Rotator Cuff Tears

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.

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.

For details of the surgery go to the ‘operations’ section

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.