Why is a Rotator Cuff Tear Sometimes Not Painful?

Introduction

Sometimes a rotator cuff tear is an incidental finding. This is why rotator cuff tears sometimes are not painful. Pain is often a symptom of a rotator cuff tear. However, it is not seen in every rotator cuff tear. We will explore why within this article.  A rotator cuff tear can be an incidental finding that shows up on an MRI or a CT scan that is being done for another reason.  I recently saw a patient that was referred to me because they had a rotator cuff tear seen on MRI.  The MRI was done for cancer screening.  This patient had a mass and the MRI was performed to better evaluate the mass.  When the MRI came back, they saw a torn rotator cuff.  (the mass was a benign, non cancerous, lipoma)  They were then sent to me for evaluation of the rotator cuff tear. 

Why a rotator cuff tear might not be painful

So why are  rotator cuff tears sometimes not painful?  There are several reasons for this. We know from cadaveric studies (evaluation of bodies after death) that over 50% of 80 year olds have a rotator cuff tear. Most had no documented symptoms prior to death.

Pain is not always a symptom associated with a rotator cuff tear. When a tear however occurs, if it is painful, it’s essential to seek help as soon as possible. A rotator tear left untreated may become unfixable. These complications can have very significant impacts on the life of the individual.  So, if it is a symptomatic rotator cuff tear, it should be seen by a specialist as soon as possible.

Rotator cuff tears can be partial or complete. A partial tear involves some part of the tendon of one of the muscles of the rotator cuff. A full thickness tear means the tear of the rotator cuff tendon goes all the way through. It may involve complete detachment of this tendon group from the bone. Thus, the symptoms of a rotator cuff can progressively worsen, partial tears can become full-thickness tears. It is important to note that rotator cuff tears often begin with the fraying of the tendon fibers that may not be symptomatic.

Various ranges of rotator cuff tears occur

Small (up to 1cm)

Medium (about 1-3cm)

Large (3-5cm)

Massive tear (above 5cm, and involving more than one tendon)

Degenerative Tears

The degenerative type of rotator cuff tear is less likely to result in pain. This is simply because it occurs over time with a little tear in the rotator cuff tendons. The tear in this case is usually a partial tear. This tear can affect just a single muscle in the rotator cuff which results in less symptoms. Degenerative rotator cuff tears are chronic and seen mostly in the elderly.  These tears can be asymptomatic because they are small.  They also can be asymptomatic because the elderly are more sedentary and therefore the shoulder is only used for very low demand activities. This can be the reason why some rotator cuff tears are not painful.

Pain Perception-why some rotator cuff tears are not painful

Pain in itself is a personal experience. This means that different people experience pain in different ways. Even if exposed to the same stimulus. Our perception of pain differs because stress toleration differs for everyone. In individuals with a low pain threshold, a slight tear could result in pain. Meanwhile, individuals with higher pain thresholds can tolerate more stress without feeling pain or less pain. 

Rotator cuff tears, just like any other injury results in an inflammatory process around the area of insult. The inflammatory process is what essentially gives rise to some of the symptoms seen. However, some people with rotator cuff tears do not present with pain. This is most likely due to a chronic tear that no longer initiates the inflammatory process.  If there is no inflammatory process there is no pain. This is why a rotator cuff tear may not be painful.

In some patients with pain, the rotator cuff pain is mild. It is often dull aching, chronic, and less severe. This can mean that the tear occurred over a long period and the pain is less severe.  The extent of the tear can determine the symptoms. In very severe cases where the tendon is traumatically ripped off from the bone, there is a higher tendency for pain . This is mainly seen in an acute rotator cuff tear. 

Symptoms of a rotator cuff tear

 Your rotator cuff consists of 4 muscles, whose tendons come together to form a cuff over the shoulder joint for stability. Rotator cuff tears are a tear in one  or more of the tendons.. Rotator cuff tears occurs more commonly among the elderly. However, rotator cuff tears in the young are usually symptomatic. When a rotator cuff tear is found in ages 40 years and below, there is typically a history of trauma. Trauma could be from contact sports, car accidents, or falls.

One common symptom of the rotator cuff tear is shoulder pain. Rotator cuff pain is usually directed to the outside of the upper arm.  The pain is felt when trying to reach behind the back, or during overhead activity. People with symptomatic rotator cuff tears usually have pain at nighttime. They can also have pain even when the shoulder is not in use. This is a very significant symptom because it suggests that surgery might be necessary. This is not true all the time but there is a higher chance. Rotator cuff with pain at rest or when trying to sleep often leads to surgery. 

Another symptom of rotator cuff tear is shoulder weakness. On strength testing, there is weakness in external rotation of the arm, and or abduction.  Abduction is the ability to raise the arm out to the side. Weakness with abduction is very common in large rotator cuff tears.

Shoulder popping or crepitus on moving the shoulder is common in rotator cuff tears as well as bursitis.  Bursas are fluid-filled sacs located on the joint to aid movement and also provide some form of lubrication. When the bursas become inflamed the popping sound will be heard on movement in any direction. 

One condition that often resembles a rotator cuff tear is a frozen shoulder. A frozen shoulder occurs because the capsule over the shoulder joint thickens causing pain with attempts to move the shoulder.  A significant difference is that while there is pain with a rotator cuff tear and limited range of motion, it can be lifted passively.  This means that it can be moved using the other arm or the doctor can move it . With a frozen shoulder, it cannot be lifted beyond a certain point, even with assistance.  

Conclusion

Rotator cuff tears can occur with or without pain. Pain is an indication of an inflammatory process but could be absent in a rotator cuff tear. However, a painful rotator cuff tear needs to be treated.  Pain is a warning sign and helps us in determine the  proper treatment plan.  The plan may be nothing if there is an asymptomatic tear.  On the other end of the spectrum it may require a major surgery if it is a very large symptomatic tear.  So, some rotator cuff tears are not painful, but if you have one that is painful please go see medical provider today!

References

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