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Rotator Cuff Injury

When one or more of the rotator cuff tendons is torn, the tendon no longer fully attaches to the head of the humerus. Most tears occur in the supraspinatus muscle and tendon, but other parts of the rotator cuff may also be involved.

In many cases, torn tendons begin by fraying. As the damage progresses, the tendon can completely tear, sometimes with lifting a heavy object.

There are different types of tears.

  • Partial Tear. This type of tear damages the soft tissue, but does not completely sever it.
  • Full-Thickness Tear. This type of tear is also called a complete tear. It splits the soft tissue into two pieces. In many cases, tendons tear off where they attach to the head of the humerus. With a full-thickness tear, there is basically a hole in the tendon.

Cause

There are two main causes of rotator cuff tears: injury and degeneration.

Acute Tear

If you fall down on your outstretched arm or lift something too heavy with a jerking motion, you can tear your rotator cuff. This type of tear can occur with other shoulder injuries, such as a broken collarbone or dislocated shoulder.

Degenerative Tear

Most tears are the result of a wearing down of the tendon that occurs slowly over time. This degeneration naturally occurs as we age. Rotator cuff tears are more common in the dominant arm. If you have a degenerative tear in one shoulder, there is a greater risk for a rotator cuff tear in the opposite shoulder — even if you have no pain in that shoulder.

Several factors contribute to degenerative, or chronic, rotator cuff tears.

  • Repetitive stress. Repeating the same shoulder motions again and again can stress your rotator cuff muscles and tendons. Baseball, tennis, rowing, and weightlifting are examples of sports activities that can put you at risk for overuse tears. Many jobs and routine chores can cause overuse tears, as well.
  • Lack of blood supply. As we get older, the blood supply in our rotator cuff tendons lessens. Without a good blood supply, the body’s natural ability to repair tendon damage is impaired. This can ultimately lead to a tendon tear.
  • Bone spurs. As we age, bone spurs (bone overgrowth) often develop on the underside of the acromion bone. When we lift our arms, the spurs rub on the rotator cuff tendon. This condition is called shoulder impingement, and over time will weaken the tendon and make it more likely to tear.

Risk Factors

Because most rotator cuff tears are largely caused by the normal wear and tear that goes along with aging, people over 40 are at greater risk.

People who do repetitive lifting or overhead activities are also at risk for rotator cuff tears. Athletes are especially vulnerable to overuse tears, particularly tennis players and baseball pitchers. Painters, carpenters, and others who do overhead work also have a greater chance for tears.

Although overuse tears caused by sports activity or overhead work also occur in younger people, most tears in young adults are caused by a traumatic injury, like a fall.

Symptoms

The most common symptoms of a rotator cuff tear include:

  • Pain at rest and at night, particularly if lying on the affected shoulder
  • Pain when lifting and lowering your arm or with specific movements
  • Weakness when lifting or rotating your arm
  • Crepitus or crackling sensation when moving your shoulder in certain positions

Tears that happen suddenly, such as from a fall, usually cause intense pain. There may be a snapping sensation and immediate weakness in your upper arm.

A rotator cuff injury can make it painful to lift your arm out to the side.

Tears that develop slowly due to overuse also cause pain and arm weakness. You may have pain in the shoulder when you lift your arm to the side, or pain that moves down your arm. At first, the pain may be mild and only present when lifting your arm over your head, such as reaching into a cupboard. Over-the-counter medication, such as aspirin or ibuprofen, may relieve the pain at first.

Over time, the pain may become more noticeable at rest, and no longer goes away with medications. You may have pain when you lie on the painful side at night. The pain and weakness in the shoulder may make routine activities such as combing your hair or reaching behind your back more difficult.

Doctor Examination

Medical History and Physical Examination

Your doctor will test your range of motion by having you move your arm in different directions.

After discussing your symptoms and medical history, your doctor will examine your shoulder. He or she will check to see whether it is tender in any area or whether there is a deformity. To measure the range of motion of your shoulder, your doctor will have you move your arm in several different directions. He or she will also test your arm strength.

Your doctor will check for other problems with your shoulder joint. He or she may also examine your neck to make sure that the pain is not coming from a “pinched nerve,” and to rule out other conditions, such as arthritis.

Imaging Tests

Other tests which may help your doctor confirm your diagnosis include:

  • X-rays. The first imaging tests performed are usually x-rays. Because x-rays do not show the soft tissues of your shoulder like the rotator cuff, plain x-rays of a shoulder with rotator cuff pain are usually normal or may show a small bone spur.
  • Magnetic resonance imaging (MRI) or ultrasound. These studies can better show soft tissues like the rotator cuff tendons. They can show the rotator cuff tear, as well as where the tear is located within the tendon and the size of the tear. An MRI can also give your doctor a better idea of how “old” or “new” a tear is because it can show the quality of the rotator cuff muscles.

Treatment

If you have a rotator cuff tear and you keep using it despite increasing pain, you may cause further damage. A rotator cuff tear can get larger over time.

Chronic shoulder and arm pain are good reasons to see your doctor. Early treatment can prevent your symptoms from getting worse. It will also get you back to your normal routine that much quicker.

The goal of any treatment is to reduce pain and restore function. There are several treatment options for a rotator cuff tear, and the best option is different for every person. In planning your treatment, your doctor will consider your age, activity level, general health, and the type of tear you have.

There is no evidence of better results from surgery performed near the time of injury versus later on. For this reason, many doctors first recommend nonsurgical management of rotator cuff tears.

Nonsurgical Treatment

In about 50% of patients, nonsurgical treatment relieves pain and improves function in the shoulder. Shoulder strength, however, does not usually improve without surgery.

Nonsurgical treatment options may include:

  • Rest. Your doctor may suggest rest and and limiting overhead activities. He or she may also prescribe a sling to help protect your shoulder and keep it still.
  • Activity modification. Avoid activities that cause shoulder pain.
  • Non-steroidal anti-inflammatory medication. Drugs like ibuprofen and naproxen reduce pain and swelling.
  • Strengthening exercises and physical therapy. Specific exercises will restore movement and strengthen your shoulder. Your exercise program will include stretches to improve flexibility and range of motion. Strengthening the muscles that support your shoulder can relieve pain and prevent further injury.
  • Steroid injection. If rest, medications, and physical therapy do not relieve your pain, an injection of a local anesthetic and a cortisone preparation may be helpful. Cortisone is a very effective anti-inflammatory medicine.

The chief advantage of nonsurgical treatment is that it avoids the major risks of surgery, such as:

  • Infection
  • Permanent stiffness
  • Anesthesia complications
  • Sometimes lengthy recovery time

The disadvantages of nonsurgical treatment are:

  • No improvements in strength
  • Size of tear may increase over time
  • Activities may need to be limited

Surgical Treatment

Your doctor may recommend surgery if your pain does not improve with nonsurgical methods. Continued pain is the main indication for surgery. If you are very active and use your arms for overhead work or sports, your doctor may also suggest surgery.

Other signs that surgery may be a good option for you include:

  • Your symptoms have lasted 6 to 12 months
  • You have a large tear (more than 3 cm)
  • You have significant weakness and loss of function in your shoulder
  • Your tear was caused by a recent, acute injury

Surgery to repair a torn rotator cuff most often involves re-attaching the tendon to the head of humerus (upper arm bone). There are a few options for repairing rotator cuff tears. Your orthopaedic surgeon will discuss with you the best procedure to meet your individual health needs.

Cure Your Rotator Cuff Injury today. Call us at +65 6471 2744 or Email to: info@boneclinic.com.sg for Appointment.

Arthroscopic Rotator Cuff Repair

Rotator cuff repair leads to good and excellent outcomes in most patients. However, structural failure of the repair occurs in a substantial number of cases and can lead to an unsatisfactory result. Several factors have been implicated, including patient related factors (eg. patient age, tear size) and extrinsic factors (eg, surgeon surgical volume, biomechanical failure). Structural failure requires a detailed patient evaluation to elucidate the cause of persistent symptoms. Function can be maintained despite a recurrent tear; therefore, a recurrent tear alone is not an indication for revision repair. The major indication for revision rotator cuff repair is the persistence clinical symptoms, despite nonsurgical management, in the absence of substantial risk factors for failure. Although the outcome is poorer than after primary repair, satisfactory results have been reported following revision repair of recurrent rotator cuff tears, particularly with arthroscopic techniques.

About rotator cuff injuries

Shoulder pain affects around one in five people in the UK and a rotator cuff injury is the most common cause.

Your shoulder joint is a ball and socket joint, formed by the ball-shaped end of your upper arm bone (humerus) and a shallow socket on the edge of your shoulder blade (scapula).

Your rotator cuff is made up of a group of four muscles (the subscapularis, supraspinatus, infraspinatus and teres minor) and their tendons. It plays a crucial role in keeping your shoulder joint stable. Tendons wrap around your shoulder joint, forming a cuff around the ball of your humerus.

On top of your shoulder joint is a bone called the acromion. In the gap between your shoulder joint and acromion is a space that some of your rotator cuff tendons run through. In this space is a fluid-filled pad called the subacromial bursa, which cushions your tendons.

Rotator cuff injury is a general term to describe inflammation (soreness and swelling) or damage to one or more of the muscles or tendons that make up your rotator cuff.

Types of rotator cuff injury

There are a number of conditions that can affect your rotator cuff. The most common are inflammation of your rotator cuff tendons and tearing of your muscles or tendons.

Rotator cuff tendonitis
If the tendons of your rotator cuff become inflamed, this is known as tendonitis. The tendons can become pinched against one of the other structures that make up your shoulder joint. This can be both the cause and the result of tendonitis. Tendonitis most often affects the tendons that run underneath your acromion. When a tendon becomes trapped or squeezed, it’s known as impingement syndrome.

Calcium is sometimes deposited in your rotator cuff tendons if they are inflamed for a long period of time. The tendons become ‘calcified’ and this is called calcific tendonitis.

Your subacromial bursa can also become inflamed – this is called bursitis.

Rotator cuff tear
This is when one or more of the muscles and tendons that make up your rotator cuff become completely or partially torn. It may be a result of trauma, such as a fall, or due to tiny tears in the tendon caused by use and wear over time. It may also be caused by impingement syndrome.

Symptoms of rotator cuff injuries

Symptoms of a rotator cuff injury include:

  • pain and tenderness in your shoulder (this may extend down your arm too), particularly when you raise your arm out to the side, reach behind you or lift or pull a heavy weight
  • pain at night, particularly when you sleep on the affected side
  • a feeling of weakness in your shoulder
  • being unable to move your shoulder as you usually would

Depending on the type of injury you have, the pain may come on gradually (common if you have tendonitis) or you may have sudden twinges of pain (common if you have a tear).

If you have any of these symptoms, contact your GP or a physiotherapist (a health professional who specialises in maintaining and improving movement and mobility).

Causes of rotator cuff injuries

Rotator cuff injuries may occur for a specific reason, for example:

  • lifting or pulling an object that is too heavy for you or lifting it in the wrong way can cause you to strain or tear a rotator cuff tendon or muscle
  • landing on an outstretched hand to break a fall can tear or strain a rotator cuff muscle or tendon

There are some things that increase the likelihood of you getting a rotator cuff injury, including the following.

  • Age – if you’re over 40, you’re at an increased risk of rotator cuff injuries because your tendons start to wear down with age and become more prone to injury.
  • Certain sports, activities and jobs – you’re more likely to have a rotator cuff injury if you do something that involves repetitive overhead motions with your arms. Examples include swimming, weight lifting, playing racquet sports and occupations such as painting, decorating or window cleaning.
  • Musculoskeletal diseases, such as rheumatoid arthritis, can cause your rotator cuff muscles to become weaker making an injury more likely.

Diagnosis of rotator cuff injuries

Your GP or physiotherapist will ask about your symptoms and examine you. He or she may ask about your medical history and any activities that may be causing your condition.

You may be referred for further tests such as an MRI scan, ultrasound scan or X-ray so that your doctor can look at your shoulder in more detail.

Treatment of rotator cuff injuries

Treatment of a rotator cuff injury depends on the type of injury you have and how severe it is.

Self-help

The following measures may help.

  • Rest your shoulder initially, avoiding any movements that cause you pain. Start to do gentle movements as soon as possible to prevent any stiffness in your shoulder.
  • Apply an ice pack or ice wrapped in a towel to your shoulder to reduce swelling and bruising. Don’t apply ice directly to your skin as it can damage your skin. Don’t use ice if you have a skin disorder that makes your skin sensitive. Also, don’t put ice on your left shoulder if you have any known heart problems.
  • Take an over-the-counter anti-inflammatory medicine, such as ibuprofen, to reduce pain and inflammation. Always read the patient information leaflet that comes with your medicine and if you have any questions ask your pharmacist for advice.

Non-surgical treatments

Stretches and strengthening exercises can help build up strength and flexibility in your shoulder. It’s important to get advice from a medical professional, such as a physiotherapist, on which exercises and stretches you should do and how to do them correctly. The exercises will be tailored to your specific injury.

If you have rotator cuff tendonitis, your doctor may recommend an injection of a medicine called a corticosteroid. This is usually only done when other treatments haven’t helped.

You may be able to have extracorporeal shock wave lithotripsy (ESWT) if you have calcific tendonitis. ESWT uses vibrations caused by sound waves to break up the calcium deposits.

Surgery

Rotator cuff injuries can usually be successfully treated without the need for surgery. However, sometimes you may need to have an operation, for example to repair a tear in your rotator cuff or to remove calcium deposits.

Rotator cuff repair surgery is done under general anaesthesia. This means you will be asleep during the operation.

In general, there are two different procedures that may be used to repair a rotator cuff injury: open surgery and shoulder arthroscopy. The type of surgery you have will depend on where your injury is, and if it’s a tear, how big it is and it’s shape.

Open surgery means that your surgeon makes a cut in the skin over your shoulder and repairs your injury through the cut. In an athroscopy, a narrow, flexible, tube-like telescopic camera called an arthroscope is inserted through a small incision in your shoulder and this is used to repair your injury. It’s commonly known as keyhole surgery.

If you have a rotator cuff tear, the two sides of your muscle or tendon will be stitched back together and, if necessary, attached back on to your humerus. Your surgeon may also carry out a procedure called debridement. This means that he or she will remove any damaged tissue, so that the remaining healthy tissue can heal.

If you have impingement syndrome, your surgeon will remove excess bone from the front part of your acromion. This will create more room for your rotator cuff and prevent pinching of the rotator cuff, when you move your arm above your head. This procedure is called subacromial decompression.

Your surgeon will be able to give you advice on which type of surgery you need for your condition.

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