Rotator cuff injuries

Rotator cuff injuries are one of the most common types of shoulder injury. The rotator cuff is the name given to a group of four muscles and their tendons, which form a supportive cuff around the shoulder joint. Rotator cuff injuries refer to irritation, inflammation, or a tear to any of these muscles or tendons.

The shoulder

The shoulder is a very mobile joint in your body. It is a ball-and-socket joint - the top bone of your arm, known as the humerus, is ball-shaped and fits into the socket of the shoulder bone (scapula). The joint is surrounded by a fibrous capsule that helps to hold all the parts of your joint together. The rotator cuff attaches around the shoulder joint to provide support and control shoulder movements. The rotator cuff comprises four muscles (and their tendons):

• Supraspinatus;
• Infraspinatus;
• Teres minor, and;
• Subscapularis.

The front view of a shoulder joint. 

Many shoulder issues tend to involve the rotator cuff, such as inflammation, also known as tendonitis, tears, and impingement syndrome. As we get older our tendons lose strength and flexibility, so repetitive movements and overuse can lead to inflammation, pain and a reduced range of movement.

Causes

Rotator cuff injuries are very common and the causes include:

• Pulling or lifting a heavy weight, especially in a jerking motion;
• Falling onto your outstretched hand;
• Receiving a blunt impact, such as during a football tackle or in a bad fall;
• Continuing to use an already inflamed tendon, especially in sudden forceful movements;
• Repetitive movements, such as sawing wood;
• Awkward physical movements, such as painting a ceiling;
• Poor posture at work or rest, putting tendons under strain;
• Activities using repetitive overhead action such as bowling, tennis or volleyball, and;
• As you age, bone spurs can form within your shoulder causing further restriction and irritation to your tendons. These usually require surgical intervention.

Signs and symptoms

Rotator cuff disorders usually cause weakness and pain, especially when attempting to lift your arm or reach above your head. The level of pain and weakness will depend on your specific injury.

It is possible to have a full or partial rotator cuff tear and not be aware of it, as symptoms can be confusing. The severity of symptoms do not necessarily match the severity of the injury. Smaller or partial tears can be incredibly painful, while full tears can sometimes cause little or no pain. Always get medical attention if you think you have injured yourself, even if you are unsure.

Signs of rotator cuff injury can include the following:

• Pain, often in the front part of your shoulder and arm;
• Weakness and inability to reach your arm behind your back, above your head, or lift or pull any weight;
• Being unable to lie or sleep on the affected shoulder;
• Deep, aching or throbbing pain that is worse with activity and better with rest;
• Pain that gets worse at night and makes it difficult to sleep;
• Clicking or popping sounds when you move the affected shoulder, and;
• Fear of moving the affected shoulder, preferring to keep it still.

Methods for diagnosis

Your doctor will take a full medical history and do a physical examination of your shoulder to find out what is causing your pain. The type of work you do, your age and how active you are will all be taken into consideration when seeking a diagnosis.

Musculoskeletal examination

Your doctor may ask you to perform a number of gentle arm movements, to check the range of movement in your shoulder. These movements will involve using each of the different muscles and tendons in your shoulder in a slow, methodical fashion. Quite often these tests are enough to diagnose where your pain is coming from.

Imaging tests

If the cause of your shoulder pain is still unclear you may have one of the following procedures:

• An ultrasound, which is a scan that uses high-frequency sound waves to produce images of your body's internal structures. Ultrasound is very useful in assessing soft tissue injuries of the shoulder, including rotator cuff injuries;
• An X-ray, which uses ionizing radiation to create an image of the bones in the shoulder joint;
• A computerized tomography (CT) scan, which sends X-ray beams from multiple angles using a machine that circles your body, and;
• Magnetic resonance imaging (MRI), which is similar to a CT scan, but uses magnetism and radio waves, instead of X-rays, to create an image of the body composed of multiple cross-sections that can be used to identify tissue damage. MRI and CT may be used in some circumstances for shoulder injury to provide more detailed images of bones and soft tissues.

Types of treatment

The majority of rotator cuff injuries can be treated at home without the need for surgery or medical intervention. However, if you have a full tear, you will probably need surgery to repair this.

Home care

A range of home-care measures can be used to treat rotator cuff injuries, including the following:

• Ice or heat packs - these can provide immediate relief from some types of pain, but experiment to see which one works best for you or seek advice from your doctor or physiotherapist regarding the most appropriate for your situation. Icepacks should not be placed directly on your skin, as they may cause nerve damage. First wrap the ice pack in a towel and only use for 10 minutes each time;
• Avoiding triggers - if you have an injury or inflammation due to overuse, the best remedy is to avoid that action until you have healed;
• Pain-relief medication - many types of shoulder pain will respond well to pain-relief medication such as ibuprofen or acetaminophen. To avoid stomach upsets, do not take ibuprofen or other anti-inflammatory medication on an empty stomach, and;
• Exercise and stretching - not using your shoulder can result in decreased muscle mass and further stiffness. Your doctor or physiotherapist can advise you on how to gently exercise your shoulder and increase blood flow to the area.

A shoulder sling and an icepack are used to treat a rotator cuff injury. 

Shoulder injections

These injections use hydrocortisone, a corticosteroid, and/or local anesthetic to provide relief from inflammation and pain. They tend to be injected directly into the area that is most inflamed, allowing movement to return. Injections are only considered if rest and home care have not helped.

Physiotherapy

A physiotherapist is an expert in how muscles work and, in particular, how to rehabilitate them after an injury or sprain. They can assess the condition of your muscles, tendons and ligaments, then design exercise programs to strengthen them. Strapping your muscles with special tape may help keep your shoulder in place, reducing further injury while you recover. Your physiotherapist can teach you exercises and stretching techniques, which you can then use at home.

Surgery

Certain rotator cuff injuries, particularly tears and/or impingement syndrome, may require surgery. These are usually performed under a general anesthetic. They are increasingly being performed using arthroscopy, which uses small incisions to allow a camera and fine surgical instruments to perform the procedure, or mini-open repairs, which use slightly longer incisions to directly perform the procedure. Your surgeon can discuss the benefits and risks of these procedures.

Potential complications

If you have long-term tendon problems, it may lead to arthritis in the affected joint. In some cases this can result in the need for surgery. Depending on the level of degeneration, you may be offered a joint replacement. In milder cases, arthroscopy and debridement of the existing bone surfaces may be helpful, where spurs or rough areas are shaved off, to smooth the joint surface.

Prognosis

Rotator cuff injuries need to be properly assessed and treatment options followed, otherwise you may have reduced movement or use of the joint. Severe rotator cuff injury can result in a reduced range of motion and ongoing disability. Avoiding trigger factors such as repetitive, irritating movements is an essential part of your ongoing management of this condition.

Prevention

Some prevention measures include the following:

• Protect your shoulders in your day-to-day activities to help you avoid injury and damage;
• Do gentle stretching exercises daily, to maintain flexibility in your shoulders;
• Avoid activities that aggravate your shoulders, especially overhead lifting;
• Rest the affected joint as soon as symptoms return;
• Wear appropriate padding if involved in high-impact sports;
• Maintain good posture, sit upright and use an ergonomic work station;
• Try to stay flexible through exercise. Tai chi or yoga may help you to maintain smooth movement in your shoulders, and;
• Ask your physiotherapist to suggest specific exercises for your condition, to help you to avoid further injury.