Rotator Cuff Tears

Rotator cuff tears are one of the most common causes of shoulder pain, affecting many age groups, from active young adults to the elderly, and can cause significant disability. There incidence increases with age with 28% having a full-thickness tear (symptomatic or asymptomatic) after the age of 60 and 65% after the age of 70. Known risk factors include apart from age, smoking, hypercholesterolemia and a positive family history.  

The rotator cuff is a soft tissue layer surrounding the shoulder joint capsule formed by the tendons of four muscle originating from the scapula: the supraspinatus, the infraspinatus, the teres minor and the subscapularis. Its primary function is to act as an important dynamic stabilizer to the shoulder joint throughout the whole arc of its motion.  

Rotator cuff tears can be the result of different pathologic mechanisms. In the elderly, tears are due to the intrinsic tendon degeneration that comes with ageing and are thus termed chronic degenerative. In younger and more active individuals, on the other hand, they can occur as acute avulsion injuries as a result of trauma or dislocation (falls, sports injuries etc.). Another common cause is chronic impingement of the tendon as it glides beneath the acromion, a bony eminence of the scapula. Finally, rotator cuff tears can occur after shoulder surgery despite the physicians’ best attempts at repairing them and restoring function. 

Rotator cuff disease is a continuum which may begin with milder, more benign conditions, such as subacromial impingement or calcific tendonitis, before it manifests as a rotator cuff tear or even, when chondral damage and arthritis develops, rotator cuff arthropathy. It can also coexist with pathology of the acromio-clavicular joint, long head of the biceps tendon, or, more specifically in throwing athletes, internal impingement. 

Rotator cuff tears can be classified based on their location, i.e. the tendon they involve (supraspinatus, infraspinatus, teres minor or subscapularis), their size (small: up to 1 cm, medium: 1-3cm, large: 3-5cm, massive: more than 5 cm), their thickness and the side of the tendon they involve (less than 25%, 25-50%, more than 50% – articular, bursal or intratendinous) and, finally, their shape (crescent, U-shaped, L-shaped, massive). Another important factor to assess is the percentage of fatty infiltration/atrophy of the mass of the corresponding muscle whose tendon has been torn (Goutallier classification, stages 0-4). All the above factors are taken into consideration when discussing a certain treatment plan (be it operative or non-operative) with the patient, as they can affect the course of tendon healing and, as a result, the restoration of shoulder function. 

The symptoms of rotator cuff tears can vary based on their etiology from acute onset pain and weakness in shoulder motion after an acute injury to chronic, insidious onset of pain during overhead activities or during the night along with gradual loss of shoulder strength and function. Depending on the location of the tear, the decrease in strength may involve lifting the arm to the side/abducting the shoulder (supraspiantus), externally rotating the shoulder with the arm on the side (infraspiantus) or abducted at 90 degrees (teres minor) or even internally rotating the shoulder (subscapularis). 

Imaging studies in rotator cuff pathology involve, at first, common radiography, which is helpful in assessing the bony components of the shoulder joint as well as identifying concomitant disease such as calcific tendonitis, degenerative changes in the shoulder or acromio-clavicular joint and the type of the acromion. The diagnostic standard, however, for rotator cuff disease remains the magnetic resonance imaging (MRI) which is highly sensitive and specific in assessing the size, shape and degree of retraction of the tear along with the quality of the involved muscles in terms of fatty infiltration. It can also help evaluate the long head of the biceps tendo and provide useful information for structures within and around the shoulder joint. Finally, the ultrasound is another modality available for the diagnosis of rotator cuff pathology, which can also be used to guide intra-articular injections. In the hands of an appropriately trained operator its diagnostic capability can be compared to that of the MRI.  

The treatment of rotator cuff tears is tailored to each patient’s needs and expectations taking into consideration their age and level of activity, the mechanism responsible for the tear as well as its anatomic characteristics (size, depth, retraction, muscle atrophy). Conservative management consists the first line of treatment for almost every rotator cuff tear. More precisely, for some tears, such as carefully selected partial-thickness tears or even massive tears in the elderly or less active individuals, conservative management may be the only treatment necessary to achieve pain relief and favorable outcomes. This may involve an initial period of rest and avoidance of overhead activities along with oral analgesia and/or subacromial corticosteroid injections, followed by a tailored, rigorous physical therapy regimen, comprising among other methods rotator cuff and scapular stabilizer strengthening exercises. These programs can generally last between three and six months. 

Operative treatment of rotator cuff tears involves many different techniques the use of which depends on the aforementioned patient and tear characteristics. More precisely surgery can be performed both in an arthroscopic or mini-open fashion and can consist of debridement (trimming) in select low grade, partial, articular-sided tears or rotator cuff repair in acute, full-thickness tears, bursal-sided tears involving >25% of the tendon thickness and articular-sided tears involving >50% of the tendon thickness. In cases of massive, irreparable tears where return to the pre-injury activity and functionality level is of utmost importance (manual laborers etc.), the tendons of select adjacent muscles, such as the pectoralis major or the latissimus dorsi, can be transferred so as to approximate the function of the torn rotator cuff tendons. Finally, in cases of massive cuff tears with concomitant shoulder arthritis and a functioning deltoid muscle, the reverse shoulder arthroplasty technique can provide pain relief and good functional outcomes. 

Patients undergoing surgery to the rotator cuff must be aware of the prolonged rehabilitation period necessary for tendon healing, rotator cuff and periscapular muscle strengthening as well as return to full function and occupation. During the first six to eight weeks patients are placed in a shoulder abduction brace and are allowed to gradually perform gentle passive range of motion exercises, such as pendulum exercises, while active range of motion is not permitted. Following this initial period, patients are guided by their physical therapist to progressively actively mobilize their shoulder and strengthen their rotator cuff and periscapular muscles. Return to full activity and occupation (especially contact sports or heavy manual labour) is expected six to ten months postoperatively. 

In conclusion, rotator cuff tears are a common pathology of the shoulder affecting many age groups. They can occur after a specific injury but can also be the result of chronic tendon degeneration. The individual characteristics of each patient as well as the anatomy of the tear are important parameters in formulating a management plan. Their treatment begins with conservative measures, which of themselves can be sufficient in certain cases, but often require appropriate surgical treatment followed by rigorous, specialized physical therapy in order to achieve optimal functional outcomes.