The “rotator” cuff is a collective term for a group of four muscles and their associated tendons that join together within the shoulder. These four muscles originate at different points on the shoulder blade and insert into the upper arm bone (humerus) as a common tendon. A healthy rotator cuff gives the shoulder strength, flexibility and stability. Injury to the rotator cuff may result from aging, trauma, repetitive stress or overexertion of a weakened shoulder muscle. Injury to the rotator cuff can result in continuous pain, pain at night, tenderness and the loss of shoulder mobility.
- Rotator cuff tears may occur with or result from other conditions in the shoulder such as: shoulder impingement, tendonitis, shoulder instability and arthritis.
- This injury is more common in adults 40 years or older.
- Non-surgical treatment can be an effective therapy for most cuff injuries.
- A full thickness or large tear may require surgery; the rotator cuff will not repair itself without surgical repair. Younger people, more active people and those that have involvement of their dominant extremity will probably require surgical repair of their cuff tear to restore function and decrease pain.
Signs and Symptoms
- Pain or weakness with overhead arm activities
- The sudden onset of shoulder weakness after a fall or other injury
- The shoulder may “catch” or “grate” when arm is rotated or raised
- Pain at night, especially while sleeping on the shoulder
- May not be able to raise arm
Contact the Doctor if …
- The signs and symptoms indicating a rotator cuff injury are present.
- Non-surgical therapy has failed to control the pain and restore shoulder function.
- You experience unexpected side effects from over the counter or prescription medications.
Common Causes of Injury
- Impingement occurs when the rotator cuff tendon rubs against the acromion bone, as if a tire were rubbing against a fender because the fender was too close. This can cause the tendon to become inflamed.
- Rotator cuff injuries can occur from a sudden violent movement of the shoulder, chronic repetitive motions, aging or overuse.
- A rotator cuff tear occurs most commonly in patients in their mid 50′s to late 60′s and older.
- Sports commonly associated with rotator cuff tears include tennis, swimming, baseball, softball and football.
- Breaking a fall with your arms can cause bruising or even tearing in the tendons of the rotator cuff.
- Lifting heavy objects overhead can stress or cause a tear in the rotator cuff.
- Poor posture may cause a shoulder muscle or tendon to become pinched under the top of the shoulder (acromion) and result in impingement or tearing of the rotator cuff.
Expectations of Recovery
- Small or partial thickness tears may respond to an aggressive rotator cuff strengthening program.
- Full thickness tears, especially large tears, often require surgical repair. Patients are generally able to return to all pre-injury activities within 3-6 months.
- Occasionally, large tears are not repairable. Some of these patients will regain function with debridement of the cuff; however, other patients will not.
Medical Details
The shoulder is a complex and unique joint. Although it provides the most range of motion of any joint in the body, it also has the greatest potential for instability. The muscles which support and stabilize the shoulder literally hold the joint together. Like the hip, the shoulder is formed from a ball and socket design, but the socket is much more shallow in the shoulder. The surrounding muscles, tendons and ligaments provide the additional necessary support for the joint. Any injuries to these structures, such as a rotator cuff injury, directly affect the stability and strength of the shoulder.
Rotator cuff injuries are categorized into four stages based on the severity of the injury.
Stage I: Swelling and Mild Pain
Stage II: Inflammation and Scarring
Stage III: Partial or Complete tears of the rotator cuff
Stage IV: Cuff tear arthropathy. This is severe shoulder arthritis from long-standing cuff disease.
Diagnosis
A detailed history and physical exam should be conducted by an orthopedic surgeon to confirm a rotator cuff tear. Rotator cuff tears, impingement syndrome, frozen shoulder, shoulder arthritis or a nerve injury within the shoulder may present similar symptoms on initial examination. The physical exam may include movement and resistance tests that will help to determine your stability, flexibility and strength and the extent of the rotator cuff injury.
The clinical findings may indicate a rotator cuff tear, but to make an accurate and complete diagnosis, radiographic imaging studies may also be ordered. These tests will provide the physician with highly detailed views of the shoulder’s muscles and tendons. Standard x-rays will be taken of the involved shoulder to evaluate the bones. An MRI (magnetic resonance imaging scan) may also be ordered. The images from the MRI will show if there is inflammation, tears and other conditions or injuries involving the muscles and tendons.
If a rotator cuff tear is confirmed, the physician will discuss surgical versus non-surgical treatment options. If the tear is complete, surgery is usually recommended in the young, active patient. In patients over the age of 60 or with those who are have increased health risks, surgical treatment is suggested only after a careful assessment of the risks vs. the benefits of an operation.
Treatment Options
Most patients with a diagnosed rotator cuff tear will not require surgical treatment. Injuries to the rotator cuff can range from mild tendonitis to a complete tear. Initial treatment for a rotator cuff injury is rest and anti-inflammatory medication, mainly to control pain. While a true rotator cuff tear will not heal, some partial tears may not significantly disrupt shoulder function and may not require a surgical repair. In cases where the tear is severe, surgery should be considered.
- A mild to moderate rotator cuff injury will not require surgery and is commonly treated with non-steroidal anti-inflammatory drugs (NSAIDs), ice packs, rest, and activity modification and participation in physical therapy rehabilitation program.
- The identification of the activity which caused the injury, and the modification of that activity in the future, will help in the healing as well as the prevention of a more severe tear in the future.
- A complete tear in the dominant arm of younger, active patients will probably require surgery. This is because a tear in the rotator cuff will not repair itself.
