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Rotator Cuff Symptoms and Evaluation

Rotator cuff injuries can be very painful and are a common cause of limited shoulder function. People with rotator cuff disorders often have pain or weakness when trying to play golf or tennis, throw a ball, fish, work in the yard, or do any kind of overhead activity.  You may have difficulty sleeping on your side because of pain at night.  Or, you may have trouble reaching behind your back to reach your billfold or bra.  The problem may start suddenly, after a fall, after reaching into the back seat of the car to get a heavy briefcase, or when trying to catch or lift a heavy object.  Alternatively, it may come on gradually with repetitive overhead shoulder activities at work or play with no obvious single injury.

The pain generated from the rotator cuff is usually felt on the front or side of the shoulder, but it can also be felt around the shoulder blade.  Sometimes, the pain moves up into the neck or down the arm towards the elbow.  Rarely does pain from the shoulder go past the elbow, but it can in some instances.

Rotator cuff disorders range from tendonitis to partial tears to full thickness tears, when the muscle is completely detached from the bone.   The rotator cuff is a group of four muscles that surrounds the shoulder and functions to provide the strength and support to perform overhead activities.  This group of muscles is precariously situated between the shoulder blade and collarbone above and the shoulder joint below.  Some people have a spur on the underside of the shoulder blade and collarbone which pinches the rotator cuff and can cause inflammation or tearing of the rotator cuff.  This is frequently known as impingement and can be seen with tendonitis, partial tears, or full thickness rotator cuff tears.

normal rotator cuff tendon
Normal Rotator Cuff

 medium rotator cuff tear
Rotator Cuff Tear: Medium

large rotator cuff tear
Rotator Cuff Tear: Large

impingement type 1 acromion
Normal Acromion without Spur

impingement type 2 acromion spur
Subacromial Spur: Impingement

 

You will see one of our orthopedic surgeons who specialize in shoulder arthroscopy during your visit.  A thorough history of your symptoms and a physical exam focused on your shoulder can be used to make a diagnosis of a rotator cuff injury.  X-rays during that same visit can demonstrate a spur which might cause impingement on the rotator cuff.  A MRI is frequently used to confirm the diagnosis by noninvasively looking at the rotator cuff to find partial or complete tears of the muscles and tendons.

Supraspinatus intact mri
Rotator Cuff: Normal MRI

Supraspinatus partial tear mri rotator cuff
Rotator Cuff Partial Tear

rotator cuff tear full thickness
Complete Rotator Cuff Tear

Non-Operative Treatment of Rotator Cuff Disorders

Early treatment of rotator cuff disorders may include physical therapy, anti-inflammatory medication, or a cortisone injection into your shoulder.  These might completely resolve your symptoms.  Physical therapy for the spectrum of rotator cuff disorders begins by focusing on the muscles around your shoulder blade and core, including your abdominals and low back, and then works into strengthening your rotator cuff muscles.  After several visits with the therapist here or near your home, you can complete much of the therapeutic exercises on your own at home.  Anti-inflammatory medicine can reduce the swelling that accompanies rotator cuff tendonitis and can help with the pain.  Over-the-counter and prescription medications are both useful.  Additionally, your doctor may offer you a cortisone shot on the day of your visit in an attempt to bring you pain relief right away.  The injection is actually a mixture of cortisone, a steroid similar to a chemical your own body makes, and lidocaine, a numbing medicine that may take your pain away within minutes of the injection.  The injection is placed inside your shoulder, just on top of the rotator cuff.  This injection may relieve your pain permanently.  If not, the injection can be repeated.  Numerous injections are to be avoided, as they may only mask a problem that needs more definitive treatment.

Arthroscopic Rotator Cuff Repair

If you continue to have pain or if you cannot get back to your normal activities, your doctor may offer you a surgery known as arthroscopic rotator cuff repair. This procedure uses specially designed instruments to sew the torn rotator cuff muscle back to the bone.  This is all done through three or four ¼ inch incisions around the shoulder.  Using a pencil sized digital camera inserted into your shoulder for the duration of the surgery, the doctor views the action on a high definition flat screen monitor.

This is a day surgery procedure which goes on here at the hospital or at a nearby outpatient surgical center.  You may spend one night in the hospital for pain control and antibiotics.  You will be seen by an anesthesiologist prior to surgery, who will discuss the option of putting another kind of injection in your shoulder so that your whole arm goes to sleep prior to the surgery and stays asleep for 12 to 24 hours afterwards.  Additionally, you will go to sleep with general anesthesia for the entirety of the surgery.  The surgery takes 1 to 2 hours.  When you wake up, you will have a sling and pillow stabilizing your shoulder.  You will stay in the recovery room until your pain is controlled and you are ready to leave for home or be admitted to the hospital overnight.

During the operation, your surgeon will use sutures to sew the torn muscle and tendon back down to the bone where it was originally attached.  Those stitches hold the rotator cuff down to bone for the next three months while the two grow and heal back together.  It takes three months for that to happen, and that is why your activities will be quite limited during that same time span.  Rotator cuff tears come in four different sizes, small, medium, large, and massive, based upon how many tendons of the 4 muscles are torn.

Small tears involve less than one of the 4 muscles.  Usually this is the supraspinatus, the muscle at the top of the rotator cuff, which sits just under the spur on the shoulder blade, and is usually the first muscle to tear.  Partial tears are included in this category as well.  Small rotator cuff tears can be fixed arthroscopically using 1 to 2 bone anchors and 2 to 4 stitches.

Arthroscopic Rotator Cuff Repair: Small Supraspinatus Tear

small rotator cuff tear
Rotator Cuff Tear: small

Small rotator cuff tear with anchor
First Anchor Placed into Bone

small rotator cuff tear with stitches
Stitches Passed Through Tendon

Small rotator cuff tear repaired
Complete Rotator Cuff Repair

Medium sized rotator cuff tears involve at least one but less than two of the four rotator cuff muscles.  This usually includes the supraspinatus and infraspinatus muscles.  Arthroscopic rotator cuff repair of medium sized tears can be accomplished with 2 to 4 anchors and 4 to 8 stitches.

Arthroscopic Rotator Cuff Repair: Medium Supraspinatus Tear

medium-cuff-tear
Rotator Cuff Tear: medium

Medium cuff tear stitches passed
Medial Stitches Passed Through Tendon

Medium cuff tear partial repair
Partial Rotator Cuff Repair

Medium cuff tear complete repair
Complete Rotator Cuff Repair

Arthroscopic Subscapularis Mobilization and Reduction

Intact subscapularis ia view
Normal Subscapularis Tendon

Subscapularis tear ia view
Subscapularis Tear

Subscapularis repaired ia view
Complete Subscapularis Repair

Large and massive rotator cuff tears involve at least two, but sometimes three or all four rotator cuff muscles, being torn from the bone.  Repairing these tears is far more difficult, but a great repair can be accomplished arthroscopically.  In the past, people may have been told their rotator cuff tears were too large to be repaired.  Sports medicine doctors specializing in shoulder arthroscopy can recognize the pattern of the tear and mobilize the edge of the torn muscle to complete an arthroscopic repair of large and massive tears.  Additionally, some people may benefit from a patch augmentation of their repair. 

Large cuff tear
Rotator Cuff Tear: Large

Large cuff tear 2 partial repair
Rotator Cuff Partial Repair

Large cuff tear 2 complete repair
Complete Rotator Cuff Repair

Arthroscopic Rotator Cuff Repair - Large Supraspinatus and Infraspinatus Tear

Large cuff tear
Rotator Cuff Tear

Large cuff tear partial repair
Rotator Cuff Partial Repair

Large cuff tear partial repair
Rotator Cuff Complete Repair

Post-Operative Experience and Rehabilitation

Immediately following the surgery, your shoulder and arm will be stabilized in a sling and pillow.  Ice packs or a “cryocuff” will be applied to your shoulder to limit the swelling and pain.  Your initial dressing will become soaked with blood tinged fluid.  The following morning, remove your dressing and cover each incision with a simple band aid.  Your first appointment will likely be just a few days after surgery, and your skin sutures will be removed at that time.  Until your skin sutures are removed, do not get your shoulder wet.  You can use rubbing alcohol to clean your shoulder if you like.

Rehabilitation and physical therapy are critical for a successful outcome after an arthroscopic rotator cuff repair.  Immediately following surgery, you can begin moving your hand, wrist, and elbow.  You will receive your first therapy instructions or prescription at your first postoperative visit.  Just as no two people are identical, no two arthroscopic rotator cuff repairs are identical, and so too shall each person’s rehabilitation be unique.  As a general guide, for the first six weeks following surgery, you are allowed passive motion only in your operative shoulder.  Gravity and your good arm will be used to move your operative shoulder.  For the second six weeks after surgery, you can begin active motion and your operative shoulder begins to help with motion.  Only three months after your surgery, when the torn muscle has healed back down to the bone, will you be allowed to begin strengthening for your rotator cuff.  If you try to add strengthening too soon, the stitches holding the repair will come loose.

For the first three months following surgery, your activities are very limited.  It usually takes another three months after that to get back to your full activities and sports.  Your doctor will follow your progress closely and allow you to resume activities when you can do so in a safe manner.  Expect to see your doctor two days, two weeks, six weeks, three months, six months, and twelve months after your surgery.

initial-postoperative-exercises-page1.doc

initial-postoperative-exercises-page2.doc

active-assist-exercises-page1.doc

active-assist-exercises-page2.doc

Outcomes of Arthroscopic Rotator Cuff Repair

Success rate from arthroscopic rotator cuff repair depends on what is being measured. Patient satisfaction is the most common reported outcome from arthroscopic rotator cuff repair. Patient satisfaction is measured with standardized tests based upon patient responses to questions regarding their pain levels following surgery and their ability to carry out daily household, work, and sporting activities. Additional data is derived from physician measures of shoulder motion and rotator cuff strength.

Patient satisfaction is rated excellent and good for 93 to 97% of patients after arthroscopic rotator cuff repair in recent studies from Flurin et al in Arthroscopy 2007, Burns and Snyder in Journal of Shoulder and Elbow Surgery (JSES) 2008, and Charosset et al in American Journal of Sports Medicine (AJSM) 2007.

Success measures of patient satisfaction after rotator cuff repair depend upon age. Looking specifically at patients over 62 years of age, 87% had good to excellent results in a study by Grondel and Savoie in JSES 2004. Whereas, 100% of patients less than 40 years old had pain relief and 95% had improved function after arthroscopic single row repair in Krishnan Arthroscopy 2008.

While improvements of pain and return of function are clearly important to both patients and surgeons, healing of the arthroscopically repaired rotator cuff tendon may be a better measure of a successful outcome of the planned surgical anatomic goal. On closer inspection of the data, patients with an intact, healed rotator cuff repair had higher scores than those with a recurrent tear in the Flurin study. That study reported a 15% retear rate. Sugaya in Arthroscopy 2005 reported a retear rate of 25% for patients repaired with a single row of anchors, but that rate was lowered to 10% for those patients who had a dual row arthroscopic rotator cuff repair. Dual row arthroscopic repair uses two sets of anchors and does increase the area with which the rotator cuff has to heal. Lafosse in JBJS 2007 reported a 0% retear rate for small and medium sized tears after arthroscopic dual row rotator cuff repair.

Rotator cuff tears are described as small or medium if they are less than 3 centimeters, about 1 inch. Sugaya in Journal of Bone and Joint Surgery (JBJS) 2007 reported a 5% retear rate for small and medium sized tears. Gladstone in AJSM 2007 reported a 39% retear rate, and stated that size of the tear was the only single variable that predicted retear.

Rotator cuff tears are described as large or massive when they are larger than 3 to 5 centimeters or involve 2 or more of the 4 rotator cuff tendons. Outcomes of arthroscopic repair of large and massive tears are less successful than repair of small and medium rotator cuff tears, but nonoperative treatments have even lower success rates in patients who desire to regain or retain function in Zingg JBJS 2007. Galatz in JBJS 2004 reported good functional results and patient satisfaction despite a 94% retear rate based upon ultrasound for patients with massive rotator cuff repair. Based upon MRI and CT arthrogram, Sugaya reported a 40% retear rate for large and massive tears, and Lafosse reports only a 17% retear rate for large and massive rotator cuff tears that underwent arthroscopic dual row repair.

Investigational techniques to reduce the retear rates for arthroscopic rotator cuff repair of large and massive tears have been reported. Park in AJSM 2008 reported improved results in patients with large and massive cuff tears with a dual row arthroscopic repair. Burkhead in Seminars in Arthroplasty 2007 reported on 17 patients with massive tears greater than 5 centimeters that underwent open rotator cuff repair with allograft patch augmentation of the repair with a 25% retear rate. Snyder and Bond in International Journal of Shoulder Surgery 2007 describe a technique of allograft patch rotator cuff replacement for irreparable rotator cuff tears measuring greater than 5 centimeters and report only 3 recurrent defects in 16 patients. Doctors Taylor Brown and Marc Labbe are currently using arthroscopic dual row rotator cuff repair as well as arthroscopic allograft augmentation and replacement to help improve the outcomes and success rates for their patients at the Bone and Joint Clinic of Houston.

Patch Augmentation of Large and Massive Rotator Cuff Tears

Now, there is a new technique offering hope for people with large and “massive” rotator cuff tears.  In the April 2007 issue of Arthroscopy, Dr. Stephen Burkhart reported original research describing improvement in both function and pain for patients with very large rotator cuff tears who would have previously been told that their tears where irreparable.  Using arthroscopic techniques similar to those described in the above study, Drs. Marc Labbé and Taylor Brown of the Bone and Joint Clinic of Houston are repairing large and “massive” rotator cuff tears. Additionally, they are involved in ongoing research to continue to improve the outcome for people with this terrible shoulder problem.

Using an arthroscopic technique developed and reported by Dr. Labbé in the October 2006 issue of Arthroscopy, these two orthopedic sports medicine surgeons are adding a “patch” to strengthen the repaired muscle.  Just as your grandmother might have patched a hole on the knee of your jeans with a swatch of cloth, they add a patch over the rotator cuff, sewing it down over the repaired muscle and bone.  In early studies, addition of this patch has been shown to increase the success rate for people with large and “massive” rotator cuff tears.  The patch is skin obtained from organ donors which has been tested and specially processed for use as a graft.  Results from the study in which Drs. Labbe and Brown participated were presented at the Annual Meeting of the Arthroscopy Association of North America May 2010 and demonstrated an improved healing rate and diminished failure rate with the addition of the patch graft compared to rotator cuff repair alone.

Arhroscopic Allograft Patch Augmentation Video

Large cuff tear
Large Rotator Cuff Tear

Large cuff tear 2 complete repair
Complete Rotator Cuff Repair

Stitches from rotator cuff ready for patch
Stitches from 4 Corners for Patch

Stitches through patch 2
4 Corner Stitches Through Patch

Stitches through patch
Patch Slides Down Stitches

Patch entering through cannula
Patch Enters Shoulder

Patch slides down over stitches
Patch Slides Down Onto Cuff

Patch sewn into place
Patch Complete Over Repair

 

The complete surgical technique as developed by Dr. Labbe can be found online.  A brief description of this technique can be found at the link below.

http://www.arthroscopyjournal.org/article/PIIS0749806306007328/abstract 

Related Conditions and Treatment:

AcromioClavicular (AC) Arthritis and Excision of Distal Clavicle (Mumford Procedure)

Your shoulder has two joints.  The glenohumeral joint is where the ball and socket meet and is enveloped by the muscles of the rotator cuff and the joint capsule.  The AcromioClavicular (AC) joint is where the shoulder blade, or Acromion, and collarbone, or Clavicle, meet.  This joint often has arthritic wear and tear changes in people with rotator cuff disorders, but it, too, can generate pain independently.  Pain from the AC joint is felt in the top and front of the shoulder when your arm is brought across your chest.  Cortisone injections within the AC joint may alleviate your pain.  Alternatively, you may undergo a surgical treatment for this problem.  This is one of the few joints in the body that can be removed without any undue harm.  By removing the end of the collar bone, there are no longer two worn down surfaces to rub against each other and cause pain.  With the same three or four ¼ inch incisions around the shoulder that are used for your arthroscopic rotator cuff repair, your surgeon will use a bone cutting grinder to remove the end of your collarbone and the pain that goes with it.

Arthritic Distal Clavicle
Subacromial Decompression Reveals Arthritic Distal Clavicle

Distal clavicle excised
The Distal Clavicle After Excision

Distal clavicle excised 2
Complete Mumford Procedure

Subacromial Impingement and Arthroscopic Subacromial Decompression

Subacromial impingement is a common associated finding with rotator cuff tears.  The impingement is caused by a bone spur on the undersurface of the acromion.  During your arthroscopic rotator cuff repair, your doctor will likely remove the bone spur on the underside of the shoulder blade to prevent any further impingement or injury to the rotator cuff muscles after your repair.  Removal of this bone spur is known as arthroscopic subacromial decompression.   This arthroscopic surgery is completed through the same three or four ¼ inch incisions around the shoulder that are used for your arthroscopic rotator cuff repair.  If your only procedure is arthroscopic subacromial decompression, you will be in a sling for 1 to 2 weeks and can resume all of your normal activities once you regain all of your shoulder motion.


 Arthroscopic Subacromial Decompression Video

Biceps tendonitis, Bicep tendon tears, and Biceps Tenotomy and Tenodesis

The bicep tendon is another important structure within your shoulder.  The biceps muscle has two attachments at your shoulder, with only one being within your shoulder joint.  This tendon can become inflamed in addition to or independently from your rotator cuff problems.  Normally, the biceps tendon appears as a smooth, white tubular structure crossing the front part of your shoulder joint.  Tendonitis appears as redness around the tendon.  The tendon can also be partially or completely torn as well.  Tears can happen slowly or suddenly.  Sudden, complete biceps tears frequently cause a “Popeye deformity,” and the shape of your biceps muscle changes as it bunches up just above your elbow.  Tendonitis and the very smallest partial tears can be treated with debridement, or shaving to smooth the tendon, whereas, larger partial and complete tears can be treated with a biceps tenotomy and tenodesis, when the torn or damaged portion of the tendon is removed and then the good remaining portion is reattached to the humerus, or arm bone.  Arthroscopic biceps tenodesis and arthroscopic biceps tenotomy can be carried out at the same time as your arthroscopic rotator cuff repair.

Intact biceps tendon ia view
Normal Biceps Tendon

Partial biceps tear ia view
Partial Biceps Rupture