Rotator Cuff Tear

The rotator cuff tendons are the strong thick sheets that attach the rotator cuff muscles to the bone of the top of the shoulder (the humerus). They are involved in keeping the ball (humeral head) central in the shoulder socket (glenoid), while also being involved in all movements of the shoulder. The supraspinatus tendon (lifts the arm out to the side) and infraspinatus tendon (rotates the arm to the side) are most frequently involved in cuff tears.
Rotator cuff tears occur in the following situations:
  • Acute tear – these happen suddenly as a result of a fall or trauma causing the tendon to pull off the bone or tear within its substance. This can be a complication of shoulder dislocations and other injuries.
  • Degenerate tear – these happen as a result of age and activity related wear and tear, especially where there have been spurs of bone catching on the tendons. Sometimes a fairly innocuous event can be the final straw that leads to a tear in a weakened worn tendon.
What are the signs and symptoms?
Some rotator cuff tears occur as a normal part of ageing and remain symptom free. Those tears that occur after an accident or a fall tend to be very painful over the top and outside part of the shoulder. Movement makes the pain worse and some activities are no longer possible due to the pain. It is not uncommon to experience weakness on certain movements, especially when trying to lift the arm up, or perform activities over shoulder height.

Degenerate rotator cuff tears often occur on a background of niggling and discomfort that could have been present for months or years. Pain is often associated with certain movements. Weakness is often felt with tasks above shoulder height and strenuous activities, such as gardening or sports. Pain from both types of tears can disturb your sleep, especially when lying on the affected side. Clicking and cracking may be a feature of a rotator cuff tear, although pain-free clicking can occur in normal shoulders.

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How are rotator cuff tears diagnosed?

Diagnosing a rotator cuff tear requires a careful questioning about any accidents or events that may have brought on the symptoms. The location and timing of the pain can give clues as to any underlying damage as well as any weakness noticed. A thorough examination testing all the muscles and tendons will often raise suspicions of a cuff injury.
When a tear is suspected, an X-ray can reveal any bone spurs or signs of arthritis. The best way to look at the tendons is through ultrasound or MRI scanning. These scans will better assess the tendons and soft tissues for any tears and muscle loss.

How are they treated?

Many rotator cuff tears are asymptomatic and cause no problems. As such it is perfectly reasonable to "keep an eye on these" and not intervene unless pain or weakness arise. Rotator cuff tears will not heal on their own, but in many cases the tear will cause minimal symptoms, which can improve with simple measures.
For chronic and degenerate tears, rest, painkillers and physiotherapy can be very effective in managing symptoms. If, however, the patient has lost strength, has had symptoms for over six months, or has a large tear then it is worth discussing those issues with regard to further treatment options.
For acute rotator cuff tears in higher-demand or younger individuals, such as people involved in heavy manual jobs, overhead occupations (joiners, electricians etc), and sportsmen, it is worth considering surgical repair. In these cases a better healing rate is seen if the tears are repaired early and before they can extend and get bigger.

What does surgery involve?

The surgery can be done entirely using the latest keyhole techniques. It does, however, require either general anaesthesia (asleep) or a nerve block (awake while the shoulder and arm are temporarily made numb for several hours). Three to four small incisions are required to introduce the camera and instruments into the shoulder. A complete examination of the entire shoulder is made prior to repairing the torn tendons. The tendons are fixed back to the bone using special anchors, which are inserted inside the bone of the humerus. Any other abnormalities can be dealt with at the same time, such as shaving away any spurs of bone or dealing with other damaged tendons.

The surgery takes approximately 40 to 60 minutes. It is normal to be able to leave hospital on the same day of the surgery. If small stitches are inserted, the nurse at your local GP practice at can remove these around 10 days post surgery.

What are the potential complications?

Complications from this type of surgery are uncommon but include pain and stiffness (in 5% of cases). These generally improve over the course of time. Re-tears of the tendon can occur, particularly if the tendon is very worn. These are more likely to happen with advancing age and in those who smoke or have diabetes, or in the case of massive retracted tears. Rare complications include infection, blood clots in the legs or lungs, nerve injuries and strokes.

What rehabilitation is necessary after surgery?

It takes a minimum of three months for the rotator cuff to heal back to the bone of the humerus. As such, the arm would be immobilised in a sling for the first three to six weeks.

Physiotherapy is absolutely essential during the rehab period to help minimise the chances of stiffness, but it is important to undertake only the exercises prescribed to avoid doing any damage to the underlying repair. Overdoing things in the first six to twelve weeks post surgery is a potential cause for damaging the repaired tendon.

Shoulder Dislocations

The shoulder is a very mobile ball and socket joint. This gives it the great advantage of being able to move our hand and arm in many directions. To permit this great mobility, the socket must be very shallow and, as such, the stability of the shoulder is very dependent on the surrounding muscles, tendons and ligaments to keep it in joint. Any condition or injury that disrupts these structures can lead to the shoulder slipping slightly out of joint and back in again (subluxation or partial dislocation) or coming out completely (dislocation).

Why does it happen?

There are three main reasons for the shoulder to feel unstable or dislocate.
Trauma  This usually results from a fall or an accident. In sportsmen this is most frequently due to a tackle or collision event. In these traumatic cases, the shoulder often stays out of joint (dislocates) and requires someone to put it back in joint. In over 90% of cases, the shoulder dislocates forwards and downwards (anterior). Traumatic dislocations are almost always associated with damage to the structures that stabilise the shoulder. This makes the shoulder more prone to dislocations in future.


In this group of patients, there is often no specific traumatic event or the trauma has been relatively minor. Despite this, patients can experience the sensation of their joint slipping or it even coming out of joint completely. This tends to occur with the arm in certain positions or even during their sleep. The shoulder almost always relocates itself rather than needing to go to hospital to have it put back. These patients have a greater degree of laxity of the ligaments that hold the shoulder in joint and a similar degree laxity can usually be seen in other joints. It is less frequent to have any underlying joint damage in these cases.

Non-structural atraumatic

These patients can dislocate their joints at will and may demonstrate a dislocation as a party trick. This is usually painless and there is no previous history of accidents or trauma. This form of instability is due to muscle imbalances and a change in the coordination of the muscles that control the stability and movement of the shoulder.

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How are rotator cuff tears diagnosed?


How is it treated?

The treatment is very much based on the cause of the dislocation. For all causes, however, physiotherapy is a fundamental part of successful treatment.

• Physiotherapy
This is essential to regain safe controlled and balanced movement in the shoulder. In many cases, this is all that is needed.

• Surgery
There are several operations that are used in treating unstable and dislocating shoulders and these are based on the repairing or addressing the underlying damage. In young individuals who sustain traumatic dislocations, there is a high chance of the shoulder re-dislocating in the future if left alone. This is particularly true in those who take part in collision sports, overhead sports and manual jobs. In these cases, a good success rate can be achieved by surgically stabilising the shoulder. Surgery available for shoulder dislocations includes:
Arthroscopic labral repair – in the majority of traumatic shoulder dislocations, the labrum is damaged or torn. This tear is also known as a Bankart lesion and can even extend to involve the bone of the socket (Bony Bankart lesion). To restore shoulder stability and reduce the chances of redislocating, the labrum can be repaired back to the edge of the socket using keyhole surgery. This requires two to three small incisions through which the labrum can be restored back to its original position on the edge of the socket.
Latarjet procedure – the Latarjet procedure was described by the French Surgeon Dr Michel Latarjet in 1954. It is used in cases of recurrent shoulder instability where surgery has been performed before and the shoulder continues to dislocate. It also has a special role in managing shoulder dislocations where there has been damage to the bone of the humeral head or the socket or both. This procedure can be performed using keyhole surgery (Arthroscopic Latarjet), open surgery or a combination of the two.

What are the potential complications?

Complications are uncommon, but include getting a stiff shoulder or recurrence of dislocations. Further possible, but rare, complications include infection, nerve damage, pain, and wound-healing problems. Finally, specific to the Latarjet procedure, non-union (non healing) and malunion of the bone transfer.

What rehabilitation is necessary after surgery?

The surgery can be performed as a day case procedure meaning you can leave hospital the same day as your operation. A period of immobilisation in a sling is then needed for four to six weeks and your stitches can be removed after 10 days. A structured course of physiotherapy is started immediately. Driving can be commenced after six to eight weeks subject to review by your surgeon and physiotherapist. Return to contact sports is considered from three months post surgery.



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