While full thickness rotator cuff tears are very common, let’s back up and start with the basics about these 4 little muscles. The rotator cuff plays a key role in the proper function of the shoulder. The four muscles which make up the “rotator cuff” are under a lot of stress. They need to maintain proper function of the shoulder. If the cuff sees too much stress they can become inflamed, or start to tear. Age or activity related degeneration can also leave our rotator cuff at risk of injury. The rotator cuff can be a source of pain for many many reasons.
Your shoulder pain can be due to:
- inflammation of the rotator cuff
- degeneration (tendinosis) of the rotator cuff
- tears of the rotator cuff.
Tears of the rotator cuff come in all shapes and sizes. Fraying of the rotator cuff tendon surface, partial thickness tears, and full thickness rotator cuff tears are all quite common. Interestingly, the degree of damage seen on the MRI does not predict how severe your pain will be. That means that there are some of you with small rotator cuff tears, or no rotator cuff tear, yet you have severe shoulder pain. On the other hand, there are many people with large full thickness rotator cuff tears who have very little pain. It can be confusing.
How do Orthopedists figure out which type of rotator cuff problem you have and how does that effect our treatment plan for your shoulder pain?
Rotator Cuff Tears:
Before we delve briefly into whether or not you have a full thickness rotator cuff tear (complete tear),you need to know what the rotator cuff is.
The rotator cuff is a series of four muscles, which combine at the shoulder to form a cuff of tissue completely surrounding the top of the arm bone or humerus.
Rotator cuff tears can be described in many different ways.
- There are traumatic tears (accident or a fall), acute tears (just happened)
- Chronic tears (present for a while, you just didn’t know it)
- Degenerative tears ( your tendon just wore out).
Rotator cuff tears can also be described as being partial, or full thickness. With partial thickness rotator cuff tears only part of the tendon has torn off the bone. With full thickness tears the entire tendon has separated or torn from the bone. Click here to learn about partial thickness tears.
Can you tell if you have a full thickness rotator cuff tear?
After a significant trauma such as a fall or a car accident, your rotator cuff tendon can literally pull right off the bone. We call that an acute, traumatic full-thickness rotator cuff tear. On the other hand, I see many patients in the office who do not recall any significant injury, but their exam and MRI demonstrate that they have a full thickness tear — why is that? The risk of developing a rotator cuff tear increases with age because our tendons begin to gradually wear, lose its blood supply and its resilience. In that situation, even routine daily activities like gardening or working around the house increase the potential for wear, degeneration, and tearing.
Whether your tear is chronic, attritional (wear and tear) or acute and traumatic (fall or injury) is a VERY important element of the decision-making process in how we treat full-thickness rotator cuff tears. Treatment decisions are based not only on the type of tear you have, but whether or not other treatments have failed, and how poor your quality of life is.
Rotator cuff tears, whether acute or chronic can cause severe pain. Many of you report temporary relief using:
- A shoulder ice sleeve
- A shoulder compression sleeve
- A Shoulder support pillow to help you sleep at night
- A sling to support the arm
Full thickness rotator cuff tears
Rotator cuff tears come in all shapes and sizes. Many patients have full thickness rotator cuff tears and do not even know it. As a matter of fact, by the time you reach 65 you have more than a 50% chance of having a degenerative rotator cuff tear because of wear and tear. No need to panic…
>How can Orthopedic Surgeons tell if you have a full thickness rotator cuff tear?
Shoulder Pain:
Does the amount of pain you are having correlate with the size or thickness of your rotator cuff tear?
The size of the tear usually doesn’t correlate with the pain you are experiencing. Many patients mistakenly believe that they must have a large full thickness rotator cuff tear because they are in severe pain … usually, the opposite is true. Many patients with severe shoulder pain have very small full thickness rotator cuff tears, partial thickness rotator cuff tears, or no tear at all. Yet some patients with mild shoulder pain have massive rotator cuff tears. Bottom line… the size of your tear will not correlate with the amount of pain you are experiencing. Many patients with tendonitis or bursitis have more pain than patients with rotator cuff tears. Many patients with tendinosis, small tears, large tears or just bursitis usually have very severe pain at night. Night pain can be very disruptive, aggravating and demoralizing. Night pain is frequently the reason many patients cite why they opted for surgery to repair a full thickness rotator cuff tear.
Weakness:
The rotator cuff muscles control the motion and the overall strength of the shoulder. Small tears do not produce shoulder weakness, however, large or massive tears can produce very significant shoulder weakness.
Patients with large rotator cuff tears complain of weakness and the inability to place the arm in certain positions. They have difficulty taking milk out of the refrigerator and may need to support their injured arm with their other arm when attempting to lift something.
Loss of motion:
Most rotator cuff conditions which produce pain will lead to loss of motion. Many patients with rotator cuff related pain will complain of difficulty with hair care, putting on a bra or belt, and weakness when trying to lift the arm away from the side. Sometimes patients with full-thickness tears will have significant loss of motion, and sometimes patients with large rotator cuff tears will have normal motion. That means that loss of motion, in general, is a poor predictor in and of itself of the presence of a full thickness rotator cuff tear.
A thorough physical examination by a Sports Medicine trained specialist is usually necessary to determine whether a rotator cuff tear is present.
Ultimately an MRI or an ultrasound may be necessary to confirm the presence and size of a rotator cuff tear and determine if it is partial thickness or a full thickness rotator cuff tear.
Whether you have a full thickness tear or a partial thickness tear, your shoulder pain may be so severe that your quality of life is very poor. You’re not sleeping well and you have very limited use of your arm. Not all rotator cuff tears require surgery… but some do.
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Scott
Dr a few days ago while on vacation. I fell and landed on my right shoulder. Didn’t feel much pain for about 48 hours. I went to the doctor and got x-rays. Which showed no fracture break or dislocation. After icing and ibuprofen I seem to have decreased pain and better mobility. However when getting out of bed and few times. I have used the arm to push up. And feel something pop and it’s extremely painful. Once my arm is straightened again. It seems to pop back and the pain is gone. At what point should I be concerned? The injury is recent . And the doctor seems to think time will fix it
Howard J. Luks, MD
Tough to say what is happening without examining you. In some cases the biceps may be causing this… in others in can be the rotator cuff, etc. Hopefully your doctor, or a second opinion can figure it out.
RPP
I have a full thickness tear and am still pitching. I need to do lots of stretching and rubber band strengthening but after slowing warming up, i’m able to still pitch competitive baseball. How long do you think i’ll be able to get away with it before the tear worsens and stops functioning?
Howard J. Luks, MD
unfortunately no one can give you that answer. For some it may be years, for others it will be less time. Good luck!
Debbie
Hi Dr. Luks,
I had a rotator cuff repair surgery for a massive rotator cuff tear back in Jan. 2014 which I sustained from a fall in Dec. 2013. The surgery went well and my rehab was good as I gained back most of my ROM and strength, however my External Rotation ROM and strength didn’t really all come back. But I was able to return to playing tennis and softball without much problems. At the beginning of June 2016 I began to notice weakness in my arm when I tried to reach overhead, was harder to steer the wheel in circles, my shoulder felt tight when reaching in front. I went to see my Ortho doctor and he ordered an MRI.
My MRI results are a recurrent tear of the surgically repaired posterior supra supraspinatus and infraspinatus tendons with 23 mm of medial retraction and 23 mm anterior to posterior gap. Mild decrease in muscle bulk.
I don’t recall doing anything to cause the recurrent tear. I don’t have much pain just the weakness. I can function normally except for the weakness in doing somethings with my shoulder or arm in certain positions. I had no previous shoulder problems before my initial injury. My rotator cuff tissue is good quality.
My Ortho doctor doesn’t really know what could have caused the tear. He feels that the retear either is due to a recent aggravation of my condition or there is a possibility that my posterior rotator cuff never fully healed following the initial surgery. My doctor suggests to try strengthening me with physical therapy and If I do regain my strength and I’m asymptomatic, then I won’t need further surgery. But If I continue to experience weakness, I’ll most likely need to undergo a re-repair of my posterior rotator cuff. Well, I have been to physical therapy for 4 weeks, but I haven’t seen too much improvement yet. My physical therapist says that it is highly unlikely that I will be able to strengthen much of the rotator cuff since it is a full thickness tear, thus physical therapy will not help me in this case.
I saw another Ortho doctor for a second opinion and he said that I will eventually need revision surgery to repair it.
What are your thoughts? Can physical therapy help strengthen the rotator cuff so that I won’t need to have revision surgery? How many weeks of PT before deciding that it is not working and thus will need to have surgery? Should I have surgery to re-repair the recurrent tear if I want to continue to be playing tennis and softball and is there a certain time frame that it should be done by for better outcome? Is 23 mm retraction pretty far? If if I don’t have the surgery now or at all, can the tears get larger and muscle atrophy and fatty infiltration occur and tendons retract further away in the future thus making the revision surgery irreparable?
Thanks!
Howard J. Luks, MD
Unfortunately recurrent tears are very common in large tears. Up to 50% or more will fail. Revision surgery is far less effective than the first attempt. Most experienced shoulder docs will consider using a graft or augmentation during a revision surgery… but the research is not clear as to the benefits of that. Difficult decision making for the patient and the surgeon. Sadly, this is the nature of rotator cuff tears and why I refer to it as rotator cuff disease… because the tendons truly start to wear out… and we have not found a definitive way of reversing that degeneration. So most tears occur or reoccur because of a biological (tendon degeneration) problem… not necessarily because of a failed mechanical issue or poor repair.
Debbie
My rotator cuff tissue is of good quality according to my Ortho surgeon. Dr. Luks do you recommend that I get this recurrent tear fixed or should I just leave it alone? I will be seeing my Ortho surgeon next week to discuss my options.
Thanks.
Regina B
I’m a 54 y/o active woman. MRI on right should revealed 1) Complete tear of the supraspinatus tendon with 3 cm medial retraction of the tendon on a background of tendinosis. Moderate grade intrasubstance tear of the anterior fibers of the infraspinatus tendon. Low grade intrasubstance tear of the upper fibers of the subscapularis tendon. 2) Moderate tendinosis of the intra-articular portion of the long head of the biceps tendon. 3) Tear of the posterosuperior and superior labrum. 4) Small joint effusion communicating with the subacromial sub deltoid bursa.
Would you recommend surgery knowing I am in constant pain & cannot sleep? Which procedure would you recommend? Would arthroscopy be an option?
Any advise you could give me would be most appreciated. Thank you for doing this post. Reading your responses has been extremely helpful.
Howard J. Luks, MD
That will be a difficult tear to fix… and it will likely re-tear after surgery. For degenerative rotator cuff tears — the most appropriate initial treatment appears to be PT/Injections for a while to see how you do.