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Rotator cuff injury

Overview

The rotator cuff is a group of muscles and tendons that surround the shoulder joint, keeping the head of your upper arm bone firmly within the shallow socket of the shoulder. A rotator cuff injury can cause a dull ache in the shoulder, which often worsens when you try to sleep on the involved side.

Rotator cuff injuries occur most often in people who repeatedly perform overhead motions in their jobs or sports. Examples include painters, carpenters, and people who play baseball or tennis. The risk of rotator cuff injury also increases with age.

Many people recover from rotator cuff disease with physical therapy exercises that improve flexibility and strength of the muscles surrounding the shoulder joint.

Sometimes, rotator cuff tears may occur as a result of a single injury. In those circumstances, medical care should be provided as soon as possible. Extensive rotator cuff tears may require surgical repair, transfer of alternative tendons or joint replacement.

Rotator cuff injuries

Rotator cuff injuries can range in severity from simple inflammation to complete tears.

Symptoms

The pain associated with a rotator cuff injury may:

  • Be described as a dull ache deep in the shoulder
  • Disturb sleep, particularly if you lie on the affected shoulder
  • Make it difficult to comb your hair or reach behind your back
  • Be accompanied by arm weakness

When to see a doctor

Shoulder pain that is short-lived may be evaluated by your family doctor. See your doctor right away if you have a sudden loss of motion after an injury — you could have a substantial rotator cuff tear. If you have pain lasting longer than a few weeks or you've been formally diagnosed with a rotator cuff tear, you need to be seen by a shoulder specialist, because some of the surgical procedures are time sensitive.

Causes

Rotator cuff disease may be the result of either a substantial injury to the shoulder or to progressive degeneration or wear and tear of the tendon tissue. Repetitive overhead activity, heavy lifting over a prolonged period of time, and the development of bone spurs in the bones around the shoulder may irritate or damage the tendon.

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.
  • Certain sports. Athletes who regularly use repetitive arm motions, such as baseball pitchers, archers and tennis players, have a greater risk of having a rotator cuff injury.
  • Construction jobs. Occupations such as carpentry or house painting require repetitive arm motions, often overhead, that can damage the rotator cuff over time.
  • Family history. There may be a genetic component involved with rotator cuff injuries as they appear to occur more commonly in certain families.

Complications

Without treatment, rotator cuff disease may lead to permanent stiffness or weakness and may result in progressive degeneration of the shoulder joint.

Although resting your shoulder is necessary for your recovery, keeping your shoulder immobilized for a prolonged time can cause the connective tissue enclosing the joint to become thickened and tight (frozen shoulder).

Diagnosis

During the physical exam, your doctor will press on different parts of your shoulder and move your arm into different positions. He or she will also test the strength of the muscles around your shoulder and in your arms.

In some cases, he or she may recommend imaging tests, such as:

  • X-rays. Although a rotator cuff tear won't show up on an X-ray, this test can visualize bone spurs or other potential causes for your pain — such as arthritis.
  • Ultrasound. This type of test uses sound waves to produce images of structures within your body, particularly soft tissues such as muscles and tendons. It allows dynamic testing, assessing the structures of your shoulder as they move. It also allows a quick comparison between the affected shoulder and the healthy shoulder.
  • Magnetic resonance imaging (MRI). This technology uses radio waves and a strong magnet. The images obtained display all structures of the shoulder in great detail. The quality of the images depends greatly on the quality of the equipment used.
MRI of torn rotator cuff

Magnetic resonance imaging (MRI) can reveal the existence and severity of rotator cuff tears.

Treatment

Conservative treatments — such as rest, ice and physical therapy — sometimes are all that's needed to recover from a rotator cuff injury. If your injury is severe and involves a complete tear of the muscle or tendon, you might need surgery.

Injections

If conservative treatments haven't reduced your pain, your doctor might recommend a steroid injection into your shoulder joint, especially if the pain is interfering with your sleep, daily activities or exercise. While such shots are often helpful, they should be used judiciously, as they can contribute to weakening of the tendon.

Therapy

Physical therapy exercises can help restore flexibility and strength to your shoulder after a rotator cuff injury. Sometimes it is possible to eliminate pain and restore function without surgery.

Surgery

Many different types of surgeries are available for rotator cuff injuries, including arthroscopic tendon repair, open tendon repair, bone spur removal, tendon transfer and shoulder replacement.

Arthroscopic tendon repair

In this procedure, surgeons insert a tiny camera (arthroscope) and tools through small incisions to reattach the torn tendon to the bone. Arthroscopic tendon repair can provide restoration of the patient's normal anatomy with a relatively pain-free procedure.

Open tendon repair

In some situations, an open tendon repair may be a better option. In these types of surgeries, your surgeon works through a larger incision to reattach the damaged tendon to the bone. Open tendon repairs typically have a longer recovery time than that seen with more minimally invasive procedures done arthroscopically.

Bone spur removal

If an overgrowth of bone is irritating your rotator cuff, this excess bone can be removed and the damaged portion of the tendon can be smoothed. This procedure is often performed using arthroscopy, where a fiber-optic camera and special tools are inserted through tiny incisions.

Tendon transfer

If the torn tendon is too damaged to be reattached to the arm bone, surgeons may decide to use a nearby tendon as a replacement.

Shoulder replacement

Massive rotator cuff injuries may require shoulder replacement surgery. To improve the artificial joint's stability, an innovative procedure (reverse shoulder arthroplasty) installs the ball part of the artificial joint onto the shoulder blade and the socket part onto the arm bone.

Arthroscopic rotator cuff repair

During an arthroscopic repair of a rotator cuff tendon, the surgeon inserts a tiny camera and tools through small incisions in the shoulder.

Arthroscopic rotator cuff repair

During an arthroscopic repair of a rotator cuff tendon, the surgeon inserts a tiny camera and tools through small incisions in the shoulder.

Open repair of rotator cuff

During an open repair of a rotator cuff tendon, the surgeon works through a large incision to reattach the tendon to the bone.

Reverse shoulder replacement

Reverse shoulder replacement installs the ball part of the artificial joint onto the shoulder blade and the socket part onto the arm bone.

Preparing for an appointment

You'll probably start by seeing your family doctor. If your injury is severe, you might be referred to an orthopedic surgeon. If you've been treated for a similar problem in the past, you may need to bring past records and imaging studies with you to your appointment.

What you can do

Before the appointment, you might want to write a list that answers the following questions:

  • When did you first begin experiencing shoulder pain?
  • What movements and activities worsen your shoulder pain?
  • Have you ever injured your shoulder?
  • Have you experienced any symptoms in addition to shoulder pain?
  • Does the pain travel down your arm below your elbow?
  • Is the shoulder pain associated with any neck pain?
  • Does your job or hobby aggravate your shoulder pain?

What to expect from your doctor

Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your doctor may ask:

  • Where exactly is the pain located?
  • How severe is your pain?
  • What movements and activities aggravate or relieve your shoulder pain?
  • Do you have any weakness or numbness in your arm?

Lifestyle and home remedies

A minor injury often heals on its own, with proper care. If you think you've injured your rotator cuff, try these steps:

  • Rest your shoulder. Stop doing what caused the pain and try to avoid painful movements. Limit heavy lifting or overhead activity until your shoulder pain subsides.
  • Apply ice and heat. Putting ice on your shoulder helps reduce inflammation and pain. Use a cold pack for 15 to 20 minutes every three or four hours. After a few days, when the pain and inflammation have improved, hot packs or a heating pad may help relax tightened and sore muscles.
  • Take pain relievers. Over-the-counter pain relievers such as ibuprofen (Advil, Motrin IB), naproxen sodium (Aleve) or acetaminophen (Tylenol, others) may be helpful.

Prevention

If you are at risk of rotator cuff injuries or if you've had a rotator cuff injury in the past, daily shoulder stretches and strengthening exercises can help prevent future injury.

Most people exercise the front muscles of the chest, shoulder and upper arm, but it is equally important to strengthen the muscles in the back of the shoulder and around the shoulder blade to optimize shoulder muscle balance. Your doctor or a physical therapist can help you plan an exercise routine.

Rotator cuff exercises

Exercises that involve pressing your arm against a wall can help strengthen the muscles that make up your rotator cuff. With your elbow at a 90-degree angle, put the palm of your hand on the side of a wall or door frame that's in front of you (A). Place a folded towel between your side and upper arm. Your goal is to keep the towel there as you press your palm against the wall or doorframe for several seconds. For the second exercise, keep the towel in place (not shown) and shift your body so that you're standing next to a wall (B). With your elbow at a 90-degree angle, press your elbow and forearm against the wall for several seconds. Repeat each exercise 10 times for five sets.

Last updated: June 28th, 2016

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