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Joseph Norris, MD
Orthopedic Surgeon Sports Medicine
Home Patient Info Rotator Cuff Problems

Rotator Cuff Problems

Definition

Rotator Cuff Problems

  • The Rotator Cuff is a group of four muscles and tendons that attach to the humeral head, allowing the shoulder to move and keeping it stable. The four muscles and tendons making up the rotator cuff are:
    • Supraspinatus
    • Infraspinatus
    • Teres Minor
    • Subscapularis
  • Rotator Cuff tendinitis refers to irritation of these tendons and inflammation of the bursa (a normally smooth layer) lining these tendons
  • A rotator cuff tear occurs when one of the tendons is torn from overuse or injury

Alternative Names

  • Impingement Syndrome
  • Rotator Cuff Tendinitis

Causes

  • The shoulder joint is a ball and socket type joint where the top part of the arm bone (humerus) forms a joint with glenoid or socket off the scapula.
  • The rotator cuff holds the head of the humerus into the glenoid and controls movement of the shoulder joint
  • The tendons of the rotator cuff pass underneath a bony area (acromion) on their way to attaching the top part of the arm bone. When these tendons become inflamed, they can become more frayed over this area during shoulder movements
  • Sometimes a bone spur may narrow the space even more

This problem is called rotator cuff tendinitis, or impingement syndrome, and may be due to:

  • Keeping the arm in the same position for long periods of time, such as doing computer work or hairstyling
  • Playing sports requiring the arm to be moved over the head repeatedly as in tennis, baseball (particularly pitching), swimming, and lifting weights over the head
  • Working with the arm overhead for many hours or days (such as in painting and carpentry)
  • Poor control or coordination of your shoulder and shoulder blade muscles

Rotator Cuff Tears may occur in two ways:

  • A sudden or acute tear may happen when you fall on your arm while it is stretched out, or after a sudden jerking motion when you try to lift something heavy
  • A chronic tear of the rotator cuff tendon occurs slowly over time. It is more likely in those with chronic tendinitis or impingement syndrome. At some point, the tendon wears down and tears

There are two types of Rotator Cuff Tears:

  • A partial tear is when a tear does not completely sever the attachments to the bone
  • A complete or full thickness tear refers to a through and through tear. It may be as small as a pinpoint or all of the muscle tendon
  • Complete tears have detachment of the tendon from the attachment site

Symptoms

Tendinitis or Impingement Syndrome

  • Early on pain occurs with overhead activities and lifting of the arm to the side
  • Any overhead activities or playing an overhead sport may aggravate the shoulder
  • Pain is often felt in the front of the shoulder and may radiate to the side of the arm. However, this pain always stops before the elbow, and if the pain travels beyond the arm to the elbow and hand, or if there is any numbness or tingling involved, this may indicate a pinched nerve in the neck
  • At first, this pain may be mild and occur only with certain movements of the arm. Over time, pain may be present at rest or at night, especially when lying on the affected shoulder, thus affecting sleep

Rotator Cuff Tears

  • The pain with a sudden tear after a fall or injury is usually intense, and weakness of the shoulder and arm is often present
  • Symptoms of a chronic rotator cuff tear include a gradual worsening of pain, weakness, and stiffness or loss of motion
  • Most people with rotator cuff tendon tears have pain at night but during the day the pain is more tolerable and only hurts with certain movements
  • Over time, the symptoms become much worse and are not relieved by medicines, rest, or exercise.

Signs and Tests

  • A physical examination may reveal tenderness over the shoulder, specifically in the front where the biceps tendon is located
  • Pain may occur when the shoulder is raised overhead and there is usually weakness of the shoulder when it is placed in certain positions
  • X-rays are typically normal, but may show an elevated humeral head if it is a large cuff tear
  • MRI is best test to assess if there is a cuff tear

Treatment (Non-Surgical)

Tendinitis or Impingement Syndrome

Treatment involves resting the shoulder and avoiding activities that cause pain. It may involve:

  • Ice packs applied 20 minutes at a time, 3 – 4 times a day to the shoulder
  • Taking anti-inflammatory medications by mouth like ibuprofen or naproxen to help reduce inflammation and pain
  • Applying medications topically like Voltaren Gel, or P-30 which is a compound of various medicines used in our practice
  • Steroid injections
  • Physical therapy to stretch and strengthen the rotator cuff
  • Avoiding or reducing activities that cause or worsen your symptoms

With rest and exercise, symptoms often improve or go away. However, this may take weeks or months to occur.

Treatment (Surgical)

  • To treat rotator cuff tendinitis or impingement syndrome arthroscopically, common things done in surgery are:
    • Removal of the bone spur on the underside of the acromion (collar bone) which is referred to as a subacromial decompression (SAD)
    • Biceps tenotomy, which is where the long head of the biceps tendon is cut. It is a common pain generator and is not needed functionally
    • A biceps tenodesis is where the cut biceps tendon is re-inserted further down the humerus, but this is usually only done in younger populations
    • Removal of the bursa, called a bursectomy, is also usually done. This eliminates another pain generator in the rotator cuff
    • A distal clavicle excision is also usually performed if you are tender over you’re A-C joint (collar bone)
    • And if the rotator cuff tendon is torn then it would be repaired too

Post-Op and Rehabilitation

  • Post-op and rehabilitation can be broken down into a three part phase:
    • Immobilization Phase
    • Range of Motion Phase
    • Strengthening Phase
  • Immobilization phase is usually anywhere from 2-4 weeks of immobilization depending on how much work was done
  • Regaining your range of motion usually starts around week3- 5, depending on how long the immobilization period was
  • And around the 6-8 week mark, you will begin to try and regain your strength
  • Overall, this anywhere from 3-6 month recovery

Prognosis

  • Many people recover full function after a combination of medications, physical therapy, and steroid injections after an episode of rotator cuff tendinitis or impingement syndrome
  • Some may need to change or reduce the amount of time they play certain sports to remain pain-free
  • People with tears of their rotator cuff tend to do well, although their outcome is strongly dependent upon the size of the tear and how long the tear has been present, as well as their age and pre-injury level of function

Complications

  • The most common complication is adhesive capsulitis, also known as "frozen shoulder"
  • This is in large part due to the period of immobilization and post-op inflammation associated with the surgery
  • Infection is always a risk with surgery, but the chances of getting an infection are extremely low
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