Rotator Cuff Impingement
What is the rotator cuff?
The rotator cuff is a group of four tendons that originate on the shoulder blade and attach to the front, back, and top of the head of the humerus (upper arm bone) like a cuff on a shirt sleeve. These tendons are connected to short, but very important, muscles that originate from the scapula. When the muscles contract, they pull on the rotator cuff tendon, causing the shoulder to rotate upward, inward, or outward, hence the name "rotator cuff."
What kind of symptoms does a patient have when the rotator cuff is injured?
The most common complaint is aching located around the shoulder that commonly radiates down the outer side of the upper arm (deltoid area), even to the elbow or hand. Typically, the pain increases when the arm is lifted to the overhead position. Frequently, the pain seems to be worse at night, and may interrupt sleep. Depending on the severity of the injury, there may also be weakness in the arm. With some complete rotator cuff tears, the arm may not be able to be lifted in the forward or outward direction at all.
How is the diagnosis of rotator cuff disease proven?
The diagnosis of rotator cuff tendon disease starts with a careful history and physical examination. An X-ray is utilized to evaluate the anatomy of the bones of the shoulder. An MRI (magnetic resonance imaging) scan is used to evaluate the soft tissue structures surrounding the shoulder including the rotator cuff tendons.
What is the initial treatment for rotator cuff disease and impingement?
If rotator cuff tendinitis or only partial tearing without a full thickness (complete) tear of the rotator cuff tendon is diagnosed, a period of rest coupled with antiinflammatory medicines and physical therapy is initially utilized to decrease the inflammation and improve muscle and shoulder balance. . Application of ice to the tender area three or four times a day for 15 minutes at a time is also helpful. Activities causing the pain can be slowly resumed as the pain dissipates. Sometimes a cortisone injection into the shoulder above the rotator cuff tendon is helpful to relieve swelling and inflammation
What is the second line of treatment if the rotator cuff pain and weakness persists?
If a patient does not respond to nonsurgical treatment, an option may be arthroscopic evaluation of the shoulder. This procedure can often be performed on an outpatient basis, and any minor damage or fraying to the rotator cuff tendon or bursal tissue can be removed. Sometimes the partial rotator cuff tear appears worse at the time of arthroscopic surgery, and requires repair. The repair can be done during the same procedure.
If the rotator cuff is already torn, what are the options?
If the tendon of the rotator cuff has a full thickness (complete) tear, the tendon may need to be repaired surgically. As a result of limited blood supply to the rotator cuff tendons, a complete tear will not heal without surgery. The choice of surgery will depend on the severity of the symptoms, the extent of the tear, and the functional requirements for that shoulder. In younger individuals, repair of the tendon is most often recommended to prevent the tear from getting bigger (propagating). In some older individuals, surgical repair may not be as important. If chronic pain and disability are present at any age, surgical repair of the rotator cuff should be considered.
What will happen if the rotator cuff is not repaired?
It is difficult to predict long term outcomes for patients with complete rotator cuff tears who choose to not have the tendon repaired, because the tendon tear will not heal without surgery. In some patients, physical therapy and rest will allow for the remaining rotator cuff tendons to compensate for the torn tendon. However, for patients with a complete rotator cuff tear, the concern is that the tear will continue to get bigger (propagate), causing increased pain and limited function. In addition, when the tendon is completely torn off of the bone, the rotator cuff muscle begins to weaken (atrophy), and essentially die. If the tear is long standing, sometimes the muscle is too atrophied to repair and surgical options become limited.
How is a major injury to the rotator cuff tendon repaired surgically?
Torn rotator cuff tendons may be repaired with an open or arthroscopic technique. Both techniques repair the torn tendon back to its insertion on the humeral head with heavy grade suture. This suture holds the tendon in its correct position as the bone-tendon interface heals.
How is my shoulder treated after surgery?
Immediately following repair, the shoulder is placed into a sling. The shoulder is kept in the sling at all times for 4-6 weeks to allow for repair to heal. After this initial period, the sling is taken off and passive motion exercise is initiated. Typically, the shoulder is not allowed to move by itself for 8-12 weeks following surgery. After this initial period, active motion and formal therapy may be initiated to begin strengthening the arm and the repaired tendon. Most patients will have a weight bearing restriction for 6 months following surgery. In addition, patients tend to improve in motion, strength, and pain for up to 18 months following surgery.