Rotator cuff tears: how to choose the right recovery pathway for you

Rotator cuff injuries are a common adult shoulder condition that causes pain, weakness, and shoulder dysfunction. They are the leading cause of adult shoulder disability. Deciding what treatment pathway is right for you requires a discussion and MRI review with an orthopedic surgeon. Rotator cuff tears are evaluated by the depth of the tear, the width of the tear, the tear configuration/pattern, if there is retraction away from the attachment site, and if there is impingement on top of that area from bone spurring. When the tear is less than 50% of the tendon's depth, also known as a partial-thickness tear, nonsurgical treatment may be considered. Tears at a shallow depth can accommodate activity while healing. Conservative treatment would include oral and topical medications, ice, activity modification/rest, and physical therapy with a home exercise program. Partial rotator cuff tears with impingement or who have failed conservative treatment could consider surgical intervention for debridement of the torn portion of the tendon, removal of bursitis, and decompression of the bone spurs. High-grade partial- and full-thickness tears (50-100% of the thickness) typically do not heal on their own, and surgery is often recommended. The procedure is often done arthroscopically for primary rotator cuff repairs, which means minimally invasive camera-assisted joint surgery. These repairs have evolved from older open incision repairs. Depending on the patient's condition and the repair's characteristics, the recovery is approximately 4-6 months. If the patient does not wish to undergo surgery or they are not healthy enough to undergo surgery, then a nonsurgical treatment pathway is recommended to reduce symptoms and maintain function through rest and rehabilitation. That recovery may take 6-12 months. The long head biceps tendon runs in a groove between two rotator cuff tendons. Often, that long head biceps tendon is also damaged when the rotator cuff is damaged. A biceps tenodesis or biceps tenotomy can be done if there is injury to that tendon. The long head biceps tendon can be a source of front shoulder pain, and it is helpful to address it at the same time as the rotator cuff. Patients with a rotator cuff tear and impingement also undergo decompression of the bone spurs at the time of their repair to reduce friction on the repair. This creates space and can provide healing marrow cells (stem cells) to support and facilitate repair. Patients living with rotator cuff insufficiency may fail conservative treatment or develop arthritis, also known as rotator cuff arthropathy. Those patients who have persistent dysfunction from a chronic rotator cuff tear could consider a reverse total shoulder arthroplasty or "replacement" to restore function and reduce pain. Total shoulder arthroplasty is a procedure that replaces the ball-and-socket joint of the shoulder with metal and plastic components. In the case of a patient without an intact rotator cuff, the prosthesis is placed in the shoulder so the rotator cuff does not need to function. This is called a reverse total shoulder replacement, in which the ball is placed where the socket used to be, and the socket is placed where the ball used to be. Recovery for a reverse total shoulder replacement is approximately 3-4 months. Lifetime lifting restrictions and antibiotic prophylaxis are recommended after the procedure. A patient with a chronic or irreparable rotator cuff tear may also consider a temporizing procedure to restore function and delay a total shoulder arthroplasty. Part of the function of an intact rotator cuff is to keep the ball well seated in the socket. When there is rotator cuff dysfunction, the ball of the humerus is allowed to elevate. That biomechanical dysfunction causes functional limitations and pain. The temporizing procedure is known as a tuberoplasty. A connective tissue graft is placed on top of the humerus, where the rotator cuff used to attach. This creates a bumper between the top shoulder bone and the top of the humerus, reducing the biomechanical dysfunction of a "high-riding" humeral head. Patients who are candidates for this procedure are younger, not candidates for reverse total shoulder arthroplasty, have a large, chronically retracted rotator cuff tear, and have high-riding of the humeral head on X-ray. No matter which treatment pathway is the right fit for the patient with a rotator cuff tear, adherence to the recovery and physical therapy protocol gives the patient the best chance of healing tissues and restoring function. The timing of the repair also increases the likelihood of success. Therefore, do not hesitate to see your orthopedic surgeon if you have shoulder pain or dysfunction. The sooner the plan is in place, the sooner you can move on to recovery. James Davidson is a physician and Katie Fultz is a physisian assistant with Blanchard Valley Orthopedics & Sports Medicine.