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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Barry A. Perlmutter
I am 59 years old and have had Surgery on both shoulders due to complete tears of my Rotator Cuff. The Surgeon told me there was a lot of Atrophy and a re tear is possible. A couple of years later I re tore both shoulders. Repair is not possible due to the lack of Tendon fiber and Atrophy. I’ve had Cortisone injections in my Right Shoulder which temporarily helped. Pain came back and The 3rd injection (spaced apart) didn’t help at all. The Left shoulder had 1 Cortisone shot that didn’t help either. I have full ROM and some weakness. My Dr. says I am to young for Replacement Surgery or any other repair. My pain is a 8 when I move it wrong or try to lift something. Any thoughts would be appreciated. Also I have Chronic Neck Pain.
howard2
There are various options that we offer patients with non-repairable cuff tears and severe pain. They range from a
1- superior capsular reconstruction
2- tendon transfer
3. reverse shoulder prosthesis
I think you should do some research and find a shoulder doc who can examine you and discuss your alternatives and what the pros and cons are for each approach.
Good Luck
Rachel N
I had an injury over a year ago where I lost my footing going down some stairs and landed on my right side very HARD! I didn’t land right on my shoulder, but pretty sure I landed on my right arm. It was a very hard fall. I’ve gone to 2 orthopedic Doctors who both examined X-rays and a MRI I had done and both confirmed I had a moderate wide rotator cuff tear on my right shoulder and would need surgery, especially because I am in alot of pain and regular OTC pain med and physical therapy have not helped. My question is: I don’t just have pain right on the rotator cuff area, but also on my upper trapezius muscle, neck, and now headaches. Basically, the pain moves all around the upper right quadrant of my back and shoulder areas. My Ortho Dr said it’s because the areas I’m feeling pain is compensating for the rotator cuff tear itself. Is that a possibility?
Thanks,
-Rachel
Howard J. Luks, MD
Hard to say Rachel… sorry.
Carl J.
Hi Dr. Luks,
thanks for the great website. I have truly learnt a lot about sports injuries.
I`m 41 and I`ve been doing some weights and climbing and cross country skiing at quite high level. I was diagnosed full thickness, 10mm wide tear of the supraspinatus tendon (medium and back parts) all other muscles and tendons are ok. No ROM restrictions, very little strenght loss, little pain too. Generally, my PT who specialises in climbing injuries says I will be able to get back to the same level of activity under the condition of lots of rotator cuff and shoulder stability exercises. My Ortho says I may be ok for some time but sooner or later it will be completely torn and if I want it to be really fixed I will need surgery.
1. Who is right: PT or Ortho?
2. Would you recommend surgery in my case?
many thanks
Carl
Howard J. Luks, MD
Sadly no one can answer that question reliably. These small degenerative tears are common. Most do not need immediate treatment. In active overhead athletes there is a risk that the tear can become larger over time. We really can not accurately quantify that risk. Some studies show that it might take years to become larger. Further injuries or falls of course can worsen the tear more abruptly. NO harm in waiting an re-imaging (MRI or Ultrasound) in a few months to be sure the tear is not becoming larger.
Melvin
Hi Dr Howard,
3 months ago I’ve had a bad landing on an outstretched arm playing ultimate frisbee. MRI has shown that I have a 1.2cm by 1.8cm wide full thickness supraspinatus tear.
The orthopedic has recommended surgery as expected. However, physiotherapy seems to be working and I seem to be having almost a full range of motion right now. I have a few questions I’d like to ask to make a more informed decision on whether to undergo the surgery:
1. The supraspinatus tear does not seem to be affecting my movement much. If I were to continue my sport without surgery, what would the implications be since my supraspinatus is already torn anyway?
2. I am 24 now. Will a surgery bring about any problems like osteoarthritis at old age?
3. I am actually able to get by my daily routine with my injured shoulder (without sports). So does strengthening other muscles actually compensate and “replace” the functions of the supraspinatus? I’ve read that the supraspinatus allows for the first 15degrees of raising the arms laterally but I seem to be doing that fine with a torn supraspinatus?
Howard J. Luks, MD
In general Shoulder surgeons recommend surgery to repair acute traumatic tears in young patients…. The tears we tend to move more slowly on are chronic degenerative tears that occur in patients over 40.
Ktt
About 9 weeks ago I fell from a bicycle directly on my shoulder. The x-rays revealed a fractured my proximal humerus. Starting about week 4 I started to get severe soreness in my shoulder that wakes me up, usually 2 to 6 hours after I go to sleep. It gets much better when I get up and move around. The bone break is or close to healed by now.
I asked my doctor what this night pain is and if it could be a rotor cuff problem. He said it’s normal soreness from the fracture which will go away and that he does not think I have a rotor cuff injury. Is this true? I now can move my arm straight up to about 110 degrees (up from 0 the first weeks) but the pain at night is terrible and it is not getting better. What do you think?
Howard J. Luks, MD
Hard to say… it is not uncommon for pain to persist following a fracture, but that residual pain can be due to a rotator cuff injury. If PT, stretching does not improve the pain I will usually image the rotator cuff (ultrasound or MRI)
Ktt
Thank you for your prompt reply. One thing I forget to add is that what appears to be a muscle that is part of my deltoid (that wraps around the side and back to the front?) looks swollen and like it has “slipped down” into the center of my humerus between the bicep and tricep meet. When I straighten my arm it goes back up into the deltoid. Is this simply part of the fallout from the fracture or does it indicate something else? It looks like my other arm has the same muscle structure but is “intact”without the part of the deltoid slipping down.