Rotator Cuff Tear

Shoulder

Before you read this section, I suggest you read the article on Tendonitis because that includes a bit of basic knowledge that will help you understand about the cuff.

I have a painful shoulder and my therapist is worried that I might have a cuff tear. It sounds pretty serious and it has got me worried.

Sadly an awful lot of people are told they have cuff tears without any evidence that you actually do and, you are absolutely right, it can be worrying thinking you might need a major operation to fix that tear.

So the first thing to do is get the terminology right.

To me a ‘tear’ is an acute event; something that happens quickly and in one go. The rotator cuff tendons are strong and it is not easy to tear them from the bone – it needs a lot of force. So it doesn’t happen just through normal activities or your job or your sports. To tear a tendon you have to do something pretty forceful – a big fall (especially when the arm is yanked or pulled awkwardly away from you) for example and you will know straight away that you have done some major damage.

The management of Rotator Cuff Tears is a controversial subject and there are two groups of surgeons; those who believe that every tear or erosion needs to be operated on and those, like me, who don’t. There is evidence to support both schools of thought and it might seem to the patient that a hole ought to be repaired. However more and more we are realising that that is not the case and surgery should be reserved for those who have a functional problem. In fact in the last few months the biggest insurance company in the UK (BUPA) have stopped paying for surgery to repair partial thickness tears or full thickness tears which aren’t causing any functional problems because their reading of the medical evidence is that such surgery is unnecessary.

So, a tear is only an issue if it causes you a functional problem: usually weakness using the hand at or above shoulder height. An acute tear caused by trauma should be repaired but chonic tears are a very different thing and do not always need to be fixed. Don’t be scared by being told you have a cuff tear and need surgery because very often an injection or a decompression is all that is required.

The essence of dealing with rotator cuff tears is that they only need to be fixed if they are causing a functional problem. Otherwise the pain you are getting is from the tendonitis element of the condition and not from the hole in the tendon.

How do you fix the tendon back?

I do what is called a mini-open repair. That means that I do the first half of the surgery as a key-hole procedure – that includes the decompression, the ACJ excision if required and a Biceps Tenotomy if required. This also allows me to accurately assess the size of the tendon tear and the quality of the tendon and to decide if it is fixable or not.

The actual reattachment of the tendon back to the bone is done through a 6 – 8 cm incision on the outside of the shoulder.

I divide the deltoid muscle so I can see the hole in the tendon and the bone that it was attached to. Then I roughen up that area on the bone– called the footprint – so the bone is fresh and bleeding because that gives the best environment for the tendon to bond back on to it. The tendon is released from any scarring around it and pulled back over the footprint. I use things called ‘suture anchors’ to do the reattachment. These are metal or plastic screws with sutures attached to them which I drill into the bone and then pass the sutures through the tendon and tie knots in the sutures pulling the tendon back down onto the bone. It usually requires between 2 and 5 anchors depending on the size of the tear.

Then I close the wounds and put your arm in a sling. The sling might be the normal type with your arm by your side. However if there was quite a bit of tension on the repair then I may well put you in a brace sling with your arm at 45 degrees away from your body. I am afraid that is a real pain to manage but it is very important.

How long do I have to be in the sling?

Usually 6 weeks. Tendon has a poor blood supply (which explains why it can erode through in the first place) so it needs a good long period without any tension on it to really bond back to the bone.

Can I move my arm?

What I let you do depends on the size of your tear and how happy I am with the repair.

So, if it’s a smallish tear with good quality, elasticy tissue that I could easily pull over the footprint without much tension, then we will get you doing passive range of motion exercises straight away. That’s where you use your good arm to move the bad one. After only 4 weeks we let you start doing active exercises – firing up the muscles in your bad arm and starting to move it under it’s own steam.

And if it’s a big tear?

That is a different story! The first thing is that you will be in a shoulder brace with your arm held away from your body at about 45 degrees – this is to keep any tension or pull off the repair while it heals. And the second thing is that you will be in that for 6 weeks before we get you out and start moving the shoulder.

That sounds like a nightmare!

It is not easy – it really isn’t. Make no bones about it because I am being truly realistic here about what you are letting yourself in for if you need to have a massive cuff tear repaired. The brace gets in the way, it is awkward to manage and can be sweaty and uncomfortable.

You aren’t really selling this operation to me!

Too many people are told that fixing a cuff tear is not a big deal and that they will be back to normal in a couple of months. That is just not the case. With a big tear it is a big operation and big recovery time.

But remember that you presented with a shoulder that really was not much good. You couldn’t lift it up, it was no real use to you and it was painful. Those are the elements we are planning to get rid off but it is going to take you between 6 months and a year to achieve that. So you are going to go through a lot but you should gain a lot – a useful and pain-free shoulder.

How long do you think the recovery time is? Be honest.

For a medium sized chronic tear or any size of acute tear then you should be pretty much back to normal by 6 months.

For a larger chronic tear that can take a year.

Let’s take the acute tear as an example: hopefully you will just need the ordinary sling and will be in that day and night for 4 weeks but coming out regularly to do passive exercises.

Between weeks 4 and 6 you can start active exercises and start to wean yourself out of the sling so that by the end of week 6 you won’t need it any more.

At that point you should have reasonable to full passive movement but active movement will be lagging a long way behind.

By 3 months though you should have full passive movement and a pretty good functional active range.

You should have been driving a car after 8 weeks and starting to do some gentle exercises about then as well: maybe some swimming, gentle running and perhaps hitting a few golf-balls with a half-swing .

After 3 months you start building up strength, stamina and resistance in the shoulder muscles and do more physical activities: weights in the gym (guided by your physio!!); playing some tennis and playing 9 holes of golf for example.

At the 6 month mark I would expect you to be 80 to 90% back to normal and happy that you had the operation and that you can see just how well you have done and that normality is not too far away.

And what is the timescale for the massive chronic tear? Double that?

Yes – just about. It is long and it is slow but it is worth it.

What happens if you can’t fix my tendon?

Remember the basic ethos here – I will only fix your tendon if it is a functional problem to you. There are a lot of massive tears that don’t need to be fixed even if they could be because functional weakness or lack of movement is not the issue. And even if there is weakness using the arm over head height, a lot of my older patients are happy to adapt around that if I can do something to get rid of their pain: steroid injections, a decompression or a biceps tenotomy.

However there are a group of patients who have what we call ‘massive irreparable cuff tears’ and have an associated loss of function that makes that arm pretty useless. These are the poor souls who can’t lift their hand to their face or head and are really struggling to manage.

What can you do for them?

Well we know the tendon can’t be repaired because the hole is too big, the tendon has retracted back too far and the muscle has wasted away. Often times too the humeral head is no longer sitting centrally on the glenoid so the joint has become eccentric and that can’t be sorted out with a cuff repair.

In this situation I offer a Reverse Geometry Shoulder Replacement and if you go to the section on Cuff Tear Arthropathy you can find out all about that.

The rotator cuff tendons wear through as we get older –that is just what happens so many people will have a tear without even knowing about it. The corollary of that is just because you someone finds a tear it may well NOT be the cause of your pain and therefore does not need to be repaired.

I will only put you through a cuff repair if you have a functional problem directly related to it.

I didn’t have a big injury and this just sounds like the tendonitis you described earlier. Why was I told I had a tear then?

That’s because the same word is used to describe a chronic, or bit by bit erosion, through a tendon which eventually can cause a hole. But is a very different thing indeed to an acute tear.

The thing is you may have a hole in your tendon (called a full thickness tear) anyway because that is just what happens to tendons as the years go by. In fact about 10% of people aged 60 have an asymptomatic erosive tear i.e. a scan shows they have a hole in the tendon but they have no symptoms from it and, as far as they are concerned, don’t have a problem at all. As you get older so that percentage increases and by 80 nearly 50% of people have a rotator cuff that has rubbed through. This is callen ‘intrinsic cuff disease’ and simply means that the tendon degenerates with age due to a poor blood supply.

And as 50% of 80 year olds do not have shoulder pain or weakness then we know that just having a hole in the tendon is not necessarily a cause of either pain or dysfunction.

The other problem is that patients with shoulder pain are often told they have to have an MRI scan. So they get that organised (maybe even paying for it themselves) and the report says they have a ‘tear’. Then their treating therapist or GP latches onto that bit and tells them they have a hole in their tendon and will need an operation.

Finally the patient gets to see me and they always seems a bit surprised when I don’t immediately want to see their scan! “Surely the scan is the Gospel Truth and what it shows is what is wrong.”

No.

I always start by listening to your story because, most of the time, your history will tell me what is wrong with you. Then I do an examination to try and confirm the diagnosis and then, and only then, will I look at the scan.

So the MRI isn’t the be all and end all then?

No it isn’t. As we said above, an MRI – and indeed any form of investigation – has a significant false positive rate. That means it shows things that aren’t actually relevant or related to your history or a cause of your symptoms.

So just because something is seen on the scan does not mean that is your problem.

You have done all that with me; told me I have tendonitis and a small tear that isn’t causing me any problems and I just need a decompression but not a cuff repair. What happens to the tear? Will it repair itself?

A tendon can’t repair itself back to the bone because fluid from the joint gets between the two surfaces and stops them bonding and, more importantly, because the pulling force of the muscle attached to the tendon keeps tugging the end of the tendon away from the bone. It is a bit like detaching one end of a spring – it doesn’t stay there but retracts.

So the tear will get worse then?

We honestly don’t know what exactly happens to erosive cuff tears. Remember the reason the tendon has failed is because it is intrinsically poor quality due to having a very bad blood supply, so even if I fixed it back to the bone, I can’t change the quality of the tendon and the likelihood is that it will just rub through again. Probably, left alone, it will slowly get bigger – remember that 50% figure for cuff tears in 80 year olds but 50% of 80 year olds don’t have shoulder pain? – but won’t be a problem. And the decompression operation should be all that you need.

What about a ‘partial thickness tear’? My scan says I have that. Should I be concerned?

Well at least they have retained the ‘partial’ bit because very often that important word is forgotten and all the patient reads, remembers or is told is that they have a tear and we are back to square 1! A partial thickness tear is sort of one up from tendonitis and, in my view, is nothing to get any more excited about than tendonitis and it does not need specific repair surgery.

I am struggling to use my hand over head height. I need to use my other arm to get my bad arm up to the cupboard and I can’t hold anything heavy with my arm out straight. Is that a torn tendon?

Certainly sounds like it. It could be an acute tear if you had a fall or something like that or a chronic tear if it has crept up on you. So in this case you would need a cuff repair because you have a functional problem with your shoulder.