Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

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Complete Tears

Complete rotator cuff tears are classified as follows:
1. A small complete tear such as a puncture wound.

2. A moderate tear that still encompasses only one of the rotator cuff tendons; the tear is usually less than 2 cm (0.8 in) in size, with no retraction of the torn ends.

3. Large complete tear involving an entire tendon with minimum retraction of the torn edges. The tear is usually 3–4 cm (1.2–1.6 in) in size.

4. A massive rotator cuff tear involving two or more rotator cuff tendons. This is frequently associated with retraction of the remaining tendon ends.

Symptoms and diagnosis

– Intense pain is felt when the injury occurs. The pain returns on exertion, may increase during the next 24 hours and may extend down the upper arm. A diagnosis of a tear of the supraspinatus tendon is suspected if the athlete has fallen on the shoulder, or has lifted or thrown a heavy object.

– Pain is often intense, or increased, at night. The patient often complains of problems with sleeping or lying on the injured side.

– Pain occurs when the arm is externally rotated or is raised upwards and outwards. When the tendon is only partially torn, the arm can be abducted to an angle of 60–80° to the body with little or no pain. The
pain increases as the arm is lifted to an angle of 70–120°; it may increase once more when the arm is lowered. Between these angles the arm is also weak. When the tendon has sustained total rupture
the arm can be held at an angle of more than 120° to the body, but when it is lowered further it suddenly drops. This is an important diagnostic sign (the ‘dropping arm’ sign).

– The rotator cuff test is positive. The arms are held in 90° of elevation in the scapular plane and the thumbs are rotated down towards the ground. When pressure is placed on the arm, the
patient complains of pain and weakness.

– Injection of anesthetic solution into the subacromial space can give relief in 75% of athletes with a partial tear on the bursa side; the relief supports the diagnosis.

– X-ray views, including a supraspinatus outlet view, are helpful in demonstrating acromial morphology and bony spurs that originate from the acromioclavicular joint.

– Ultrasonography can be sensitive and specific in identifying full-thick-ness rotator cuff tears.

– MRI is highly sensitive in the diagnosis of rotator cuff tears. It can demonstrate not only the size of the tear, but also the exact location. It can be made more accurate when combined with an arthrogram.

– Arthroscopy can verify the diagnosis of a tear that can be seen on the bursal or the articular side.

Treatment

The athlete should:
– treat the shoulder with ice at the scene of the injury;
– rest;
– avoid abuse of the arm;
– consult a doctor if the symptoms persist.

The doctor may:

– prescribe an exercise program designed to promote dynamic stability of the humeral head. Often a physical therapist or trainer is needed to monitor the program. The program should consist of stretching the posterior capsule and maintaining good range of motion, as well as shoulder girdle strengthening. The goal of the rehabilitation should be to restore symmetry between the two arms with respect to (1)
range of motion, especially internal rotation which is commonly decreased on the affected side; (2) quality of motion, with decreased compensatory shoulder blade motion; (3) strength, with an emphasis
on strengthening the rotator cuff muscles to hold the humeral head centered within the glenoid; and (4) strengthening the periscapular muscles to provide a stable base for shoulder motion;

– if pain continues despite physical therapy, give a subacromial injection or operate in certain circumstances as described below.

Healing and complications

– Spontaneous healing of a partial tear appears to be clinically unlikely because of the poor circulation at the site of the tear, the physical separation of the stump ends, and the subacromial impingement. Bursal-side tears have a poor prognosis, so a more aggressive surgical approach is required.

– If there is a partial thickness tear of the rotator cuff, arthroscopic (or, if necessary, open) debridement of the lesion may be performed in the hope that this will reactivate the healing process. This procedure is
often combined with an anterior acromioplasty where a part of the acromion is removed. If subtle instability is present, the surgery is focused on this problem. Postoperatively, a gradual progressive
strengthening program is begun after full range of motion is achieved.

– If there is a complete rotator cuff tear (one with full thickness tear), surgery is usually recommended. Symptoms generally improve, but functional recovery is less predictable: 75% of patients usually have
significant pain relief, but only about 40% of top-level throwers return to their preinjury level of function. A gradually increased rehabilitation program under supervision is important for this injury.

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