The rotator cuff is an intricate group of four small tendons that regulate movement of the shoulder. The four tendons are:
4. Teres minor.
The purpose of these four tendons are to maintain the position of the humeral head (ball) on the glenoid (socket) of the shoulder during movement. These deep tendons around the shoulder are referred to as postural muscles. A postural muscle is one which is active with many fine and mundane movements in normal life. In contrast, the deltoid muscle provides power and strength to the shoulder and is primarily active with more strenuous movements. There are two types of rotator cuff tears: Degenerative and traumatic. While the rotator cuff does not directly contribute to power movements of the shoulder, significant damage to the rotator cuff leads to an “uncoupling” of the powerful deltoid from the shoulder joint.
Since the rotator cuff is involved in so many aspects of shoulder and arm use, it is vulnerable to wear and tear as we age, even from routine everyday use. The simplest issue involving the rotator cuff is shoulder bursitis, which involves inflammation of the bursa that lies on top of the rotator cuff. The purpose of the bursa is to cushion, lubricate and provide nutrition to the rotator cuff tendon. Since the bursa is very rich in nerve endings, inflammation of the bursa can be quite painful. The same activities that can irritate the rotator cuff can also irritate the bursa, which tends to be a little more prone to irritation than the rotator cuff tendon itself. Often, however, if not appropriately addressed, shoulder bursitis can be a precursor to development of rotator cuff tendonitis or even degenerative tearing. Fortunately, bursitis can be treated with nonsurgical means.
Rotator cuff tendonitis is inflammation of the tendon itself, often following a prolonged course of bursitis. This can be a more tenacious problem than bursitis but still typically does not require surgery for successful treatment. Rest, physical therapy and anti-inflammatory medications (either oral or injected) are typically successfully employed to treat these issues. While surgery is occasionally necessary, this is not the norm in our office as our nonsurgical options have a high rate of long-term success.
Degenerative tears occur over one’s lifetime. Two people with similar activities, compared side to side over time, may develop tears in their tendon at vastly different periods in their life. These differences are largely due to health and genetics. Certainly, prolonged strenuous use of the shoulder can make these tears more likely. Additionally, bone spurs in the shoulder can mechanically damage the tendon over time. However, this phenomenon, known as external impingement, is less common than previously thought. Degenerative tears occur over time and may not always be symptomatic initially. Frequently these types of tears can be successfully treated with rest, physical therapy and injections, or a combination of these measures. Surgical repair is a reasonable option for degenerative tears that don’t respond to nonsurgical measures. Surgery is typically done in an outpatient setting and done arthroscopically. Often, other minor issues which typically may not otherwise require surgery, such as arthritis, bone spurs and bursitis, are addressed at the same time as the rotator cuff.
Conversely, traumatic tears occur suddenly, with injury. Violent pulling of the arm, falling onto the shoulder and other types of trauma can cause the rotator cuff to acutely tear. These result in pain and sudden loss of the ability to raise the arm away from the body. These typically have a narrow window of several weeks during which they can be repaired with the best results. Beyond this window, the tendon quality and ability to heal can become impaired.
Common symptoms of rotator cuff problems include pain with reaching, painful clicking in the shoulder, and difficulty performing strenuous or athletic activities, especially throwing. Loss of strength holding the arm away from the body can occur as can pain radiating down the arm, not necessarily at the shoulder itself. Arm pain at night is also strongly associated with rotator cuff disease.
Physical therapy is highly effective for rotator cuff disease when targeted to the particular parts of the shoulder that is affected. Oral anti-inflammatory medications may be recommended. Additionally, cortisone injections can be quite helpful as a part of treatment but are used on a repeated basis only in specific settings. Regenerative medicine, particularly PRP injections can be effective in select types of rotator cuff issues.
If surgery is recommended, this is typically done arthroscopically and in an outpatient setting. While this is not a long or overly risky procedure, the recovery can take some time since the rotator cuff is a slow healing tendon. Recovery from rotator cuff surgery can take several months and involves extensive physical therapy. Depending on the physical demands of your job, some time off work may be necessary. However, success rates of arthroscopic rotator cuff repair are very high and the vast majority of people return to previous activities including golf, tennis and other more vigorous activities with appropriate postoperative guidance. We will continue to follow and guide you until you’ve reached that point.