Rotator Cuff Tears: How They Are Treated and How Recovery Can Be Supported

Rotator cuff problems cover a range of conditions: subacromial/subdeltoid bursitis, rotator cuff tendinopathy, and partial- and full-thickness rotator cuff tears. Among these, rotator cuff tendinopathy is very common, and the more frequent cause is repeated impingement of the supraspinatus tendon between the bones, producing chronic micro-trauma.

The rotator cuff is one of the most important muscular structures of the shoulder joint. It is made up of four muscles: the supraspinatus, infraspinatus, subscapularis, and teres minor. Together they help keep the shoulder joint stable and assist its movement. The subscapularis lies in front of the scapula and is responsible for internal rotation of the shoulder. The supraspinatus, infraspinatus, and teres minor lie behind the scapula and are responsible for abduction and external rotation of the shoulder.

Epidemiology

• Rotator cuff problems account for about 70% of shoulder pain. Apart from acute injuries caused by accidents, the problem mostly appears in people over 40, especially those with a history of repeated overhead activity. When the arm performs overhead movements, a centering force is needed to keep the humeral head in a stable position. This stabilizing force is provided mainly by the rotator cuff, which explains why rotator cuff problems often appear in manual workers who do repeated overhead movements and in athletes who do throwing movements.

• The junction of the supraspinatus and infraspinatus tendons is one of the most common sites of tearing. In addition, the part of the supraspinatus tendon near the joint surface has a particularly poor blood supply, and this is also a common site of tearing.

Risk factors

• Athletes over 40: swimming (freestyle, butterfly), tennis, volleyball, gymnastics, weightlifting, and throwing sports
• A past history of injury, or sports with a risk of falls (skiing, equestrian, surfing, etc.)
• Less space for the tendon to move because the acromion is hook-shaped (type 3) or the surrounding coracoacromial ligament is thicker
• Poor scapular motor control and instability
• Tears caused by an accident can happen at any age; degenerative tendon tears are more common after 40 and are accompanied by chronic tendinitis, bursitis, increased surrounding vascular tissue, and fatty infiltration. In addition, about 54% of tendon tears in people over 60 cause no symptoms.

History

• Accident-related history: falls, over-stretching or over-abduction, excessive external or internal rotation
• Night pain is very common; there may be pain on the outer side of the shoulder along the lateral triceps, pain when raising the arm overhead, and worse pain when lying on the affected side at night
• Pain location varies and may be anterior, posterior, or lateral, and can extend toward the elbow. A few movements especially trigger pain, such as abduction and external rotation.

Physical examination

• Range of motion, which may be accompanied by joint sounds

• Pain may occur on abduction, especially around 80 to 120 degrees, though research notes that the extent of the tear does not correspond in a fixed proportion to pain

• Chronic problems may show muscle atrophy

• Common orthopedic physical examination tests each have different sensitivity and specificity

Diagnostic tools

X-ray

• Includes the AP (anteroposterior) view and other positioning views (supraspinatus outlet, axillary view).
• If the AP view shows the distance between the acromion and the humerus is less than 7 mm with sclerosis of the bone at the lower border of the acromion, a full-thickness tendon tear can be suspected.
• X-ray can be used to rule out calcification, bone spurs, and anterior displacement of the humerus.

Ultrasound

• Research indicates that its diagnostic ability shows no statistical difference from MRI, and it allows dynamic examination; its practical value for diagnosing rotator cuff problems is increasingly recognized in clinical practice.
• It can be combined with a diagnostic injection to see whether symptoms ease.

MRI

• Full-thickness tears: 80 to 97% sensitivity; partial tears: 67 to 89% sensitivity.
• Compared with ultrasound, it can also show the severity of tendon retraction, muscle atrophy, and fatty infiltration.
• MRA has better diagnostic ability (sensitivity and specificity); but because it is invasive and carries an allergy risk (a contrast agent must first be injected into the joint space for the best imaging), it is usually considered when another lesion is suspected as well, such as a labral injury.

Non-surgical treatment

• NSAID anti-inflammatory painkillers and muscle relaxants can be considered for short-term use. In the past, the mainstream injection treatment was local corticosteroid injection, which can improve pain for 8 to 12 weeks or more; hyaluronic acid injection also has an effect in reducing pain and inflammation. Prolotherapy mainly includes dextrose prolotherapy and autologous platelet-rich plasma (PRP) injection.

• For recovery from partial rotator cuff tears, there is growing research evidence for PRP, which can avoid the risks of surgery and the longer post-operative rehabilitation period. In the medium to long term, its outcomes were reported to be better than those of corticosteroid, and ultrasound-guided injection is recommended. Most research supports corticosteroid or hyaluronic acid for short-term pain relief, while for longer-term improvement in pain and functional recovery, PRP performed better in the studies.

Surgery

• If conservative treatment does not work, symptoms show no clear improvement after more than six months, or an acute injury involves a very large, near-complete tear in a younger patient, surgery can be considered. For tendon tears caused by chronic degeneration, conservative treatment is generally advised first, with surgery considered if daily function cannot be restored.

• Early repair is associated with a better outcome. Current research suggests that within one year (comparing 3 months, 6 months, and 1 year afterward), the timing of surgery has little effect on functional outcome, but if the tendon begins to retract and the muscle starts to atrophy and undergo fatty change, the outcome tends to be worse.

• A recent outcome study on arthroscopic rotator cuff repair divided patients by the duration of their condition (the interval from injury to surgery) into 3 months or less and more than 3 months. Tear size was classified using the method described by DeOrio and Cofield: a small tear is under 1 cm, a medium tear is between 1 and 3 cm, a large tear is between 3 and 5 cm, and a massive tear is strictly 5 cm. The Goutallier grading was used to assess the degree of fatty infiltration.

• After rotator cuff repair (RCR), PROMIS-UE was used to assess three thresholds. Most study participants reached the MCID, SCB, and PASS thresholds of the PROMIS-UE score within 12 months after RCR. Patients who did not reach these thresholds within 12 months after surgery were also less likely to reach them at the 24-month follow-up.

• Minimal clinically important difference (MCID): mean time 9.5 plus or minus 3.8 months

• Substantial clinical benefit (SCB): mean time 10.3 plus or minus 4.4 months

• Patient acceptable symptom state (PASS): 9.8 plus or minus 4.6 months

• This study has some limitations and shortcomings: not every patient had complete PROMIS-UE data at each surgical time point, and each surgeon’s technique and rehabilitation protocol may differ slightly, including several additional procedures performed in the study (such as distal clavicle excision and biceps tendon procedures) that may have been done together and could affect the results. What surprised me, though, was that severe findings on pre-operative imaging (such as tear size and Goutallier grade) were not significantly associated with a worse outcome.

Related training

• If surgery is done, the tissue swells afterward, so for the first 1 to 3 weeks avoiding excessive activity is advised; after that, depending on how the wound is recovering, activity can begin with the help of a healthcare professional. Whether or not surgery is done, the accompanying training is important in the long term, including strengthening the scapular stabilizing muscles, such as the rhomboids, lower trapezius, scapular retractors, and serratus anterior.
• Stretch and release the pectoralis minor and upper trapezius to reduce impingement, and address tightness of the posterior joint capsule.
• Closed-chain exercise can be used to improve stability and proprioception, followed by open-chain training to address strength imbalances between different muscle groups. Building shoulder stability requires a period of repeated and sustained training.

References

• Comparison of three common shoulder injections for rotator cuff tears: a systematic review and network meta-analysis. J Orthop Surg Res. 2023 Apr 3;18(1):272. doi: 10.1186/s13018-023-03747-z.
• Platelet-Rich Plasma Injection Can Be a Viable Alternative to Corticosteroid Injection for Conservative Treatment of Rotator Cuff Disease: A Meta-analysis of Randomized Controlled Trials. Arthroscopy. 2023 Feb;39(2):402-421.e1.
• Role of Delay Between Injury and Surgery on the Outcomes of Rotator Cuff Repair: A Systematic Review and Meta-analysis. Am J Sports Med. 2023 Apr;51(5):1328-1339.
• Platelet-Rich Plasma Injection Can Be a Viable Alternative to Corticosteroid Injection for Conservative Treatment of Rotator Cuff Disease: A Meta-analysis of Randomized Controlled Trials. Arthroscopy. 2023 Feb;39(2):402-421.e1.
• Determining the Time Required to Achieve Clinically Significant Outcomes on the PROMIS Upper Extremity Questionnaire After Arthroscopic Rotator Cuff Repair. Orthop J Sports Med. 2023 Apr 4;11(4):23259671231157038.