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Rotator Cuff tear Treatment
Dr Poh Seng Yew
MBBS
MRCSEd
MMED (Ortho)
FRCSEd
What is a Rotator Cuff Tear?
A rotator cuff tear involves the rupture or damage to one or more of the tendons or muscles in the rotator cuff group. The rotator cuff is an assembly of muscles and their tendons that provide stability and mobility to the shoulder joint. The four muscles in this group — supraspinatus, infraspinatus, teres minor, and subscapularis — converge to form a cuff over the head of the humerus (the upper arm bone) and are integral for shoulder movement and support.
Causes of Rotator Cuff Tears
Rotator cuff tears occur due to a range of factors, broadly categorised as either acute or degenerative.
Acute tears
These are often the result of a sudden, forceful movement. This can include lifting an object that is too heavy or falling on an outstretched arm. In athletes, acute tears might happen during activities involving overhead motion, such as throwing, or from a direct blow to the shoulder.
Degenerative tears
These are more common and develop over time. They are typically seen in the ageing population as tissue elasticity diminishes and tendons wear down. Repetitive stress from tasks that involve lifting the arms overhead can also contribute to tendon wear and tear. Occupations such as painting or construction, or sports like tennis or baseball, which involve repetitive arm movements, can predispose individuals to degenerative tears.
Other Contributing Factors
- Poor blood supply: As people age, the blood supply to the rotator cuff tendons decreases, impeding the body’s natural ability to repair tendon damage.
- Bone spurs: Osteophytes or bone spurs can develop on the underside of the acromion bone. Over time, these spurs can rub against the tendon tissue during shoulder movement, leading to a condition known as shoulder impingement. Repeated rubbing can weaken the tendon and contribute to a tear.
- Genetic predisposition: Some individuals may be genetically predisposed to rotator cuff injuries, with a family history of tears being common among those affected.
Symptoms Indicative of a Rotator Cuff Tear
- Pain: Pains could occur at rest and at night, particularly if lying on the affected shoulder. Pain may also be present when lifting and lowering the arm or with specific movements.
- Weakness: The arm feels weak when lifting or rotating.
- Crepitus: A crackling sensation which occurs when moving the shoulder in certain positions.
- Limited range of motion: Including having difficulty with activities such as combing hair or reaching behind the back.
Diagnosing a Rotator Cuff Tear
Diagnosis of a rotator cuff tear involves a combination of clinical evaluation and imaging techniques.
Initial Evaluation
The clinician will enquire about the onset of symptoms, any preceding injuries, and activities that exacerbate the pain. During the physical examination, the doctor assesses range of motion, shoulder strength, and the presence of pain with movement.
Imaging Studies
- X-rays: This can reveal a narrowing of the space between the acromion and the rotator cuff, indicating a tear.
- Ultrasound: A dynamic test allowing for real-time evaluation of the rotator cuff tendons.
- Magnetic resonance imaging (MRI): Provides a detailed image of the shoulder structure, including the extent of the tear and the quality of the rotator cuff muscles.
Further Tests
In certain cases, further diagnostic tests such as arthrography or magnetic resonance arthrography may be used to enhance visualisation of the rotator cuff tear.
Non-Surgical Treatment Options
Non-surgical treatment options are often the first approach, particularly for patients with partial-thickness tears or those for whom surgery presents too high a risk. The main approaches are as follows.
- Physical Therapy - Physical therapy is a cornerstone of non-surgical treatment, designed to strengthen the muscles around the shoulder and restore flexibility.
- Pain Management - Pain relief can be managed through nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce inflammation and pain. Corticosteroid injections may also be considered to provide temporary pain relief.
- Activity Modification - Patients should avoid activities that cause shoulder pain, especially those involving overhead movement. This helps to minimise further injury and inflammation.
- Rest and Cold Compresses - Resting the affected shoulder and applying cold packs can reduce swelling and pain.
- Support Devices - Using slings or shoulder immobilisers may be recommended to limit shoulder movement and provide support, especially in the acute phase following an injury.
Surgical Treatment Options
When non-surgical treatment options do not provide relief, or in cases of complete rotator cuff tears, surgical intervention may be recommended. These include the following.
- Arthroscopic Repair
This is a minimally invasive procedure where an arthroscope and small instruments are inserted through tiny incisions to reattach the torn tendon to the bone. - Open Repair
In some cases, an open surgical repair may be necessary. This involves a larger incision over the shoulder and is typically reserved for large or complex tears. - Mini-Open Repair
The mini-open repair utilises both arthroscopic and open methods. The arthroscopic portion is used for initial assessment and treatment of damage within the joint, followed by a smaller open procedure to repair the rotator cuff. - Tendon Transfer
If the torn rotator cuff is not repairable, a tendon transfer may be performed. This involves using a nearby tendon as a substitute. - Shoulder Replacement
In severe cases, especially where there is concomitant arthritis, shoulder replacement surgery may be an option. This procedure replaces the damaged parts of the shoulder joint with artificial components.
Recovery and Rehabilitation Post-Surgery
Recovery and rehabilitation following surgical treatment of a rotator cuff tear should be tailored to individual needs. The stages are outlined below.
- Immobilisation: Initially, the shoulder must be kept immobile to allow the tendon to heal. This involves wearing a sling for a prescribed period, which varies depending on the repair’s extent.
- Passive Exercise: The first stage of physical therapy involves passive exercises where the shoulder is moved without the patient’s muscle use to maintain flexibility without stressing the repair.
- Active-Assistive Exercises: As healing progresses, active-assistive exercises commence. These involve using the patient’s strength along with some assistance to help move the joint.
- Strengthening Exercises: Gradually, isolated strengthening exercises are introduced to rebuild muscle strength without overloading the repaired tendons.
- Return to Activities: The timeline for returning to daily activities varies. Guidance is provided based on the patient’s progress, with the return to full activities typically taking several months.
- Ongoing Assessment: Regular follow-up appointments are required to assess recovery and modify rehabilitation as needed.
Prevention Strategies for Rotator Cuff Tears
Effective prevention strategies can mitigate the risk of rotator cuff tears, particularly for individuals engaged in activities that place them at higher risk.
- Strengthening Exercises - Engaging in exercises that strengthen shoulder muscles can provide better support to the rotator cuff, reducing the risk of injury.
- Proper Technique - Using correct form and technique during physical activities, especially those involving the shoulder, helps minimise undue stress on the rotator cuff tendons.
- Ergonomic Adjustments - Making ergonomic adjustments to the work environment can prevent prolonged overhead activity and reduce the strain on the shoulder.
- Regular Breaks - Taking regular breaks during repetitive or overhead activities allows time for the muscles and tendons to rest and recover.
- Maintaining Flexibility - Ensuring adequate shoulder flexibility supports a full range of motion, which can help prevent tears.
- Gradual Increase in Activity - Gradually increasing the intensity of activities allows the shoulder to adapt and strengthen without becoming overloaded.
- Balanced Fitness Regimen - Incorporating a balanced fitness regimen that includes cardiovascular, strength, and flexibility training contributes to overall shoulder health.
- Protective Gear - Using appropriate protective gear during sports can prevent injuries that may lead to rotator cuff tears.
- Education and Awareness - Being educated about the risks and signs of rotator cuff injury enables early intervention and prevention of worsening injury.
Dr Poh Seng Yew
MBBS
MRCSEd
MMED (Ortho)
FRCSEd
With over 18 years of experience, Dr Poh Seng Yew is an orthopaedic surgeon specialising in hip, knee, shoulder and elbow surgery, sports medicine, and trauma surgery.
- Former Director of Sports Service, Department of Orthopaedic Surgery, Singapore General Hospital
- Clinical Hip and Sports Medicine Fellow, Orthopädische Chirurgie München (OCM), Germany
- Fellow, Royal College of Surgeons of Edinburgh, FRCSEd (Orthopaedic Surgery)
- Master of Medicine (Orthopaedic Surgery), National University of Singapore
- Member, Royal College of Surgeons of Edinburgh (MRCSEd)
- Bachelor of Medicine, Bachelor of Surgery (MBBS), National University of Singapore
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38 Irrawaddy Road, #08-62/63
Singapore 329563
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Mount Elizabeth Novena Specialist Centre
38 Irrawaddy Road, #08-62/63
Singapore 329563
Frequently Asked Questions (FAQ)
What is a Rotator Cuff Tear?
A rotator cuff tear refers to a rupture or tear of one or more of the four tendons of the rotator cuff muscles in the shoulder.
Who is at Risk for a Rotator Cuff Tear?
Individuals over the age of 40, those engaging in repetitive overhead activities, athletes, and individuals with a history of shoulder injuries are at increased risk.
How is a Rotator Cuff Tear Diagnosed?
Diagnosis typically involves a physical examination, assessment of symptoms, and imaging tests such as MRI or ultrasound to visualise the tear.
What are the Treatment Options for a Rotator Cuff Tear?
Treatment options range from conservative approaches, like physiotherapy and medications, to surgical interventions, depending on the tear’s severity and the patient’s lifestyle requirements.
Can Rotator Cuff Tears Heal Without Surgery?
Some partial tears can heal with conservative treatment methods, such as rest, physiotherapy, and injections, especially in less active individuals.
What Does Rotator Cuff Surgery Involve?
Rotator cuff surgery can involve arthroscopic tendon repair, open tendon repair, tendon transfer, or in severe cases, shoulder joint replacement.
What is the Recovery Time After Rotator Cuff Surgery?
The recovery period can vary, generally taking several months, with an initial phase of immobilisation followed by graduated rehabilitation exercises.
How Can I Prevent a Rotator Cuff Tear?
Prevention can include strengthening exercises for the shoulder, proper technique during activities, ergonomic workplace adjustments, and avoiding repetitive strain on the shoulder.