Why your rotator cuff tear may or may not require surgery
[blockquote]The tendon is like a rubber band, and after a tear, the cuff only connects on one end.[/blockquote]
About the Rotator Cuff
So the rotator cuff tendon attaches to the…there are four tendons that create the entire rotator cuff: the supraspinatus, the infraspinatus, the subscapularis, and the teres minor.
Those four tendons each attach on the bone and go around the bone sort of like a cuff on your shirt. So when people say they have a torn rotator cuff, typically it can mean anywhere from one tendon to multiple tendons torn, which will directly indicate the size of the tear.
Types of tears by grade:
- Partial thickness tears
- Bursal side: tears on the top of the tendon
- Articular side: tears on the bottom of the tendon
- Full thickness tears: usually categorized by size in centimeters
- Small
- Medium
- Large
- Massive
- Irreparable
As you can imagine, a small, partial thickness tear would be easier to fix with a better outcome for the patient than a massive tear or an irreparable tear.
The rotator cuff doesn’t just come in to the bone and hook on at one point. It comes in and attaches to what we call the footprint, like the footings of your house. The walls of your house come down and sit on the foundation and the footings of your house.
So keeping that in mind, sometimes you’ll have a partial thickness tear where the undersurface, the articular side, is torn a little bit, or you may have a bursal-sided tear (the top of the rotator cuff), but it’s considered a partial thickness tear because it doesn’t go all the way through the cuff.
Let’s go back to the house analogy. With an articular side tear, the ceiling has a problem, but the roof is still strong, and with a bursal-sided tear, the ceiling has some missing shingles, but the roof is generally strong.
Full thickness means that whether you are in the room or on the roof, you can see the sky or the floor, because there is a hole in the ceiling and the roof.
The Meat of It All
Each year, roughly 7.5 million people visit their physicians complaining about shoulder problems, and about 4 million of those people find out they have some sort of rotator cuff injury.
When people visit their physicians and, at some point in their care, have an MRI, which shows a “rotator cuff tear,” they often begin worrying and thinking the worst, and that makes sense. Something in their bodies is torn. It’s torn, and the MRI proves it. Well, an MRI saying “rotator cuff tear” is like pointing out that the ocean is blue. It’s a broad statement that fails to offer a great deal of insight by itself.
That’s not to diminish the concerns or feelings of those with cuff tears, but a little education about the complexity of rotator cuff tears could go a long way to calm some of the anxiety surrounding those MRI results.
Often times, in my own clinic, I will sit down with folks, talk to them about their symptoms, examine them to discern their level of disability, locate the source of the pain, and then look at the MRI. I need to correlate all that together to try and decide whether or not that tear is relevant. You also have to decide if that tear needs treatment.
Now, you may be asking, “what does he mean by relevant, and if the rotator cuff is torn, shouldn’t that require treatment?”
I’ll offer a very ambiguous maybe.
There are some partial thickness tears that are operable, but often times, partial thickness tears revealed by an MRI are not operable because tendons tend to undergo wear and tear with normal use, so overreacting by operating on every partial thickness rotator cuff tear, would lead to far too many unnecessary operations.
If you had to pin an orthopedic surgeon down, typically a partial thickness tear should be (and this is a little dogmatic) 50% torn or more before a surgeon would even consider operating on it.
Why is that? Well, you may come in and say, “I’ve got shoulder pain on my left side, and then I had pain on the right side. I got an MRI, and both look identical, but my right one is killing me. Why?” The diagnosis probably isn’t partial cuff tear, but bursitis and impingement instead. That’s a big difference because bursitis and impingement is treatable with the usual conservative treatment options.
Scenario 1: an active, elderly patient
Someone who is fairly active in his early 80s with shoulder pain has a 1 centimeter full thickness tear (remember: full thickness means we can see from the kitchen table to the sky). His function is excellent, but he just has a sore shoulder, so he schedules an appointment three weeks out, but when he arrives, his shoulder feels better, way better.
What should be done? He and his physician know he has a one centimeter full-thickness tear.
80% of eighty year olds have a full thickness rotator cuff tear, varying in size, and they don’t even know about it.
Remember the 4 million people each year with a rotator cuff injury? Well, those diagnosed with partial thickness tears can experience more wear and it becomes a full thickness tear, but it’s irrelevant because they have good function, they don’t do manual labor or strenuous work because they’re usually retired.
Is it really the best option to put this patient through an operation that they don’t necessarily need, to take away six months of their lives? They may have mobility loss after surgery and will have to go through therapy all because a test showed a cuff tear.
With conservative treatment, they can live with the tear. It’s not going to interrupt their life.
When treating a rotator cuff, it’s important to look at symptomatology, function, relevance, and convalescence (how long will this person be down?).
Scenario 2: the active 45 year old
A 45 year old with a partial tear and pain should not undergo a big operation just to fix something that’s not relevant. It’s not sensible.
Now, flip the tables. A 45-year-old woman comes in who slipped on the ice while ice-skating with her kids, and she felt a big rip or crunch. She has some weakness that does not affect her daily activities, but her pain is significant. Her physician then orders an MRI and finds a 3-centimeter cuff tear (medium).
In this scenario, surgery should receive a strong consideration. Given her age (and likely function), she will do much better throughout her life by having this addressed surgically. In addition, she has a 47% chance that the tear may progress in size. It may even become inoperable in the future. Therefore, surgery sooner is often times better in this scenario.
What causes the tear to get worse? Simply put: you’re using it.
Remember that the tendon is like a rubber band, and after a tear, the cuff only connects on one end. The four tendons intertwine, so if one tendon is pulling, the others experience increased stress. That patient needs to have her cuff fixed and typically right away for function, pain control, return to work, or just dealing with crazy toddlers scampering around everywhere.
Scenario 3: the complete tear
Now another man comes in, and he’s young, doesn’t have any pain, can’t lift his arm very high, and he’s experiencing weakness.
The MRI comes back showing a complete tear. The rotator cuff could be fixed, but it will likely cause some lasting range of motion loss and potential pain at end range that pain will never go away. In fact, there is a chance that pain may worsen after surgery, but he will get most, if not all, of his functionality back.
A small tear that progresses hinders the shoulder from rotating through the ball. Rather, it slides up and down like a piston because the deltoid, which is the next muscle layer out, takes over, meaning the tendons are no longer doing their job.
The cuff holds the ball in the socket so that it can roll. When those are not functioning, the deltoid creates an up and down motion, which creates a high riding humeral head, creating rotator cuff tear arthropathy. That basically means the rotator cuff tear is inoperable because of its massive size, and the ball and socket joint quickly wear out because of the dysfunction this situation creates. Now you have the worst of all worlds: a weak, painful, and arthritic shoulder that hurts all the time.
Needless to say, this is an extremely debilitating condition.
Instead of reaching up, your shoulder will just slide up until it hits the next bone. The hand will never go over the head with this condition. In addition, it aches with or without activity.
So dealing with a little pain and scar tissue after surgery pales in comparison to the alternatives.
So it’s not always an easy process to discern exactly what a patient needs. Each patient is different, and these three scenarios provide some insight into the breadth of possible situations and demonstrate the importance of looking at what the patient needs rather than what a test says.
Thoughts? Questions? Feel free to share in the comments.
