Shoulder Pain and the Rotator Cuff
Shoulder Pain and the Rotator Cuff
Richard B. Jones, M.D.
Sports Medicine Orthopaedic Surgeon
1. What is the rotator cuff in the shoulder?
The rotator cuff is a group of four muscles that help you to do certain motions and activities with your shoulder. Without a properly functioning rotator cuff, you may experience pain, weakness, and have difficulty performing certain activities. The 4 muscles have flat tendons that fuse together and surround the front, back, and top of the shoulder joint like a cuff on a shirtsleeve. These tendons are connected individually to short, but very important, muscles that originate from the scapula. These muscles are the supraspinatus, infraspinatus, teres minor, and subscapularis. When the muscles contract, they pull on the rotator cuff tendon, causing the shoulder to rotate upward, inward, or outward, hence the name "rotator cuff."
2. What is impingement syndrome?
The uppermost tendon of the rotator cuff, the supraspinatus tendon, passes beneath the bone on the top of the shoulder, called the acromion. In some people, the space between the undersurface of the acromion and the top of the humeral head is quite narrow. The rotator cuff tendon and the adherent bursa, or lubricating tissue, can therefore be pinched when the arm is raised into a forward position. With repetitive impingement, the tendons and bursa can become inflamed and swollen and cause the painful situation known as "chronic impingement syndrome."
3. How does impingement syndrome relate to rotator cuff disease?
When the rotator cuff tendon and its overlying bursa become inflamed and swollen with impingement syndrome, the tendon may begin to break down near its attachment on the humerus bone. With continued impingement, the tendon is progressively damaged, and finally, may tear completely away from the bone.
4. Why do some people develop impingement and rotator cuff disease when others do not?
There are many factors that may predispose one person to impingement and rotator cuff problems. The most common is the shape and thickness of the acromion (the bone forming the roof of the shoulder). If the acromion has a bone spur on the front edge, it is more likely to impinge on the rotator cuff when the arm is elevated forward. Activities that involve forward elevation of the arm may put an individual at higher risk for rotator cuff injury. Sometimes the muscles of the shoulder may become imbalanced by injury or atrophy, and imbalance can cause the shoulder to move forward with certain activities that again may cause impingement. The classic slumped, poor posture position causes rounded shoulders and a stiff, curved middle back. This causes the ball to not move properly in the socket and often contributes to pinching of the rotator cuff. Poor biomechanics, falls, and improper weight lifting techniques can also contribute to shoulder problems.
5. Other than impingement, what else can cause rotator cuff damage?
In young, athletic individuals, injury to the rotator cuff can occur with repetitive throwing, overhead racquet sports, or swimming. This type of injury results from repetitive stretching of the rotator cuff during the follow-through phase of the activity. The tear that occurs is not caused by impingement, but more by a joint imbalance. This may be associated with looseness in the front of the shoulder caused by a weakness in the supporting ligaments.
6. What kind of symptoms does a patient have when the rotator cuff is injured?
The most common complaint is aching located in the top and front of the shoulder, or on the outer side of the upper arm (deltoid area). The pain is usually increased when the arm is lifted to the overhead position. Frequently, the pain seems to be worse at night, and often interrupts sleep. Depending on the severity of the injury, there may also be weakness in the arm and, with some complete rotator cuff tears, the arm cannot be lifted in the forward or outward direction at all. A pinching or catching sensation in the front/top of the shoulder while reaching is another common complaint.
7. How is the diagnosis of rotator cuff disease proven?
The diagnosis of rotator cuff tendon disease includes a careful history taken and reviewed by the physician, an x-ray to visualize the anatomy of the bones of the shoulder, specifically looking for bone spurs, and a physical examination. Atrophy may be present, along with weakness, if the rotator cuff tendons are injured, and special impingement tests can suggest that impingement syndrome is involved. An MRI (magnetic resonance imaging) scan frequently gives the final proof of the status of the rotator cuff tendon. Although none of these tests is guaranteed accurate, most rotator cuff injuries can be diagnosed using this combination of exams.
8. What is the initial treatment for rotator cuff disease and impingement?
If minor impingement or rotator cuff tendonitis is diagnosed, a period of rest coupled with medicines taken by mouth, and physical therapy will frequently decrease the inflammation and restore the tone to the atrophied muscles. Activities causing the pain should be slowly resumed only when the pain is gone. Sometimes your physician will give a cortisone injection into the bursal space above the rotator cuff tendon to help relieve swelling and inflammation. Application of ice to the tender area three or four times a day for 15 minutes is also helpful.
9. What is the second line of treatment if the rotator cuff pain and weakness persist?
If there is a thickened acromion or acromial bone spur causing impingement, it can be removed with a burr using arthroscopic visualization. This procedure can often be performed on an outpatient basis, and at the same time, any minor damage and fraying to the rotator cuff tendon and scarred bursal tissue can be removed. Often this will completely cure the impingement and prevent progressive rotator cuff injury.
10. If the rotator cuff is already torn, what are the options?
When the tendon of the rotator cuff has a complete tear, the tendon often must be repaired. The choice of surgery, of course, depends on the severity of the symptoms, the health of the patient, and the functional requirements for that shoulder.
If you are experiencing any of the symptoms mentioned above, you should contact your regular physician. He or she will evaluate your condition and may recommend physical therapy. The staff of Southeastern Sports Medicine is uniquely qualified to help treat all types of shoulder problems. Ask your physician if physical therapy is right for you.
Richard B Jones, M.D.
Southeastern Sports Medicine
828-274-4555