Anyone who has injured a shoulder’s rotator cuff has a deep appreciation for the role this group of muscles and tendons plays in a healthy lifestyle. A painful rotator cuff makes it difficult to reach up into a cabinet for something, or down to pick up a child, or around to swing a baseball bat.

Yale Medicine Orthopedics & Rehabilitation offers comprehensive and skilled care for rotator cuff injuries. Our surgeons provide nonoperative care, as well as all of the latest surgeries, including arthroscopic and minimally invasive procedures, open procedures and revision surgery.

The rotator cuff, which measures about a half-inch thick, is a sheath made up of muscles and tendons that helps the shoulder to move and stay stable. It provides dynamic stability and support so the arm can reach above the head, pick up heavy objects or rotate, internally and externally.

Most rotator cuff injuries are caused by repetitive overhead arm actions, such as painting, swimming or practicing a serve in tennis. Less often, but of greater concern, is a traumatic event (i.e. a single injury or multiple episodes) that tears the rotator cuff all the way through. In order of severity, rotator cuff injuries include:

• Inflammation, which is irritation caused by overuse
• Impingement, which develops when inflamed tissue rubs against the bone
• Partial tear, leaving frayed tissue that creates small rips and tears
• Full tear, when the muscles and tendons are completely torn and no longer attached to the bone

Patients with rotator cuff injuries commonly complain of shoulder discomfort that ranges from a dull ache to sharp pain. Most report that the discomfort may be greater at night to the extent where it is difficult to sleep.

A rotator cuff tear that occurs suddenly, as the result of a traumatic event, is likely to be excruciatingly painful and can be associated with a tearing sensation, a pop and even muscle bruising. In those circumstances, it’s important to be evaluated by a doctor as quickly as possible.

Diagnosis is based on the patient’s history and symptoms, a physical exam and imaging studies. In-office tests evaluate what patients can and cannot do with their shoulder joints. Yale Medicine doctors look at range of motion of the shoulder and at the muscle bulk of the shoulder girdle, and then assess the strength of the rotator cuff by taking the patient through specific maneuvers.

An X-ray can show if there has been a long-standing problem where calcifications have started to develop or the upper part of the arm bone has been impacted by a chronic massive tear. Sometimes magnetic resonance imaging (MRI) is helpful, especially for those patients who have sustained a traumatic injury and may have injured muscles and tendons in addition to the rotator cuff.

Unless a rotator cuff is severely damaged, it’s reasonable to try nonoperative treatments, which are often effective. These include:

• Anti-inflammatory medications: Prescription-strength or over-the-counter drugs may be used to reduce the inflammatory response and decrease pain.
• Patient-specific physical therapy: Patients begin by working with a therapist in the Yale Medicine network and then typically continue on their own, at home, with regular check-ins to monitor whether they are doing the exercises correctly and making progress as expected.
• Cortisone injections. For more severe inflammation, steroid injections can relieve pain and decrease inflammation for patients with impingement and partial tears.

Extensive rotator cuff tears, including those caused by traumatic injuries, usually require surgical repair. The good news is the majority of rotator cuff injuries can be managed with arthroscopic or minimally invasive procedures. The primary goals of surgery are to relieve pain, restore function and improve quality of life.

Rotator cuff procedures offered at Yale Medicine include:

• Rotator cuff repair: This arthroscopic procedure involves “use of a camera and small working instruments to surgically repair the rotator cuff with one or more suture anchors,” Dr. Kovacevic says. This is an outpatient procedure that requires several days of rest and shoulder immobilization with a sling for a specified period of time, followed by physical therapy to restore motion and regain muscle strength.
• Rotator cuff repair with biologic augmentation: For patients with medical challenges that diminish the potential for healing (such as advanced age or conditions such as diabetes or inflammatory arthritis), the doctor may recommend biologic augmentation for revision of an unsuccessful repair, a massive rotator cuff tear or a poor healing environment. Yale Medicine surgeons use biologic scaffold devices derived from human tissue or made from Food and Drug Administration-approved polymers. These specialized devices provide structure that allows the body to build new tissue and/or improve the rate and quality of healing.
• Rotator cuff tendon transfer: Damaged tendons can be replaced by other tendons taken from a different part of the patient’s body, such as the back or chest. Tendon transfer may be appropriate for a young, highly active patient who has an irreparable rotator cuff tear with loss of motion. This surgery is followed by a long rehabilitation process.
• Reverse shoulder replacement. For patients with a combination of an irreparable massive rotator cuff deficiency and shoulder arthritis, a new shoulder joint may offer the best solution. 

Not only does Yale Medicine offer the very basic nonoperative care, doctors also perform the full armamentarium of operative treatments, including arthroscopic and minimally invasive procedures, open procedures and even revision surgery, where we are redoing a previously failed repair.

Yale Medicine Orthopedics & Rehabilitation surgeons have also done extensive clinical research into improving the treatment of rotator cuff injuries. 

But the priority is taking time to understand each particular patient’s goals, whether that is just to be able to raise their shoulder or go back to being a high-level tennis player, and then planning treatments to achieve those goals.