Rotator Cuff Tear

**The rotator cuff** consists of four muscles (supraspinatus, infraspinatus, teres minor, subscapularis) whose tendons converge on the humeral head, stabilizing the shoulder joint and producing rotation. A **rotator cuff tear** is partial or complete disruption of one or more of these tendons. **Tear Classifications:** **By Cause:** - **Acute (Traumatic) Tears**: Sudden injury — falls on outstretched arm, sudden lifting, dislocations; younger patients - **Degenerative (Chronic) Tears**: Wear-and-tear over years; most common in adults >50; often after years of [shoulder impingement](/condition/shoulder-impingement-syndrome) **By Depth:** - **Partial-Thickness Tear**: Affects part of the tendon thickness — articular-side, bursal-side, or intratendinous - **Full-Thickness Tear**: Tendon completely torn through; communicates with subacromial bursa **By Size (Cofield Classification — full-thickness):** - Small: <1 cm - Medium: 1-3 cm - Large: 3-5 cm - **Massive: >5 cm or involving 2+ tendons** — much harder to repair **By Tendon Involved:** - **Supraspinatus** (95% of tears) — most common; affects abduction - **Infraspinatus** — affects external rotation - **Subscapularis** — affects internal rotation - **Teres minor** — rarely torn in isolation **The Critical Zone:** The supraspinatus tendon has a relatively poor blood supply 1-2 cm proximal to its insertion ("watershed area"). This region is most vulnerable to degenerative tears.

## Root Causes **Acute (Traumatic) Tears:** - Fall on an outstretched arm - Heavy lifting with the arm extended - Sudden forceful pulling movements - Shoulder dislocation (often associated with subscapularis tears) - Direct trauma to the shoulder (e.g., motor vehicle accident) **Degenerative (Chronic) Tears:** - **Age-related tendon degeneration** — collagen disorganization, vascular insufficiency - **Chronic [shoulder impingement](/condition/shoulder-impingement-syndrome)** — repetitive compression weakens tendon - **Critical zone vulnerability** — relative hypovascularity 1-2 cm proximal to insertion - **Acromial morphology** — Type III (hooked) acromion accelerates tendon wear - **Cumulative microtrauma** from overhead activities over years **Risk Factors:** - Age >50 — most important risk factor; prevalence doubles every 10 years after 50 - **Smoking** — single most modifiable risk factor; 1.5-2x increased risk; impairs tendon healing - Diabetes — accelerates tendon degeneration - Repetitive overhead work or sports - Genetic predisposition (family history increases risk 2-3x) - Prior shoulder dislocation - High BMI - Hypercholesterolemia — affects tendon vascular health

## Conservative Treatment (First-Line for Most Cases) **Best for**: Partial-thickness tears, small full-thickness tears, low-demand patients, elderly patients **1. Physical Therapy:** - **Rotator cuff strengthening** — start with isometric exercises, progress to band/light dumbbell - **Scapular stabilization** — rows, scapular squeezes, prone Y-T-W raises - **Posterior capsule stretching** — cross-body stretch, sleeper stretch - **Postural correction** — addresses underlying impingement contributing to tear - **Pain-free range of motion** initially; progress as tolerated **2. Pain Management:** - NSAIDs (ibuprofen, naproxen) for 2-4 weeks during flares - Topical NSAIDs as alternative - Acetaminophen as adjunct - Avoid long-term opioids **3. Subacromial Corticosteroid Injection:** - Provides 70-80% short-term relief - Should be combined with physical therapy - Limit to 2-3 injections per year (excessive injections weaken tendon) - Best for those with concurrent [subacromial bursitis](/condition/shoulder-impingement-syndrome) **4. Activity Modification:** - Avoid overhead activities during acute phase (4-6 weeks) - Sleep with a pillow under the arm to support shoulder - Modify work and sport activities - Address postural and scapular issues **Conservative Treatment Success Rates:** - Partial-thickness tears: 70-80% improve significantly - Small full-thickness tears: 50-70% improve - Massive tears in low-demand patients: Reasonable functional outcomes - Younger patients with full-thickness tears: Lower success rates (40-60%) ## Surgical Treatment (For Persistent Pain or Functional Loss) **Indications:** - Failed 3-6 months of conservative treatment - Acute traumatic tear in active patient - Full-thickness tear in younger patient (<60) - Progressive tear size or fatty muscle degeneration - Significant functional impairment **Procedures:** - **Arthroscopic rotator cuff repair** — gold standard; 1-2 cm incisions; faster recovery - **Mini-open repair** — for larger or more complex tears - **Tendon transfer** — for massive irreparable tears (latissimus, lower trapezius) - **Reverse total shoulder arthroplasty** — for massive tears with arthritis in older patients - **Superior capsular reconstruction** — newer technique for irreparable massive tears **Post-Surgical Recovery:** - Sling for 4-6 weeks - Passive ROM phase 0-6 weeks - Active ROM phase 6-12 weeks - Strengthening phase 3-6 months - Full return to activities 6-12 months - Re-tear rates: 15-25% medium tears, 40-50% massive tears