What is a rotator cuff tear?

A rotator cuff tear is characterized by pain and weakness of the shoulder due to tearing of the rotator cuff tendons and is often associated with inflammation of the bursa (subacromial bursa). The rotator cuff is a series of four muscles that surround the ball of the shoulder (humeral head). The muscles attach to the shoulder blade on one side and to the humeral head on the other. The muscles attach to bone via tendons. The main function of the rotator cuff is to maintain the humeral head in the center of the socket.

The rotator cuff is important in keeping the humeral head in the socket when initiating shoulder motion, such as to reach overhead or perform any activity that requires shoulder strength. The rotator cuff is also important in maintaining shoulder stability and in guiding shoulder motion.

How our shoulder experts can help

Our shoulder experts will diagnose and treat your condition using the latest advances in orthopaedic technology. To request an appointment with our physicians, please call 202-833-1147.

How does a rotator cuff tear occur?

• Strain from sudden increase in amount or intensity of activity
• Direct blow or injury to the shoulder
• Agingor degeneration of the tendon with normal use
• Acromial (roof of the shoulder) spur

What increases the risk?

• Contact sports, such as football, wrestling and boxing
• Throwing sports, such as baseball, tennis or volleyball
• Weightlifting and bodybuilding
• Heavy labor
• Previous injury to rotator cuff, including impingement
• Poor physical conditioning (strength and flexibility)
• Inadequate warm-up before practice or play
• Inadequate protective equipment
• Increasing age
• Spurring of the acromion
• Repeated cortisone injections

What are the symptoms of a rotator cuff tear?

• Pain around the shoulder, often at the outer portion of the upper arm
• Pain that is worse with shoulder function, especially when reaching overhead or lifting
• Aching when not using your arm; often, pain awakens you at night, especially when sleeping on the affected side
• Occasionally, tenderness, swelling, warmth or redness over the outer aspect of the shoulder
• Loss of strength
• Limited motion of the shoulder, especially reaching behind  or across your body
• Crepitation (a crackling sound) when moving the shoulder
• Biceps tendon pain (in the front of the shoulder) and inflammation, worse with bending the elbow or lifting

How is it treated?

Non-operative treatment: Initial treatment consists of medication and ice to relieve the pain, stretching and strengthening exercises, and modification of the activity that initially caused the problem to occur. These all can be carried out at home, although referral to a physical therapist or athletic trainer may be recommended. An injection of cortisone to the area around the tendon (within the bursa) may be recommended.

Operative treatment: In athletes, surgery is usually recommended to remove the chronically scarred bursa and spur from the acromion and repair the tendon to itself or back to bone. Surgery may be performed arthroscopically or with an open incision.

Surgery for a rotator cuff tear is reserved for people who have continuing shoulder pain that affects activities of daily living or sports activities despite completing an appropriate rehabilitation program for at least three months. For younger athletes, surgery may be recommended without attempting to resolve symptoms with rehabilitation alone. This is because rotator cuff tears do not heal and usually progress to larger tears. The goal of surgery is to eliminate the shoulder pain and attempt to regain motion and strength. The thickened and chronically inflamed bursa and the curve, hook or spur of the acromion likely cause mechanical wear to the rotator cuff and may play an important role in the cause of rotator cuff tears. Therefore, these structures are removed. Then the torn rotator cuff is repaired to itself or, more commonly, back to the bone of the humeral head.

Different techniques are in use at this time. The overall goals are to remove the chronically inflamed and scarred bursa; remove the acromial curve, hook or bone spur; occasionally, to remove an arthritic AC joint; and to repair the rotator cuff to itself or to the humeral head. These can be done arthroscopically or through an open incision.

Arthroscopic techniques involve using small incisions (arthroscopy portals) to look in the shoulder joint; then electricity is used to cauterize small capillaries. Electricity or a motorized shaver is used to remove the bursa and cut the coracoacromial ligament (usually). Next, a power burr is used to remove the bony curve, hook, or spur from the acromion. The rotator cuff is repaired with sutures (threads) to itself or to the bone of the humeral head with or without surgical anchors, which are inserted into the bone of the humeral head. Often the humeral head is roughened to help stimulate healing of the tendon to bone. Sometimes this surgery is performed with a small incision at the outer shoulder.

Open rotator cuff repair involves detaching the large deltoid muscle from the acromion, as well as cutting the coracoacromial ligament. Next the acromial curve, hook, or spur is removed using a saw or osteotome (chisel). A rasp is often used to smooth the cut bone edges. The bursa is then removed with scissors. The torn edge of the rotator cuff is freshened by removing the old edge; the bone of the humeral head where the rotator cuff originally attached is roughened, often making a trough; and the tendon is sutured in the trough. This may be done by making bony tunnels and tying the sutures over the bone below the trough or by placing surgical anchors with sutures attached into the humerus and tying the rotator cuff to the bone anchors. The deltoid muscle is then sewn back onto the acromion.

What are the complications from treatment?

Possible complications of operative treatment include:

• Surgical complications not specifically associated with rotator cuff repair/reconstruction, such as pain, bleeding (uncommon), infection (<1percent), nerve injury (uncommon), stiffness, problems with anesthesia, and inability to return to previous level of pre-injury activity.

When can you return to your sport/activity?

Symptoms may resolve spontaneously. However, rotator cuff tears do not heal on their own. Surgery is often needed to optimize shoulder strength and alleviate pain. Return to full activity usually requires six to 12 months. Full shoulder motion and strength are necessary before returning to sports.

How can a rotator cuff tear be prevented?

• Appropriately warm up and stretch before practice or competition
• Allow time for adequate rest and recovery between practices and competition
• Maintain appropriate conditioning:
  • Cardiovascular fitness
  • Shoulder flexibility
  • Strength and endurance of the rotator cuff muscles and muscles of the shoulder blade
• Use proper techniques

IMPINGEMENT SYNDROME (Rotator Cuff Tendonitis, Bursitis)

What is impingement syndrome?

Impingement syndrome is characterized by pain in the shoulder due to inflammation of the tendons of the rotator cuff or the bursa (subacromial bursa) that sits between the rotator cuff and the roof of the shoulder (acromion). The rotator cuff is a series of four muscles that surround the ball of the shoulder (humeral head). The subacromial bursa sits over the top of the cuff, allowing the cuff tendons to slide near the roof of the shoulder without undue friction. Normally, the humeral head gets closer to the acromion when the shoulder is moved, particularly as you reach overhead. When the rotator cuff becomes inflamed because of injury or overuse, or when the bursa becomes inflamed, then both the swollen tendon and swollen bursa may become pinched between the humeral head and the acromion.

Impingement syndrome may represent a grade 1 or 2 strain of the tendon. A grade 1 strain is a mild strain. There is a slight pull without obvious tearing (it is microscopic tendon tearing). There is no loss of strength, and the tendon is the correct length. A grade 2 strain is a moderate strain. There is tearing of fibers within the substance of the tendon or where the tendon meets the bone or muscle. The length of the whole muscle-tendon-bone unit is increased, although there usually is decreased strength. A grade 3 strain is a complete rupture of the tendon.

How our shoulder experts can help

Our shoulder experts will diagnose and treat your condition using the latest advances in orthopaedic technology. To request an appointment with our physicians, please call 202-833-1147.

How does impingement syndrome occur?

• Strain from sudden increase in amount or intensity of activity
• Direct blow or injury to the shoulder
• Aging, degeneration of the tendon with normal use
• Acromial spur

What increases risk?

• Contact sports such as football, wrestling or boxing
• Throwing sports, such as baseball, tennis or volleyball
• Weightlifting and bodybuilding
• Heavy labor
• Previous injury to rotator cuff, including impingement
• Poor physical conditioning (strength and flexibility)
• Inadequate warm-up before practice or play
• Inadequate protective equipment
• Increasing age
• Spurring of the acromion

What are the symptoms of impingement syndrome?

• Pain around the shoulder, often at the outer portion of the upper arm
• Pain that is worse with shoulder function, especially when reaching overhead or lifting
• Occasionally, aching when not using the arm
• Often, pain that awakens you at night
• Occasionally, tenderness, swelling, warmth or redness over the other aspect of the shoulder
• Loss of strength
• Limited motion of the shoulder, especially reaching behind (such as to back pocket or to unhook bra) or across your body
• Crepitation (a crackling sound) when moving the arm
• Biceps tendon pain and inflammation (in the front of the shoulder); worse when bending the elbow or lifting

How is impingement syndrome treated?

Non-operative treatment: Initial treatment consists of medication and ice to relieve the pain, stretching and strengthening exercises and modification of the activity that initially caused the problem. These all can be carried out at home, although referral to a physical therapist or athletic trainer may be recommended. An injection of cortisone to the area around the tendon (within the bursa) may be recommended.

Operative treatment: Surgery for rotator cuff tendonitis, subacromial bursitis or impingement is reserved for people who have continued shoulder pain that affects activities of daily living or sports activities despite completing an appropriate rehabilitation program for at least 3 months. Persons with an acromion (roof of the shoulder) that has a curve, hook or spur and those with partial thickness rotator cuff tears are most likely to benefit from this surgery. The goal of surgery is to eliminate the shoulder pain by removing the thickened and chronically inflamed bursa, removing the curve, hook or spur from the acromion, and cutting the cora-coacromial ligament to increase the space under the acromion so that the rotator cuff is less likely to be pinched between the acromion and humeral head.

Different techniques are in use at this time. The overall goal is to remove the chronically inflamed and scarred bursa and remove the acromial curve, hook, or bone spur. This can be done arthroscopically or with an open incision. Arthroscopic techniques involve using small incisions (arthroscopy portals) to look in the shoulder joint; then electricity is used to cauterize small capillaries. Electricity or a motorized shaver is used to remove the bursa. The cora-coacromial ligament is usually removed. Next a power burr is used to remove the bony curve, hook, or spur from the acromion.

Open decompression involves detaching the large deltoid muscle from the acromion, as well as cutting the coracoacro-mial ligament. Next, the acromial curve, hook, or spur is removed using a saw or osteotome (chisel). A rasp is often used to smooth the cut bone edges. The bursa is then removed with scissors. The deltoid muscle is sewn back onto the acromion.

What are the complications of treatment?

Possible complications of operative treatment include:

• Surgical complications not specifically associated with rotator cuff repair, such as pain, bleeding (uncommon), infection (<1percent), nerve injury (uncommon), stiffness, problems with anesthesia, and inability to return to previous level of pre-injury activity.

When can you return to your sport/activity?

This condition is usually curable within six weeks if treated appropriately with conservative treatment and resting of the affected area. Healing is usually quicker if injury is caused by a direct blow (versus overuse). If surgery is performed, keep the shoulder in a sling, brace or immobilizer for as long as your surgeon tells you; this is usually a couple of days if done arthroscopically or up to six to eight weeks if done as an open procedure, after which the deltoid needs to heal to the acromion. Return to full activity is usually possible in 3 months. Return to sports depends on the type of sport and the position played, and full shoulder motion and strength are necessary before returning to sports.

How can impingement syndrome be prevented?

• Appropriately warm up and stretch before practice or competition
• Allow time for adequate rest and recovery between practices and competition
• Maintain appropriate conditioning:
  • Cardiovascular fitness
  • Shoulder flexibility
  • Muscle strength and endurance
• Use proper technique