Orthopedics-Online

Rotator cuff tear

Synonyms

Rotator cuff lesion, rotator cuff rupture, tear of the supraspinatus tendon, rotator cuff rupture, periathropathia humeroscapularis pseudoparetica, tendon tear, tendon tear

definition

The Rotator cuff forms the roof of the Shoulder joint and is made up of four muscles and their Tendons together, which run from the shoulder blade to the greater or lesser tuberosity. These four muscles are:

the infraspinatus muscle,
of the Supraspinatus muscle,
of the Subscapularis muscle,
the teres minor muscle.

The rotator cuff has important functions. It stabilizes the shoulder, is responsible for the internal and external rotation, and partly for the lateral spreading of the upper extremity.

If a rotator cuff tear occurs, the tendon sheath of these rotators tears, most often the supraspinatus tendon because of its anatomically narrow position under the roof of the shoulder.

Such a tear occurs either as a result of a severe accident, for example a fall on the outstretched arm, or as a result of degeneration (wear and tear) of the weakened supraspinatus tendon.

Appointment with a shoulder specialist

I would be happy to advise you!

Who am I?
My name is Carmen Heinz. I am a specialist in orthopedics and trauma surgery in the specialist team of .

The shoulder joint is one of the most complicated joints in the human body.

The treatment of the shoulder (rotator cuff, impingement syndrome, calcified shoulder (tendinosis calcarea, biceps tendon, etc.) therefore requires a lot of experience.
I treat a wide variety of shoulder diseases in a conservative way.
The aim of any therapy is treatment with full recovery without surgery.
Which therapy achieves the best results in the long term can only be determined after looking at all of the information (Examination, X-ray, ultrasound, MRI, etc.) be assessed.

You can find me in:

Lumedis - your orthopedic surgeon
Kaiserstrasse 14
60311 Frankfurt am Main

Directly to the online appointment arrangement
Unfortunately, it is currently only possible to make an appointment with private health insurers. I hope for your understanding!
You can find more information about myself at Carmen Heinz.

Figure shoulder

Collarbone / clavicle
Shoulder roof (acromion)
Space between the head of the humerus and the roof of the shoulder
Upper arm bone / humerus
Shoulder joint (articulatio glenohumerale)

Figure rotator cuff tear

Rotator cuff rupture
Humerus head
Supraspinatus - muscle (Musculus supraspinatus)

Symptoms of rotator cuff tear

The symptoms of a rotator cuff tear vary depending on the underlying cause.

Most often, a rotator cuff tear occurs due to wear, i.e. that over the years the tendon level is thinned by stress and abrasion and the natural tendon quality and tear resistance decreases.
Minor injuries or even without an accident can ultimately tear the tendon. In such cases the patient initially feels the arm is weak during certain movements. For example, the arm can no longer be held at shoulder height or only with great effort. The pain occurs with various movements (see functional shoulder joint examination), which is why the patient usually begins to avoid painful movements. One speaks of taking a relieving posture.

If the rotator cuff tears as a result of an accident, sudden pain occurs. In the case of a total rupture, external rotation or splaying (see functional shoulder joint examination) is either impossible or difficult.

Pressure pain in the insertion area of the supraspinatus tendon is typical in both cases (greater tuberosity).

The pain caused by a rotator cuff rupture can radiate across the upper arm and into the hand, but most of the time the pain is concentrated in the shoulder and lateral upper arm.

Often one finds an impingement syndrome at the same time.

Loss of strength in a rotator cuff tear

The loss of strength is a typical symptom of a rotator cuff tear. In an acute case, this loss of strength occurs immediately, depending on the severity of the rotator cuff tear. In addition, there is immediate pain. With only slightly pronounced tears in the rotator cuff, those affected sometimes only feel weakness. Otherwise, with a complete loss of strength, one can assume a pronounced rotator cuff tear.

The loss of strength manifests itself when the arm moves. Sufferers find it difficult to raise their arms to shoulder level. In addition, external rotation or spreading of the arm are difficult or even impossible.

Rotator cuff pain

With a rotator cuff tear, severe pain often occurs in the shoulder during the acute accident, which can also spread to the surrounding area. Movements in the shoulder are associated with uncomfortable pulling pains that sometimes make it impossible to move. The patients hold the arm in a relieving position in front of the body so as not to strain it. This causes sharp pain at night and when lying on the shoulder. Raising the arm is a particular problem. If it is a rotator cuff tear due to occlusion, it may be that this is not actively perceived with pain and is only noticeable through the restricted movement.

Diagnosis of a rotator cuff tear

With a view to diagnosing a Rotator cuff rupture different examination options are available.

Usually with a functional shoulder joint examination began.
This examination includes, among other things, the examination of the force development of the Rotator cuff by lifting the arm sideways (Abduction) against resistance, through External rotation (-rotation) against resistance with a hanging arm and bent elbow as well as by internal rotation of the arm against resistance.
While the splay prevents the Supraspinatus muscle the function test, which checks the external rotation against resistance, refers to the Teres minor muscle and the Infraspinatus muscle.
The verification of the powerful internal rotation of the arm controls the functionality of the Subscapularis muscle.

In addition to the functional shoulder joint examination, there are imaging procedures such as:

X-ray
Sonography (ultrasound)
Magnetic resonance imaging of the shoulder (MRI, NMR)

to disposal.

The X-ray cannot directly detect a tear in the rotator cuff because tendons and muscles belong to the soft tissue of the body and these are transparent to X-rays, so they are not shown.
However, since the absence of the rotator cuff leads to the humerus head rising up below the canopy, the observation of this phenomenon is an indirect indication of the presence of a severe rotator cuff tear.
However, small cracks do not cause this phenomenon. However, it is more important that concomitant diseases are revealed by an X-ray (e.g. omarthrosis = arthrosis of the shoulder joint, Tendinosis calcarea) and it can provide clues about the cause of the rotator cuff rupture.
For example, a bony spur under the roof of the shoulder should be mentioned here (subacromial spur = Impingement syndrome) that made a hole in the Rotator cuff may have torn.

The big advantage of Sonography lies in their easy availability and usability as well as in the possibility of dynamic shoulder examinations, in which the arm can be moved during the examination. So you can examine the rotator cuff “at work”. Even small holes in the rotator cuff can be discovered by an experienced examiner.

A MRI of the shoulder is increasingly used when a rotator cuff tear is suspected. Cracks in the rotator cuff can be reliably identified. In addition, the tendon quality and retraction (retraction of the tendon after the tear) can be assessed well by the MRI, which can have direct consequences on the doctor's therapy recommendation.

A suspected diagnosis can be made by a Shoulder arthroscopy (Arthroscopy) secured. The extent of the rotator cuff lesion can also be assessed here (partial or total rupture) and, if necessary, therapy can also take place at the same time (rotator cuff suture = suture of the torn tendon).

MRI of the shoulder for a rotator cuff tear

Soft tissue structures such as tendons and muscles can be better represented in the MRI compared to the CT and X-rays.
A rotator cuff tear can be seen on MRI at the point where the continuous structure of the tendon ends abruptly. The radiologist can do this at the appropriate point and also along the other muscle edema (Liquid) that appears light or dark depending on the setting of the MRI scanner.
With an MRI, the extent and location of the rotator cuff tear can be described in more detail and statements can already be made about how to proceed surgically - for example, whether a tendon plasty is used. In addition, accompanying problems can also be recorded here, such as an impingement (shoulder tightness) or osteoarthritis.
Compared to other examinations, however, the shoulder MRI is significantly more expensive and time-consuming.

You can find more information at: MRI for rotator cuff damage

How can I recognize a rotator cuff tear myself?

In the case of a rotator cuff tear, the function of the affected muscle becomes painful or can only be carried out to a limited extent. Most of the time it is Supraspinatus muscle affected. This muscle is for lifting (Abduction) the shoulder responsible. If this muscle ruptures or tears, lifting the shoulder is only possible with pain. Movements that are often difficult are overhead movements or putting on jackets. In the case of complete and fresh cracks, the initial lifting of the shoulder may no longer be possible. With a prolonged rotator cuff tear, some patients complain that the entire shoulder becomes stiff over time.

How can you tell whether it is an injury or wear and tear?

There are two common causes of a rotator cuff tear. On the one hand the tear caused by trauma and on the other hand the wear and tear. Patients in whom wear and tear is the cause of the rotator cuff tear tend to be older patients (55 years and older). If patients report that there has been no adequate trauma, such as a fall or severe stress, then it is very likely that the rotator cuff tear is due to wear and tear. The condition of the tendon can be assessed well through an ultrasound or MRI examination, which are often done in the course of diagnostics. If the visible parts of the torn tendon show signs of thinning and calcification, this indicates a process of wear.

Furthermore, the patient's history of a rotator cuff tear caused by wear is often conspicuous. A crack caused by an injury is indicated by the fact that the patient is younger (50 and significantly younger). At this age, closure can occur - but it is not so pronounced that it would crack. If patients report an accident that also affects the shoulder and after which the corresponding shoulder discomfort occurred, then an injury is likely to be the cause of the rotator cuff tear. If arthroscopy, ultrasound and MRI make it clear that the tendon looks normal and healthy except for the tear, wear and tear can be ruled out as the cause. In older people who are worn out and have an accident, it is likely a combination of the two that causes the rotator cuff tear.

examination

With regard to various diagnostic options, some functional tests for checking the functionality of the shoulder joint have already been described. In addition, there are other examination options that should be included as part of a physical (clinical) examination. This examination usually includes the delineation of two clinical pictures, the impingement syndrome and the rupture of the rotator cuff.

The triggering of the so-called painful arc (= painful arc). To do this, the arm is passively raised over the side. In the event of an impingement syndrome, the arch passes through a narrow point between 60 and 120 °, which then causes pain if an impingement syndrome is present. This examination can diagnose complaints caused by a tightness under the roof of the shoulders.

In the event that the pain is so severe that the arm cannot move independently, an anesthetic is injected into the bursa. If the patient is unable to move the arm actively despite the sedative, a rotator cuff tear can be assumed. One speaks of a pseudoparalysis if the symptoms do not only relate to the functional failure, but also resemble paralysis.

therapy

In the context of a rotator cuff rupture, both conservative and surgical therapeutic measures can be followed. As a rule, an incomplete rupture of the supraspinatus tendon results in conservative therapy. If there is a complete rupture, an individual decision is made. As a rule, patients who are older than 65 years and who have tolerable pain are also treated conservatively.

conservative therapy

Conservative therapeutic measures can include the following areas:

Protection, for example by immobilization with a thoracic abduction orthosis. This is an aid that keeps the arm away from the side of the chest. After removing the orthosis, mobilization takes place through physiotherapy measures.
Administration of anti-inflammatory drugs (non-steroidal anti-inflammatory drugs - NSAIDs) such as diclofenac, ibuprofen, indomethacin or newer generation NSAIDs (Cox2 inhibitors) such as Celebrex®.
Cryotherapy (cold applications), especially after an accident.
Physiotherapeutic, pain-free movement exercises, including stretching and strengthening exercises to avoid joint stiffening. Training the remaining muscles
Infiltration (syringe) under the shoulder roof to reduce pain

In contrast to surgical therapy, the conservative form of therapy does not allow torn tendon parts to “heal together”. This is due, among other things, to the fact that the torn tendon parts have pulled together and thus no healing is possible. Despite this fact, the conservative measures can have the effect that the shoulder function can be restored to such an extent that normal "everyday use" can be guaranteed.

If such a result is not indicated after about three months, you should think together with your treating doctor about whether the conservative therapy is still promising or whether surgical measures should be taken. These measures are described below.

Exercises for rotator cuff tear

Not every rotator cuff tear is automatically treated surgically. A good option is conservative treatment, in which physiotherapy and muscle strengthening play an important part. Exercises should be discussed with the attending physician or the physiotherapist, as incorrect execution of the exercises can further aggravate the rotator cuff tear. A first important group of exercises for rotator cuff tear are stretching and loosening exercises. The aim is to loosen the surrounding joints and muscles and make them suitable for everyday use. Circling your arms is a good way to loosen up your shoulder. This should be done carefully and evenly, avoiding jerky movements. For stretching, it is important to include the chest and back. To stretch the chest, it is advisable to keep your arms stretched horizontally to the side while standing. Now try to move both arms straight towards the back as far as possible and then hold for 30 - 60 seconds. You should feel a pull in your chest.

The following is suitable for the upper back and the rear shoulder: An arm is placed around the neck from the front and the hand is placed on the rear shoulder. The other hand is carefully pressed against the elbow so that the arm moves further towards the back. A physiotherapist can show you more stretching exercises. The next important step is to strengthen the muscles. Since the torn parts of the rotator cuff usually do not grow back together, other muscles have to compensate for their task as much as possible and this has to be learned.

Most exercises can be performed in physiotherapy on the cable pull or simply at home with the Theraband. Thera bands can be purchased for under € 20. It is important to train the internal and external rotation. The Theraband is placed around a door handle so that you can hold both ends in your hand. To train the external rotation, stand sideways with the other shoulder to the door handle. Now you hold both ends of the Theraband with your hand, the shoulder to be trained. The elbow is placed on the side of the body and bent at 90 ° so that the forearm is pointing horizontally forward. With your hand you now pull the Theraband outwards and backwards, while the Theraband is stretched. It is important that the elbow stays close to the body. This can be done in three sets of 15-20 repetitions. Do the same for the other arm, only you have to turn around.

To train the internal rotation, stand again to the side of the door handle.This time you stand with the shoulder to be trained in the direction of the door and hold the Theraband with your hand on the shoulder to be trained. Here, too, the elbow is bent to 90 ° and remains attached to the body. This time the forearm is rotated towards the stomach, as if trying to touch the stomach. There are three rounds of 15-20 repetitions each. To train the other shoulder you have to turn around accordingly. An additional good exercise that trains the external rotation and shoulder lift goes as follows. The Theraband is held on the hip on the opposite side with the arm stretched and held on. With the side to be trained, hold the stretched Theraband at the end and pull it evenly up and out with the arm extended. The arm makes a slight bow. Then the arm is moved back slowly and evenly. This exercise can be done in three sets of 10-15 repetitions for each arm. It is important that if you are in pain, you do not continue, but first consult your doctor or physiotherapist.

A fourth helpful exercise for strengthening the shoulder muscles is to keep the arms horizontal and stretched in front of the body, about shoulder width apart. The Theraband is held tight with both hands. Now both arms are pulled back evenly so that you have the feeling that the shoulder blades are touching. This exercise can be done in three sets of 10-15 repetitions each. Another group of exercises that strengthen muscles are the support exercises. You can lie down in the forearm support. You lie on your stomach, then place your forearms lengthways under you on the floor and lift your stomach, bottom and knees so that you only touch the floor with your forearms and toes. One tries to hold this position as long as possible. You can do something similar in the push-up position. You push yourself with your hands a little wider than shoulder width from the floor and try to hold it. In both exercises, body tension must be maintained by tensing the stomach, back and buttocks. For all exercises, it is essential that they be discussed with the attending physician or physiotherapist, as complicating factors can arise individually for each patient.

This article may also be of interest to you: Exercises against shoulder instability in impingement syndrome

(Kinesio) tapes for rotator cuff tear

Taping the shoulder for a rotator cuff tear can help and relieve discomfort. The aim is to redistribute the load that the affected tendon would otherwise have to bear. Furthermore, the circulation should be improved and the pain reduced. The tapes can be glued in different ways. There are different methods and views behind this. The basic type and method is the same as that used when taping shoulder impingement.

More information can be found here: Kinesio tape

operative therapy

Indication criteria with regard to surgical treatment of a rotator cuff rupture are, for example:

strong pain
Age (<65 years) in combination with professional and / or sporting activities
Rupture of the rotator cuff on the dominant arm, usually the right arm
Resistance to therapy or degenerative / wear-related changes in the shoulder joint.

Surgical therapy differentiates between incomplete and complete rupture with regard to the surgical procedure. Whether the operation is / can be operated arthroscopically or openly depends on the size of the tear. The smaller the crack, the better it can be treated as part of an arthroscopy of the shoulder joint. Larger cracks can usually only be cleaned arthroscopically and the pain can be alleviated with endoscopic subacromial decompression (ESD). Different procedures are available, such as Neer's acromionplasty or excision of the tendon area. The suture of the supraspinatus tendon is also conceivable, for example in the event of a transverse tear in the rotator cuff. In this case one speaks of a so-called transosseous suture, i.e. of a seam to be sewn through the bone in the place where it originally tore off. There are various anchoring options for this procedure:

Screw anchors made either from titanium or from bio-absorbable (= self-dissolving) material. All interventions require postoperative treatment.
Transosseous sutures, which means that the thread is pulled through the bone, which is sutured using a special suture and knot technique (e.g. Mason - Ellen technique).

Follow-up treatment of the rotator cuff tear

The follow-up treatment for rotator cuff tear is very dependent on the patient, the type of treatment and the size of the tear. If it is a small tear that does not require surgery, physiotherapy usually follows. In addition to building muscle with the exercises mentioned above, the focus here is initially on healing the crack. It is advisable to take it easy in the first few weeks. In addition, cold applications, acupuncture and also pain injections into the tendon area are helpful. However, this is primarily useful in the first few weeks to reduce the pain of the accident or the inflammation. In the case of fresh ruptures, movement may only be carried out passively for the first 6 weeks.

In the case of larger cracks and operations, the surgeon creates a follow-up treatment plan that is passed on to the physiotherapist. After an operation, it is assumed that the tendon suture will only be stable again after about 6 weeks. That is how long the arm usually has to be held in a kind of abduction bandage. Exactly how long this bandage has to be worn depends on the condition of the tendon and how well it heals. In the first 4 weeks you can only move passively and only in limited angular degrees. From the 4th week you can usually move assistively (supported by the therapist) and from the 6th week you can move actively and carefully. Movements against resistance should be made from the 7th week at the earliest. Weight-bearing exercises should not be done for the first 2 months.

Further information can be found here: Follow-up treatment of rotator cuff tear

Which tendon is most commonly affected?

The rotator cuff consists of a total of 4 muscles: infraspinatus muscle, supraspinatus muscle, subscapularis muscle and teres minor muscle. If the rotator cuff is torn, the tendon of the supraspinatus muscle is most often affected. The reason for this is the anatomical position of the sinewy part. The tendon runs directly between the roof of the shoulder and the head of the humerus. As soon as there is a small narrowing of this space, the tendon can be affected. Since this is very often the case in the context of inflammation of the bursa, for example, injuries or degenerative changes, the tendon of the supraspinatus muscle is considered to be very susceptible to irritation that leads to a tear. Classically, a tear in the supraspinatus tendon can be identified by preventing the arm from splaying apart. The function of this muscle, namely the abduction or splaying of the arm in the shoulder joint, is not retained in the event of a tear.

Can a rotator cuff tear heal on its own?

A rotator cuff tear is unlikely to heal itself without taking conservative or surgical measures. In order to regain full functionality and resilience, torn parts are surgically brought together again. With purely conservative therapy, this goal of growing together can no longer be achieved, so that movement and exercise restrictions can remain.

If a rotator cuff tear is left to its own devices, only symptoms such as pain can be reduced. Restriction of movement or a loss of strength persist, as the torn parts do not come together again by themselves. Without therapeutic measures, pain can be effectively reduced over time - but in terms of functionality and mobility, the arm and shoulder joint will have to lose.

How long have I been on sick leave or unable to work with a rotator cuff tear?

The length of a sick leave or incapacity for work depends on the severity of the tear, on the type of therapy and largely on the occupation.

As a rule, the rotator cuff tear is treated surgically to completely restore functionality and stress. This means that the arm must first be immobilized 4-6 weeks after the operation. In the meantime, physiotherapy is usually started to avoid stiffening due to the immobilization. This may be followed by a rehabilitation of several weeks.

The duration of sick leave or incapacity for work varies depending on whether the person concerned only has to work in an office with minimal stress on the shoulder and arm or whether they are active in physically active occupations such as construction workers or craftsmen. For pure office jobs, it comes down to 2-3 weeks. Since a torn tendon can take up to 4 months to heal completely, a sick leave or incapacity for work for physically demanding jobs is issued for a period of 3-4 months.

Duration of a rotator cuff tear

A rotator cuff tear can occur in the very short term due to trauma, but also due to long-term damage over many years. At first only a small crack can appear, which continues to tear over several weeks until it becomes painful and causes problems. After a crack, it can be assumed that, regardless of whether it is an operation or conservative treatment, 6 weeks must be planned in which no active movement at all is allowed. You can only move slowly again after 6 weeks. But even then, no heavy work may be carried out or heavy weights lifted. Some patients are ready to go again after 3-4 months. Other sufferers have had complaints and pain for years and are not fully operational. What those affected have in common, however, is that sports and professions that put strain on the shoulder are only allowed to fully strain again after about half a year. And even then, it is essential that you consult with us if you are in pain.