Rotator cuff tears are a common source of shoulder pain, weakness and dysfunction. However, not all rotator cuff tears need to be fixed surgically. Many rotator cuff tears are a natural part of the aging process. Over time, many of us lose our hair, many lose their bone density, and many of us lose part of our rotator cuff from normal degeneration. These rotator cuff tears are usually painless. In fact, 27% (over 1 in 4) of people 60 years or older with no shoulder pain at all have a full-thickness rotator cuff tear. And it doesn’t bother them.
Should one of these people with a pre-existing tear develop some rotator cuff tendinosis, they may develop pain. But this doesn’t necessarily mean that their rotator cuff needs to be fixed. In patients 60 years or greater with no history of trauma (car crash, falls, etc) and good remaining strength, 50-82% (an average of 2/3) can get better using rotator cuff and shoulder blade strengthening exercises without surgery. These are the same exercises discussed in my last blog and on my website in the ‘Therapy Protocol’ section. Please note you need to be taught the correct form for these exercises by a therapist. An elastic resistance, not a dumbbell weight, works best. Once you know what to do and have the appropriate elastic device, the exercises can be performed at home. If 3 months of therapy, and often a steroid injection, don’t decrease the pain down to a tolerable amount, then arthroscopic rotator cuff repair may be considered. It should also be noted that patients younger than 60 years of age, those who developed the rotator cuff tear from trauma, or those with significant weakness should probably have their rotator cuff tears surgically repaired.
Rotator cuff repair may be performed arthroscopically, which leads to less pain and stiffness than open repairs. For photographs of arthroscopic repair, please see the ‘Rotator Cuff Tear‘ section of this website. Arthroscopic rotator cuff repair is performed as outpatient surgery. For the least amount of pain and stiffnes, a subacromial decompression (acromioplasty) is not performed in the vast majority of cases. As noted in my previous blog, removing the bony ‘hook’ or ‘spur’ may increase postoperative pain and stiffness, and can result in the loss of shoulder elevation, which is exactly what we’re trying to improve. A recent research study I published showed that performing a subacromial decompression unfavorably alters the biomechanics of the shoulder, which is not good (1).
Following surgery, rotator cuff repairs need to be protected. Because the rotator cuff is slowly healing tissue, the repair needs to be protected for 6-12 weeks. For 6 weeks following rotator cuff repair an abduction pillow (sling with a pillow in it) is worn around the clock except when showering. It is slept in. Nobody likes it, but it prevents reinjury to the rotator cuff and increases its blood supply to help it heal better. No active shoulder elevation (ie. raising your arm using those shoulder muscles) is allowed for 6 weeks. A home motion program is begun after the first follow-up appointment at 2 weeks. Therapy is used as needed; it’s better if the patient can regain motion on their own at home. No lifting anything heavier than one pound for 3 months. Most people can return to heavy work or sports at 4-6 months, depending on the size of the tear and the stressfulness of the activity.
Most people usually do very well following arthroscopic rotator cuff repair. Those who wait too long often develop atrophy of the rotator cuff muscle that the tendon is attached to, leading to worse results. However, even in these cases it’s usually worth performing the repair to decrease pain and regain whatever function the shoulder can regain.
1: WR Su, Budoff JE, Luo ZP: The Effect of Coraco-Acromial Ligament Excision and Acromioplasty on Superior and Anterosuperior Glenohumeral Stability. The Journal of Arthroscopy 25: 13-18, 2009