Written by Michael Codsi, MD
Partial rotator cuff tears are responsible for pain and loss of arm function in thousands of patients every year. The pain is usually located on the side and front of the shoulder, and it is made worse when patients try to raise their arms to the side and above their shoulders. When the partial tear worsens, patients can experience pain when making any motion away from their side, and the constant ache can keep them awake at night.
The diagnosis of a partial rotator cuff tear can be made by an experienced doctor who listens to the patient’s symptoms and performs a thorough physical exam. An X-ray may be taken to eliminate other common causes of shoulder pain, such as calcific tendonitis or arthritis. An MRI of the shoulder is only needed if physical therapy does not work as expected. For a partial rotator cuff tear, an MRI will show a thin, worn tendon with fluid on top of it from the irritation.
In order to understand how physical therapy and other treatment options eliminate shoulder pain, patients need to understand how the rotator cuff works. The end of the arm bone is a ball that connects to a shallow cup in the shoulder blade bone. Four different muscles connect to the ball through four tendons, which are needed to move the ball of the shoulder in the cup. The tendons blend together around the shoulder ball. If some of the tendon detaches from the bone, then the muscles cannot rotate the arm bone, and the patient feels weakness in the arm. Eventually the tendon will tear completely, but before that happens, it becomes worn, like an old, frayed shoe lace that is about to break. This is a partial tear of the rotator cuff. The tendon is still attached, but it is worn and thin. Irritation of the partially torn tendon can cause mild to severe pain, depending on the size of the tear and the amount of irritation it causes in the tissue around the tendon.
The goal of treating a partially torn rotator cuff tendon is to allow the irritation of the tendons and the bursa around the tendons to cease. This can be done with rest, activity modification, ice, heat, and over the counter pain medications. Once the pain improves, a physical therapy program can be used to:
Accomplishing all 5 goals can take several months.
- Regain any loss of motion of the shoulder.
- Strengthen the muscles around the shoulder blade.
- Practice proper posture and shoulder mechanics to avoid unnecessary stress on the rotator cuff tendons.
- Strengthen the other rotator cuff tendons that are not partially torn.
- Return to normal activities.
Some patients are unable to participate in physical therapy because the pain from the partial tear is too severe. For these patients, a steroid injection around the irritated tissue on top of the rotator cuff can stop the pain, allowing patients to do therapy. The injection is not a cure for the problem — it is more like a Band-AidTM that temporarily protects a cut on the skin while the body heals. Some patients need more than one injection, and while multiple steroid injections can cause tendon damage, the risk is small unless multiple injections (more than 3 to 4) are given in a short period of time, i.e., 1 year. Most steroid injections are not very painful if given by a doctor who is experienced in giving such injections.
When 8 to 12 weeks of therapy and an injection do not help alleviate the pain of a partial rotator cuff tear, surgery can be considered as a treatment option. The surgery can be done arthroscopically. An arthroscope is an instrument with a tiny camera on the end that can be inserted through small incisions around the shoulder and used to examine the shoulder and rotator cuff tendon. The irritated bursa on top of the tendon will be removed, along with any bone spurs that may be contributing to the pain. If the partial tear can be repaired, the surgeon will place sutures through the end of the tendon and tie the tendon to the bone. The sutures will hold the tendon against the bone so that it heals there. This healing process takes 12 weeks, so the patient must protect the arm while the tendon is healing. Any lifting or reaching with the arm could pull the tendon through the sutures, meaning the repair will not heal. After the tendon heals, the patient can start a physical therapy strengthening program. The entire recovery can take a full year, but most patients no longer feel a constant ache in the shoulder after 6 to 8 weeks.