The rotator cuff is a familiar source of pain in the shoulder. When you have a tear in your rotator cuff, routine daily activities, like combing your hair, may become painful and difficult. A rotator cuff tear refers to an injury of the tendons or muscles of the shoulder rotator cuff. Symptoms may worsen with movement.
Rotator cuff injuries have a domino effect. When the tendon is frayed, other areas get torn or strained as well. You may concurrently suffer from a strained rotator cuff muscle or develop a bone spur in your shoulder as well. If the rotator cuff tear remains untreated, it can result in a frozen shoulder (adhesive capsulitis) – an injury of the shoulder joint that causes thickening of the shoulder joint capsule that “freezes” your arm and shoulder in place.
Your shoulder is a ball-and-socket joint. The humerus (head of the upper arm bone), fits into the scapula (a shallow socket in your shoulder blade). The rotator cuff tendons cover the head to keep it firmly in the socket. Among the cluster of four rotator cuff tendons – supraspinatus, infraspinatus, teres minor, and subscapularis – the supraspinatus is the most vulnerable to injury.
The supraspinatus tendon assists in the stabilization of the rotator cuff and controls the movement of the shoulder. The infraspinatus tendon externally rotates the humerus and stabilize the shoulder joint. The teres minor prevents the head from sliding upward during abduction and also functions to rotate the humerus laterally. The subscapularis muscle is located on the underside of your shoulder blade and is responsible for rotating your shoulder inward.
The bursa (lubricating sac) – which sits between the rotator cuff and the acromion (the bone on top of your shoulder) – allows the rotator cuff tendons to glide when you move your arm. If the rotator cuff tendons are injured or damaged, the bursa can also become inflamed. If you ever have bursitis, the supraspinatus tendon may be the real source of your pain, not the shoulder bursa. In this case, the pain would not dissipate with typically prescribed anti-inflammatory medications.
Rotator Cuff Tears
When you tear one or more of the rotator cuff tendons, the tendon no longer fully attaches to the head of the humerus. In many cases, torn ligaments begin by fraying. As the damage progresses, the ligaments can completely tear, sometimes with lifting a heavy object.
There are different types of tears:
- Partial tear (incomplete tear): Damages or frays the tendon, without completely severing it.
- Full-thickness tear(complete tear): Separates all of the tendons from the bone, creating a hole in the tendon.
Signs and Symptoms
The most common symptom is shoulder pain or discomfort. This pain is known as “trigger point pain,” which comes from a specific spot in your rotator cuff muscle that is hypersensitive. Pain may occur with particular activities, particularly those that require you to raise your shoulder above the horizontal position. If your significant tear in the rotator cuff, your shoulder might feel weak and unstable. Over time this weakness will limit your range of motion. At this point, throbbing pain may interfere with your sleep and force you to wake up to adjust your sleeping position.
The most common symptoms include:
- Dull ache deep in the shoulder that progresses to radiating pain, especially when sleeping on the affected shoulder
- Pain when lifting or lowering your arm with specific movements
- Muscle spasm, loss of range of motion or weakening of rotator cuff
- The crackling sensation when moving your shoulder in certain positions
Keep in mind, many people with rotator cuff tears do not experience any symptoms. And the severity of the damage (partial versus full) does not correlate with the pain intensity.
The two leading reasons for rotator cuff tears are acute injury and chronic degeneration of the shoulder joint.
- Injury (acute tear)
Acute tears, such as from an accident, usually cause intense pain. There may be a crackling sensation (crepitus) and immediate tenderness or weakness in your upper arm. Movement of the shoulder may be limited and painful.
The amount of stress needed for an acute tear will depend on the underlying condition of the tendon. If healthy, the severe stress needs to be high, such as falling on an outstretched arm. This stress may coexist with other shoulder injuries, such as dislocation.
- Degeneration (chronic tear)
Degenerative rotator cuff tears are mental pain that worsens over time. Most damages are the result of wear-and-tear that occurs progressively over time as we age and in conjunction with other factors such as muscle imbalance or poor biomechanics. Degenerative tears are more likely to happen in the dominant arm.
As you grow older, the blood supply can become impaired, and blood circulation to the rotator cuff tendons decreases. This would compromise the natural ability of the body to repair the damaged ligament.
The impingement syndrome may also contribute to rotator cuff tear. Impingement is the most common non-sports related injury, which occurs when the tendons of the rotator cuff muscles become irritated when passing through the bursa beneath the acromion. This leads to overgrowth (bone spurs), which further narrows the space.
Age and repetitive arm motions may increase the risk of a rotator cuff tear.
- Age: Because most rotator cuff tears are primarily due to normal wear and tear that increases with age, people over 40 are at higher
- Repetitive arm motions: People who do repetitive lifting or overhead movements are also at risk of tearing the rotator cuff. Athletes, particularly racket players and swimmers, are especially vulnerable to overuse tears. Painters, carpenters, cleaners, construction workers, and others who do overhead work are also susceptible.
Although overuse tears caused by sports or overhead work also occur in younger people, most damages in young people are caused by traumatic injury.
Do you have a rotator cuff tear?
If you feel sore on your rotator cuff, you can carry out simple tests at home before your doctor’s appointment.
A few at-home tests include:
- Empty Can Test
The empty can test a simple test used to assess the status of the supraspinatus tendon. The action mimics dumping out a soda can.
- Sit or stand comfortably with a companion present
- Lift your arm, so it is parallel to the floor
- Bring your arm forward about 45 degrees
- Turn your hand over, so that your thumb is pointing toward the ground (as if you are emptying a can of soda)
- Have your companion gently push your arm down
If you are unable to maintain your arm in the “empty can” position due to pain or weakness, you may have a supraspinatus rotator cuff injury.
- Lift-off test
The lift-off test can determine if you have a tear in the subscapularis. To perform the lift-off test:
- Stand and place the back of your hand against the small of your back
- Face the palm of your hand away
- Lift your hand away from your body
If you are unable to raise your hand away from your low back, you might have a subscapularis rotator cuff injury.
- Resistance test
Perform manual strength testing by doing this:
- Sit on a chair
- Bend your elbow 90 degrees, with elbows, tucked to the side
- Have a companion push your hand in toward your abdomen
If you are unable to hold this position, you might have a rotator cuff tear.
A seemingly harmless injury that’s not treated correctly can lead to a chronic rotator cuff problem that can persist for ages. Do not continue using your shoulder when there’s a nagging pain.
Try a few self-care measures to prevent the development of a rotator cuff tear.
- Warming up and stretch before exercising
- Engaging in stretching and strengthening shoulder exercises
- Lift weights properly (for example, maintain a straight back and use your legs)
- Practicing good posture
- Avoiding smoking
- Maintaining a healthy body weight
When to see a doctor
Any severe or sharp shoulder pain warrants medical attention, as does any significant weakness around the shoulder joint.
If you have a torn rotator cuff, it’s essential to healing it quickly and thoroughly. Minimizing the healing time should be a clear goal, as a chronic rotator cuff tear will limit your ability to resume your daily routine. Early treatment can prevent your symptoms from worsening. The purpose of therapy is to restore function and reduce pain.
Those with pain but reasonably maintained function are suitable for non-surgical treatment. In 80% of patients, nonsurgical treatment relieves pain and restores function in the shoulder.
- Rest: Rest and modify your activities, such as limiting overhead activities until the pain subsides. You may also use a sling to restrict the movement of your shoulder. Avoid activities that aggravate the pain.
- Strengthening exercises and physical therapy: Exercises tailored to the specific injury location with strengthen the shoulder and restore full range motion. You should incorporate stretches that enhance flexibility and range of motion surrounding your shoulder joint.
- Cold and heat therapy: Ice helps to reduce pain and inflammation. Use a cold pack for 20 minutes every four hours. After several days, when the pain and swelling subside use a hot pack or a heating pad to help relax sore and tightened muscles.
- Non-steroidal anti-inflammatory medication can reduce pain and swelling.
- Steroid injection: If conservative treatments do not relieve your pain, a dose of a local anesthetic and cortisone may be helpful. Use these shots judiciously, as they can contribute to the weakening of the tendon.
- Iontophoresis is a battery-powered patch which “drives” the medication to the target tissue.
The main advantage of non-surgical treatment is that it avoids the significant risks of surgery, such as infection, permanent stiffness, anesthesia complication, and lengthy recovery time.
You may need surgery if the pain does not improve with non-surgical efforts.
Signs that you need surgery:
- You rely on your arms heavily for daily activities, eg., work or sports
- Your symptoms lasted more than six months
- You have a large tear (> 3cm), and the surrounding tissue is healthy
- Loss of function and significant weakness in your shoulder
Surgery to repair a torn rotator cuff likely involves re-attaching the tendon to the head of the humerus (upper arm bone).
Recovering from surgery usually requires 4 to 6 months, but full recovery can take up to a year. There are several precautions to ensure you recover fully from rotator cuff surgery:
- Arm sling or immobilizer. You’ll need to restrict the movement of your arm for 4 to 6 weeks by securing it in an arm sling or immobilizer. Mild arm movements are allowed one-week post-surgery but do not lift your shoulder until your doctor says it’s ok.
- Pain relievers. Since certain medications worsen bleeding, you need to follow instructions on pain reliever types and dosage amounts.
- You should ice your shoulder every day during the first couple of days following surgery.
- Physical therapy. Rehabilitation exercises are essential to regain shoulder strength and range of motion.
The Bottom Line
Rotator cuff tear is a common condition, especially as people age. The good news is that most people recover quickly with simple measures like avoiding certain activities.
How your recovery goes will depend on the size of the tear and how long your rotator cuff was torn. The smaller and more new the crack, the better your chances of a full recovery be patient. Recovery is a gradual process.