Rotator Cuff Tears

What is a rotator cuff tear?

A rotator cuff tear is an injury affecting the muscles and tendons in your shoulder.
Rotator cuff tears occur when one or more of these tendons either become; partially torn (called a partial thickness tear), fully torn (called a full thickness tear) or the tendon becomes completely detached from the bone (called a complete tear). Most tears occur in the supraspinatus tendon, but other parts of the rotator cuff may also be involved.

In many cases, a torn tendon begins with ‘fraying’ or minor tears. This is sometimes known as tendinopathy. As the damage progresses, the tendon can partially tear which can lead to a full thickness or a complete tear. It can be a very debilitating condition and often prevents patients from carrying out simple, daily activities such as reaching up, lifting their arm and dressing/undressing.

It is important to consider that early treatment can result in a rapid reduction in pain and can prevent the tear getting worse.

Anatomy of the Rotator Cuff

The rotator cuff is a group of four muscles which originate from the shoulder blade (scapula) and attach to the main bone of the upper arm (humerus). They form a cuff around the head of the humerus and provide stability and strength as the arm moves through all planes of movement.

The four muscles, collectively known as the rotator cuff, are your subscapularis, supraspinatus, infraspinatus, and teres minor. These muscles help to centralise the shoulder joint, keeping the ball in the centre of the socket. This enables you to lift and rotate your arm with pain-free, smooth movement.

There are different types of rotator cuff tears

• Partial Tear

This type of tear does not completely detach the tendon from the bone. It is called partial because the tear goes only partially through the thickness of the tendon. The tendon is still attached to the bone, but it is thinned.

• Full-thickness Tear

With this type of tear, there is detachment of part of the tendon from the bone. When only a small part of the tendon is detached from the bone, it is referred to as a full-thickness, incomplete tear. It is incomplete because although it does go through the full thickness of the tendon it does not go through the full width of the tendon.

• Complete Tear

When a tendon is completely detached from the bone, it is referred to as a full-thickness, complete tear. With a full-thickness complete tear, the tendon is torn through the full thickness of the tendon AND the full width of the tendon.

What causes a rotator cuff tear?

A rotator cuff tear can occur in two ways:

• Acute tear – a specific trauma or injury which causes a sudden tear. These are more common in younger people and athletes between the age of 20 and 40 years old, but they can also occur in older adults and athletes.
• Chronic degenerative tear – repeated microtrauma that accumulates in a tear overtime. This is more common in older adults, above 40 years of age.

Traumatic rotator cuff tears occur quickly or under heavy load, e.g., a fall onto the shoulder or lifting a heavy weight – this makes up a small percentage (approx. 5%) of rotator cuff tears. However, the most common cause of a rotator cuff tear (approx. 95%) is repeated chronic microtrauma, or wear and tear, which can occur over several weeks, months or years.

Repetitive overhead sports like swimming, tennis, and activities like painting can cause overload of the rotator cuff tendons. This can lead to the tendon thickening and becoming pinched in the subacromial space, which may result in a tear of the tendon.

Repeated rotator cuff injury from straining or pinching the tendons will injure the soft tissue, resulting in swelling of the tendon and bursa. It is not uncommon that rotator cuff injuries and shoulder bursitis occur together to cause a shoulder impingement. This ongoing shoulder impingement if left untreated, can cause the rotator cuff tendon (or tendons) to tear.

Risk Factors:

• Age – Rotator cuff tears are more common in people over 40. As we get older, the rotator cuff tendons become weaker (known as degeneration) and this can lead to tendon dysfunction and sometimes tears. Traumatic tears are much more common in young adults.
• Occupation – People with jobs that involve repeated overhead movements, such as painters and decorators, carpenters, construction workers, etc are at greater risk of developing a tear.
• Sports – Rotator cuff tears are often seen in athletes who participate in sports such as tennis, swimming, cricket, or weightlifting.
• Anatomical variation – Some people have a reduced subacromial space due to the shape of their shoulder joint or because they have developed bony spurs. This can cause added friction between the tendon and the bone, causing the tendon to fray and potentially tear.
• Family history – There may be a genetic component involved with rotator cuff injuries as they appear to occur more commonly in certain families.

What are the symptoms of a rotator cuff tear?

The main symptom of a rotator cuff injury is pain at the top and outside of your shoulder, however the exact location can vary and sometimes the pain can spread down towards your elbow. The pain can be a dull, general ache, or it can feel severe and sudden if you tear your rotator cuff in an accident or related trauma.

You may have shoulder pain even at rest, but the pain often gets worse if you are doing something where you lift your arm or raise it above your head such as lifting an object onto the shelf. It can also be painful in the gym if you lift weights such as a bench press or shoulder press or playing racquet sports, especially a serve in tennis.

Other symptoms of a rotator cuff injury include:

• Weakness – Your arm may feel heavy and difficult to move when you lift or raise your arm. In severe cases you may not be able to lift your arm much at all.
• Pain at night – Especially if you lie on your affected arm.
• Limited range of movement – Being unable to move your shoulder fully.
• Clicking – You may hear a clicking or grating sound when you move your shoulder.

It should be noted that some rotator cuff tears are not painful. These tears, however, may still result in arm weakness and an inability to lift and carry.

How is a rotator cuff tear diagnosed?

The diagnosis of a rotator cuff tear can be established clinically by your physiotherapist during the assessment. Your specialist clinician will initially ask a series of questions to uncover how and why your pain started. They will then perform a series of clinical tests to help develop a diagnosis. This may include:

• Postural assessment of your shoulder joint, shoulder blade and spine.
• Shoulder range of movement tests.
• Rotator cuff strength tests – a series of specific tests designed to assess the strength of the rotator cuff and diagnose which muscle/tendon has been torn.
• Palpation – gently, but skilfully, feeling around your shoulder joint, muscles, and tendons to locate the exact source of your pain.
• Functional tests – if your pain is present during a specific activity or task, you may be asked to perform these, so the physiotherapist can assess exactly what is aggravating your pain.

There are other conditions in the shoulders that may cause similar symptoms, so it is vital that you see a specialist clinician who can correctly diagnose your condition and allow for a rapid and effective treatment approach.

Diagnostic Ultrasound

If a rotator cuff injury is suspected, it is crucial to confirm its exact type, since treatment varies depending on the severity and whether there is any other underlying pathology. This is especially important if you have had a specific trauma or fall where the injury occurred as some acute rotator cuff tears are best managed with surgical intervention.

Diagnostic ultrasound is a very sensitive imaging modality for diagnosing a rotator cuff tear and will provide key information on the size and type of tear. It is cost effective and highly accurate. Not only can the scan assess your rotator cuff tendons, it can also assess the bursa, biceps tendon and other structures of the shoulder. During your diagnostic ultrasound scan, your clinician will ask you to move your arm to assess what is happening as your shoulder moves through the painful region. This can provide essential information to ensure we obtain the correct diagnosis.

At Complete Physio, our clinical specialists carry out an ultrasound scan as part of their clinical assessment. The combination of the physical examination and ultrasound will help determine the provision of an evidence-based treatment program to relieve your symptoms and allow you to return to the activities you enjoy.

We do not charge extra for an ultrasound scan, and you do not require a GP referral. If you would like to book a physiotherapy appointment, including an ultrasound scan, please ensure you inform our administration team that you need to book with a clinical specialist.

MRI and Xray

Ultrasound can diagnose a rotator cuff tear; an MRI scan is not always necessary. An MRI scan can also be used to diagnose rotator cuff tears, but it can also visualise deeper structures in the joint better than ultrasound, such as the articular cartilage on the humerus i.e., the “ball” of the “ball and socket”. It also visualises the labrum, which is the cartilage attached around the “socket” of the joint, known as the glenoid labrum. An MRI scan is recommended if you have dislocated your shoulder.

An X-ray is of little diagnostic value when a rotator cuff tear is suspected as it does not show soft tissue structures. However, it may be appropriate if needing to rule out other pathologies, such as fractures, arthritis, or bone spurs.

How do we treat a rotator cuff tear?

If you have a rotator cuff tear, and keep using it despite increasing pain, you may cause further damage. A rotator cuff tear can get larger over time.
Early treatment can prevent your symptoms from getting worse. It will also get you back to your normal routine quicker.

The goal of any treatment is to reduce pain and restore function. There are several treatment options for a rotator cuff tear, and the best option is different for every person.

The optimal management for rotator cuff tears depends on several factors, these include:

• Your age
• The cause of your pain e.g., whether you had a fall/injury or whether the pain came on gradually for no apparent reason
• The size, type, and location of tear (determined on the ultrasound scan)
• Your general health and other health issues
• Your activity level and goals

Physiotherapy

Physiotherapy can effectively treat most rotator cuff tears and is one of the first treatment options your doctor or shoulder specialist would suggest.

In about 80 to 85% of patients, physiotherapy i.e., nonsurgical treatment relieves pain and improves function in the shoulder. Recent studies have suggested that patients opting for physiotherapy have demonstrated high satisfaction, an improvement in function, and success in avoiding surgery.

Your physiotherapist at Complete will discuss your goals, time frames and training schedules to optimise you for a complete return to sport or work. They will provide you with an individual, tailored regime based on your personal profile.

This will often include:

• Education and advice – one of the most important and effective aspects of rehabilitation is to understand more about the problem and the best ways to facilitate and take part in your own recovery. You will be given a clear explanation of the diagnosis and any other underlying causes, and we will discuss what is required to address these issues and reach your goals.
• Activity modification, posture re-education and ergonomic advice – to help allow your pain and symptoms to settle.
• Manual therapy – including joint mobilisations or manipulations, and soft tissue techniques such as massage.
• The application of corrective physiotherapy tape – this is used to help correct shoulder position and allow a reduction in pain during movement.
• Range of movement exercises – for your shoulder and neck.
• Specific strengthening exercises – for the muscles surrounding your shoulder. This part of your treatment will be closely monitored to ensure that you are not causing any further damage to the injured tendon. You will work on both the smaller, stabilising shoulder muscles, as well as the bigger, more global muscles in the whole of the upper limb, back and neck.

• Targeted stretching and manipulation – for any tight muscles and joints.
• Upper limb proprioception exercises – exercises to help to retrain your brain and regain its trust in using the affected arm
• Functional activity, work, and high-level sport specific exercises – this part of your rehab will ensure that you regain your preinjury strength, power, and endurance. It will also help ensure that your injury does not reoccur.

Often there is no one single treatment that is a magic cure for a rotator cuff tear, and your therapist will likely work through a varied programme involving some ‘hands-on’ therapy and some specific exercises for you to do independently.

Throughout your treatment at Complete Physio, we will keep revisiting your personal goals and activities, so that we maintain the focus on making your life easier, ensuring that you feel supported and involved in your rehab process.

Ultrasound-guided Steroid Injection

When the pain is not improving, and particularly if the pain is waking you at night, an ultrasound guided injection can provide fast, effective pain relief.

There are two main injection options for rotator cuff tears:

1. Ultrasound guided steroid injection

The first option is a steroid injection into the subacromial bursa. Steroid is a strong anti-inflammatory that can provide fast, effective pain relief. This provides a pain-free window for you to engage in a course of physiotherapy.

Exercise based treatment following a rotator cuff tear is essential to restore full strength and movement in the shoulder. However, it is not uncommon that patients struggle to perform physiotherapy exercises due to high pain levels and so the combination of treatment (injection and physiotherapy rehabilitation) works very well.

2. Platelet-Rich Plasma (PRP) injections

The second option for a rotator cuff tear is platelet-rich plasma (PRP) injections. PRP injections are an injection technique which aims to encourage new healing of the tendon.

These injections are most effective in younger patients who have had a specific injury/incident that resulted in the tearing of the rotator cuff such as a fall or lifting weights in the gym. It is most effective when carried out as soon as possible after the injury. Three PRP injections are carried out over a six-week period, with one injection every two weeks.

No injection should be considered as a stand-alone treatment. Research has shown significantly better outcomes when injection therapy is combined with physiotherapy rehabilitation, and so Complete highly recommend you start a course of physiotherapy within 2 weeks after receiving an injection. If you would like more information or would like to book an appointment, please contact us on 0207 4823875 or email info@complete-physio.co.uk

Rotator Cuff Repair Surgery

Rotator cuff repair surgery is a treatment option for large, partial-thickness, full-thickness, complete tears, that do not improve with physiotherapy. Most shoulder surgeons will recommend at least 6-12 weeks of physiotherapy before contemplating rotator cuff repair surgery.

If you have sustained an acute rotator cuff tear due to a fall or trauma it is essential that you get a diagnostic ultrasound to assess the size and location of the rotator cuff tear and visit a surgeon as soon as possible. If you have sustained an acute rotator cuff tear surgery that is carried out within the first few weeks is likely to have a better result.

Your physiotherapist may also refer you to a surgeon if you do not improve with nonsurgical methods including physiotherapy and an injection. Continued pain and reduced function are the main indications for surgery. However, your consultant may also suggest surgery if you are very active and/or use your arms for overhead work or sports.

Other signs that surgery may be a good option for you include:

• Your symptoms have lasted 6 to 12 months
• You have a large tear (more than 3 cm), and the quality of the surrounding tissue is good
• You have significant weakness and loss of function in your shoulder
• Your tear was caused by a recent, acute injury

Surgery to repair a torn rotator cuff most often involves re-attaching the tendon to the head of the humerus (upper arm bone). There are a few options for repairing rotator cuff tears. Your orthopaedic surgeon will discuss with you the best procedure to meet your individual health needs.

A physiotherapy guided rehabilitation programme will be needed following surgery to restore the full range of movement, strength, and function to your shoulder.

Your post-operative rotator cuff repair recovery commonly takes between six to twelve months.

If your physiotherapist feels that you need surgery, then they will refer you on to the most appropriate orthopaedic specialist. At Complete Physio we work with some of the most highly regarded and experienced surgeons in the country.

At Complete Physio we provide a comprehensive, “one stop clinic” for rotator cuff tears, from diagnosis to treatment, including ultrasound guided injections. All these treatments can be carried out within our London clinics, which means you do not need to visit different specialists. Our “one stop service” also makes your treatment more affordable and accessible.

If you would like to discuss your treatment before booking in, please do not hesitate to contact us, and one of our expert physiotherapists will call you back.

To make an appointment please email info@complete-physio.co.uk or call 020 7482 3875.