Rotator Cuff Tear
Rotator cuff tears of the shoulder are one of the most common causes of shoulder pain. The deep tendons of the shoulder are called the rotator cuff tendons and consist of four tendons: supraspinatus, infraspinatus, teres minor and subscapularis. The subscapularis tendon runs at the front of the shoulder and the other three tendons fuse to form a sheet of tendon known as the ‘cuff’. This group of tendons play a very important role in moving the shoulder and also stabilising the humeral head (head of the arm bone) in the centre of the socket whilst the shoulder moves. The supraspinatus tendon, which is the upper most part of the rotator cuff passes under the shoulder tip (acromion bone) and the ligament which runs from the shoulder tip (coracoacromial ligament).
Rotator cuff tears are common in patients over sixty years of age although they can occur in younger patients. However not all patients with a rotator cuff tear necessarily have symptoms from it as their shoulder has compensated by strengthening the remaining muscles and tendons. The most common tendon to be torn is the supraspinatus tendon at the top of the shoulder which runs under the shoulder tip. Tears of the rotator cuff tendons can be broadly divided into degenerative tears, whereby the tendon gradually degenerates and tears, or acute traumatic tears where the tendon has been forcefully torn from the bone due to an acute injury. Rotator cuff tears can also be further divided as to whether they are partial or full thickness, the duration of time since the tendon was torn and also by the size of the tear. 
Patients may complain of the following symptoms:
Pain - this is usually felt in the upper arm, is often constant and worse on activity. Night pain is a common feature of symptomatic rotator cuff tears and keeps the patient awake at night time. Patients may also find it difficult lying on the affected side at night.
Weakness- the patient may experience weakness in movement of the shoulder secondary to the torn rotator cuff tendon.
When the patient is assessed in clinic an x-ray is usually performed to exclude other causes of shoulder pain. To investigate for rotator cuff tears the most common investigations are either an ultrasound of the shoulder or an MRI scan. 
Treatment Options
If a patient is suffering from a symptomatic rotator cuff tear then the options include:
1. Analgesia and physiotherapy to strengthen the remaining tendons and muscles
2. Subacromial steroid injection to improve pain from secondary bursitis. However a steroid injection should be avoided if consideration is being taken to repair the rotator cuff tendon as the steroid may weaken the tendon making a repair more difficult.
3. Arthroscopic subacromial decompression - this is a keyhole procedure to debride any inflamed tissue in the shoulder joint. There is some evidence that patients with a small rotator cuff tear may achieve a satisfactory outcome from this. Patients can rehabilitate quickly post-operatively, however the rotator cuff tendon itself is not repaired back to the bone. (see Arthroscpoic Subacromial Decompression under Shoulder Operations)
4. Arthroscopic rotator cuff repair. This is a surgical procedure to repair the torn tendon back to the bone. This is a highly successful operation in terms of pain relief and evidence has shown that strength in the shoulder is much better if there is a healed tendon repair. However, there is a lengthy rehabilitation period following the surgery compared to performing an Arthroscopic Subacromial Decompression. (see arthroscopic rotator cuff repair page under Shoulder Operations)
5. If the rotator cuff tear is so big and retracted that it is not repairable then if the patient is young, compliant with no signs of glenohumeral shoulder arthritis then there is the potential to improve pain and movement with a latissimus dorsi tendon transfer operation. (See latissimus dorsi tendon transfer under Shoulder Operations)
6. In an older patient with an irreparable massive retracted rotator cuff tear then there is the option to perform a reverse geometry shoulder arthroplasty (shoulder replacement) to improve pain and function.
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