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Rotator Cuff Injury

Your rotator cuff is made up of the muscles and tendons in your shoulder. These muscles and tendons connect your upper arm bone with your shoulder blade. They also help hold the ball of your upper arm bone firmly in your shoulder socket. The combination results in the greatest range of motion of any joint in your body.

A rotator cuff injury includes any type of irritation or damage to your rotator cuff muscles or tendons. Causes of a rotator cuff injury may include falling, lifting and repetitive arm activities — especially those done overhead, such as throwing a baseball or placing items on overhead shelves.

About half of the time, a rotator cuff injury can heal with self-care measures or exercise therapy.

Symptoms:

Rotator cuff injury signs and symptoms may include:

  • Pain and tenderness in your shoulder, especially when reaching overhead, reaching behind your back, lifting, pulling or sleeping on the affected side
  • Shoulder weakness
  • Loss of shoulder range of motion
  • Inclination to keep your shoulder inactive

The most common symptom is pain. You may experience it when you reach up to comb your hair, bend your arm back to put on a jacket or carry something heavy. Lying on the affected shoulder also can be painful. If you have a severe injury, such as a large tear, you may experience continuous pain and muscle weakness.

When to see a doctor
You should see your doctor if:

  • You’re experiencing severe shoulder pain
  • You’re unable to use your arm or feel weak in the arm
  • You have shoulder pain that’s lasted more than a week

Causes:

Four major muscles (subscapularis, supraspinatus, infraspinatus and teres minor) and their tendons connect your upper arm bone (humerus) with your shoulder blade (scapula). A rotator cuff injury, which is fairly common, involves any type of irritation or damage to your rotator cuff muscles or tendons, including:

  • Tendinitis. Tendons in your rotator cuff can become inflamed due to overuse or overload, especially if you’re an athlete who performs a lot of overhead activities, such as in tennis or racquetball.
  • Bursitis. The fluid-filled sac (bursa) between your shoulder joint and rotator cuff tendons can become irritated and inflamed.
  • Strain or tear. Left untreated, tendinitis can weaken a tendon and lead to chronic tendon degeneration or to a tendon tear. Stress from overuse also can cause a shoulder tendon or muscle to tear.

Common causes of rotator cuff injuries include:

  • Normal wear and tear. Increasingly after age 40, normal wear and tear on your rotator cuff can cause a breakdown of fibrous protein (collagen) in the cuff’s tendons and muscles. This makes them more prone to degeneration and injury. With age, you may also develop calcium deposits within the cuff or arthritic bone spurs that can pinch or irritate your rotator cuff.
  • Poor posture. When you slouch your neck and shoulders forward, the space where the rotator cuff muscles reside can become smaller. This can allow a muscle or tendon to become pinched under your shoulder bones (including your collarbone), especially during overhead activities, such as throwing.
  • Falling. Using your arm to break a fall or falling on your arm can bruise or tear a rotator cuff tendon or muscle.
  • Lifting or pulling. Lifting an object that’s too heavy or doing so improperly — especially overhead — can strain or tear your tendons or muscles. Likewise, pulling something, such as a high-poundage archery bow, may cause an injury.
  • Repetitive stress. Repetitive overhead movement of your arms can stress your rotator cuff muscles and tendons, causing inflammation and eventually tearing. This occurs often in athletes, especially baseball pitchers, swimmers and tennis players. It’s also common among people in the building trades, such as painters and carpenters.

Risk Factors:

The following factors may increase your risk of having a rotator cuff injury:

  • Age. As you get older, your risk of a rotator cuff injury increases. Rotator cuff tears are most common in people older than 40.
  • Being an athlete. Athletes who regularly use repetitive motions, such as baseball pitchers, archers and tennis players, have a greater risk of having a rotator cuff injury.
  • Working in the construction trades. Carpenters and painters, who also use repetitive motions, have an increased risk of injury.
  • Having poor posture. A forward-shoulder posture can cause a muscle or tendon to become irritated and inflamed when you throw or perform overhead activities.
  • Having weak shoulder muscles. This risk factor can be decreased or eliminated with shoulder-strengthening exercises, especially for the less commonly strengthened muscles on the back of the shoulder and around the shoulder blades.

What you can do in the meantime
In the days before your appointment, you can make yourself more comfortable by:

  • Resting your shoulder. Avoid movements that aggravate your shoulder and give you more pain.
  • Applying cold packs to reduce pain and inflammation.
  • Taking pain medications, if necessary.

If your injury appears to be severe or your doctor can’t determine the cause of your pain through physical examination, he or she may recommend diagnostic imaging tests to better delineate your shoulder joint, muscles and tendons. These may include:

  • X-rays
  • A magnetic resonance imaging (MRI) scan
  • An ultrasound scan

Treatments:

Most of the time, treatment for rotator cuff injuries involves exercise therapy. Your doctor or a physical therapist will talk with you about specific exercises designed to help heal your injury, improve the flexibility of your rotator cuff and shoulder muscles, and provide balanced shoulder muscle strength. Depending on the severity of your injury, physical therapy may take from several weeks to several months to reach maximum effectiveness.

Other rotator cuff injury treatments may include:

  • Injections. Depending on the severity of your pain, your doctor may use a corticosteroid injection to relieve inflammation and pain.
  • Surgery. If you have a large tear in your rotator cuff, you may need surgery to repair the tear. Sometimes during this kind of surgery doctors may remove a bone spur or calcium deposits. The surgery may be performed as an open repair through a 2 1/2- to 4-inch (6- to 10-centimeter) incision, as a mini-open repair through a 1 1/4- to 2-inch (3- to 5-centimeter) incision, or as an arthroscopic repair with the aid of a small camera inserted through a smaller incision.
  • Arthroplasty. Some long-standing rotator cuff tears over time may contribute to the development of rotator cuff arthropathy, which can include severe arthritis. In such cases, your doctor may discuss with you more extensive surgical options, including partial shoulder replacement (hemiarthroplasty) or total shoulder replacement (prosthetic arthroplasty).

A unique treatment option now available involves the use of a reverse ball-and-socket prosthesis. This reverse shoulder prosthesis is most appropriate for people who have very difficult shoulder problems. These include having arthritis in the joint, along with extensive tears of multiple muscles and tendons (rotator cuff) that support the shoulder, or having extensive rotator cuff tears and a failed previous shoulder joint replacement.

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Rotator Cuff Injury and Inflammation

Rotator cuff injury and inflammation is one of the most common causes of shoulder pain. There are three common conditions that can affect the rotator cuff: rotator cuff tendonitis, rotator cuff impingement syndrome and a rotator cuff tear. Most people with rotator cuff problems can be successfully treated by a combination of rest, painkillers, anti-inflammatories, physiotherapy and injections.

The shoulder joint

There are three bones in the shoulder region, the clavicle (collar bone), the scapula (shoulder blade) and the humerus (upper arm bone). The scapula is a triangular-shaped bone that has two important parts to it: the acromion and the glenoid. The three bones in the shoulder region form part of two main joints:

  • The acromioclavicular joint between the acromion of the scapula and the clavicle.
  • The glenohumeral joint between the glenoid of the scapula and the humerus.

There are also a number of muscles, ligaments and tendons around the shoulder. Ligaments are fibres that link bones together at a joint. Tendons are fibres that attach muscle to bone.

What is the rotator cuff?

The rotator cuff is a group of four muscles that are positioned around the shoulder joint. The muscles are named:

  • Supraspinatus
  • Infraspinatus
  • Subscapularis
  • Teres minor

The rotator cuff muscles work as a unit. They help to stabilise the shoulder joint and also help with shoulder joint movement. The four tendons of the rotator cuff muscles join together to form one larger tendon, called the rotator cuff tendon. This tendon attaches to the head of the humerus (the bony surface at the top of the upper arm bone). There is a space underneath the acromion of the scapula, called the subacromial space. The rotator cuff tendon passes through here.

What are the types of rotator cuff injury/inflammation?

There are a number of different problems that can affect the rotator cuff and lead to rotator cuff injury or inflammation. The most common problems include:

  • Rotator cuff tendonitis
  • Rotator cuff impingement syndrome
  • Rotator cuff tear

Rotator cuff tendonitis

Who gets rotator cuff tendonitis?

Rotator cuff tendonitis is the most common cause of shoulder pain.

What causes rotator cuff tendonitis?

Rotator cuff tendonitis is caused by irritation and inflammation of the tendons of the rotator cuff muscles. It tends to have an acute (sudden) onset. There is often a specific preceding injury. It can happen because of recent overuse of the shoulder. For example, it can occur in athletes, particularly those who participate in throwing sports. In non-athletes, there may be a history of recent heavy lifting or activities involving repetitive movements of the shoulder.

Sometimes the rotator cuff tendons can become ‘calcified’. This is when calcium is deposited in the tendons due to long-standing inflammation. This is called calcific tendonitis.

What are the symptoms of rotator cuff tendonitis?

The main symptoms are an acute (sudden) onset of pain and painful movement of the shoulder. Pain is worst when you use your arm for activities above your shoulder level. This means that the pain can affect your ability to lift your arm up – for example, to comb your hair or dress yourself. Swimming, basketball and painting can be painful but writing and typing can produce little in the way of pain. Pain may also affect sleep.

How is rotator cuff tendonitis diagnosed?

Our doctor is usually able to make the diagnosis just by talking to you and examining your shoulder. They usually start by asking questions about your shoulder. These questions may include when your shoulder problems started, whether you have had any specific injury and what aggravates your shoulder problem.

They may then perform an examination of your shoulder. This usually involves moving your shoulder in various positions. One of the tests that can help to diagnose rotator cuff tendonitis is called the ‘painful arc test’. Our doctor may ask you to start with your arm by your side and then lift your arm outwards from your side in an arc. In rotator cuff tendonitis, pain is usually felt at a maximum between 70 and 120° in this arc.

Occasionally, Our doctor may suggest an X-ray of your shoulder or they may refer you for more detailed investigations such as an ultrasound scan or an MRI scan.

What are the treatment options for rotator cuff tendonitis?

  • Rest: this is the main treatment for rotator cuff tendonitis. You should stop any aggravating activities that may have brought on the tendonitis. However, do not completely rest your shoulder. You should still try to keep your shoulder mobile.
  • Painkillers: painkillers such as paracetamol are usually helpful. Occasionally, stronger painkillers may be needed.
  • Anti-inflammatories: these are painkillers but they also reduce inflammation and are commonly prescribed. Side-effects sometimes occur with anti-inflammatories. Always read the leaflet that comes with the drug packet for a full list of cautions and possible side-effects.
  • Physiotherapy: your doctor may refer you to a physiotherapist for advice and exercises.
  • Injections: these can help reduce the inflammation in the rotator cuff tendons. Injections can be repeated if the initial response is good.

Calcific tendonitis is treated in the same way with rest, anti-inflammatory drugs, steroid injections and physiotherapy. Rarely, surgery is needed. An alternative to surgery is a procedure called lithotripsy. In lithotripsy, shock waves are generated and delivered by an external power source to the affected tendon(s) using a specialised machine known as a lithotripter. This helps to break up the deposits of calcium.

What is the prognosis (outlook) for rotator cuff tendonitis?

If rotator cuff tendonitis is adequately treated, there can be complete recovery.

If treatment of any rotator cuff problem is delayed or inadequate, it can lead to the affected person being cautious about moving their shoulder because of pain. This means that the shoulder can stiffen up and can lead to adhesive capsulitis (frozen shoulder). See separate leaflet called ‘Frozen Shoulder’.

Rotator cuff impingement syndrome

What causes rotator cuff impingement syndrome?

As discussed above, the rotator cuff tendon passes in the subacromial space (the space underneath the acromion part of the scapula, or shoulder blade). In impingement syndrome, the rotator cuff tendon gets ‘trapped’ in the subacromial space. The tendon is repeatedly ‘scraped’ against the shoulder blade which can eventually lead to fraying of the tendon. This means that the tendon weakens and is more likely to tear.

Impingement syndrome can occur because of long-standing ‘wear and tear’. It can also happen due to problems with the bone of the acromion. These can include arthritis and bony spurs (protrusions).

What are the symptoms of rotator cuff impingement syndrome

Rotator cuff impingement syndrome also causes shoulder pain. However, the pain tends to be more chronic (long-standing). The pain tends to be worse during activities when your arm is raised over your head. Pain can also be worse at night time.

How is rotator cuff impingement syndrome diagnosed?

Again, our doctor will usually diagnose rotator cuff impingement syndrome just by talking to you and examining your shoulder. You will experience the same painful arc as described above when your shoulder is moved.

Our doctor may also perform a special test when they examine your shoulder called the Neer Impingement Test. In this test they ask you to straighten your arm. They then raise your arm forward, keeping your palm pointing away from your body. If this test is painful, the test is positive and rotator cuff impingement syndrome is likely.

What are the treatment options for rotator cuff impingement syndrome?

The treatment for rotator cuff impingement syndrome is similar to that for rotator cuff tendonitis. You should rest from any activity that involves repetitive movement of the shoulder. This particularly includes overhead activity such as that performed by plasterers or painters and decorators. This may mean that you have to modify or change your work activities. However, be careful to keep your shoulder mobile so that it does not stiffen up. Painkillers, anti-inflammatories, physiotherapy and injections can help.

If these treatments do not work, some people with rotator cuff impingement syndrome need to have an operation to ‘widen’ the subacromial space. This is usually referred to as a ‘decompression’ operation.

What is the outlook (prognosis) for rotator cuff impingement syndrome?

If rotator cuff impingement syndrome is not recognised and treated promptly, it can lead to excessive wear and tear of the rotator cuff tendon. This in turn can lead to weakening of the tendon and the tendon can break, or rupture, causing a rotator cuff tear.

Some people do not have any symptoms from rotator cuff impingement syndrome and may not realise that they have it until they get a rotator cuff tear.

Rotator cuff tears

Who gets rotator cuff tears?

Rotator cuff tears are most common in people over the age of 40 years.

What causes a rotator cuff tear?

Rotator cuff tears are usually tears in the rotator cuff tendon rather than in the muscles themselves. In younger people, a rotator cuff tear normally happens as a result of trauma (injury) due to a fall or accident. In older people, they are often caused by rotator cuff impingement syndrome. In impingement syndrome, repeated damage to the ‘trapped’ tendon means that the tendon frays, weakens and is more likely to tear.

Rotator cuff tears can be minor/partial or full/complete depending on the degree of damage to the tendon.

What are the symptoms of a rotator cuff tear?

Pain is the most common symptom of a rotator cuff tear. The pain tends to be over the front and outer part of the shoulder. It is worse when your shoulder is moved in certain positions. For example, when your arm is moved above your head on dressing or combing your hair, or moved forwards to reach for something.

Your shoulder or arm can also feel weak and you may have reduced movement in your shoulder. Some people feel clicking or catching when they move their shoulder.

How is a rotator cuff tear diagnosed?

  • History and examination: again, our doctor will usually be able to diagnose a rotator cuff tear by talking to you and examining your shoulder.
  • The ‘drop arm test’: one of the tests that can help to diagnose a rotator cuff tear is called the ‘drop arm test’. If our doctor carries out this test they will ask you to stand with your arm by your side. They will lift your arm outwards from your side and up towards your head. They will then ask you to move your arm back down slowly towards your side. In a rotator cuff tear, you are usually able to lower your arm slowly to 90° but when you try to lower your arm below 90°, it drops quickly to your side because of the tear.
  • Other investigations: occasionally, our doctor may suggest an X-ray of your shoulder or they may refer you for more detailed investigations such as an ultrasound or MRI scan.
  • Referral to a specialist: if our doctor suspects a complete/full tear of your rotator cuff, they may suggest that they refer you to an orthopaedic surgeon (bone and joint specialist).

What are the treatment options for a rotator cuff tear?

  • Painkillers: painkillers such as paracetamol are usually helpful in rotator cuff tears. Occasionally, stronger painkillers may be needed.
  • Anti-inflammatories: our doctor may also suggest that you take regular anti-inflammatories. These are painkillers but they also reduce inflammation and are commonly prescribed. Side-effects sometimes occur with anti-inflammatories. Always read the leaflet that comes with the drug packet for a full list of cautions and possible side-effects.
  • Ice packs: these can also help to reduce pain. A bag of frozen peas is an easy ice pack to use in the home.
  • Physiotherapy: this may be helpful for people with minor rotator cuff tears. Our doctor may refer you to a physiotherapist for advice and shoulder exercises.
  • Injections: sometimes our doctor may suggest injections around your shoulder joint as a treatment for minor tears. The idea is that the injection may help to reduce any inflammation.
  • Surgery: this is sometimes needed in large/complete tears. Surgery usually involves decompression (widening) of the space underneath the acromion and may also include repair of the rotator cuff tendon. The surgery can be done using either a keyhole or an open method.

What is the prognosis (outlook) for rotator cuff tears?

About half of people with rotator cuff tears do well with just conservative treatment. That means the rotator cuff tears heal with treatment including rest, physiotherapy, painkillers, anti-inflammatories and injections. Surgery is needed in the other half in whom this conservative treatment does not work.

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Rotator Cuff Injury

Rotator Cuff Injury

The rotator cuff is a group of four tendons that covers the humeral head and controls arm rotation and elevation. These muscles and their tendons work together with the deltoid muscle to provide motion and strength to the shoulder for all waist-level and shoulder-level or above activities.

Rotator cuff tendonitis is an inflammation of a group of muscles in the shoulder together with an inflammation of the lubrication mechanism called the BURSA. In fact, ‘bursitis’ should not be considered a diagnosis but rather a symptom of rotator cuff tendonitis.

This condition is often caused by or associated with repetitive overhead activities such as throwing, raking, washing cars or windows and many other types of highly repetitive motions. It may also occur as a result of an injury. Rotator cuff injuries are the most common cause of shoulder pain and limitation of activities in sports in all age groups. Rotator cuff tendonitis is the mildest form of rotator cuff injury.

The shoulder has a unique arrangement of muscle and bone. The rotator cuff (which is muscle) is sandwiched between two bones much like a sock lies between the heel and the edge of a shoe. In the same way that repeated walking eventually wears out the sock, the rotator cuff muscles fray with repeated rubbing on the bone. As the muscle begins to fray, it responds to the injury by becoming inflamed and painful. With continued fraying, like a rope, it may eventually tear.

What are the symptoms?

The classic symptoms include a ‘toothache’ like pain radiating from the outer arm to several inches below the top of the shoulder. Pain may also occur in the front and top of the shoulder. It may interfere with sleeping comfortably. It may even awaken people from a sound sleep with a nagging pain in the upper arm.

The symptoms are usually aggravated by raising the arms overhead or in activities that require reaching behind the body, such as retrieving an object from the back seat of a car. Furthermore, reaching behind the back to fasten underclothing or to pass a belt may aggravate the arm and shoulder pain.

A clicking in the shoulder may occur when raising the arm above the head.

What are my treatment options?

A thorough history and physical exam will nearly always lead to a correct diagnosis. X-rays will often show changes on the arm bone where the rotator cuff muscles attach, but an MRI provides the definitive diagnosis. This test clearly shows the muscles and indicates if the muscle is inflamed, injured or torn.

Medical

The following steps should be taken as a conservative approach to treating rotator cuff tendonitis:

  • Stop or markedly decrease the activity that required the use of the shoulder at or above shoulder level.
  • Apply ice to the affected area.
  • Take anti-inflammatory medication to reduce arm and shoulder pain.
  • Begin an exercise program to maintain flexibility.
  • Avoid carrying heavy objects with the affected arm or using shoulder-strap bags on the affected side.

In the early phases, over-the-counter anti-inflammatory medications may provide benefit. However, to allow the inflammation to resolve, it is vital to curtail any repetitive activity and it is equally important to try to keep the elbow below the shoulder level when using the arm.

Daily stretching while in a hot shower is also beneficial. If shoulder pain becomes more severe, prescription strength medication or a cortisone type injection may help.

Cortisone injections can be very effective in the treatment of the pain. When used, injections should be done in conjunction with a home exercise program for flexibility and strengthening, modification of activities and ice. Other pain controlling options include heat, ice, ultrasound and therapeutic message.

For a young patient under the age of 30 and with a first time episode of rotator cuff tendonitis that is treated immediately with the above protocol, the average length of time for rehabilitation is two to four weeks. For those with recurrent episodes of tendonitis and some risk factors, rotator cuff tendonitis may take months to heal and in rare cares may require surgery.

Surgical

If symptoms persist, surgery to remove a spur on the acromion can increase the space available for the inflamed tendon and may prevent further fraying or complete rupture. If an MRI shows a complete muscle injury, surgical repair may be required.

Surgery for recurrent rotator cuff tendonitis (bursitis) is occasionally performed to:

  • Remove a prominence or spur on the undersurface of the acromion.
  • Remove chronically inflamed, thickened and fibrotic bursal tissue.
  • Inspect the tendons and tidy up and sometimes repair a tear in the tendons.

These procedures are often done in combination. This can be done either through an open or an arthroscopic approach with the start of an early rehabilitation program one or two days after surgery and advancing to a more comprehensive program between two and five weeks after surgery. The initiation and progression of these exercises is dependent upon the patient’s findings at surgery, surgical procedure and rate of healing.

What do I need to do the day of surgery?

  • If you currently take any medications, take them the day of your surgery with just a sip of water.
  • Do not wear any jewelry, body piercing, makeup, nail polish, hairpins or contacts.
  • Leave valuables and money at home.
  • Wear loose-fitting, comfortable clothing.

How long is the recovery period after surgery?

The time for complete recovery is variable and can range from two to four weeks for a first-time mild episode treated properly to several weeks or months for chronic or recurrent cases or in people with more extensive surgery.

In most case, a sport specific program can begin four to six weeks after surgery, with a return to competition six to twelve weeks after surgery. This will need to be customized to your situation. Your doctor will tell you what is appropriate for your condition.

What is the rehab after surgery?

Although there is no one set protocol for rehabilitation for rotator cuff tendonitis several principles should be followed:

  1. Regain all passive range of motion first.
  2. Begin strengthening the rotator cuff with the arm by the side.
  3. Add deltoid and shoulder level strengthening when the shoulder is less painful.
  4. Be sure to strengthen the muscles that control the shoulder blade to regain normal smooth shoulder blade motion and strength when the arm is fully elevated overhead. The level of strengthening is dependent upon the individual needs of the person and the physical demands that he or she intends to place on the shoulder as well as the progress made in the initial program.

Before returning to sports, a sport-specific component to the rehabilitation program should be started that includes an initial return to a non-competitive level of sport participation. In the sport-specific rehabilitation, the athlete performs the activity for 25-50 percent effort (duration, frequency and intensity). If the athlete performs well at this level without pain over a few days then the activity can be increased over the next few days in intensity, frequency and duration.

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