Rotator cuff tears may be partial or full thickness tears. They may occur as part of a degenerative process where the tendon progressively becomes weaker and wears out or they may be precipitated by impingement. Rotator cuff tears may also occur in relation to acute injuries such as a fall onto the shoulder or other injury.
SYMPTOMS
Symptoms of rotator cuff tears are similar to those of tendinitis and they are frequently associated with symptoms of bursitis and impingement. Frequently pain will be felt down the outer aspect of your arm. The shoulder invariably aches at night-time and often you will have trouble sleeping because of the pain that you experience. Patients will get impingement symptoms which occur when you lift your arm away from your body. This typically occurs when the arm is approximately 90 degrees away from the body. Impingement pain is a sharp catching pain. The arm will usually feel weak and if the tear is large then you may have trouble lifting the arm up. Patients may develop wasting of the muscles around the shoulder.
In a small percentage of patients, long standing untreated rotator cuff tears can progress to arthritis in the shoulder and require joint replacement surgery.
TREATMENT
Treatment will depend on the type of tear and the tendon that is affected. The most commonly affected is the supraspinatus tendon, however, tears of the infraspinatus and subscapularis tendons also occur frequently.
Tears in the rotator cuff are usually treated non-operatively with steroid injections and physiotherapy in an attempt to control symptoms. However, for full-thickness tears surgical treatment is often undertaken.
Partial-thickness tears tend to be treated non-operatively prior to any surgery being considered. Surgery for a minor partial thickness tear will often involve a simple debridement of the tear. Debridement involves trimming the frayed edges of the tear back to healthy tissue in order to allow it to heal itself. If the tear is substantial and large surgery will typically involve the repair of the tendon back to the bone.
Acute full-thickness tears in patients who are still working or playing sport and wish to continue to do so will often need to be repaired surgically before successfully returning to work or to recreational pastimes. Surgery for a full-thickness tear involves reattaching the tendon back to the bone and will normally be performed in conjunction with an acromioplasty.
UNDERSTANDING TERMINOLOGIES
Full Thickness Tear (FTT)
This term relates to the vertical depth of the tear at its insertion. The term implies that the tendon is completely detached from the insertion to the humerus. The significance of this is that a full thickness tear is unlikely to be able to heal back to its insertion because
the tendon and bone are not in contact with each other. While conservative management may lead to symptomatic relief, it is unlikely that the tear will heal.
For example, if applied to the common anterior supraspinatus tendon tear, the term full thickness means that if the tear is viewed inferiorly with the arthroscope, then it will be possible to view out through this tear into the subacromial space (the bursa).
Partial
Thickness Tear (PTT)
The significance of the term partial thickness tear refers to a tear that is not at full depth. The partial thickness tear can be articular surface; bursal surface; or intrasubstance.
For example, if viewing an articular surface tear from the joint with an arthroscope the abnormal tendon will be seen however it will not be possible to see out into the subacromial space because there is still some of the thickness of the tendon attached.
Because partial thickness tears are still attached to the insertion, it has classically been thought that healing is possible. The healing potential of partial thickness tears may not be as great as has long been thought.
The approach to treatment of partial thickness tears is different to that of full thickness tears. A rule of thumb used by many surgeons is that if the partial thickness tear represents less than 50% of the depth of the tendon then a simple debridement procedure is appropriate. The supposition is that debridement removes devitalised tissue and encourages healing by exposing vascularised tissue whilst avoiding the requirement for prolonged immobilisation to protect a repair.
If the tear is greater than 50%, then many surgeons will tend to repair the tear. The options for repair include repairing the partial tear in situ or to complete the tear to a full thickness tear and then repair it.
Complete Tear
This term is usually used to signify a full thickness tear in which the whole length of the insertion of the rotator cuff tendon has been detached.
For example, if the term is applied to the supraspinatus tendon, it signifies that the tendon has detached from the greater tuberosity from its anterior insertion, just posterior to the bicipital groove to its posterior insertion just anterior to the beginning of the infraspinatus tendon insertion.