The Normal Rotator Cuff
The rotator cuff consists of four muscles: the supraspinatus, infraspinatus, teres minor, and subscapularis. Generally, the supraspinatus muscle is located superiorly, the infraspinatus and teres minor are located posteriorly, while the subscapularis muscle is anterior in position. In 95% of rotator cuff tears, the supraspinatus tendon is involved.
Injuries to the Rotator Cuff
The most common complaint is shoulder pain. In patients over the age of 40, shoulder pain most likely is related to rotator cuff injury. Younger patients may also be affected. These patients are usually involved in activities occurring with repetitive overhead movements. There are two potential intrinsic causes of rotator cuff pain. These include mechanical origins when a portion of the tendon catching under the acromion (bony arch of shoulder), and biological causes such as synovitis. Synovitis is painful because the bursa sac has 20 times the number of nerve endings present in the rotator cuff tendon. Inflammation of the bursa that is positioned superior to the rotator cuff, and it causes pain when it is compressed. This produces signs of rotator cuff impingement.
Making the Diagnosis
The practitioner will first obtain a proper history of the patient's shoulder pain or weakness. Important information consists of the onset of the symptoms, if there was a specific injury, the duration of the symptoms, the location of the symptoms, and prior medical health conditions. Previous treatment modalities should also be discussed. This may include physical therapy, anti-inflammatory medications or an intra-articular injection of cortisone. Patients often complain of shoulder pain that awakens them at night, increases with heavy pushing or pulling, or increases with overhead activities. Some patients may report weakness, stiffness, and catching.
On physical examination, pain is elicited through the arch of impingement from 60 to 120 degrees of abduction and flexion. There may also be pain at extremes of motion. When testing muscle strength, there is generally pain and/or weakness in abduction or forward flexion. Positive Neer and Hawkins signs may suggest rotator cuff impingement.
X-rays may be obtained to evaluate for arthritis located at the glenohumeral (ball and cup) or acromioclavicular (shoulder blade and collarbone) joint. There also may be a downward sloping acromion (bony arch) that pinches the rotator cuff space. MRI evaluation may be warranted to examine the rotator cuff in detail. There may be subtle arthritic changes, bursitis, and rotator cuff injuries evident. MRI usually confirms the diagnosis of impingement, tendonopathy, and rotator cuff tears.
After Diagnosing Rotator Cuff Injury
Rotator cuff impingement and bursitis may be treated conservatively with stretching and strengthening exercises, anti-inflammatory medications, and ice. If conservative treatment fails after an appropriate length of trial, then surgery is considered.
The natural history of rotator cuff tears includes the inability to heal itself. Once the rotator cuff is injured, the damage will only get worse with time. Conservative methods may treat the patient's symptoms but will mask the underlying pathology. To address the primary condition, surgery is required.
The Surgical Procedure
Surgical intervention for impingement and bursitis includes a diagnostic arthroscopy, rotator cuff decompression (opening up the rotator cuff space), or distal clavicle resection (excising the outer end of the collarbone). In addition, if there is a rotator cuff tear, this is repaired using either sutures and/or anchors through an arthroscopic approach.
The Day of Surgery
Surgery is an outpatient procedure. The operated arm is placed in an immobilizer for the patient's protection. The length of time in the immobilizer varies with how large of repair was completed. A dressing and ice is applied to the incision site. Ice is important to help reduce swelling of the shoulder.
The patient returns home and is advised to schedule light with any activities. The patient will been seen in the office for a post-operative visit around 10 to 14 days following surgery. At this time, the incisions are checked and range of motion evaluated. Physical therapy ideally would start within 48 hours after surgery. The initiation of therapy is vital to the following recovery process.
Patients are in formal physical therapy for the next several weeks after surgery with the length depending on how quickly the patient's recovery is progressing. Initially, the patient will attend therapy 2 to 3 times a week; however, most of the shoulder rehabilitation exercises are completed on your own at home.
Once the patient is able to complete the therapy exercises on his or her own, then he or she will continue the stretching and strengthening exercises at home for the next several months.
Article by Paul A. Nitz, M.D.