Rotator cuff tear
Illustration of a healthy rotator cuff  formed by the tendons of shoulder muscles

Definition

A rotator cuff tear consists in the rupture of one or more tendons forming the rotator cuff of the shoulder.

The rupture of the rotator cuff as shown in the image

Pathology

A tear of the rotator cuff can occur in any of the four major tendons the supraspinatus, infraspinatus, subscapularis and teres minor in various combinations. It is mostly observed in the supraspinatus tendon, which inserts the supraspinatus muscle of the upper shoulder blades to the rotator cuff. 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 supporting the anatomy and function of the shoulder, an injury to the rotator cuff impacts significantly on activities of daily living.

The length of a rotator cuff tear is a criterion for pathology classification

Classification

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 partial when only a portion of the tendon is ruptured or complete 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).

Left: Distal radius intraarticular, displaced fracture; Middle: Older distal radius fracture with callus formation; Right: Distal radius and ulna fracture, extraarticular and displaced

No 2.

Intra-articular fracture extends to the wrist joint (or articulation)

Extra-articular fracture is located outside of the wrist joint

Open fracture when bone fragments perforate the skin

Comminuted fracture when the bone breaks into multiple fragments

Non-displaced when the anatomical alignment of the bone is maintained or displaced when the bone fragments move apart.

Melone’s classification describes the characteristics of intra-articular fractures of the radius:

i    Stable fracture

ii    Unstable "die-punch"

iii   "Spike" fracture

iv Split fracture

v   Explosion injuries

Acetabular fracture of the pelvis

Acetabular fractures

These fractures are divided into:

Anterior pillar (not weight bearing part of joint)

Posterior pillar (often associated with dislocation of the hip including the weight bearing part of joint)

Transverse

Comminuted involving both column type 

Sacral / coccygeal fractures

The sacrum is a triangular-shaped bone formed by 5 fused vertebrae, which provide a posterior wall to the pelvic ring. At each side of the sacrum, the ala structures articulate with the ilium bones forming the sacro-iliac joints. Sacral fractures are usually parallel to the spine and can involve the ala. Less frequently sacral fractures may display an “H” shape, including a transversal fracture uniting both sides of the sacrum. Three zones are described where sacral fractures can occur that are along vertical lines relative to the alignment of the foramina. Sacral fractures may result in sacral instability and require treatment via sacroplasty (injection of bone glue into the fracture). Surgery is necessary in case of associated neurological symptoms.

Fractures of the coccyx involve the tailbone, the terminal portion of the spine situated below the sacrum formed by 3 to 5 fused vertebrae. Coccyx fractures occur when falling on a seated position. They are more common in elderly women and seldom require surgical treatment.

Trauma is a frequent cause o rotator cuff tear in young people

Causes

A traumatic rotator cuff tear is more frequent in young individuals whereas degenerative cuff lesions occur predominantly in older people or those involved in prolonged repetitive activities that strain the rotator cuff. The pathology can arise from three different mechanisms:

Acute tear is more frequent in younger individuals. It arises as a consequence of a sudden injurious event such as a shoulder dislocation, a fall and forceful overhead activity

Chronic tear develops over time with overuse and is related to a gradual degeneration of the tendons. The latter is more frequent in older people

Iatrogenic tear is a complication following surgical tendon repair of the anterior the shoulder.

Repetitive overhead movements in tennis players increases the risk of a rotator cuff tear

Risk factors

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 in the acromion and tendon degeneration are significant risk factors to develop a rotator cuff tear.

Pain is stronger at night when laying on the shoulder with a rotator cuff tear

Symptoms

Although rarely asymptomatic, 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

Raise arm above shoulder height

Work above head

Reach back of the head

Reach of their lower back and buttocks 

Perform activities of daily living: washing, closing bra, dressing, shaving and makeup.

MRI scanner

Diagnosis

The examiner will first obtain information on the patient’s sport activities and occurrence of any traumatic events or ongoing symptoms concerning the shoulder. Clinical examination will assess the presence of any anatomical changes and the degree of impairment in shoulder abduction, adduction and external rotation. Specific tests also include drop arm and resistance tests to identify muscle weakness. X-ray is mostly performed to exclude other pathologies (shoulder luxation, fracture of the clavicle and humerus head), detect calcification deposits in the tendons, indicative of ongoing tendonitis or bony malformations of the acromion. 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.

Treatment

Ice pack application to reduce pain and inflammation

Nonoperative treatment

The management for a rotator cuff tear very much depends on the severity of the injury, its causes and patient age. In less severe cases with partial tears, conservative treatment is the first strategy to resolve the pathology. This includes: rest, application of ice or heat pads, oral administration of NSAIDs, local injection of steroids, hydrotherapy and a well-designed physiotherapy plan to restore strength and range of movement of the shoulder. Acupuncture is useful to alleviate pain.

‍Open surgery to repair the torn rotator cuff

Surgical treatment

Surgical intervention is recommended in more severe cases such as a complete rotator cuff tear, with the presence of concomitant pathologies (e.g. acromioclavicular joint osteoarthritis, shoulder impingement or when the pain persists despite conservative treatment. Rotator cuff repair can be done by arthroscopy or minimal open surgery. The aim of surgery is to repair the torn tendons and reconnect them to the humeral head nowadays preferably using suture anchoring. If a bone spur is present at the acromion it will be removed. When the tendon has been damaged beyond repair a tendon graft may be necessary to reconstruct the length required between the muscle and the bone. Rarely, if the torn tendon has deteriorated completely, it has to be excised with the result of limiting permanently the function of the shoulder.

A patient with rotator cuff tear may need prolonged physiotherapy treatment

Rehabilitation

The rehabilitation of a rotator cuff may take up to 6 months to achieve a full recovery but can be delayed by factors such as patient age, severity of injury and pre-existing conditions. This includes a first phase of rest for a period up to six weeks followed by physical therapy with initial passive and then active movements together with treatment to reduce 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 three weeks until physiotherapy begins. In the recovery phase, applications of cold pads, administration of painkillers and antiinflammatory therapy with NSAIDs comprise a standard rehabilitative plan to improve symptoms. Physiotherapy consists of a number of methods:

Massage

Joint mobilisation

Ice/heat treatment

Antiinflammatory treatment (NSAIDs)

Physical exercise (stretching, pendular movements, shoulder shrug / squeeze, rotation)

Electrical stimulation

Education in sport and daily activities

Return to sport plan

Physical training is critical to maintain healthy shoulder muscles and prevent injuries

Prevention

In order to prevent a rotator cuff injury is critical to avoid those movements that have caused the pathology, in particular overhead activities. It is important to practice a regular physical training and avoid excessive exercise or intense movements potentially leading to recidivism. In patients with increased risk of a rotator cuff injury due to strenuous sport activities, it is advised to wear proper safety equipment during training, e.g shoulder support, sport taping, and padding. Improving posture and arm movement during overhead/throwing activity is a useful method to avoid future injuries to the shoulder. It is also recommended to:

Adopt a good posture in work and daily activities

Avoid sleeping on the affected shoulder

Avoid carrying heavy weights