About seven out of 10 patients who walk into my office with shoulder pain have an issue with their rotator cuff – it’s the most common source of pain in the shoulder. For several years I led a taskforce for the American Shoulder and Elbow Society, helping decide on treatment recommendations for rotator cuff issues, so I have additional professional experience with it. However, I’d like to dispel some of the old wives’ tales about the rotator cuff.
What is the rotator cuff?
The rotator cuff is a group of muscles and tendons that helps you raise your arm above your shoulder. It rotates your arm but its main job is to hold the ball of your upper arm down against the socket of your shoulder so the big muscle on the outside of your shoulder can do the lifting.
What are rotator cuff problems?
Rotator cuff problems are almost ubiquitous. Most people will experience some shoulder pain during their lifetime, and most of that pain will not happen after an injury. Rotator cuff tearing can come from two different methods. The most obvious way is after frank injuries such as falling down stairs, where you have an accident and rip the tendon the way you may rip any other tendon in your body after an accident. However, that kind of injury-related tear only constitutes about 10% of the rotator cuff problems.
More commonly, a patient comes to the office after a gradual onset of shoulder pain. They’re surprised to find out they have a rotator cuff tear because they did not injure it. In these cases, the gradual wear and tear of a tendon that starts as early as your twenties builds up over time and leads to the breakdown of the tendon.
The wear and tear on the rotator cuff tendon may or may not cause pain. When it does cause pain, the problem has advanced enough so that the mechanics of your shoulder are thrown off. In that case the rotator cuff doesn’t do its job very well and the tendons themselves begin to get pinched when you raise your arm. In these cases, you often have pain at night or when you raise your arm up above the level of your shoulder.
Patients don’t generally recognize how ubiquitous torn rotator cuffs are. It’s very likely that a patient with pain from a torn rotator cuff in one shoulder has a torn rotator cuff without pain in the other shoulder.
If you take random patients off the street and look at their shoulders in an MRI machine, by about age 40, there’s about a 40% chance that we will find tearing in your rotator cuff, whether you have pain or not. It’s about 50% in your 50s and by the time you’re 70, it’s more likely that you have a torn rotator cuff than you don’t.
Rotator cuff tears are influenced by your genetics. Playing sports when you’re young may contribute to the tears, but genetics play a large role. If you have an MRI that shows a rotator cuff tear, someone in your family is about four times more likely to have a torn rotator cuff than someone not related to you. Rotator cuff problems are a genetic phenomenon that are somewhat influenced by your environment.
How are rotator cuff tears diagnosed?
Other shoulder conditions may look very similar to rotator cuff problems, so it’s important that your doctor does a comprehensive examination and checks how much motion you have in your shoulder. X-rays are a critical part of the evaluation of your shoulder, because it is difficult to figure out the reason behind shoulder pain unless you rule out things like arthritis or calcium deposits in the tendon, which show on x-rays. Even the alignment between the ball and socket can give your doctor information about the rotator cuff: as the rotator cuff begins to break down, the ball will shift in the socket, which can indicate you have a tear even before you have an MRI.
In the United States, an MRI is the gold standard for evaluating rotator cuff tears before surgery. MRIs can also help see how bad the tear is.
You and your physician should discuss how your rotator cuff problem affects your life, what other medical problems are contributing to it, and the specific type of rotator cuff issue that you have so you can agree on the right treatment for you.
How are rotator cuff tears treated?
Rotator cuff issues are one of the best studied problems that orthopedic surgeons deal with. Even though the tendons break down and you may get a hole in your tendon, most of the time tears can be treated without an operation. Over 80% of the people who come into the office with pain can get better, with or without a tear, by doing physical therapy exercises to correct the mechanics of the shoulder. Once your pain is better, further intervention like surgery is very uncommon.
We used to be concerned that if we didn’t surgically repair rotator cuffs, patients would have problems later in life. However, studies have shown that if we can improve the mechanics, even with the torn rotator cuff, your shoulder can work well for the rest of your life.
Surgery for torn rotator cuffs is the most common surgery we do because not everyone can improve with physical therapy. If physical therapy doesn’t help, surgery is the answer. Just as there’s a wide spectrum of problems in people’s rotator cuffs, there is a wide spectrum of surgery to treat those problems. For smaller tears in patients that are healthy and have a good capacity to heal, we do rotator cuff repairs. These repairs are traditionally done through small poke holes, and we stitch the tendon back to the bone where it’s supposed to be.
Sometimes the tears are so large and they have features on an MRI that suggest they can’t heal. In those cases we may need to do a shoulder replacement. In between these two extremes are several other surgeries. Sometimes we move tendons around the shoulder to restore function. We make decisions based on characteristics of the particular patient and the particular tear.
I think it’s important to recognize that this is an extremely common condition that is not always caused by an injury and does not necessarily require surgery.
Frequently Asked Questions
Can you make a rotator cuff tear worse?
Tears tend to increase in size over time. Once you have a hole in your tendon, there’s a 60% chance that it grows. However, the larger tear may not be dependent upon activity. It’s more likely that the increasing tear size is depending on your genetic makeup. In general, I don’t restrict the activity of people with rotator cuff tears. It’s likely a predetermined scenario where the tears will either progress or not, no matter what you do.
Do cortisone shots help with rotator cuff tears?
Cortisone shots can give you short-term pain relief. They will not heal the tear, and they have no clear, proven benefit in the long run.
Cortisone shots have some potential detrimental effects on the tendon and bone, and newer evidence suggests that the more cortisone shots you have the more likely you are to have a problem from surgery, such as an infection.
If a patient is having difficulty with therapy and it’s a struggle to get through the exercises, or if they’re being awakened at night, one cortisone shot may be used. The first shot gives you the best pain relief and subsequent shots give diminishing returns. I use cortisone shots much more sparingly than I did even a decade ago.
What about platelet-rich plasma and stem cells?
There isn’t compelling evidence that we can reverse the process of tendon breakdown, although there is some growing evidence that they can be helpful in other ways such as reducing inflammation. We’re still working out the details of which biologics to use.
Stem cells are not working as anticipated in this type of shoulder problem. Stem cells tried in rotator cuff issues seem to be morphing to the environment in the shoulder, which is one of breakdown, rather than changing the environment to one of building up. However, platelet-rich plasma is showing some promise in improving pain. Studies are ongoing on stem cells, platelet-rich plasma, and other biologics treatments.
Do torn rotator cuffs heal enough to allow for weight training?
Unless you have surgery, your rotator cuff will never heal. Physical therapy doesn’t help the tear heal itself. Instead, therapy alters the mechanics of your shoulder and optimizes the function of the other muscles in your shoulder that do the same job as the rotator cuff to get you a pain-free and fully functional shoulder. There is an enormous amount of overlapping function between the most commonly torn rotator cuff muscles and other muscles in your shoulder. There’s four muscles and tendons, and because of the overlapping function you can tear one and half to two of them and still have good function as the remaining muscles do the jobs of all four.
Part of why people develop pain and why sometimes need surgery depends on which muscles are torn, where they’re torn, and how the other muscles are responding. We treat traumatic tears, where your shoulder goes from very good to very bad very quickly, with surgery because those shoulders have not had the time to gradually compensate for the torn tendon. Whereas if you have a tear that builds up over time, it’s like fabric fraying from a thin spot into a hole over time, and there’s enough delay for your shoulder to compensate. Other muscles can take up some of the function that the torn one typically does and your shoulder will work normally. If you can have normal function, there’s no reason to fix the rotator cuff with surgery.
What is the typical recovery time after a rotator cuff surgery?
Most people feel like they have improved function and diminished pain in the first three months after their surgery and feel fully recovered around 6 months. If we do careful testing, as in research studies, we see improvements in your shoulder for up to 12 months afterwards.