Timothy S. Mologne, M.D.
Sports Medicine Center
277 Altenhofen Drive
Appleton, Wisconsin 54913
(920) 993-1643
drmologne@thesportsmedcenter.com
Rotator Cuff Tears From Start to Finish: Questions You
Have Always Wanted to Ask the Surgeon
Background Information:
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Rotator cuff tendon pathology is the leading cause of shoulder pain in the middle aged and older
patient
55-60K work related shoulder injuries/year
Approx. 7% of all musculoskeletal work injuries involve the shoulder but shoulder injuries
account for the most time off of work with a median of 3 weeks of missed work
Goals of Rx: Resolution of pain; Improvement in function; Return the employee to the
workforce
Rotator cuff tearing is a disease of aging. Tendons change biochemical and biomechanically as
we age. Ultrasound studies show incidence of 13% in people in the sixth decade of life. 50%
incidence in patients over 80 years of age.
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NORMAL ROTATOR CUFF TENDONS DO NOT TEAR EXCEPT WITH EXTREMES OF FORCE AND TRAUMA.
ABNORMAL/DEGENERATIVE TENDONS CAN TEAR WITH FORCES SEEN WITH ADLS.
1. How do rotator cuff tendons tear?
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"Easy Causation Cases" : Slips and falls; turning a tight bolt that "lets loose"; grinder kickback;
sudden and forceful accelerations or decelerations of a weight ( lowering a heavy box from
overhead, pulling a suitcase out of an airport carousel, etc ); traction injuries ( pallet jack gets
stuck as one is pulling it; sudden heavy load causing an inferior directed force );dislocations of
the shoulder after the age of 40
Causation Dilemma: Older patient with a rotator cuff tear following a questionable work exposure or
injury. Determining if the tear is truly traumatic or a pre-existing condition rendered symptomatic by
the accident may be challenging. Patients that allege a work injury truly feel that they were injured at
work. Telling them otherwise, especially as the treating physician, can strain the doctor-patient
relationship.
2. What kind of force is required to tear a rotator cuff tendon? Does the "punishment fit the crime" or
is the mechanism of injury consistent with the pathology found?
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Remember, tendons change chemically and mechanically as we age. There are middle aged
people that have asymptomatic cuff pathology that are predisposed to full thickness rotator
cuff tearing. Abnormal cuff tissue can tear with relatively normal forces of ADLs.
Example: holding a 5 kg ( 11 lbs ) weight out to the side = 1600 N of muscle force required to
hold the weight in a static, pure abducted position. The force is divided between the deltoid
and supraspinatus= 700 N of force, or 160 lbs on the supraspinatus. Accelerating the 11 lbs
weight up will only add to the resultant force required of the deltoid and supraspinatus.
Cadaveric studies have shown there are areas of the supraspinatus tendon that can tear with
forces as low as 335 N
Can the rotator cuff then tear with a 10 lbs load? The answer is yes, but it depends.
Putting it all together: There are always going to be potential worker’s compensation injury cases that
are challenging and difficult to make strong conclusions on causation. Important information that is
helpful in rendering an opinion comes from a thorough interview and history, a complete physical exam,
and close inspection and analysis of imaging studies. I realize that we are responsible to render opinions
on causation, but understand that every worker that feels that they were injured on the job are often
offended if someone opines otherwise. In every case that I can recall concluding that the findings were
not work related, those patients have sought care by someone else.
3. Are there predisposing factors that play a role in the development of a rotator cuff tear?
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Cuff tendonopathy ( cuff tendinosis, partial rotator cuff tears ) exist is asymptomatic people
and these tendons are weaker and more prone to tearing.
Workers that perform repetitive overhead activities ( warehouse workers, carpenters,
construction workers, painters )
Overhead work can lead to impingement (rubbing ) of the rotator cuff on the undersurface of
the acromion, coracoacromial ligament, undersurface of the acromioclavicular joint
Acromial morphology: Acromions can vary in shape, with some people having or developing
an anterior bony excrescence or spur. Those with a prominent spur might be more
predisposed to sustaining a rotator cuff tear. Large anterior acromial spurs resemble a metal
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can opener and one can visualize how a rotator cuff could tear if rubbed against the sharp
point of a can opener repetitively. However, there is some debate whether the acromial spur
is a risk factor for a tear or the ramification or effect of cuff pathology and dysfunction
( chicken vs. egg concept )
Smoking: The blood supply to the rotator cuff is not ideal and many feel that the poor blood
supply plays an important role in the degeneration and development of a tear in the cuff.
Smoking alters the ability to oxygenate tissues and has been shown to accelerate, not only
the aging process, but the degeneration of tendons. Smoking correlates with rotator cuff
tears, but is also a risk factor for failure after an attempting rotator cuff repair.
4. Can you determine whether a rotator cuff tear is acute or chronic ( old or new )?
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Bursal fluid: Approximately 2/3 of acute rotator cuff tears have a bursal effusion. Nearly 75% of
chronic rotator cuff tears do not have bursal fluid. The absence of bursal fluid with a cuff tear is
relatively specific, then, for a chronic tear.
Edema in the greater tuberosity is usually associated with an acute tear
Significant tendon retraction is USUALLY seen in chronic tears, but on occasion, can be seen in
acute tears ( case example of fitness expert with two tendon tear with significant tendon
retraction. The tendon tear was an L-shaped tear with excellent tendon mobility and was
successfully repaired ).
Humeral head elevation occurs when the patient has lost the humeral head depression effects
of the rotator cuff and its presence signifies a large to massive tear involving at least the
supraspinatus and infraspinatus tendons. The presence of humeral head elevation is seen in
chronic, large/massive rotator cuff tears.
Pseudoacetabularization of the acromion ( the undersurface of the flat acromion articulates
with a high riding humeral head and leads to a concave appearance of the acromion and a
pseudo-joint ). This finding is seen in chronic tears.
Fatty atrophy of the rotator cuff muscles occurs when the muscle-tendon unit is not under
tension or the muscle is dennervated. The presence of fatty atrophy can occur as early as 15
weeks in animal studies. The presence of significant fatty atrophy in patients with rotator cuff
tears is consistent with a chronic tear.
Case Examples:
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51 year old man presents with shoulder pain and weakness after lifting a box at work. He has a
history of prior shoulder surgery. On exam, he is noted to have profound weakness of the
supraspinatus and external rotators. On MRI and x-ray, he has humeral head elevation,
pseudoacetabularization of the acromion, retraction of the rotator cuff to the level of the
glenoid ( 4 cm retracted ), no bursal fluid, no edema in the greater tuberosity, significant fatty
atrophy of the supraspinatus and infraspinatus, and a fragment of bone displaced posterior to
the glenohumeral joint. The bone fragment does not have edema around it and represents a
chronic greater tuberosity avulsion from his prior surgery. Conclusion: The pathology in his
shoulder is all chronic and the alleged work exposure did not cause any further injury or
pathology in his shoulder.
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52 year old man with a known rotator cuff tear that was deemed not repairable, experiences a
painful pop in his shoulder after firmly pulling a piece of paper out of his paper mill machine. On
exam, he has weakness of the supraspinatus and external rotators. He has tenderness along the
anterior shoulder over the biceps tendon and biceps groove. On MRI, he is noted to have a
massive rotator cuff tear with the cuff retracted to the level of the AC joint ( 5 cm ). There is no
subacromial fluid and there is humeral head elevation. These findings are all consistent with a
chronic tear. He is also noted to have fluid and edema around his biceps tendon, and the biceps
tendon is dislocated medially out of the bicipital groove. Conclusions: His cuff tear is chronic
and has not been further damaged by the work injury. The large cuff tear predisposed him to
biceps tendon pathology and the biceps tendon dislocation occurred as a result of the work
injury. Treatment of the biceps tendon pathology is compensable by the WC insurance.
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61 year old professional mover sustains a traction injury to his shoulder while moving a heavy
piece of furniture out of a moving truck. He presents with acute pain, weakness, and limited
motion in his shoulder. On exam, he has weakness of the supraspinatus and external rotators.
His x-rays show moderate glenohumeral joint arthritis. His MRI shows glenohumeral joint
arthritis but also a full thickness rotator cuff tear. Conclusions: The glenohumeral joint
arthritis is preexisting and not precipitated, aggravated, and accelerated by his work injury.
He likely had some cuff tendonopathy/tendinosis that predisposed him to cuff tearing, but the
full thickness tear is compensable by the WC insurance. Assigning PPD for this patient is
difficult due to the shoulder dysfunction and limited motion as a result of his pre-existing
arthritis.
Putting it all together: Again, we gain important information on causation from the history,
examination, and imaging studies
5. Why does it take so long to recover from rotator cuff repair surgery?
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Animal studies have shown that is takes between 4-6 months before the tendon attachment site
has mature tissue and a strength of attachment sufficient to resist normal ADL forces.
2013 clinical study looking at retears of the rotator cuff following an arthroscopic repair. 17% of
the patients sustained a retear, with the majority of retears occurring between 12-26 weeks
post-op.
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Combining the information from clinical studies as well as mechanical and histological data from
the animal studies, we really do not want patients to return to unrestricted activities and lifting
for at least 6 months
Simplified overview of a cuff repair timeline:
Immobilization x 5-6 weeks
Range of motion phase x 5-6 weeks ( restore near normal ROM by 12 weeks post op )
Early strengthening phase ( simple and gentle resistance exercises ) x 5-6 weeks
More complex strength exercises ( sport and job specific ) x 5-6 weeks
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Most individuals can attempt a full duty trial about 5-6 months post-op
6. When does a patient regain full strength in their shoulder following a rotator cuff repair?
 Patients have many preoperative expectations from rotator cuff repair. Restoration of strength
and return to normal function are reasonable expectations for most.
 Improvement or relief of pain is usually quoted as the most important goal of patients
 Restoration of strength and function is dependent on many variables, including the quality of
the tendon and repair, the presence of or absence of poor prognostic factors, as well as the
patient’s effort and motivation to get well
 Rotator cuff strength is can be less than it was prior to surgery at 3 months post-op and
improvements over baseline become noticeable by 5-6 months post-op.
 Strength gains continue for 12-16 months following rotator cuff repair
 Usually 80-90% return of strength seen by 1 year post-op
7. What is the typical PPD ( Permanent Partial Disability ) assigned following a rotator cuff repair?
 Wisconsin Guidelines for PPD for Shoulder Conditions
Shoulder fusion:
50%
Arthroplasty:
50%
Abduction to 90°
15%
Abduction to 120°
10%
Abduction to 135°
5%
 No guidelines to help in determining PPD following a rotator cuff tear and subsequent repair
 Even with a successful outcome, patients usually lose 5-10 degrees of internal rotation and a
few degrees of overhead motion
 As mentioned in question 6, there is usually ongoing weakness at 6 months post-op
 I do believe the ongoing weakness and mild motion loss should be rated.
 Typically 3-5% PPD for a successful and straight forward rotator cuff tear and repair
 If a biceps tenotomy or tenodesis is also performed, I will usually add an additional 2-3% for loss
of the intraarticular function of the biceps tendon
Conclusions:
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Rotator cuff tears are a common ailment in middle aged and older patients
Many anatomic and biological factors exist for many that predispose them to cuff tearing
Assessment of causation can usually be made through a thorough history and exam, as well as
close analysis of imaging studies
Getting a rotator cuff tendon to adequate heal to the bone occurs in 80-90% of cases and
usually takes up to 6 months for a solid attachment
Patients want pain relief over strength gains, but most patients will regain 80-90% of their
strength by 1 year