Rotator Cuff Tears
Background
The rotator cuff is a group of four muscles and tendons that help stabilize the shoulder and move the arm. Its tendons are called the supraspinatus, infraspinatus, teres minor, and subscapularis, with the supraspinatus being the most commonly affected. A tear can occur suddenly after a fall or lifting injury, or develop gradually as a tendon wears down over time.
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Rotator cuff problems range from tendon irritation and partial tears to complete tears that extend through the tendon. Some tears cause substantial pain or weakness, while others cause few symptoms. The biceps tendon can also be irritated or injured alongside the rotator cuff.
Symptoms
Diagnosis begins with a discussion of how the symptoms started and an examination of shoulder motion and strength. An acute tear may cause sudden pain and difficulty lifting the arm after an injury. A gradual tear may cause increasing pain, nighttime discomfort, or weakness over time.
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X-rays help assess the bones and look for arthritis. An MRI or ultrasound can show whether a tendon is torn. An MRI also provides information about the tear’s size, how far the tendon has pulled back, and the condition of the rotator cuff muscles. These findings help guide treatment.
Diagnosis
Dr. Fliegel will review how the injury happened, examine the knee for swelling and stability, and check for signs of meniscus or other ligament injuries. X-rays help evaluate for a fracture or associated bone injury. An MRI can confirm the ACL tear and show whether the meniscus, cartilage, or other ligaments were also injured.
Treament Options
Treatment depends on how the tear occurred, its size and severity, the condition of the tendon and muscle, and the patient’s symptoms and goals.
Nonoperative Treatment
Many patients with gradual or degenerative rotator cuff tears improve without surgery. Treatment may include physical therapy to restore motion and strength, activity changes, and anti-inflammatory medication when appropriate. A corticosteroid injection may be considered to relieve pain and help a patient participate in rehabilitation.
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Repeated corticosteroid injections may affect tendon health and are considered carefully, particularly when surgery may be needed.
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Platelet-rich plasma (PRP) injections may be considered for rotator cuff tendinitis or partial tears. Some patients experience pain relief, but results are inconsistent.
Rotator Cuff Repair
Surgery may be recommended for an acute traumatic tear, persistent pain or weakness despite nonsurgical treatment, or a tear that is likely to worsen. During rotator cuff repair, the torn tendon is secured back to the bone, usually through small incisions using a camera and specialized instruments. In selected cases, a graft or biologic implant may be used to augment the repair and provide additional support.
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The ability to repair a tear depends on factors such as its size, tendon quality, how far the tendon has pulled back, and changes in the muscle. These findings also affect the expected recovery.
Lower Trapezius Transfer
Some large tears involving the back and top of the rotator cuff cannot be reliably repaired. For active patients with little or no shoulder arthritis, particularly those who have difficulty rotating the arm outward, a lower trapezius tendon transfer may be an option.
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This joint preserving procedure moves the lower trapezius tendon to help perform the work of the damaged rotator cuff. An Achilles tendon allograft is commonly used to connect the transferred tendon to the upper arm bone. The goal is to improve shoulder function and outward rotation. The condition of the remaining rotator cuff muscles helps determine whether the procedure is appropriate.
Return to Sport
With nonsurgical treatment, patients gradually resume activities as pain, motion, and strength improve. After rotator cuff repair, rehabilitation protects the healing tendon before progressing to strengthening and more demanding activities. Return to sports or strenuous shoulder activity often takes six months or longer.
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Recovery after a lower trapezius tendon transfer is more gradual. Patients may feel considerably better by three months, but the graft is still healing and activity must remain controlled. Strengthening typically begins around three to four and a half months, depending on progress and the rehabilitation plan. Running, swimming, golf, and other sports are added gradually as strength and shoulder control return. Patients may need 10 to 12 months to feel confident using the shoulder, with improvement continuing beyond a year. The timeline for full return depends on healing and the demands of the activity.