Acute Tear

If you fall down on your outstretched arm or lift something too heavy with a jerking motion, you can tear your rotator cuff. This type of tear can occur with other shoulder injuries, such as a broken collarbone or dislocated shoulder.

Degenerative Tear

There are many causes of rotator cuff tears. Most commonly, degeneration of the rotator cuff and normal aging results in a weak tendon that can easily tear. Often, the patient cannot recall a specific event that may have caused the tear. In other cases, a specific event can be identified.

When a rotator cuff tears, the shoulder becomes painful and often weak. Pain often radiates down the arm in the region of the deltoid muscle. Shoulder motion may be lost. It may be difficult to sleep at night and to use the affected arm during the day.

Most tears are the result of a wearing down of the tendon that occurs slowly over time. This degeneration naturally occurs as we age. Rotator cuff tears are more common in the dominant arm. If you have a degenerative tear in one shoulder, there is a greater likelihood of a rotator cuff tear in the opposite shoulder — even if you have no pain in that shoulder.

Several factors contribute to degenerative, or chronic, rotator cuff tears.

• Repetitive stress. Repeating the same shoulder motions again and again can stress your rotator cuff muscles and tendons. Baseball, tennis, rowing, and weightlifting are examples of sports activities that can put you at risk for overuse tears. Many jobs and routine chores can cause overuse tears, as well.
• Lack of blood supply. As we get older, the blood supply in our rotator cuff tendons lessens. Without a good blood supply, the body’s natural ability to repair tendon damage is impaired. This can ultimately lead to a tendon tear.
• Bone spurs. As we age, bone spurs (bone overgrowth) often develop on the underside of the acromion bone. When we lift our arms, the spurs rub on the rotator cuff tendon. This condition is called shoulder impingement, and over time will weaken the tendon and make it more likely to tear.

The most common symptoms of a rotator cuff tear include:

• Pain at rest and at night, particularly if lying on the affected shoulder
• Pain when lifting and lowering your arm or with specific movements
• Weakness when lifting or rotating your arm
• Crepitus or crackling sensation when moving your shoulder in certain positions

Tears that happen suddenly, such as from a fall, usually cause intense pain. There may be a snapping sensation and immediate weakness in your upper arm.

Tears that develop slowly due to overuse also cause pain and arm weakness. You may have pain in the shoulder when you lift your arm, or pain that moves down your arm. At first, the pain may be mild and only present when lifting your arm over your head, such as reaching into a cupboard. Over-the-counter medication, such as aspirin or ibuprofen, may relieve the pain at first.

Over time, the pain may become more noticeable at rest, and no longer goes away with medications. You may have pain when you lie on the painful side at night. The pain and weakness in the shoulder may make routine activities such as combing your hair or reaching behind your back more difficult.

It should be noted that some rotator cuff tears are not painful. These tears, however, may still result in arm weakness and other symptoms.

Examination and Imaging

Clinical findings of rotator cuff tears include signs of mechanical impingement and weakness of the rotator cuff. This can be tested by abducting the arm to shoulder level, bending the elbow, and rotating the forearm internally and externally (Hawkins Test). Pain during this maneuver is consistent with impingement. Alternatively, impingement can be tested by simply elevating the arm above shoulder level (Neer Test). To isolate the supraspinatus, the arm is placed at shoulder level with the elbow extended and the thumb pointing down (internal rotation). Weakness during isolated supraspinatus testing is consistent with a tear of the supraspinatus.

Other tests which may help Prof Imam or a member of the team confirm your diagnosis include:

• X-rays. The first imaging tests performed are usually x-rays. Because x-rays do not show the soft tissues of your shoulder like the rotator cuff, plain x-rays of a shoulder with rotator cuff pain are usually normal or may show a small bone spur.
• Magnetic resonance imaging (MRI) or ultrasound. These studies can better show soft tissues like the rotator cuff tendons. They can show the rotator cuff tear, as well as where the tear is located within the tendon and the size of the tear. An MRI can also give Prof Imam a better idea of how “old” or “new” a tear is because it can show the quality of the rotator cuff muscles.

Treatment