Last Updated: April 2, 2013
By Jeannette Franks, PhD
Sometimes I wish I could take my body in for repairs just like I
take my car to a mechanic to get new parts. "New battery or
headlights-no problem!" But while wecanreplace more and more parts
of the human body, some areas are less amenable to repairs and yet
more subject to breakdown, particularly the knees and shoulders.
Rotator cuff tears are one of the most common injuries in older
My own shoulder injury happened while hiking uphill on a rugged
trail, fully-loaded with a heavy backpack. I grabbed a tree to keep
falling when I slipped, and although I broke my fall, my
shoulder has not worked well since. It can happen to older people
of all levels of fitness.
How the Shoulder Works
The shoulder is the most flexible joint in the body. While this
allows us great range of motion, this same flexibility makes us
more vulnerable to instability and injury. The shoulder is a
ball-and-socket joint made up of three bones: the humerus (upper
arm bone), the scapula (shoulder blade), and the clavicle
The joint capsule surrounding the shoulder joint is a thin sheet
of fibers. The rotator cuff consists of four muscles (the
supraspinatus, the infraspinatus, the subscapularis, and the teres
minor) and their tendons covering the shoulder joint and joint
capsule. Tendons are the stretchy cords that connect muscles to
These tendons and muscles enable you to lift your arm, reach
overhead, participate in sports, and perform normal activities of
How the Rotator Cuff Can Become Injured
A rotator cuff tear is most common in people over 40. However,
it can occur at any age, either as a result of trauma, such as a
fall or sharp tug on the arm, or a repetitive injury such as in
sports, weight lifting, or overhead activities. Often tennis
players, swimmers, pitchers, and basketball players will tear a
rotator cuff. Workers in jobs such as construction, painting, or
stocking overhead shelves are also at risk of shoulder injury.
A tear may also occur as a result of an accident causing a
dislocation or fracture.
Most people with an acute tear immediately know something is
wrong. The primary symptom is pain, especially on raising the arm
or reaching behind. In an injury such as a collision, there may be
a snapping sensation and weakness of the arm, as well as pain.
Of course, one should never continue to use the shoulder or
participate in a sport if one suspects a shoulder injury has
occurred. Use the "RICE" protocol as soon as possible:
- Elevation (for a leg, foot, or ankle)
In the case of wear and tear over time, the repetitive activity
becomes more and more difficult. As the tendon degenerates, one may
feel pain radiating down the side of the arm or a burning
sensation. It may be mild at first and easily alleviated with
over-the-counter analgesics, ice, and rest. But the range of motion
may be steadily decreasing, while the damage worsens.
Other symptoms include weakness in the arm, or a clicking or
crackling sound or sensation when the arm is moved.
Diagnosis and Treatment
The physician will subject the patient to a variety of positions
and stresses to elicit the major sign of a rotator cuff tear-pain.
In addition to the physical examination, x-rays and an MRI
(magnetic resonance imaging) may be required. Some cases may call
for an arthrogram, where dye is injected into the joint in order to
see the tear clearly.
Since there may be some ambiguity, the first line of treatment
is generally ice, rest, and physical therapy. Non-surgical
treatment options may also include the use of a sling,
anti-inflammatory medication, and a steroid injection. If these do
not restore the joint to normal function, the patient should
revisit the doctor promptly for further examination and
If the tendon or muscle has truly separated or become detached
from the bone, surgery may be required. Tendons do not regenerate
or reattach to the bone, no matter how excellent the physical
therapy. Since there is no blood circulation in tendons, there is
no re-creation of tissue. In some instances, delaying the surgical
repair can increase the possibility that it will be more difficult
to treat later.
Three types of surgery are available. Inarthroscopicrepair, a
fiber optic scope and tiny instruments are inserted through small
punctures. This minimally invasive surgery may result in a more
Newer techniques and instruments permit surgeons to repair the
rotator cuff through a very small incision-a "mini-open repair"
using fiber optic instruments.
Anopen surgical repairis indicated if the tear is large or
complex or further reconstruction is required. In some cases,
shoulder replacement may be an option, especially with severe
The choice of surgical technique is, of course, up to the
Be sure to notify your physician immediately if you have any of
these symptoms following surgery:
- Fever after the 2nd day following surgery
- Increasing pain or swelling
- Redness, warmth, or tenderness
- Unusual bleeding
- Numbness or tingling of the arm or hand
The duration of immobilization depends on the type of tear and
type of surgery. Physical therapy tends to begin quite soon after
the operation, often the same week. It is absolutely crucial to
follow the regimen faithfully. Human nature being what it is, we
tend to be dutifully compliant at first and then slack off once the
arm starts working again. However, hard, painful work for at least
several months is required for full recovery.
An important prevention to shoulder injury is to increase upper
body strength. This must be done very slowly and with proper
technique and form. Usually a class or trainer is required, but
make sure that he or she is an excellent certified professional.
Many injuries occur at the gym under the supervision of someone who
should have known better.
Arms should not be raised above the shoulder when standing and
working out with weights in exercises such as the upright row. Many
overhead lifts are performed in the safer prone position. I've
witnessed many injuries in process when a group weight instructor
demonstrates poor technique or fails to correct participants with
After mastering good form with an instructor, it's easy for the
patient to work out with weights at home; there are also many
excellent DVDs to guide the patient. Or it may be more motivating
to work out while watching a favorite TV show or listening to
It's also important to do daily stretches, especially during and
after working out.
It's extremely important to "listen to your body." Athletes no
longer say, "No pain, no gain." Pain is the body's way of
indicating that something is wrong. A bit of muscle tenderness or
soreness is fine the day after. But pain during or immediately
after a sport or working out indicates a problem. People need to
learn to differentiate between the mild, tight feeling a muscle
gets the day after being challenged, and the pain (even slight)
during or immediately after doing damage to a joint, muscle, or
Regular exercise is the absolutely most important thing one can
do to avoid a shoulder injury. Tendon injuries often occur in
poorly conditioned muscles or "weekend athletes." Older people are
especially at risk and even simple activities such as getting out
of a car can cause a serious injury in a sedentary person with poor
upper body strength. Poor mobility leads to an even more restricted
life and a downward spiral to frailty.
Jeannette Franks, PhD, is a passionate gerontologist who teaches
at University of Washington and Bastyr University; she is the
author of a book on assisted living and numerous