Rotator cuff tears are a common source of shoulder pain. The incidence of rotator cuff damage increases with age and is most frequently caused by degeneration of the tendon, rather than injury from sports or trauma. Although the information that follows can be used as a guide for all types of rotator cuff tears, it is intended specifically for patients with complete degenerative tears of the rotator cuff.

Treatment recommendations vary from rehabilitation to surgical repair of the torn tendon(s). The best method of treatment is different for every patient.

The decision on how to treat rotator cuff tears is based on the patient's severity of symptoms, functional requirements, and presence of other illnesses that may complicate treatment.

In consultation with an orthopaedic surgeon, the information that follows is intended to assist patients in deciding on the best management of their rotator cuff tear with the understanding that all patients are unique.

The rotator cuff is a group of four muscles that surround the humeral head (ball of the shoulder joint). The muscles are referred to as the "SITS" muscles: supraspinatus, infraspinatus, teres minor, and subcapularis. The muscles function to provide rotation, elevate the arm, and give stability to the shoulder joint (glenohumeral joint). The supraspinatus is most frequently involved in degenerative tears of the rotator cuff. More than one tendon can be involved. There is a bursa (sac) between the rotator cuff and acromion that allows the muscles to glide freely when moving. When rotator cuff tendons are injured or damaged, this bursa often becomes inflamed and painful.

Pain, loss of motion, and weakness may occur when one of the rotator cuff tendons tears. The tendons generally tear off at their insertion (attachment) onto the humeral head.

What will happen if a torn rotator cuff is not treated with surgery? Will I lose the use of my arm? Will the tear get larger over time? These are common concerns patients have, and the answers are not always clear. In one study, 40% of patients with a rotator cuff tear showed enlargement of the tear over a 5-year period; however, 20% of those patients had no symptoms. Therefore, less than half of patients with a rotator cuff tear will have tear enlargement, but 80% of patients whose tear enlarges will develop symptoms.7 Tempelhof S, Rupp S, Seil R: Age-related prevalence of rotator cuff tears in asymptomatic shoulders. J Shoulder Elbow Surg 1999;8:296-299. 10471998 These data, however, are based on a small group of patients; it is important to realize that once symptoms develop, progression may have already progressed and enlarged.

Treatment options include:

• Nonsurgical (conservative) treatment
• Surgical treatment (rotator cuff repair)
• Open repair
• Mini-open repair
• All-arthroscopic repair

Nonsurgical treatment typically involves activity modification (avoidance of activities that cause symptoms). Nonsurgical management of a rotator cuff tear can provide relief in approximately 50% of patients.

	Hawkins & Dunlop8 Hawkins RH, Dunlop R: Non-operative treatment of rotator cuff tears. Clin Orthop Relat Res 1995;321:178-188. 7497666	Itoi & Tabata9 Itoi E, Tabata S: Conservative treatment of rotator cuff tears. Clin Orthop Relat Res 1992;275:165-173. 1735208	Bokor et al.10 Bokor DJ, Hawkins RJ, Huckell GH, Angelo RL, Schickendantz MS: Results of non-operative management of full-thickness tears of the rotator cuff. Clin Orthop Relat Res 1993;294:103-110. 8358901	Bartolozzi et al.11 Bartolozzi A, Andreychik D, Ahmad S: Determinants of outcome in rotator cuff disease. Clin Orthop Relat Res 1994;308:90-99. 7955708
Patients who were satisfied	54%	82%	56%	25%
Patients with pain relief	45%	55%	77%	Not reported

These studies show that approximately 50% of patients have decreased pain and improved motion and are satisfied with the outcome of nonsurgical treatment. Surgeons may recommend nonsurgical treatment for patients who are most bothered by pain, rather than weakness, because strength does not tend to improve without surgery.

There are a few predictors of poor outcome from nonsurgical treatment:

• Long duration of symptoms (more than 6 to 12 months)
• Large tears (more than 3 centimeters)

Nonsurgical treatment has both advantages and disadvantages.

Advantages:

• Patient avoids surgery and its inherent risks:
• a. Infection
• b. Permanent stiffness
• c. Anesthesia complications
• Patient has no "down time"

Disadvantages:

• Strength does not improve
• Tears may increase in size over time
• Patient may need to decrease activity level

Surgical management is indicated for a rotator cuff tear that does not respond to nonsurgical management and is associated with weakness, loss of function, and limited motion. Because there is no evidence of better results in early versus delayed repairs, many surgeons consider a trial of nonsurgical management to be appropriate.1 Ruotolo C, Nottage WM: Surgical and non-surgical management of rotator cuff tears. Arthroscopy 2002;18:527-531. 11987065 Tears that are associated with profound weakness, are caused by acute trauma, and/or are very large (greater than 3 centimeters) on initial evaluation may also be considered for early surgical repair. Surgical treatment of a torn rotator is designed to repair the tendon back to the humeral head (ball of the shoulder joint) from where it is torn. This can be accomplished in a number of ways. Each of the methods available has its own advantages and disadvantages; all have the same goal—getting the tendon to heal to the bone. The choice of surgical technique depends on several factors, including the surgeon's experience and familiarity with a particular procedure, the size of the tear, the patient's anatomy, the quality of the tendon tissue and bone, and the patient's needs. Regardless of the repair method used, studies show similar levels of pain relief, strength improvement, and patient satisfaction.

The three commonly used surgical techniques for rotator cuff repair are:

• Open repair
• Mini-open repair
• All-arthroscopic repair

An individual surgeon's ability to repair a torn rotator cuff and achieve a satisfactory result varies by technique. Variation is based on experience and familiarity with the technique. Although one surgeon may be capable of achieving a quality repair through all-arthroscopic means, another may have better results with mini-open repair. Prior to surgery, patients should discuss the options available to them with their surgeon. The surgeon can share results of using different techniques so that the most appropriate treatment plan can be designed.

This is a non-exhaustive list of potential additional resources. AAOS does not review or endorse accuracy or effectiveness of materials, treatments or physicians.

The overall complication rate following rotator cuff repair surgery is estimated to be approximately 10%. This is based on a large review of 40 published series on rotator cuff repairs.26 Mansat P, Cofield RH, Kersten TE, Rowland CM: Complications of rotator cuff repair. Orthop Clin North Am 1997;28:205-213. 9113716 Complications generally involve:

• Nerve Injury (1% to 2%): Nerve injury usually involves the axillary nerve, which activates the deltoid muscle. Careful surgical dissection and limiting forceful manipulation and traction on the arm during surgery will decrease the likelihood of nerve injury.
• Infection (1%): Use of antibiotics during the procedure and sterile surgical technique limits the risk of infection. Antibiotic use after discharge from the hospital does not further decrease risk of infection.
• Deltoid Detachment (less than 1%): Careful repair of the deltoid and protection during rehabilitation after an open repair procedure are important to avoid deltoid detachment. This complication should not occur after a mini-open or arthroscopic repair because these procedures preserve the deltoid attachment or do not require detaching the deltoid.
• Stiffness (less than 1%): Early rehabilitation protocols decrease the likelihood of permanent stiffness or loss of motion following a rotator cuff repair.
• Tendon Re-tear (6%): Several studies have documented tearing of the rotator cuff following all types of repairs. It appears that tendon re-tear does not guarantee a poor result, return of pain, or poor function.27, Harryman DT II, Mack LA, Wang KY, et al: Repairs of the rotator cuff: Correlation of functional results with integrity of the cuff. J Bone Joint Surg Am 1991;73:982-989. 1874784 28 Liu SH, Baker CL: Arthroscopically assisted rotator cuff repair: correlation of functional results with integrity of the cuff. Arthroscopy 1994;10:54-60. 8166903 A recent study comparing rates of tendon re-tear showed a higher rate of tendon re-tear with all-arthroscopic repair when the tear was more than 3 cm. Smaller tears had a similar rate of re-tearing when comparing open and arthroscopic repairs. Again, there was little difference in patients' function regardless of whether there was tendon re-tear.

Following rotator cuff surgery, therapy progresses in stages. Initially, the repair needs to be protected until adequate healing of the tendon to bone occurs. For this reason, most patients use a sling for the first 4 to 6 weeks after surgery and are instructed to limit active use of the arm during this period. Passive range-of-motion exercises are begun with a therapist; () may be taught as well. Progressive strengthening and range-of-motion exercises continue during the next 6 to 12 weeks. Most patients have a functional range of motion and adequate strength by 4 to 6 months after surgery.

The incidence of full-thickness rotator cuff tears increases with age; however, tears are not always painful. Tears can be managed successfully with nonsurgical treatment in 50% of patients. Pain and range of motion will improve with nonsurgical management, but strength will not. Large tears, significant weakness, and an acute traumatic event are possible causes of poor outcome from nonsurgical management.

Surgical repair results in pain reduction and improved function and strength in more than 80% of patients. About one in ten surgeries can result in complications. Surgical procedures to repair a torn rotator cuff have become increasingly less invasive. Minimally invasive procedures are less painful and have less blood loss, shorter hospital stays, and a generally easier rehabilitation period. Although less invasive procedures are more attractive, they are often more difficult for the surgeon to perform and require an experienced surgeon for best results. Lastly, all repair methods appear equal in outcomes when the surgery is performed well.