Watch Out for Rotator Cuff Tears
Jeannette Franks, PhD
Reviewed by David Belfie, MD, Orthopedics and Sports Medicine, Virginia Mason Medical Center, Seattle
September 2015
Sometimes I wish I could take my body in for repairs just like I take my car to a mechanic to get new parts. “New battery or headlights—no problem!” But while we can replace more and more parts of the human body, some areas are less amenable to repairs and yet more subject to breakdown, particularly the knees and shoulders. Rotator cuff tears are one of the most common injuries in older people. The risk factors for a rotator cuff tear included a history of trauma, dominant arm, and age.
My first shoulder injury happened twenty years ago while hiking uphill on a rugged trail, fully-loaded with a heavy backpack. I grabbed a tree to keep from falling when I slipped, and while I broke my fall, my shoulder was clearly and seriously annoyed.
How the shoulder works
The shoulder is the most flexible joint in the body. While this allows us great range of motion, this same flexibility makes us more vulnerable to instability and injury. The shoulder is a ball-and-socket joint made up of three bones: the humerus (upper arm bone), the scapula (shoulder blade), and the clavicle (collarbone).
The joint capsule surrounding the shoulder joint is a thin sheet of fibers. The rotator cuff consists of four muscles (the supraspinatus, the infraspinatus, the subscapularis, and the teres minor) and their tendons covering the shoulder joint and joint capsule. Tendons are the stretchy cords that connect muscles to bones.
These tendons and muscles enable you to lift your arm, reach overhead, participate in sports, and perform normal activities of daily living.
How the rotator cuff can become injured
A rotator cuff tear is most common in people over 40. However, it can occur at any age, either as a result of trauma, such as a fall or sharp tug on the arm, or a repetitive injury such as in sports, weight lifting, or overhead activities. Often tennis players, swimmers, pitchers, and basketball players will tear a rotator cuff. Workers in jobs such as construction, painting, or stocking overhead shelves are also at risk. A tear may also occur as a result of an accident causing a dislocation or fracture.
Symptoms
Most people with an acute tear immediately know something is wrong. The primary symptom is pain, especially on raising the arm or reaching behind. In an injury such as a collision, there may be a snapping sensation and weakness of the arm, as well as pain. Many tears are asymptomatic—you don’t even know it’s there.
Of course, one should never continue to use the shoulder or participate in a sport if one suspects an injury has occurred. Use the “RICE” protocol as soon as possible:
Rest
Ice
Compression
Elevation (for a leg, foot, or ankle)
In the case of wear and tear over time, the repetitive activity becomes more and more difficult. As the tendon degenerates, one may feel pain radiating down the side of the arm or a burning sensation. It may be mild at first and easily alleviated with over-the-counter analgesics, ice, and rest. But the range of motion may be steadily decreasing, while the damage worsens.
Other symptoms include weakness in the arm, or a clicking or crackling sound or sensation when the arm is moved.
Diagnosis and treatment
The physician will subject the patient to a variety of positions and stresses to elicit the major sign of a rotator cuff tear—pain. In addition to the physical examination, x-rays and an MRI (magnetic resonance imaging) may be required. Some cases may call for an arthrogram, where dye is injected into the joint in order to see the tear clearly.
Since there may be some ambiguity, the first line of treatment is generally ice, rest, and physical therapy. Non-surgical treatment options may also include the use of a sling, anti-inflammatory medication, and a steroid injection. If these do not restore the joint to normal function, the patient should revisit the doctor promptly for further examination and testing.
If the tendon or muscle has truly separated or become detached from the bone, surgery may be required. Tendons do not regenerate or reattach to the bone, no matter how excellent the physical therapy. Since there is no blood circulation in tendons, there is no re-creation of tissue. In some instances, delaying the surgical repair can increase the possibility that it will be less likely to be amenable to repair later.
Current techniques and instruments often permit surgeons to repair the rotator cuff through a very small incision—a “mini-open repair” using fiberoptic instruments.
An open surgical repair is indicated if the tear is large or complex or further reconstruction is required. In some cases, shoulder replacement may be an option, especially with severe arthritis.
Be sure to notify your physician immediately if you have any of these symptoms following surgery:
Fever after the 2nd day following surgery
Increasing pain or swelling
Redness, warmth, or tenderness
Unusual bleeding
Numbness or tingling of the arm or hand
Rehabilitation
The duration of immobilization depends on the type of tear and type of surgery. Physical therapy tends to begin quite soon after the operation, often the same week. It is absolutely crucial to follow the regimen faithfully. Human nature being what it is, we tends to be dutifully compliant at first and then slack off once the arm starts working again. However, hard, painful work for at least several months is required for full recovery.
Prevention
An important prevention to shoulder injuries is to increase upper body strength. This must be done very slowly and with proper technique and form. Usually a class or trainer is required, but make sure that he or she is an excellent certified professional. Many injuries occur at the gym under the supervision of someone who should have known better. Physical Therapist Keith Heinzelman, DPT, MTC, CHT, suggests that everyone should start learning how to strengthen their rotator cuffs at least before his or her 40s. Prevention is so much more effective than treatment.
Arms should not be raised above the shoulder when standing and working out with weights in exercises such as the upright row. Many overhead lifts are performed in the safer prone position. I’ve witnessed many injuries in process when a group weight instructor demonstrates poor technique or fails to correct participants with incorrect form.
After mastering good form with an instructor, it’s easy for the patient to work out with weights at home; there are also many excellent DVDs for guidance. Or it may be more motivating to work out while watching a favorite TV show or listening to music. It’s also important to do daily stretches, especially during and after working out.
It’s extremely important to “listen to your body.” Athletes no longer say, “No pain, no gain”. Pain is the body’s way of indicating that something is wrong. A bit of muscle tenderness or soreness is fine the day after. But pain during or immediately after a sport or working out indicates a problem. People need to learn to differentiate between the mild, tight feeling a muscle gets the day after being challenged, and the pain (even slight) during or immediately after doing damage to a joint, muscle, or tendon.
Regular exercise is the absolutely most important thing one can do to avoid injury. Tendon injuries often occur in poorly conditioned muscles or “weekend athletes.” Older people are especially at risk and even simple activities such as getting out of a car can cause a serious injury in a sedentary person with poor upper body strength. Poor mobility leads to an even more restricted life and a downward spiral to frailty.
Jeannette Franks, PhD 