Rotator Cuff Tear Print

Acromial Shape And Slope

The shape of the acromion can be seen on a specific X-ray view known as an outlet view. The acromion has been described as having three general confirmations: (Type I) flat, (Type II) curved, (Type III) hooked (Figure 1).

Rotator Cuff Tear, Dr. Allen F. Anderson, Nashville, Orthopaedic Sports Medicine, Figure 11
Figure 1

Patients with flat acromions are very unlikely to develop rotator cuff symptoms. On the other hand, patients with hooked acromions frequently have rotator cuff disease. The hook on the acromion may rub on the rotator cuff with arm elevation. Impingement syndrome  that doesn't respond to conservative treatment may be treated with an arthroscopic  subacromial decompression.

Function Of The Rotator Cuff

The rotator cuff generally functions to elevate and rotate the upper arm. The rotator cuff compresses the shoulder in the socket and allows other shoulder muscles to work on the upper arm by providing a stabile fulcrum. Loss of rotator cuff function may allow the humeral head to ride out of the shoulder socket and eventually may result in severe osteoarthritis involving the shoulder.

Rotator cuff symptoms are unusual, but not unheard of, in patients under forty years of age. In general, the patient with rotator cuff disease presents at age fifty or later with a history of pain and weakness in the shoulder. The pain tends to be worse with overhead movements or reaching back. It may be exacerbated by overhead strokes in tennis, for instance. The pain also may severe at night and may prevent patients from sleeping. In some patients, a specific traumatic event may have triggered the onset of symptoms. However, it is much more common for the pain to come on gradually and to gradually worsen with time.

Rotator Cuff Tear, Dr. Allen F. Anderson, Nashville, Orthopaedic Sports Medicine, Figure 13
Figure 2

In severe cases, the patient may be completely unable to elevate the arm. However, this is seen in only extreme cases and many patients with rotator cuff tears can lift the arm over their head with some difficulty.

Treatment Options

In patients with rotator cuff symptoms, a general philosophy of treatment has evolved. Rotator cuff disease may be thought of as a progressive disease which begins with inflammation of the tendons and which often will progress to tendon breakdown and eventually to a complete tear. 

I. Rotator Cuff Strengthening and Anti-inflammatory Medication

Many patients with early rotator cuff disease will respond to a simple exercise program and to the use of nonsteroidal anti-inflammatory medications which are derivatives of aspirin. After an initial visit, the patient will be sent to a physical therapist to learn some simple exercises which they can then perform on their own at home. These exercises are designed to strengthen the rotator cuff. In theory, they will increase a compressive force which contains the ball within the shoulder socket. The hope is that by increasing this compressive force, the ball of the shoulder will be less likely to rise out of the socket with arm elevation.  The rotator cuff also holds the ball down. In this way, it is hoped that the space between the ball of the shoulder and the acromion will not be compromised and that the rotator cuff will not sustain further injury. In most patients, these exercises initially increase pain. However, if they are performed regularly, they appear to result in symptomatic relief in 60 to 70% of patients. It has been our opinion that patients with hooked acromions are less likely to respond to an exercise program than those who have relatively small curves in their acromions.

II. Subacromial Injections

Injections into the subacromial space perform two basic functions: (1) to confirm the presence of rotator cuff disease and (2) to help ameliorate symptoms. Injection of a local anesthetic into the subacromial space may confirm that the patient's pathology is localized to the rotator cuff area. This can be extremely helpful in patients who have a history of neck problems or in whom the clinical presentation is equivocal. When a local anesthetic alone is administered, relief from the injection is short-lived.

III. Corticosteroids

Corticosteroids (forms of cortisone) can also be placed in the subacromial space. However, these medications can have a significant down side affect on rotator cuff integrity.  If used repeatedly, cortisone shots may do further rotator cuff deteriorator.  For that reason, corticosteroid injections are used sparingly in selected patients who are over 60 years of age, or poor surgical candidates, or who have undergone a study which shows that the rotator cuff is intact.

Radiographic Imaging

The MRI has become our standard imaging tool for evaluating the rotator cuff in patients who do not respond to an exercise program. The MRI is a noninvasive tool which utilizes a large magnet to provide images of the rotator cuff musculature. Plain X-rays show only bones and do not show soft tissues. Therefore, the MRI provides much more anatomic detail and can often differentiate between tendinitis and a frank rotator cuff tear. This information can be used to decide whether or not to perform an injection on in the planning of a surgical procedure.

We are fortunate to have an excellent MRI and MR radiologist who works in association with our group. As a result, we can be extremely confident that what is reported on the MRI is consistent with what is actually going on in the shoulder. At times, MRI's which are obtained from other centers are much less accurate in their interpretation and, in these cases, it may be difficult to compare, for instance, an incomplete tear with a complete tear of the rotator cuff. 

Figure 3

Figure 3

Shows an MRI image of a rotator cuff tear.

In general, we will consider an injection into the subacromial space using a corticosteroid preparation in a patient who does not demonstrate frank rotator cuff tearing on an MRI. The patient is then returned to physical therapy in the hope that the injection will resolve his or her symptoms over the long-term. Our general rule is to limit the number of these injections to three in a lifetime and to space them apart by at least three months. 

In patients with demonstrated tears of the rotator cuff, we usually do not recommend subacromial injections unless the patient is an extremely poor operative risk or if it is our belief that the tear is so large that it cannot be repaired. 

IV. Rotator Cuff Repair

It is our belief that complete tears of the rotator cuff are best treated surgically. Untreated tears of the rotator cuff will enlarge. If they are observed for a significant length of time, they may progress to the point where they can no longer be repaired. Patients with irreparable rotator cuff tears often are forced to live with severe pain since there are very few good treatment options for this group. As a result, we prefer to attempt to repair the rotator cuff when the tear is relatively small. Most patients with small rotator cuff tears tend to fare very well after surgical treatment.

In our practice, rotator cuff surgery is always proceeded by an arthroscopic examination of the shoulder. The arthroscope is a small fiberoptic tube which may be inserted into the shoulder through a small puncture wound. The arthroscope may be used to confirm the presence or absence of a rotator cuff tear. In many cases, the rotator cuff may be repaired by a completely arthroscopic method. Figure 5 shows a rotator cuff tear that has been repaired with bioabsorbable suture anchor. Bone spurs and other offending pathology is removed from the shoulder arthrscopically.  A  mini open rotator cuff repair is performed by making a small incision on the outside part of the shoulder and the rotator cuff is then repaired back into bone by passing sutures into drill holes in the ball of the shoulder. Use of the arthroscope has greatly facilitated our ability to visualize rotator cuff tears. It has also allowed us to perform the "mini open" procedure using a much smaller incision with significantly less pain after surgery.

In patients with very large or massive tears results of rotator cuff repair appear to be directly proportional with the size of the tear. Patients with small tears do quite well with surgical treatment. However, some patients with large tears may do poorly even if surgical repair is attempted. This may have to do with chronic deterioration of the rotator cuff tissue in patients with long-standing tears, scarring and retraction of the tendon in patients with large tears and overstretching of nerves which supply muscles when large tears are brought back to their normal position.

After rotator cuff surgery, most patients are started immediately on gentle passive range of motion exercises. A sling is worn, except during exercise, for the first month after surgery. The patient can expect to be in formal physical therapy for a  three months after surgery. Gradual improvement in strength and pain relief may be expected for up to a year after the initial procedure.

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Figure 5A Figure 5B




© Allen F. Anderson, M.D. 2017