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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Jon Serper
Hi Dr Luks,
I am 51 years old and play competitive basketball and golf. In Feb I was diagnosed with impingement in the left shoulder. A few weeks later on a followup the doctor noticed some weakness during an empty can test and thought i should get an MRI. I never got the MRI but I went to PT and spent the next 5 months rehabbing my shoulder. Today my shoulder feels good and i have what aooears to be full strength back. Ive been playing basketball for two months and i am just now swinging a golf club at full speed/power – both with an occasional twinge like discomfort that is a small fraction of my old impingement pain and that always goes away quickly.
My concern is that my shoulder may have a tear and that because of the stress im putting on it that it could be sort of a ticking time bomb. Ive been cautious when i do feel that twinge and it just seems that things are stable. Do you recommend i go through tests or just manage my shoulder based on feel as i have been?
Michael Brescia
Im 63 Year old male. Below is my last MRI of my left shoulder from this past February. I have the same problem with my right. However my right i have had 3 surgeries and none worked so needless to say AI am not jumping back into surgery. I am considering PRP or stem cell transplant. Is there any information you would have to help me decide. I currently go to pain management once a month. I will get injection about every other month. I go to PT 2 to 3 times per week. I am sure that is the only thing that keeps me going. Thank you
MRI-3T LEFT SHOULDER WITHOUT CONTRAST
HISTORY: M79.622 Left arm pain M25.512 Left shoulder pain M25.612 Left shoulder
stiffness M25.312 Left shoulder instability M75.02 Left frozen shoulder M75.42 Left
shoulder impingement syndrome M75.52 Left shoulder bursitis
TECHNIQUE: Left shoulder imaged on a 3.0 Tesla ultra high-field wide-bore MR scanner using
multiplanar multisequence technique.
COMPARISON: No prior studies are available for direct comparison at the time of this
interpretation.
FINDINGS:
Acromion and bursa: The acromion has a hooked configuration (type III). Mild degenerative
changes are present at the acromioclavicular joint. A moderate amount of fluid is present
in the subacromial/subdeltoid bursa.
Rotator cuff tendons: A complete full-thickness tear of the supraspinatus tendon is
present with torn fibers retracted approximately 4.0 cm. Infraspinatus tendinosis is
present with full-thickness tearing involving its most anterior aspect. Subscapularis
tendinosis is also present.
Biceps tendons: Tendinosis of the long head of the biceps tendon is present with low-grade
tearing at its intra-articular location.
Cartilage and labrum: Superficial cartilage loss is present in the glenohumeral joint.
Subchondral cyst formation is present in the inferior aspect of the glenoid. Degenerative
tearing of the posterior glenoid labrum is present. A small glenohumeral joint effusion is
present.
Bone marrow: Subchondral cyst formation is present in the greater tuberosity. The bone
marrow signal is overall age appropriate.
There is no evidence for lymphadenopathy in the visualized portions of the axilla. No
asymmetric muscle atrophy is present.
IMPRESSION:
Complete full-thickness tear of the supraspinatus tendon. Full-thickness tear involving
the anterior aspect of the infraspinatus tendon. M75.122
Subscapularis tendinosis. M67.814
Tendinosis of the long head of the biceps tendon with low-grade tearing. M75.22
Degeneration of the acromioclavicular and glenohumeral joints. M19.012
Nondisplaced tearing of the posterior glenoid labrum. M75.82
Glenohumeral joint effusion. M25.412
Howard J. Luks, MD
degernative rotator cuff tears are difficult to treat… the recurrence rate (developing a re-tear) is quite high.
PRP or stem cells will not heal the tear. They might decrease inflammation and pain… but the tear will not heal.
Sounds like PT is your friend right now… I would continue.
Jake
Can you have a large rotator cuff tear with little to no weakness but a good amount of pain?
Howard J. Luks, MD
yes… the entire supraspinatus (one of 4 rotator cuff muscles) can be torn and produce very little weakness.
Sylvia Williams
Dr. Luks, I am a 68 yr. old healthy, active woman. I have had aching arms and neck and have degenerative cervical issues. However, my shoulder hurt also but I was told it was most likely referred pain from the cervical neck issues. I insisted on an MRI of shoulder and sure enough, I have a full thickness tear. However, I am not really in THAT much pain….. sore and some pain if I “move my arm wrong”. But nothing I can’t live with. Most of my pain is related to the neck.
Orthopedic doc says I need to have rotator cuff surgery NOW because my window of opportunity is small at my age for a complete recovery. His argument is also that the tendon will retract making it impossible to repair it if I wait much longer.
Since I am not in a lot of pain and am not terribly limited in my activity due to pain, do you think this surgery is necessary? If I wait, will I get worse and miss that window of opportunity the ortho doc referred to? Thanks so much!
Howard J. Luks, MD
There truly is no such thing as a “window of opportunity” with degenerative rotator cuff tears. Truth is the consensus opinion on small full thickness tears is to treat them non-surgically. Even the Amer Academy of Orthopedic Surgeons recommends non-operative management of small degenerative full thickness rotator cuff tears. That being said,there are many different variables that go into the decision making tree for these tears (age, size of the tear, cause of the tear, what is causing your pain [may not be your tear], etc) . Many folks your age will have tears if we place them in an MRI machine… that doesn’t mean they all need surgery. I would consider a second and/or third opinion before making your final decision.
John W.
Hi Dr. Luks and thanks for the informative website!
I am 36 year old male who had RC repair for a very large (tear edge at glenoid level) U-shaped isolated supraspinatus tear a year ago. Repair was successful, although a bit “technically challenging”. I had no specific traumatic event, and somewhat surprisingly no AROM limitations and very good strength in the shoulder before the surgery. No atrophy or fatty degeneration.
I have a similar condition now in the left shoulder, for which surgery is already scheduled. It’s not as severe, “only” a 2 cm tear, but considering how close to an irreparable state the right one had developed, I opted for surgery right away.
I have never smoked and I have no other medical conditions or medications that would be known to be a risk factor for these type of injuries. I have practiced weight lifting (and wish to continue with it once I recover), but on the other hand my actual line of work is a desk job and not demanding on the shoulders in any way.
Now what I’d like to ask you, is
1) have you encountered this kind of thing with a person of my, relatively young, age?
2) in your experience, what kind of longevity can I expect from the repairs? How likely would you say it is for me to have more RC tears in, say, the next 5-15 years?
Howard J. Luks, MD
Great question … This is why I am always talking about our lack of understanding of biology of rotator cuff tears. Why do they occur? Why do they occur in some people but not others — independent of activities. This is a complex topic. A theory known as the cable and crescent theory of rotator cuff tears was put forth many years ago. According to that theory the supraspinatus will develop tears due to loss of tension because the cable which transmits the forces in the rotator cuff excludes the supraspinatus insertion.
In other folks it simply may be your genetic make-up. Everyone’s tissues are different and have differing resiliency.
Unfortunately, because many tears occur due to degeneration — after a “successful repair” the recurrence rate is pretty high.
John W.
Short update:
Got back from left shoulder surgery. Tear was about half smaller than MRI suggested, cuff tissue was very good, and the surgeon said that a “very robust” fixation was achieved due to the good quality tissue. Acromion was also better than in the right shoulder, only a type 2 (right one was a type 3 with very narrow subacromial space).
In light of those facts, it kind of seems strange that the left one even tore in the first place. Hopefully there will be better information about these injuries and more efficient therapeutic options by the time I have my next tear. At my young age, I consider it almost a certainty that I will still experience more tears during my lifetime… hopefully not too soon, though.