Head and Shoulders – Rotator Cuff

Here’s the setting. Masters competition, clean and jerk with a  toe to bar ladder (sound familiar), 50 year old male lifts a barbell for a clean and jerk and feels a searing rip in his arm and has to drop the bar. He cannot lift his arm away from his side and is in agony, maybe had a little “bursitis in past” but nothing bad enough to stop him. Second scenario is 40ish year old 930 class filled with bunch of overachievers and one of them keeps getting some pain in the side of her arm halfway down the arm everytime she reaches in front or to the side trying to lift kettlebells. She has been waking up at night with some pain and has noticed that her numbers have been dropping as she tries to protect her arm and shoulder pain from getting worse. Both people may have rotator cuff tears. Both people may have torn one of his rotator cuff muscles. Rotator Cuff tears are probably one of the the most mispronounced things that we deal with in Orthopedic Surgery. Not Rotor Cuff, Not Rotor Cup, but rotator cuff. We call it a cuff because it forms a cuff of tissue that surrounds the humerus and lifts or rotates the shoulder joint. Made up of 4 separate muscles , the cuff is responsible for most activities of daily living with regards to shoulder function. Some things that you cannot do with a decent sized tear of the rotator cuff….brush teeth, reach into a cabinet, lift a gallon of water, reach behind back, throw a ball, carry a heavy object in front of you or to the side, sleep well.
rotator-cuff-muscles
Now there are differing severities of tears and different sizes. A lot of people can live with small tears of their cuff and may not exhibit any weakness or may not have any pain. The most common muscle that is injured is called the supraspinatus which lifts your arm off to the side and helps lift it overhead. If the tear becomes big it can then tear into the next muscle or the infraspinatus tendon. The infraspinatus helps to externally rotate your arm, that is to rotate your hand away from your body vs. towards your abdomen. Here is a side view of a tear of the supraspinatus the biceps tendon is seen towards the front of the shoulder.
rotator-cuff-tear
This is a real life picture of a full thickness rotator cuff tear. Small tear.
rotator-cuff-small-tear
Here is a bigger full thickness tear. Note how retracted the tendon can get which can make it difficult to stretch the tissue back to where it belongs.
rotator-cuff-thick-tear
If the tendons have been torn for a long time like over 1 year, they pull away from the bone, becoming atrophied and scarred. The tissue also can lose its strretchiness (real medical word) and make it impossible to reattach if it is an chronic tear that happened in the past. This is what a repair looks like for a medium sized tear. Note the sutures passing through the tendon and then being tied down the to bone like a boat at a pier.
This is what it looks like before the tear is tied down. Anchors go into the bone and then the sutures are passed through the tendon.
There are different sizes of the tear. The inital tearing can be what is called a partial tear where the attachment site of the tendon to the bone is partially disrupted. Decision for treatment is made based on how symptomatic the patient is and how big the partial tear is. We call the attachment site the footprint of the rotator cuff. If I know the footprint is typically 16mm of tendon attached to bone and at the time of surgery I see 8 mm of bone exposed then I know it is a 50% tear of the tissue as seen here.
rotator-cuff-tears-classification
If something is torn greater than 50% we usually repair it. If it less than that we can shave it or smooth it edges.  An MRI is good at saying full thickness tear or not, but it is not great at showing how big a partial tear is sometimes and so it can take looking inside the shoulder and measuring the tear making an intraoperative decision whether to repair it or trim it.
 
Full thickness tear MRI
rotator-cuff-tear-MRI
Partial thickness tear MRI
rotator-cuff-partial-thickness-tear-MRI
The rehab from the repair can be substantial. You can check it out at www.orthopedicsne.com.  6 weeks of intermittent sling use, no reaching or lifting or actively elevating arm. PT will start passive range of motion of stretching your arm without actively moving it. Typing and writing are OK. After 6 weeks you can move actively your arm by yourself. Strengthening begins and getting moderate strength by 4 months  followed by another 3 -4 months to get stronger. For heavy duty lifting, people will say 9 months to 1 year to get back full strength. I would put Crossfitting at high levels in the last category. For cross fitters I can make up modified workouts for people at different stages of their rehab.
The cuff is extremely important for shoulder function. It allows full pain free range of motion when it is working, when it is not people don’t realize how important it is in life. Prevention means taking it easy when lifting at a level that you are comfortable with. If starting CrossFit, it means not loading up the barbell like a roll of lifesavers and seeing how many different colors you can put in there. It means you have to gradually build up your weights to a level that you are comfortable with and then proceed from there. Once again, being over 40 means that you have to be smarter than your youthful counterparts. When snatching and jerking, your strongest body part has to be your head, not your shoulders.

41 Comments

  1. Good morning,
    I have question regarding my Labrum.
    I swam for 14 years, 4 of which was 2Xday 4Xwk and once on friday.
    2010 At the start of my shoulder pain (a 5 year journey) I did shoulder exercises for roughly a year. And taped my shoulders during practices to keep them from popping.
    2011 I was put on a month of no swimming because my shoulders.
    2012-2013 I was taking 15-17 Ibuprofen on practice & meet days from aug-may (4-5 day X wk) and about 10 Ibuprofen from may-aug….
    Keep pushing through the pain. 2014 dropped the ibuprofen if just wasn’t helping. Also, last year of swimming.
    2016-I decide to get it looked at and found: 16mm tear in Left labrum and 2mm tear in Right labrum. Along with some other things.

    My question is how wide is the labrum? Is the 16mm tear small or should I be worried about it?

    • That 16mm usually refers to the length of the tear from top to bottom along the glenoid. Read my shoulder instability post and you can see the labrum. I would have it assessed yes.

      • Thank you, when I had assessed they said PT should heal it

      • Thank you

  2. I had an MRI done on my right shoulder last week and here is what the report stated:

    Findings:

    There is no evidence of significant joint effusion. However, important fluid collection in the subacromiodeltoid bursa suggestive of bursitis.

    Signs of tendinosis of the subscapularis, supraspinatus and infraspinatus which tendons are in hypersignal on all sequences and mildly thickened. Thee subscapularis tendon presents a very mild mid and suprasubstance laminar tear at its upper third. The supraspinatus tendon presents an important infra, mid and suprasubstance tear at its anterior two-thirds. At its posterior third, there is a full tickness tear extending on 9 mm AP x 16 mm, lateral with myotendinous retraction measuring up to 2 cm. The infraspinatus tendon presents a mild infra, mid and suprasubstance laminar tear at its most upper third. The teres minor tendon and the long head of the biceps tendon are otherwise unremarkable. There is no atrophy nor significant fatty involution of the muscle.

    Type II acromion. No evidence of fracture, luxation nor aggressive bone lesion.

    Conclusion:

    Signs of tendinosis of the rotator cuff as described above.
    Full thickness tear of the posterior supraspinatus.
    Laminar tear of the subscapularis, supraspinatus and infraspinatus.
    Subacromiodeltoid bursitis.

    I have been doing CrossFit for four years and have had a Rotator Cuff issue for six years but didn’t know it was torn. I haven’t heard back from my doctor yet but I would like to get feedback from people who have similar issues and who do CrossFit. I have been limited on how much weight I can put over head and it’s affecting kipping anything and hand stands.

    Any feedback is appreciated.

    • Usually we recommend repair for a full thickness supraspinatus tear.

      • What is the recovery for this? Can I do any type of work out while I’m awaiting surgery and after surgery? I recall reading about you providing that information.

        • look up my post on 1 armed workouts after shoulder surgery. Strengthening before is usually a good idea.

  3. Sustained an injury to my left shoulder and the ultrasound reads: “…tear of supraspinatus tendon with maximum dimensions of 9 x 2 x 6 mm seen 6 mm from the biceps…” Would this size of tear require surgery?

    • Sometimes the torn piece of rotator cuff flips into the joint like a hang nail and can cause pain, so the answer would be if it is painful yes.

  4. Dear Dr. Rockett,
    I’ve been doing CF for five years now. I went to the Games in 2013 in the master’s division (55-59). I’m currently a trainer at a box in central Vermont and just had surgery on my right shoulder for a rotator cuff repair. I bumped into your website while searching for workouts I could do post-surgery. It appears that you might be willing to provide post-surgery, workout suggestions? Is that correct? I understand that sort of advice is very case sensitive. Do you by any chance review cases and provide personalized advice for folks?

  5. Do you have any recommendation/referral for an Orthopedic Surgeon in the Philadelphia, PA area. I have a “moderate to severe partial thickness tear of the insertional fibers of the supraspinatus and infraspinatus tendons without tendon retraction.” My MRI report also states a “partial thickness tear of the subscapularis tendon”.

    I’ve been doing rehab on it for about 3 months and it feels somewhat better. However, at this point it seems surgery is probably my only option to get back to overhead lifting and playing golf.

    Any and all thoughts are greatly appreciated.

    • The docs at the Rothman institute are solid. I don’t know them personally

      • I have a question,what does 30mm segment of subscapularis tendon with 9mm thickness mean,is that small,medium,large or complete,supratinasious is also involved,8x14x22, can these heal on there own after a year of being diagnosed via mri with and without contrast?

        • Those tears sound like they are on the medium to large size, they do not reattach to the bone usually.

  6. Hello,
    I’m 40, M, been doing crossfit for almost 3 years. Have a rotator cuff tear in left shoulder. Ultrasound report says, “supraspinatus shows normal thickness and there is a hypoechoic zone on the articular face with a 9mm anteroposterior dia, long dia 5mm and 3mm thick involving 35% of the thickness in relation to a partial rupture. The rest of the tendon does not show echogenicity alteration.

    What would be the best course of action for this? Abandon crossfit and look for something else?

    • Obviously you need an examination and history to correlate these findings. If I had a patient with this I would have them do things that do not cause pain and be careful with explosive shoulder movements. So that may mean dropping weights down to a manageable number that does not stress the area.

  7. Hello Doc! Just received the MRI results for my right shoulder. “Partial Thickness high-grade articular surface tear at the insertion of the supraspinatus tendon (near fullthickness)… “Deep irregular cleft of fluid undercutting superior labrum, extended from anterior to posterior and also into the biceps anchor. Tear propagates further posteriorly extends to mid posterior labrum and there is tearing of the inferior labrum.” I am a 31 year old Firefighter/crossfitter/CF Coach, very actice, and have mild pain and near full ROM. It sounds like surgery is inevitable after reading the report. Advice/thoughts?

    • It sounds like there are some things that could be improved with surgery. It would take an exam to determine how many of those things are causing symptoms. Happy to see you if you are in the area.

  8. So, it seems my rotator surgery failed. I didn’t do anything that hurt and I have been beyond careful in building up strength. When the weather went cold in October, my shoulder just felt different and I have watched it lose all the external rotation strength I had regained to absolutely zero. I had a full tear and he wasn’t sure if he could fix it in the first place. It just is such a kick in the gut how things were going so well, and now just gone.
    I will know how large the tear is soon, but I have read that second surgeries on large tears usually aren’t successful. Is that true? I sure don’t want to go through all of that for nothing. If this is the best it’s going to be, I rather just get used to it.

    • Sorry Zina, That must be disappointing. So 2nd surgeries depend on a lot of things such as size of the tear, how long it has been torn, what kind of tissue quality there is, age of the patient, degree of retraction in the first place, atrophy of the muscle or tendon. So as you can see there are a lot of variables that can help figure out the relative chance of success or failure. Good luck, Sean

  9. I have full thickness tear of supraspinatus tendon tear measuring AP dimension -of 1.4 cm – ( MRI examination),gap on the coronal view measures width of 1 cm.
    May I please ask your advise – what are the likely best options?

    • Full thickness tears of the supraspinatus are most often treated surgically to prevent further retraction, prevent weakness, and prevent pain in the future.

    • Laura ,
      Hope you are doing well with your shoulder. Just saw your post from 2 years ago and I have the same condition a 1.4cm full thickness tear. Did you end up having surgery? Just wondering if that’s the road I am heading down.
      Thank you

  10. “The supraspinitus tendon shows a components of re-tear involving the inferior articulate surface. This involves the area of the critical zone. The area of involvement measures about 12mm in the long axis and 11mm in the short axis. This partial tear involves more then 50% of the tendon thickness. The superficial fibres however remain intact on the bursal surface”.

    What are the likely best options?

    • I would really have to examine you and see the MRI to comment. Radiologists oftentimes can over or under read MRIs and don’t have the benefit of examining the patient We do know that repairs sometimes don’t look on MRI like they have reattached as thick as a native tendon used to be.

  11. I just had an MRI and it’s impression stated that threr full-thickness tear at the far anterior distal supraspinatus tendon with small subcromial-subdeltoind bursal effusion. is this definate surgery or will PT help. Thank you in advance I am a 57 y/o female.

    • Sorry but a full tear does not reattach itself and we usually recommend surgery.

  12. No debridement is a much faster protocol and can get rid of sling in a few days with return to strength by 2 months. CrossFit heavier stuff could take 3 months

  13. Hi Dr. Rockett

    Thank you for all the information you provide through your blog. It is certainly invaluable. My question is in regards to shoulder debridement, specifically labral and rotator cuff . Do your shoulder debridement patients follow a protocol similar to a patient that has undergone a repair? Would the same apply to a “crossfit patient”?
    Thank you

  14. It would be very difficult at this late juncture unfortunately but I would not stop trying.

  15. Hi Dr. Rockett – 15 years ago, I had surgery to tighten a loose shoulder that was always dislocating…I’m 32 now and my range of motion is probably 140 degrees (in front of ear when arm is raised). Is it possible to regain mobility after such a long period of time?

  16. Dr. Rockett – I am a 48 year old Crossfitter in Atlanta dealing with a few shoulder, hip and achilles tendonitis issues. As my work schedule only gets me up to your neck of the woods a few times a year, I was wondering if you had any recommendations for Orthopedics in Atlanta that “get” crossfitting like you do? My message therapist thinks I could use an assessment to determine some of the recurring issues I see her for. Any help would be greatly appreciated.

    • Hi Stacey. I don’t know anyone there but it sounds like you need it fixed. There is only so much strengthening can do. If you want to try go to my website orthopedicsne.com and check out PT protocols for shoulder strengthening. Good luck. Sean

    • Hi Paul. I don’t know anyone in Atlanta who has drunk the Kool-aid as much as I have. You could try the local university hospitals Good luck , Sean

  17. Hey Doc! First of all, thank you for all the posts and free advice you provide to the Crossfit community! I reside in Florida, and unfortunately cannot come visit you for treatment or diagnosis. However, I am wondering if you have any recommendations for someone in the Gainesville/Ocala area that has experience treating Crossfit athletes and getting them back into shape for competition? I find that when I speak to any health professionals that I know (or am related to) they generally have a very negative view of olympic lifting and the practice of Crossfit, and typically do not understand the mentality. I’m 28, and would like to one day get to Regionals or even The Games. I have a nagging shoulder injury resulting from a shoulder dislocation during a wrestling match when I was 14 that just never went away. I wrestled for years with this issue and just iced and dealt with it. Today, I am having constant clicking and a general feeling of instability that freaks me out whenever I go overhead. Ice, rest, and the like helps, but the joint has not felt “stable” in several years and recently has grown uncomfortable enough for me to quit being stupid and seek advice. I’d prefer a nonsurgical solution but I fear it may be the only option going forward if I want to return to 100% without worry. Again, thank you for all you do.

  18. Hello,
    I have had right shoulder pain since last October, I am 41yrs old and have been doing crossfit for 3 yrs. I tried to rest it for 3 months followed by 2 months of PT. Still same pain so I broke down and got an MRI. The Dr. said it have a Type II Slap Tear. Given the time and attempt to rest I am leaning towards having surgery. I had set it up for the end of this month. Now I am starting to have second thoughts on the bicept tendonitis. The reason for my second thoughts is I want to be albe to do overhead work down the road. What is your take on a very active 41yr old?

    • It sounds like you have tried diligently to make it go away on its own and attempted conservative measures without it helping. So now your options are living with it and modifying what you do to avoid painful things or get it fixed. I am happy to see you also if you want me to go over your exam and studies.

  19. Sorry to hear about your surgery, as always you need to check with your individual surgeon regarding what he or she will allow as they are the ones operating on you. I have let people stationary bike, air squat, sit ups, one armed kettle bells, but again you need to check

  20. I found your podcast on shoulders very informative and was very happy to hear from an MD who Crossfits. I’m 45 yrs old and have been Crossfitting for 3 years and have right shoulder issues specifically bursitis, impingement and a full thickness, full width rotator cuff tear. Going for surgery this Friday to repair the tear and wanted to know if you had any advice on CF movements (lower body) that I could do post op. Thank you in advance for your thoughts.

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About Me

Dr. Sean Rockett is an Orthopedic Surgeon specializing in Sports Medicine. His group is Orthopedics New England with offices in Dedham, Natick and Newton, Massachusetts. Dr. Rockett is a CrossFit Level 1 Trainer and has been a CrossFitter at CrossFit New England since 2007. Dr. Rockett is on the Medical Team for the CrossFit Games and the Northeast Regionals.

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