ROTATOR CUFF INJURY OVERVIEW — Tendons are tough bands of tissue that connect muscles to bones. Repetitive activities and overuse can injure tendons and lead to pain and impaired function. This is called tendinitis or tendinopathy. Although the most common cause of tendinitis is overuse, it can also be caused by other conditions.
Tendinitis is a common problem that is more likely as people age and in people who routinely perform activities that require repetitive movement that increase stress on susceptible tendons. Rotator cuff disease is the most common cause of shoulder pain, particularly in people over age 30. Treatment focuses on resting the injured tendon to allow healing, decreasing inflammation, and correcting imbalances that caused stress on the injured area. In most people, tendinitis resolves with treatment. In some cases, it goes away without treatment.
Tendinitis can affect many different tendons in the body. Other types of tendon injury are discussed separately
WHAT IS THE ROTATOR CUFF? — The rotator cuff is composed of four muscles, each of which has a tendon that attaches to the upper arm bone (the humerus).
- Teres minor
These tendons form a cuff around the head of the upper arm bone (humerus). These tendons attach to the front and side of the humerus and the greater and lesser tubercles (part of the upper humerus). The muscles associated with these tendons are located in the upper back, where they are attached to the shoulder blade (scapula).
The largest component of the rotator cuff is the supraspinatus tendon, which is essential for lifting the arm. The infraspinatus and teres minor rotate the arm outward, while the subscapularis rotates the arm inward.
Rotator cuff tendinitis — Rotator cuff tendinitis occurs when the tendons are injured, usually as a result of repetitive overhead reaching, pushing, or lifting with outstretched arms. Athletes who perform overhead activity, such as swimming, tennis, throwing, golf, weightlifting, volleyball, and gymnastics, are also at risk. Tendinitis is usually treated with ice, antiinflammatory drugs, and physical therapy.
Rotator cuff tear — The rotator cuff tendon(s) may be torn as a result of injury, chronic tendinopathy, or a combination of both. Typically the injury is caused by a fall, direct blow, or a rapid use of force (pulling on a starter cable, for instance).
The goals of treatment for a torn rotator cuff are to recover lost strength, improve the function of the shoulder, and treat any underlying tendinitis. Conservative treatment is adequate in the vast majority of people, although younger people with a medium- to large-sized tear, particularly affecting the dominant arm, may be candidates for surgical repair. Surgery may also be recommended for older people who have significant pain related to a rotator cuff tear.
People with small- to medium-size tears usually improve with physical therapy exercises, stopping painful activities, and, in some cases, injection of a steroid. If shoulder strength and function do not improve after completing three to six months of physical therapy, surgical repair may be considered.
ROTATOR CUFF INJURY SYMPTOMS
Tendinitis — People with rotator cuff tendinitis typically complain of shoulder pain at the tip of the shoulder and the upper, outer arm. Specialists often refer to tendinitis as tendinopathy because there is no evidence of inflammation with this injury. The pain is often aggravated by reaching, pushing, pulling, lifting, positioning the arm above the shoulder level, or lying on the side. Painful daily activities may also include putting on a shirt or brushing hair. The pain may prevent comfortable sleep, or awaken a person from sleep, particularly if he or she sleeps on or rolls onto the shoulder.
Tear — Symptoms of rotator cuff tear often include pain and weakness of the shoulder, although some people have few or no symptoms. In addition, the severity of the tear does not necessarily correlate with the severity of a person’s pain; in other words, a person with a partial tear may have severe pain while a person with a complete tear may have little or no pain.
In most cases, x-rays and other imaging tests are not needed to diagnose tendinopathy. However, if the person’s symptoms do not improve after a course of conservative treatment, an imaging test (eg, x-ray, ultrasound, and/or MRI) may be recommended to confirm the diagnosis.
If a rotator cuff tear is suspected, an imaging test (ultrasound or MRI) is usually recommended to confirm the tear. Initially, smaller tears are treated conservatively, with rest, ice, stretching, and strengthening exercises.
If the pain or weakness does not improve or if a large tear is confirmed with an imaging test, most people are referred to a specialist (orthopedic surgeon) for further evaluation and management
ROTATOR CUFF INJURY TREATMENT — Treatment of rotator cuff injuries focuses on decreasing pain and swelling of the tendon, preserving normal range of motion, and strengthening the shoulder muscles. The first goal of treatment is to preserve the ability to move the shoulder. In many people, a decreased ability to move the shoulder means that they use the joint less frequently, which can further reduce range of motion and lead to a frozen shoulder.
There are two basic options for treatment: conservative, non-surgical treatments and surgery. Conservative treatment is discussed here while surgical treatment is discussed .
Conservative treatment usually includes:
Ice — Ice can be used to reduce the inflammation that often occurs in rotator cuff injuries. Ice can be applied over the upper and outer portion of the shoulder muscle for 15 to 20 minutes every four to six hours. The response to ice is variable since the rotator cuff tendons are located deep within the shoulder.
Rest — Rest means avoiding activities that aggravate symptoms, including all overhead activities. Avoiding painful activities in general will alleviate strain on the injured area. An example of these activities includes lifting, overhead reaching, and reaching behind (eg, reaching into the backseat or putting on a coat). It is safest to keep the arm down, in front of, and close to the body. Use of an arm sling is not recommended because this may lead to a frozen shoulder.
Some general rules to decrease shoulder strain with activities include:
- Lift objects close to the body.
- Only lift light weights and limit lifting to below shoulder level.
- Do sidestroke or breaststroke when swimming.
- Throw balls underhand or sidearm.
- Avoid pushing exercises at the gym (eg, pushups, bench press, flys, shoulder press)
- Do not serve overhand in tennis.
- Maintain good posture with writing, assembly work, and other tasks by keeping the shoulder blades down and back
Reduce inflammation — A nonsteroidal antiinflammatory medication (eg, ibuprofen or naproxen) is often used to reduce pain and inflammation. The dose of medication needed to reduce inflammation is higher than that recommended for pain relief. You should check with your healthcare provider before using high dose NSAIDs.
Heat and massage — Heat and massage help prepare the tissues for range of motion exercises and are recommended before performing these exercises. The best method to warm the tissues is to take a warm shower or bath for 10 to 15 minutes. Local heat (eg, with a moist heating pad or a hot pack warmed in a microwave) is an alternative, although local heat is generally not as effective because of the deep location of the rotator cuff tendons.
Light massage to the surrounding tissues is a very effective way to prepare the area for range of motion and strength exercises.
Stretching and range of motion exercises — Range of motion exercises are recommended early in the recovery period to help maintain joint mobility and flexibility of the muscles and tendons in the shoulder. Stretching exercises should be performed once per day every day.
Exercises should not cause more than a mild level of pain. If you experience pain, decrease the intensity of the stretch or the number of repetitions; anyone who feels sharp or tearing pain should stop exercising immediately and consult with their healthcare provider.
Muscle strengthening exercises — Muscle strengthening exercises are necessary to improve shoulder muscle strength and help to prevent further injury. You can begin strengthening the shoulder once your shoulder has full range of motion, including overhead activities, with minimal pain. Consult with your provider or physical therapist to determine when to begin strengthening exercises.
As pain improves, the level of difficulty of these exercises should be increased. Increased difficulty is necessary to improve muscle strength to a degree that reduces the risk of re-injury. Mild soreness is expected with these exercises, although pain should not continue for more than 24 hours. Sharp or severe pain during or after exercising may indicate a flare of the underlying problem; stop these exercises for a few days if this occurs.
Maintenance exercises — Once rehabilitation is complete, it is important to keep the shoulder muscles strong to maintain fitness and prevent a recurrence of pain. Non-athletes may continue to perform the exercises.
Athletes may perform exercises that are similar to those required in their sport. As examples, a tennis player may perform a service-type motion using a five pound dumbbell, while a pitcher may perform a throwing motion using a three pound dumbbell.
Anyone who performs frequent overhead activities needs to maintain strong shoulder blades and rotator cuff muscles to prevent overuse injuries of these areas. These muscles are essential in preventing aggravation to the tendons.
Return to activities — Most people with rotator cuff tendinitis see improvement in pain and function after 6 to 12 weeks of rehabilitation.
IF PAIN PERSISTS — If shoulder pain does not improve after several weeks of physical therapy exercises, most clinicians will recommend further evaluation.
If tendinitis is confirmed with an imaging study, some clinicians will inject a steroid/local anesthetic mixture into the joint. Although clinical studies of steroid injections do not show that the injection is helpful in all cases, some people do benefit. In these people, pain and inflammation may improve quickly, usually within a few days. If the injection is helpful, it can be repeated once per month for up to three months.
If you have another cause for your pain (eg, rotator cuff tear, nerve impingement), you will usually be referred to an orthopedic surgeon for further evaluation and treatment.
SURGICAL REPAIR OF ROTATOR CUFF TEARS — The need to surgically repair a torn rotator cuff depends upon your age, activity level, and the severity of your tear.
- Surgical repair is usually recommended for people with a complete rotator cuff tear, especially if the person is young and/or active. Surgery is usually recommended soon after the injury, if possible, to prevent the tendon and muscle from shrinking.
- Conservative treatment is usually recommended first if you do not have a complete rotator cuff tear or are older, less active, or if there is minimal pain. Conservative treatments (eg, stretching and strengthening exercises, injection of a steroid) are usually recommended first.
- Surgery may be recommended if you do not improve after stretching and strengthening exercises and you have persistent pain, limited strength, have arthritis or spurs that cause pain and interferes with rehabilitation, or if a new injury occurs and you have a previous rotator cuff injury.
There are several ways to repair the rotator cuff, including open and arthroscopic techniques.
- Open repairs require a 3 to 4 inch incision in the skin over the shoulder.
- Arthroscopic surgery requires several (2 or 3) smaller incisions, through which a telescope-like device with a camera and light (called an arthroscope) and other instruments are inserted.
The advantage of arthroscopic surgery is that there is usually less pain and a faster return to normal activities, including sports.
Most surgeries are performed in a hospital or surgical center, after you are given general anesthesia. The surgery takes one to two hours. Most people can go home several hours after the surgery is completed.
Return to activities — After surgical repair, most people require 6 months of rehabilitation before strength and shoulder function return to normal. Post-surgical rehabilitation is necessary and use of the shoulder must be limited. Immediately after surgery, you will be allowed to use the affected arm with your elbow at your side for eating, using the keyboard, using the telephone, and driving. Above-the-shoulder activities are not usually allowed for three months after surgery.
Sporting activities can be gradually restarted, including golfing at four months, light weight lifting at four months, swimming at five months, and throwing and tennis playing at five to six months.