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Rotator Cuff Injury
Your Guide, Jonathan Cluett, M.D.
Basic information about rotator cuff problems
What is the rotator cuff?
The rotator cuff is the name for the tendons that surround the shoulder joint. The rotator cuff aids in allowing the shoulder to function as the most unique joint in the body. In part due to the rotator cuff, the shoulder joint can move and turn through a wider range than any other joint in the body. This motion of the shoulder joint allows us to perform an amazing variety of tasks with our arms.
Unfortunately, a rotator cuff injury is not an uncommon problem, and these injuries make many routine activities difficult and painful. The rotator cuff is part of this mechanism that, when healthy functions very well, but when injured can be a difficult and frustrating problem.
What makes up the rotator cuff?
The rotator cuff is actually a group of four muscles and their tendons that wraps around the front, back, and top of the shoulder joint.
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Together the rotator cuff muscles help guide the shoulder through many motions, and also lend stability to the joint. The ends of the rotator cuff muscles form tendons that attach to the arm bone (humerus). It is the tendinous portion of the muscle that is usually involved in a rotator cuff injury.
What is a rotator cuff injury?
Like most orthopedic conditions, the most common mechanisms of a rotator cuff injury are separated into 'repetitive use' and 'traumatic.'
* Repetitive Use Injury
In repetitive use injuries to the rotator cuff, repeated activities cause damage to the rotator cuff tendons. Over time, the tendons wear thin and a tear can develop within the tendons of the rotator cuff. Patients with repetitive use injuries to the rotator cuff often have complaints of shoulder bursitis prior to developing a tear through the rotator cuff tendons.
* Traumatic Injuries
Traumatic injuries to the rotator cuff are seen after events such as falling on to an outstretched hand. The traumatic event can cause a rotator cuff injury by tearing the rotator cuff tendons. This mechanism is much less common than repetitive use injuries, but when a rotator cuff tear occurs in a patient younger than 60 years old it is usually a traumatic injury.
Who is most susceptible to a rotator cuff injury?
A rotator cuff injury is seen both in the young and old, but they are much more common in the older population. Usually in younger patients, there is either a traumatic injury, or the patient is demanding unusual use of their shoulder, as seen in professional athletes.
As people age, the muscle and tendon tissue of the rotator cuff loses some elasticity, becomes more susceptible to injuries, and is often damaged while performing everyday activities. This is the reason that rotator cuff tears are more commonly seen in older patients.
How common are rotator cuff injuries?
Not every rotator cuff injury causes significant pain or disability. In fact, autopsy studies have shown rotator cuff tears in up to 70% of people over the age of 80 and 30% of the population under the age of 70. Clearly, all of the people with rotator cuff tears are not complaining of painful symptoms. However, in many individuals, a rotator cuff injury can cause significant disability, and prompt diagnosis and treatment can have a profound improvement in symptoms.
Symptoms of a rotator cuff tear
What are the symptoms of rotator cuff tear?
The most common symptom of a rotator cuff tear is pain. It is often difficult for a patient to localize the pain to a specific area, rather it is described as a generalized discomfort that is exacerbated with specific movements of the shoulder. Depending on the severity of the rotator cuff tear, there may also be a loss of motion.
If the injury is an incomplete tear, pain will likely be the most prominent symptom; decreased strength may be demonstrated, but is usually not the patient's primary complaint. However, in a complete rotator cuff tear, the patient will likely be unable to move the shoulder through some normal motions. The diagnosis of a rotator cuff tear is best made by a physical examination where an orthopedic surgeon can isolate and test the function of the specific muscles that form the rotator cuff.
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The most common symptoms of rotator cuff tears are:
* Pain
Often the pain is felt over the outside of the shoulder and upper arm. Pain while performing overhead activities (with the arm above head height) and pain at night are also quite common.
* Decreased strength
Strength of the rotator cuff tendons can be tested by an orthopaedic surgeon. By isolating the different tendons of the rotator cuff with special tests, your doctor can determine the extent of the tear. Significant tears may affect a patients ability to raise up their arm over their head.
How is a rotator cuff tear diagnosed?
X-rays of the shoulder will be obtained if there is a concern of a rotator cuff tear. The x-rays do not necessarily need to be done before initiating treatment, but if symptoms persist, x-rays will be obtained. Your doctor will look for signs of a rotator cuff tear, although the rotator cuff tear itself cannot be seen on a regular x-ray. Signs of a problem within the rotator cuff include a narrowing of the space for the rotator cuff and bone spurs around the rotator cuff tendons.
The test most commonly used to diagnose a rotator cuff tear is a MRI, but this is not the only way to diagnose a rotator cuff tear. The following tests can all be used to make the diagnosis of a rotator cuff tear:
* MRI
A MRI is the most commonly used test to confirm a diagnosis of a rotator cuff tear. The MRI is helpful because it can show both complete rotator cuff tears and partial rotator cuff tears. The MRI can also show evidence of shoulder bursitis and other common shoulder problems.
* Arthrogram
An arthrogram used to be the most commonly used test to diagnose a rotator cuff tear. In this study a dye that shows up on x-ray is injected into the shoulder joint. An intact rotator cuff should contain the dye within the joint, while a rotator cuff tear will allow the dye to leak into surrounding tissues. By taking an x-ray after an injection, your doctor can see evidence of a rotator cuff tear.
* Ultrasound
New studies now show that an ultrasound, operated by a skilled technician, can be as effective detecting a rotator cuff tear as these other methods. Depending on your doctor's preference, you may undergo an ultrasound study to diagnose a rotator cuff tear.
What other problems could be causing my symptoms?
Rotator cuff tears are extremely common, but there are several other common causes of shoulder pain. Patients with shoulder pain will also be evaluated for other causes of shoulder pain before settling in on the diagnosis of a rotator cuff tear.
Treatment and rehab of rotator cuff injuries
What treatment is needed for a rotator cuff tear?
Rotator cuff tears do not heal well with time. They tend to either enlarge, or, at best, stabilize in size. The good news is the rotator cuff tears do not necessarily need to heal in order for the symptoms to resolve. As said earlier in this article, many people have rotator cuff tears, but no symptoms of shoulder pain.
What is the initial treatment for a rotator cuff tear?
Because many rotator cuff tears do not need surgery, the initial treatment is usually with conservative measures. While the size of the tear may not change with conservative treatment, the symptoms often diminish. In some cases, usually a traumatic rotator cuff tear in a younger patient, early surgery will be recommended.
However, the standard treatment is to start with conservative measures.
The first steps of rotator cuff treatment include:
* Physical Therapy
Physical therapy is the most important step in the treatment of a rotator cuff injury. Strengthening the rotator cuff muscles is important to maintain normal shoulder function. A few meetings with a physical therapist can help teach you exercises to help alleviate and prevent a recurrence of your shoulder pain.
* Anti-Inflammatory Medications
Medications are most helpful at controlling the symptoms of a rotator cuff tear. Simple anti-inflammatory medications can be taken regularly for a short period, and then be used when symptoms of a rotator cuff tear flare up.
* Cortisone Injections
Cortisone injections can be incredibly helpful at limiting the acute inflammatory process and allowing the patient to begin therapy. It is important to participate in the therapy and exercises even if the shoulder feels better after an injection. The therapy part of treatment will help prevent a recurrence of symptoms.
These steps may help to relieve pain and strengthen the muscles around the joint.
What treatments are available if I still have symptoms?
These conservative measures may not be effective in all patients. In general, a good effort at conservative therapy is first attempted, especially in older patients or in patients who have chronic (long-standing) injuries. In younger patients who have an acute, traumatic injury, sometimes surgery is considered early as the likelihood that conservative treatment will help is low. Surgery is also considered in patients who have tried conservative treatment, and still have difficulty with their shoulder.
There are several surgical procedures that are possible for rotator cuff treatment. The three most common procedures are:
* Open Repair
Prior to the use of the arthroscope, all rotator cuffs were repaired by looking directly at the torn tendon, through an incision about 6-10 centimeters in length. The advantage is the rotator cuff tendons are easily seen by this method, but the incision is large, and the recovery can be longer and more painful.
* Mini-Open Repair
The mini-open method of repairing a rotator cuff involves both the use of an arthroscope, and a short incision to get access to torn tendon. By using the arthroscope, the surgeon can also look into the shoulder joint to clean out any damaged tissue or bone spurs. The incision is about 3-4 cm, and the recovery is somewhat less involved than the open cuff repair.
* Arthroscopic Repair
An arthroscopic repair is done with small incisions, and the repair is done by the surgeon looking through a small camera to watch his or her repair on a television monitor. This is a more recent development in treatment of rotator cuff tears, and not all types of tears can be treated by this method. Some advantages and disadvantages of this procedure are discussed in the article comparing arthroscopic rotator cuff repairs to open methods.
The surgery to perform the rotator cuff repair generally lasts about two hours.
How long is the recovery from rotator cuff repair surgery?
This will depend on several factors, including your level of strength before the operation and the severity of the rotator cuff tear. Some period of immobilization of the shoulder joint is needed to protect the newly placed sutures from being disrupted. After one to two weeks, physical therapy begins. Initially, the therapy is gentle so as not to affect the rotator cuff repair. After four to six weeks, more active lifting with the arm begins. Several months after the rotator cuff repair, physical therapy will become more intense in an effort to strengthen the rotator cuff muscles. Complete recovery usually requires at least four to six months. |
