found in 10% of people in their 50s, 20 to 30% in their 60s and 50 to 80% in their 80s! We have also found that 50% of patients over the age of 65 with a painful rotator cuff tear have an asymptomatic tear in their other arm.
How often do asymptomatic tears develop pain?
Over the course of two to five years, 30 to 40% of patients will develop pain, but not all tears are like comparing apples to apples.
A rotator cuff tear may be full thickness, completely off the bone, or can be partial thickness. And partial thickness tears can have even more variation. They may be very small (millimeters in size) or they may be high grade and close to being full thickness.
Additional factors that help physicians decide the best course of treatment for these types of tears include:
- Patient age
- Activity level
- Medical history
If a tear was asymptomatic before, we may be able to get it back to that state. Tears typically don’t heal but they can go back to where they aren’t causing pain.
What is the treatment for a rotator cuff tear?
Treatment of non-traumatic tears consists of rest, activity modification, ice and use of over the counter medications such as Tylenol and NSAIDs for pain.
People with shoulder pain at night often find sleeping in a more upright position helpful; for example, sleeping in a recliner chair.
By the time I see patients in the office, they have often tried some of these things already. If they are still having acute pain a steroid (cortisone) injection can be considered. A formal course of physical therapy can also be considered; however, some patients prefer to try a home exercise program initially.
When do you need surgery?
Surgery is required with traumatic tears, particularly in patients under the age of 65, who can’t elevate their arm over shoulder level or have difficulty rotating the arm are good candidates for acute surgical treatment.
I recommend surgery for patients with non-traumatic tears who have failed conservative treatment and continue to have pain that affects their function and sleep. One of the biggest reasons I’ve found drives patients to consider surgery is an inability to sleep. Surgery for rotator cuff repair is very successful, but it involves a long rehab process.
Most of my patients are in a sling for six weeks. Return to more normal function takes closer to four to six months. Many patients who have had a rotator cuff repair will tell you it took them close to a year to get back to where they thought their shoulder should be.
To make an appointment with Dr. Bales please call 317.268.3632 or learn more about treatment options for shoulder injuries at OrthoIndy.
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