Many rotator cuff problems do not relate to injuries per se.  Many rotator cuff problems are simply degenerative, attritional, or age/activity  related.  That said, there are still plenty of people who present on a daily basis for evaluation who have suffered significant recent injuries to the shoulder and the rotator cuff.  

What is the rotator cuff?  

What are the most common rotator cuff problems?   

 The majority of rotator cuff problems we see are degenerative or attritional in nature.  Like your favorite pair of jeans that spontaneously develops a hole over your knee.  It simply wore out.   Prior to wearing out, the rotator cuff can hurt and we call that condition degenerative tendinosis.  As tendinosis progresses, an attritional tear may develop and now you have a full thickness rotator cuff tear.

Younger patients tend to suffer more overuse type injuries, typified by tendonitis, inflammation and secondary weakness and pain.    Many young patients have instability where the shoulder is loose.  This causes the rotator cuff to work very hard to keep the shoulder in position and therefore your rotator cuff pain is secondary to instability.  To treat your rotator cuff symptoms, you must address the underlying instability first.   

 How do I know which problem I have?

 Rotator cuff tendinosis symptoms generally come on slowly over time and reach a point where you are very uncomfortable. One of the hallmarks is terrible night pain.   Patient with tendonosis typically do not have weakness.  They may have pain with lifting their arm in certain positions, but loss of motion is not a common finding.  Pain is usually along the side of your upper arm and some people think the pain is radiating down to their elbow. 

Patients with overuse injuries are typified by a pitcher, swimmer or volleyball player with shoulder pain the day after they played an excessive amount or time.  Their pain is mild to severe.  Their pain is usually along the back or side of the shoulder and responds well to rest and anti-inflammatories.   

Patients with large rotator cuff tears will also complain of night pain, pain along the side of the arm and if the tear is large enough, significant weakness and loss of functional use. 

Is an MRI necessary?  

In many instances an accurate history and physical exam can lead to an accurate diagnosis -- and an MRI is not necessary.  If your exam reveals severe pain and weakness, then an MRI will be helpful to see if your weakness is secondary to pain or an actual tear.

Sometime an MRI is necessary to show in fine detail what the structure of the rotator cuff looks like.  With an MRI we can usually tell if the rotator cuff is torn, if the tear is attritional, or if tendinosis is present.  We can also tell if tears are repairable or are too old to attempt repair.  MRIs can be very useful in surgical decision making.

Should all rotator cuff tears be fixed?  

Without a doubt the literature clearly supports that the answer to this question is NO.  Many, many tears are very small and attritional or degenerative in nature.  That means the cuff simply wore out over time ... a long time.  Many patients with small tears can be managed with physical therapy, occasional injections, and activity modification.  If we try non-operative management and your pain persists, then perhaps a repair is necessary, but this is not the typical outcome for a small attritional tear associated with tendinosis.  One caveat:  even if you are doing well, remember that some small tears become larger.  We do not know which tears will grow and which will not, so follow-up with your surgeon is important, even if you feel fine.  

Most active shoulder surgeons separate cuff problems into acute and chronic or degenerative categories.  When we see someone who has suffered an acute, fresh rotator cuff tear, most surgeons favor early operative repair.  This is because your tissue was most likely normal prior to trauma and therefore the results of surgery should be good.  The likelihood of a successful repair is good and your functional result should be good.  As described previously  chronic or degenerative tears are looked upon and treated much differently.  People who have suffered an acute or fresh tear know it.  They have intense, immediate pain, weakness, and loss of motion.  This should prompt you to see a shoulder surgeon immediately. 

How are rotator cuff tears fixed?

Many shoulder surgeons are proficient at repairing them arthroscopically... through multiple small incisions.  Be sure your surgeon has performed a fair number of these and is very comfortable with the technique.  Many surgeons also continue to fix tears using an open incision.  As long as the surgeon can achieve the same level of success with arthroscopic and open techniques, then  the arthroscopic technique offers a number of advantages -- both to you as the patient and to me as the surgeon.

First, the view we obtain using and arthroscopic approach can not equaled. I can place a small camera in places we cannot see through an open incision.  My access is unlimited with an arthroscopic approach since I can move the camera around to see all the other structures in the shoulder to make sure that nothing else needs to be addressed at the same time.  

Second, an arthroscopic approach spares the deltoid muscle from being cut and pulled open, which can lead to significant pain and stiffness.  

Bottom line ... both methods are proven to have similar track records for small tears and medium tears. The main difference is the smaller incision, less trauma, and perhaps a shorter duration on pain medications.  An arthroscopic approach does NOT change the amount of time in a sling after surgery, nor does it change the fact that you will require an extensive amount of physical therapy after your sling comes off to restore motion, strength, and function.