The rotator cuff is composed of four muscles that come together and form one tendon called the rotator cuff. This thick tendon covers and stabilizes the shoulder joint. Problems may occur when one or more tendons of the rotator cuff tear or become inflammed from overuse or injury.
The shoulder is a ball-and-socket joint. Most ball and socket joints are constructed of a large socket into which the ball fits nicely. This is a very stable type of joint.
The shoulder joint, on the other hand, is made up of a ball which is larger than the socket. This is not a very stable type of joint. Because of this large ball and small socket, the shoulder is easily injured. To remain stable, the shoulder must be anchored by its muscles and tendons.
The shoulder joint is composed of three bones:
1. Clavicle (collarbone)
2. Scapula (shoulder blade)
3. Humerus (upper arm bone).
The bones of the shoulder joint are held in place by muscles and tendons.
Tendons are tough cords of tissue that attach the shoulder muscles to bone and assist the muscles in moving the shoulder. The rotator cuff is a structure composed of tendons that work along with associated muscles to hold the ball at the top of the arm (humerus) in the shoulder socket; it provides mobility and strength to the shoulder joint.
Muscles are bundles of specialized tissue that attach to, and move bones via their tendons.
The Muscles that make up the rotator cuff are:
Click here for more information about shoulder anatomy.
The most common rotator cuff injury is a tear of one or more of the tendons that make up the rotator cuff. Rotator cuff tears occur in many shapes and sizes, but can be thought of as a hole in one of the tendons around the shoulder joint.
The two most common causes of rotator cuff tears are:
- Repetitive or Over Use Injury
In this type of injury to the rotator cuff, repeated activities cause damage to the rotator cuff tendons. Over time, the tendons wear thin and a rotator cuff tear can develop within the tendons.
- Traumatic Injuries
Traumatic injuries to the rotator cuff are usually seen after falling on an outstretched arm and hand. The traumatic event can cause a rotator cuff tear by injuring the rotator cuff tendons. This type of injury is much less common than repetitive use injuries.
Who is most susceptible to a rotator cuff tear?
Rotator cuff tears are seen in young and old people alike, but they are more common in adults over 60 years of age. As people age, the muscle and tendon tissues of the rotator cuff lose some elasticity. When muscles and tendons become less elastic, their ability to stretch is reduced, and they become more susceptible to tears.
Symptoms of a rotator cuff tear may develop acutely (quickly) or have a more gradual onset. Acute pain usually follows trauma such as a lifting injury or a fall on the affected arm. More commonly, the onset is gradual and may be caused by repetitive overhead activity or by wear and degeneration of the tendon.
Typically, a person with a rotator cuff injury feels pain over the deltoid muscle at the top and outer side of the shoulder, especially when the arm is raised or extended out from the side of the body. Motions like those involved in throwing a ball, swimming, or even getting dressed can be painful.
At first, the pain may be mild and only present with activities. It may be relieved by over-the-counter medication such as aspirin or ibuprofen. Over time, however, the pain may become noticeable even when at rest or with no activity at all.
Other symptoms may include:
The shoulder may feel weak, especially when trying to lift the arm into a horizontal or overhead position.
Stiffness. When the should is painful we have a tendency not to move it. Lack of movement leads to stiffness in the shoulder joint.
A person may feel or hear a click or pop when the shoulder is moved.
Most people with tears of the rotator cuff complain of difficulty sleeping on the shoulder at night.
Diagnosis of a rotator cuff tear is based on the symptoms present, the doctor's examination, X-rays, and imaging studies such as MRI (magnetic resonance imaging).
Other commonly used tests to diagnose a rotator cuff tear are:
An Arthrogram at one time was the most commonly used test to diagnose a rotator cuff tear. In this study a dye that shows up on x-ray is injected into the shoulder joint. An intact rotator cuff should contain the dye within the joint, while a rotator cuff tear will allow the dye to leak into surrounding tissues. By taking an x-ray after an injection, your doctor can see evidence of a rotator cuff tear.
Ultrasound Scanning can be effective in detecting a rotator cuff tear. Ultrasonic waves are used to visualize soft tissues and to detect abnormalities which may be present.
Rotator cuff tears do not heal well with time. They tend to either enlarge, or, at best, stabilize in size. The good news is rotator cuff tears do not necessarily need to heal in order for the symptoms to resolve. Many people have rotator cuff tears, but no symptoms of shoulder pain. Therefore, the goal of treatment of a rotator cuff tear is to relieve the symptoms, not necessarily heal the tear. Many people respond well to conservative treatment and never require surgery.
Conservative Treatment (Initial Treatment):
Conservative treatment options may include:
- Rest and limited overhead activity.
- Use of a sling.
- Physical therapy is the most important step in the treatment of a rotator cuff injury. Strengthening the rotator cuff muscles is important to maintain normal shoulder function.
- Anti-inflammatory medications are helpful in controlling the symptoms of a rotator cuff tear. Simple anti-inflammatory medications can be taken regularly for a short period, and then be used when symptoms of a rotator cuff tear flare up.
- Cortisone injections can be helpful in reducing inflammation and pain, thus and allowing the person to begin therapy. It is important to participate in the therapy and exercises even if the shoulder feels better after an injection.
It may take several weeks or months to relieve the pain and restore strength and mobility to your shoulder.
The above conservative measures may not be effective for everyone. In general, conservative therapy is first attempted, especially in older patients or in patients who have chronic (long-standing) injuries. In younger patients who have an acute, traumatic injury, sometimes surgery is considered early as the likelihood that conservative treatment will help is low. Surgery is also considered in patients who have tried conservative treatment, and still have difficulty with their shoulder.
There are several surgical procedures that are performed to repair the rotator cuff. The type of surgery performed depends on the size, shape and location of the tear. The three most common procedures are:
Open Repair or a traditional open surgical incision is often required if the tear is large. The advantage is the rotator cuff tendons are easily seen by this method, but the incision is large, and the recovery can be longer and more painful.
Arthroscope Repair is done with small incisions, and the repair is done by the surgeon looking through a small camera to watch his or her repair on a television monitor; however, not all types of tears can be treated by this method.
Mini-Open method of repairing a rotator cuff involves both the use of an arthroscope, and a short incision to get access to torn tendon. By using the arthroscope, the surgeon can also look into the shoulder joint to clean out any damaged tissue or bone spurs. The incision is about 3-4 cm, and the recovery is somewhat less involved than with the open cuff repair.
People with shoulder pain have also found these products to be effective: