Repair of Rotator Cuff Tears

For up-to-date and comprehensive resources on shoulder arthritis, please visit our new online Shoulder Arthritis Book and Rotator Cuff Tear Book!

Repair of Rotator Cuff Tears: Surgery for shoulders with torn rotator cuff tendons can lessen shoulder pain and improve function without acromioplasty

Download this article as a pdf

In this Article:

Overview

The rotator cuff is a group of four tendons that blend together to help stabilize and move the shoulder. Each of the four tendons connects a muscle originating on the shoulder blade (scapula) to part of the upper part of the arm bone (humerus). The names of these muscle-tendon components of the rotator cuff are:

  • the supraspinatus which runs over the top of the ball of the shoulder joint (humeral head);
  • the subscapularis which runs across the front of the humeral head; and
  • the infraspinatus and the teres minor which run across the back of the humeral head.

Tears in the rotator cuff result from a combination of injury and weakening of the tendon from wear and tear, disuse, repeated use of steroid (cortisone) injection, and smoking.

The extent of injury necessary to tear the cuff depends on the quality of the tendon. Young healthy rotator cuff tendon is almost impossible to tear. However, older, multiply injured, multiply injected tendons or tendons in a smoker may tear with no injury at all. Tears in younger individuals are more likely to extend only part way through the tendon (partial thickness tears). Tears in older individuals are more likely to tear completely through the tendon (full thickness tears) and to involve multiple tendons.

Types of Rotator Cuff Tears

Rotator cuff tears range from small to massive. Click an image below to enlarge and enter the photo gallery of rotator cuff pathology.

The types of injuries most likely to cause cuff tears are those in which the elevated arm is forced downward (an eccentric force) or when the shoulder attempts a sudden jerky lift (a concentric force).

Full thickness tears do not heal by themselves because the muscles pull the edges of the tear apart. However it is possible for full or partial thickness tears to stabilize leaving the shoulder with reasonable comfort and function.

The more force necessary to produce a tear the more likely it is that the tear will be surgically repairable. Healthy tendon requires a major force to tear it. Tears resulting from major injury can usually be repaired successfully if surgery is not delayed more than several weeks.

Weakened degenerative cuff tissue is more easily torn even by normal activities. Durable repair of these tears may not be possible because of the lack of sufficient quantity and quality of tendon tissue. For these reasons patients should seek prompt evaluation of shoulder weakness by an experienced shoulder surgeon especially if the weakness comes on suddenly or after an injury.

A surgeon experienced in shoulder surgery can repair a rotator cuff tear if there is enough good quality tendon tissue.

Symptoms of Rotator Cuff Tears

Rotator cuff tears are common causes of shoulder weakness and pain that can often be improved by expert shoulder surgery.

Characteristics of rotator cuff tears

Individuals with rotator cuff tears usually notice weakness pain and loss of the ability to use the shoulder for their usual activities. Commonly they have difficulty sleeping on the affected shoulder and have a limited range of active motion. Some people with rotator cuff tears notice a catching or grinding feeling when the shoulder is moved. Rotator cuff tears usually get worse over time but the rate of this progression varies widely.

Rotator cuff tears may involve the entire thickness of the tendon (full thickness rotator cuff tears) or they may be incomplete (partial thickness).

Full thickness tears may involve only part of one tendon (usually the supraspinatus). They may extend to become massive involving multiple tendons as shown in the figure.

Rotator cuff tears may be degenerative (the defect arose in tendon of poor quality) or they may be traumatic (the tear arose from a major injury to otherwise healthy tissue). Cuff tear arthropathy refers to the combination of a massive cuff tear and arthritis of the shoulder joint.

Similar conditions

Rotator cuff disease must be distinguished from shoulder arthritis, arthritis of the acromioclavicular joint, subacromial bursitis, frozen shoulder, and neck arthritis; each of which may produce similar symptoms.

  • Shoulder arthritis usually causes pain and limited shoulder motion. X-rays confirm the presence of arthritis. 
  • Arthritis of the acromioclavicular joint usually produces pain localized to the top front of the shoulder that is made worse by using the arm in front of the body. Shoulder strength is usually normal.
  • Subacromial bursitis may cause catching and pain in the shoulder but shoulder strength is maintained.
  • Frozen shoulder is characterized by shoulder stiffness but the shoulder is usually strong. 
  • Neck arthritis with nerve impingement may cause shoulder pain and weakness that is worse when the head is held in certain positions. In this case electromyography may identify the presence of nerve involvement in the neck. Some have used the term "impingement syndrome" to refer to various types of cuff disease. However, modern diagnostic approaches usually permit a more specific diagnosis.

Incidence and risk factors

Conditions of the rotator cuff are the most common cause of problems of the shoulder. They are more likely to be found in people over the age of 40, smokers, and individuals who have had multiple steroid (cortisone) injections. People over the age of 40 who dislocate their shoulders are likely to have cuff tears. Those who have a cuff tear in one shoulder are likely to have similar problems in the opposite shoulder.

Diagnosis

A physician diagnoses rotator cuff disease by reviewing the patient's history, performing a thorough physical examination of the joint, taking the proper X-rays, and obtaining confirming imaging studies (such as a shoulder ultrasound or MRI). The examination of a shoulder with cuff disease reveals weakness or pain on exertion of the shoulder against isometric resistance. Sometimes the shoulder is stiff or noisy on movement.

X-rays of the shoulder are usually normal in the presence of cuff disease.  X-rays are taken to exclude other problems. Rotator cuff tendons do not show on ordinary X-ray examinations of the shoulder.

One method for diagnosis is ultrasound. In the hands of an experienced sonographer, dynamic shoulder ultrasound is a quick safe and reliable method for documenting the status of the rotator cuff tendons. By reflecting sound waves off the tendons ,sonographic images are created as the tendons move. Defects in the tendons may be revealed on these images. 

Magnetic resonance imaging (MRI) is another method for imaging the rotator cuff tendons. One risk is that some patients become claustrophobic during MRI examinations. 

An additional method that has been used to evaluate the integrity of cuff tendons is shoulder arthrography. In this technique dye is injected into the joint so that leaks through the cuff can be seen on X-rays.

It is essential that the shoulder surgeon establish the diagnosis of rotator cuff disease before surgical treatment is considered.

Treatment of Rotator Cuff Tears

Medications

Medications cannot help a torn tendon heal. However, mild pain-relieving medications may make shoulders with rotator cuff tears more comfortable. Cortisone (steroid) injections in the area of the cuff tendons may lessen the discomfort from the cuff problem but may also weaken the tendon tissue. Multiple injections of steroids are discouraged for this reason.

Exercises

While prompt surgery is usually recommended for acute cuff tears in generally healthy shoulders exercises may be helpful in maintaining the flexibility and strength of joints with long-standing cuff tears. In most cases these exercises can be done in the patient's home with little equipment. Shoulder exercises are best performed gently several times a day on an ongoing basis. The exercises are not dangerous if they are performed gently so that they do not risk enlarging the cuff tear.

The figures show two examples of these exercises. The illustration on the left shows the patient using the left arm to help lift the stiff right shoulder in a forward direction. The illustration on the right shows the patient using the left arm to gently stretch the stiff right arm in external rotation using a yardstick.

Rotator Cuff Exercises
Fig. 12 Exercises for rotator cuff tears

Sometimes physical therapists suggest other types of therapy. Patients should learn the possible risks of these approaches as well as their costs and anticipated effectiveness.

Rotator Cuff Surgery

Possible benefits of rotator cuff surgery

When combined with a good rehabilitation effort, rotator cuff surgery allows people to regain much of the lost comfort and function in shoulders with cuff disease. In experienced hands this procedure can address the restricting scar tissue and roughness that frequently accompany cuff disease. If the quantity and quality of the tissue is good, surgery can help repair the tendon back to the bone from which it has been torn. This is most likely to succeed soon after a cuff tear in otherwise healthy shoulders of non-smokers who have not had multiple cortisone injections.

Rotator cuff surgery can improve the mechanics of the shoulder but cannot make the joint as good as it was before the cuff tear. In many cases the tendons and muscles around the shoulder have been weakened from prolonged disuse before the surgery. The tissue may be insufficient for a strong repair. In such cases the mechanics of the shoulder may be improved by carefully smoothing out the cuff area and moving the shoulder immediately after surgery so that new scars are not formed.

If the cuff is repaired it takes months before the tendon is strongly healed to the bone. During this time strengthening exercises must be avoided so that healing is not impaired. After the healing it may take months of gentle exercises before the shoulder achieves maximal improvement.

The effectiveness of the procedure depends on the health and motivation of the patient the condition of the shoulder and the expertise of the surgeon. When performed by an experienced surgeon rotator cuff surgery usually leads to improved shoulder comfort and function. The greatest improvements are in the ability of the patient to sleep, perform activities of daily living, and engage in non-contact recreational activities.

Rotator cuff surgery can optimize the comfort and function of shoulders with cuff tears.

Types of surgery recommended

When healthy tendons of the rotator cuff have been recently torn it is often possible to perform a rotator cuff repair. When a repair cannot be accomplished because of insufficient tendon quantity and quality the comfort and function of the shoulder are often improved by a "smooth and move" procedure in which the upper surface of the rotator cuff and the arm bone (humerus) are smoothed and immediate post-operative motion is used to prevent the reformation of scar tissue. Partial thickness cuff tears may be treated by detaching loose tendon fibers along with the "smooth and move" procedure.

A procedure known as acromioplasty has been advocated for the treatment of cuff disease. Recently however, the routine use of this procedure has been questioned.

Not all surgical cases are the same, this is only an example to be used for patient education.

Who should consider rotator cuff surgery?

Rotator cuff surgery is considered for patients with either:

  • acute tears of otherwise healthy tendons or
  • chronic tears that remain weak or painful after a gentle exercise program.

What happens without surgery?

Before cuff surgery is undertaken the patient needs to:

  • be in optimal health
  • understand and accept the risks and alternatives of surgery and
  • understand the post-operative rehabilitation program.

In cases of chronic cuff tears, rotator cuff surgery can be performed whenever conditions are optimal. Sometimes the pain and stiffness from rotator cuff disease will stabilize at a level that is acceptable to the patient. In such cases the patient can delay surgery without compromising the potential for future surgery as long as the surgeon monitors the cuff tear to make sure it is not enlarging. Sequential shoulder sonography is particularly useful in sequentially following the integrity of the cuff.

In the case of an acute rotator cuff tear in otherwise healthy tissue the best chance of achieving an excellent result is surgical repair within the first month after the tear.

Rotator cuff surgery is not an emergency. If possible acute rotator cuff tears should be considered for repair within the first month after the injury. Rotator cuff surgery in chronic cuff tears is an elective procedure that can be scheduled when circumstances are optimal. In both instances the patient has time to become informed and to select an experienced surgeon.

Surgical options

Several variations of cuff surgery are used to manage cuff tendon problems. One important goal of this surgery is to allow the smooth passage of the upper arm bone (humerus) beneath what is known as the coracoacromial arch. This is usually accomplished by removing scar tissue, chronic bursitis, bony prominences, and irregular tendon edges. The combination of this smoothing with immediate, post-operative motion is known as the "smooth and move" procedure. When there is sufficient quantity and quality of tendon tissue, the torn edge of the cuff tendon is anchored to the humerus from which it was torn so that healing back to the bone can take place.

Some have advocated the repair of rotator cuff tears using shoulder arthroscopy. However, it is not clear that this more complicated approach has advantages over an expertly done direct open repair.

Others have suggested the use of various biological or artificial grafts or tendon transfers to bridge otherwise irreparable rotator cuff defects. The superiority of these complex procedures to the "smooth and move" procedure has yet to be demonstrated.

Effectiveness of Rotator Cuff Surgery

In the hands of an experienced surgeon, rotator cuff surgery can effectively restore comfort and function to the shoulder of a well-motivated patient. Often the greatest benefits are an improved ability to sleep on the affected shoulder and to perform usual activities of daily living. As long as the shoulder is cared for properly and subsequent injuries are avoided the benefit can last for decades. However, it is important to recognize that surgery cannot improve the basic quality of the tendon tissue. Thus, repair of poor-quality tissue is often followed`x` by recurrent tears.

Risks of Rotator Cuff Surgery

The risks of rotator cuff surgery include but are not limited to the following:

  • infection
  • injury to nerves and blood vessels
  • irreparability of the rotator cuff tendon
  • stiffness of the joint
  • re-tear of the repaired rotator cuff
  • pain
  • the need for additional surgeries

There are also risks associated with anesthesia. An experienced shoulder surgery team will use special techniques to minimize these risks but cannot eliminate them completely.

Managing risk

Many of the risks of rotator cuff surgery can be managed effectively if they are promptly identified and treated.

Infections may require a "wash out" in the operating room and subsequent antibiotic treatment. Blood vessel or nerve injury may require repair. Stiffness may require exercises or additional surgery. Retear of the repaired rotator cuff may require consideration of additional surgery.

If the patient has questions or concerns about the course after surgery the surgeon should be informed as soon as possible.

How to Prepare for Rotator Cuff Surgery

Rotator cuff surgery is considered for healthy and motivated individuals in whom rotator cuff tears interferes with shoulder function.

Successful rotator cuff surgery depends on a partnership between the patient and the experienced shoulder surgeon. The patient's motivation and dedication are important elements of the partnership.

Patients should optimize their health so that they will be in the best possible condition for this procedure. Smoking should be stopped a month before surgery and not resumed for at least three months afterwards--ideally never. This is because smoking interferes with the healing of the rotator cuff repair and the strength of the cuff tendon. Any heart, lung, kidney, bladder, tooth, or gum problems should be managed before surgery. Any infection may be a reason to delay the operation.

The patient's shoulder surgeon needs to be aware of all health issues including allergies and non-prescription and prescription medications being taken. Some of these may need to be modified or stopped. For instance aspirin and anti-inflammatory medication may affect the way the blood clots.

Timing of the surgery and recovery period

Surgery for chronic cuff tears can be delayed until the time that is best for the patient's overall well-being. Acute rotator cuff tears (those that occur suddenly) have the best chance of being strongly repaired if the surgery is carried out within a month of the tear.

After rotator cuff repair the patient needs to plan on being less functional than usual for twelve or more weeks after the procedure. The shoulder should not be used with the elbow away from the side for 3 months after a rotator cuff repair. Lifting pushing pulling and many activities of daily living place stresses on the rotator cuff and can place excessive tension on the cuff repair risking failure of the repair. Driving shopping and performing usual work or chores may be difficult during this time. Plans for necessary assistance need to be made before surgery. For people who live alone or those without readily available help arrangements for home help should be made well in advance.

The shoulder surgeon should answer any questions about the surgery or the recovery period.

Costs

The surgeon's office should be able to provide a reasonable estimate of the surgeon’s fee and the hospital fee.

Surgical team

Rotator cuff surgery is a technically demanding procedure that is ideally performed by an experienced shoulder surgeon in a medical center accustomed to performing these procedures at least several times a month. Patients should inquire as to the number of rotator cuff repairs that the surgeon performs each year and the number of these procedures performed in the medical center each year.

Surgeons specializing in rotator cuff surgery may be found through university schools of medicine county medical societies state orthopedic societies or professional groups such as the American Shoulder and Elbow Surgeons.

Rotator cuff surgery is often performed in a major medical center that performs these procedures on a regular basis. These centers have surgical teams and facilities specially designed for this type of surgery. They also have nurses and therapists who are accustomed to assisting patients in their recovery from rotator cuff surgery.

Technical details of Rotator Cuff Surgery

Rotator cuff surgery is a highly technical procedure; each step plays a critical role in the outcome.

After the anesthetic has been administered and the shoulder has been prepared a cosmetic incision is made over the top front corner of the shoulder as shown in figure 13, below.

This incision allows access to the seam between the front and middle parts of the deltoid muscle. Splitting this seam allows access to the rotator cuff without detaching or damaging the important deltoid muscle which is responsible for a significant portion of the shoulder's power. All scar tissue is removed from the space beneath the deltoid and the acromion (part of the shoulder blade to which the deltoid attaches). Thickened bursa and the rough edges of the rotator cuff and humerus (upper arm bone) are also smoothed to make sure that they pass smoothly beneath the acromion and deltoid.

The edges of the cuff tendons are identified and the quality and quantity of the cuff tissue is determined.

The goal of the repair is to reattach good quality tendon to the location on the arm bone from which it was torn. If the tendon cannot reach this spot with the arm at the side of the body the shoulder surgeon releases the tendon from the surrounding tissues. If good quality tendon will not reach its attachment site after these releases the cuff tear is deemed to be irreparable. In this situation the useless tendon is cut out and the shoulder is again examined to assure smooth and full motion. Again achieving this smooth movement may require trimming of the tendon edges or the bone of the upper humerus. Occasionally it may be necessary to perform an acromioplasty a procedure in which part of the bone overlying the rotator cuff is removed. Acromioplasty is avoided unless it is necessary because it increases the risk of weakening the deltoid and causing scar tissue.

Click an image beow to enlarge.

Shoulder & Elbow Articles

  1. About the Mechanics of Shoulder Stability.
  2. Anterior glenoid reconstruction for unstable dislocating shoulders. Surgery to restore lost anterior glenoid bone and deep the socket with a bone graft can restore shoulder anatomy and lessen pain and improve function.
  3. Arthroplasty in Cuff Tear Arthropathy: Surgery for shoulders with a rotator cuff tear and arthritis can lessen shoulder pain and improve function with joint replacement.
  4. Atraumatic Shoulder Instability.
  5. Bankart repair for unstable dislocating shoulders: Surgery to anatomically and securely repair the torn anterior glenoid labrum and capsule without arthroscopy can lessen pain and improve function for active individuals.
  6. Basics of failed shoulder surgery, complications of shoulder surgery and revision shoulder surgery
  7. Chondrolysis
  8. Clinical Presentation and Evaluation of Glenohumeral Arthritis.
  9. Clinical Presentation of Glenohumeral Instability.
  10. Compartmental Syndromes.
  11. Diagnosis of Capsulorraphy Arthropathy.
  12. Diagnosis of the Frozen Shoulder.
  13. Evaluation of Recurrent Instability.
  14. Evaluation of the Rough Shoulder.
  15. Evaluation of the Stiff Shoulder.
  16. Evaluation of the Weak Shoulder.
  17. Examination Under Anesthesia.
  18. Failed Shoulder Replacement and Revision.
  19. Glenohumeral Arthritis References.
  20. Home Exercises for the Rough Shoulder.
  21. Home Exercises for Stiff Shoulder
  22. Home Exercises for the Unstable Shoulder.
  23. Home Exercises for the Weak Shoulder.
  24. Humeroscapular Positions and Motion.
  25. Humerothoracic Positions and Motion.
  26. Injuries Associated with Anterior Dislocations.
  27. Intermediate Shoulder Instability.
  28. Management of Glenohumeral Arthritis.
  29. Mechanics of Glenohumeral Arthritis.
  30. Mechanics of Glenohumeral Arthroplasty.
  31. Mechanics of Glenohumeral Instability.
  32. Mechanics of Shoulder Strength.
  33. More Information on Rotator Cuff Surgery.
  34. Posterior glenoid osteoplasty for unstable dislocating shoulders. Surgery to build up the back of the glenoid socket using an osteotomy and graft can restore shoulder anatomy and lessen pain and improve function.
  35. Ream and Run for Shoulder Arthritis: Conservative Reconstructive Surgery for Selected Individuals Desiring Higher Levels of Activity than Recommended for Traditional Total Shoulder Joint Replacement
  36. Ream and Run non-prosthetic glenoid arthroplasty for shoulder arthritis: Regenerative cementless surgery designed for individuals desiring higher levels of activity than recommended for traditional total joint replacement.
  37. Rehabilitation after Shoulder Arthroplasty.
  38. Rehabilitation following shoulder joint replacement arthroplasty
  39. Relevant Anatomy of Glenohumeral Instability.
  40. Repair of Rotator Cuff Tears: Surgery for shoulders with torn rotator cuff tendons can lessen shoulder pain and improve function without acromioplasty.
  41. Reverse Shoulder Replacement (Delta joint replacement) for arthritis: Surgery with a reverse prosthesis can lessen shoulder pain and improve function in shoulders with failed surgery or combined arthritis, rotator cuff tears and instability.
  42. Reverse Total Shoulder or Delta Shoulder for Shoulder Arthritis Combined with Massive Rotator Cuff Tear and for Failed Conventional Total Shoulder Replacement
  43. Rotator Cuff Clinical Presentation.
  44. Rotator Cuff Differential Diagnosis.
  45. Rotator Cuff Failure.
  46. Rotator Cuff Historical Review.
  47. Rotator Cuff Imaging Techniques.
  48. Rotator Cuff Relevant Anatomy and Mechanics.
  49. Rotator Cuff Tear: When to Repair and When to Smooth and Move the Shoulder
  50. Rotator Cuff Treatment.
  51. SF 36 and Health Status.
  52. Scapulothoracic Positions and Motion.
  53. Shoulder Arthritis
  54. Shoulder Arthritis Book
  55. Shoulder and Elbow Cases to Consider.
  56. Shoulder arthritis and rotator cuff tears: The combination of arthritis and rotator cuff tears is called rotator cuff tear arthropathy. The management of this condition requires thought and experience.
  57. Shoulder arthritis: Osteoarthritis, Chondrolysis, Rheumatoid Arthritis, Degenerative joint disease, and arthritis after shoulder surgery.
  58. Shoulder joint replacement arthroplasty for shoulder arthritis pain and stiffness: two options: total shoulder and ream and run
  59. Shoulder osteoarthritis, chondrolysis, rheumatoid arthritis, degenerative joint disease, and arthritis after shoulder arthroscopy and open surgery
  60. Simple Shoulder Test.
  61. Subacromial Smoothing.
  62. Surface replacement for shoulder arthritis: Surgery with a CAP, a special type of conservative resurfacing joint replacement that resurfaces the ball of the ball and socket joint, can lessen pain and improve function.
  63. Surgery for Atraumatic Instability of the Shoulder.
  64. Surgical release for stiff frozen shoulders: Surgery to remove scar tissue and release contractures can lessen pain and improve function for stiff shoulders that have not responded to rehabilitation or physical therapy.
  65. Total Shoulder Replacement Arthroplasty for Shoulder Arthritis
  66. Total elbow joint replacement for elbow arthritis: Surgery with a dependable, time-tested prosthesis can lessen pain and improve function in elbows, especially in rheumatoid arthritis of the elbow
  67. Total shoulder joint replacement for shoulder arthritis: Surgery with a dependable, time-tested conservative prosthesis and accelerated rehabilitation can lessen pain and improve function in shoulders with arthritis.
  68. Traumatic Shoulder Instability.
  69. Treating Shoulder Dislocation / Subluxation (Instability) and Associated Pain with Minimally Invasive Arthroscopy
  70. Treatment of Recurrent Instability.
  71. Types of Glenohumeral Instability.