A rotator cuff is the anatomical name given to the group of tendons and muscles in the head of the shoulder where it connects to the scapula or shoulder blade. The rotator cuff is aptly named, as it is a part of the shoulder that allows for the up, down, back, and forward or rotating movements of the shoulder. When you roll or shrug your shoulders, the tendons of the rotator cuff are expanding and contracting.
The rotator cuff is comprised of four muscles and their tendons which form a "cuff" over the top of the humerus. The rotator cuff not only allows movement, but also helps provide stability to the ball of the shoulder in the joint. In adults, a rotator cuff injury or torn rotator cuff is common.
Either through acute injury such as a fall or chronic injury caused by repetitive motion or strain, the rotator cuff tendons and muscles can become strained or torn. A rotator cuff injury is most common in adults over the age of 40 and is frequently related to work or sports. An individual who performs work above his or her head, such as a painter or construction worker, is susceptible to rotator cuff injury. Similarly, athletes such as tennis players, swimmers, and pitchers commonly experience rotator cuff injuries.
Symptoms of a torn rotator cuff include pain in the shoulder, pain that radiates down the arm, and limited mobility due to pain. Diagnosis of a torn rotator cuff includes a history of symptoms, physical examination, and X-ray or other imaging tests. Non-operative treatment is attempted before surgery in most cases. Restricted use of the arm and a sling, in conjunction with anti-inflammatory medication or steroid injections, are common non-surgical treatments. If the affected area does not recover from the injury with non-operative treatment, or if the problem is chronic and recurring, an orthopedic surgeon may recommend rotator cuff surgery to repair the tendons and muscles.
Rotator cuff surgery is fairly common. Recovery may take several months and usually requires physical therapy and exercises for a short period of time following surgery. Many patients who undergo rotator cuff surgery recover with complete mobility and full use of the affected arm. In some cases, such as with athletes, use may be limited to prevent subsequent injuries.
The rotator cuff is a group of muscles and tendons that attach to the bones of the shoulder joint, allowing the shoulder to move and keeping it stable.
Four major muscles (subscapularis, supraspinatus, infraspinatus and teres minor) and their tendons connect your upper arm bone (humerus) with your shoulder blade (scapula). A rotator cuff injury, which is fairly common, involves any type of irritation or damage to your rotator cuff muscles or tendons, including:
Rotator cuff tendinitis refers to irritation of these tendons and inflammation of the bursa (a normally smooth layer) lining these tendons.
Rotator cuff bursitis occurs when the fluid-filled sac (bursa) between your shoulder joint and rotator cuff tendons can become irritated and inflamed.
A rotator cuff tear occurs when one of the tendons is torn from overuse or injury.
The shoulder joint is a ball and socket type joint where the top part of the arm bone (humerus) forms a joint with the shoulder blade (scapula). The rotator cuff holds the head of the humerus into the scapula and controls movement of the shoulder joint.
The tendons of the rotator cuff pass underneath a bony area on their way to attaching the top part of the arm bone. When these tendons become inflamed, they can become more frayed over this area during shoulder movements. Sometimes, a bone spur may narrow the space even more.
This problem is called rotator cuff tendinitis, or impingement syndrome, and may be due to:
Keeping the arm in the same position for long periods of time, such as doing computer work or hairstyling.
Sleeping on the same arm each night.
Playing sports requiring the arm to be moved over the head repeatedly as in tennis, baseball (particularly pitching), swimming, and lifting weights over the head.
Working with the arm overhead for many hours or days (such as painters and carpenters).
Poor control or coordination of your shoulder and shoulder blade muscles.
Poor posture over many years and the usual fraying of the tendons that occurs with age may also lead to rotator cuff tendinitis.
Rotator cuff tears may occur in two ways:
A sudden or acute tear may happen when you fall onto your arm while it is stretched out, or after a sudden, jerking motion when trying to lift something heavy.
A chronic tear of the rotator cuff tendon occurs slowly over time. It is more likely in those with chronic tendinitis or impingement syndrome. At some point, the tendon wears down and tears.
There are two types of rotator cuff tears:
A partial tear is when a tear does not completely sever the attachments to the bone.
A complete or full thickness tear refers to a through and through tear. It may be as small as a pinpoint or all of the muscle tendon. Complete tears have detachment of the tendon from the attachment site and would not heal very well.
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.
Being an athlete. Athletes who regularly use repetitive motions, such as baseball pitchers, archers and tennis players, have a greater risk of having a rotator cuff injury.
Working in the construction trades. Carpenters and painters, who also use repetitive motions, have an increased risk of injury.
Having poor posture. A forward-shoulder posture can cause a muscle or tendon to become irritated and inflamed when you throw or perform overhead activities.
Having weak shoulder muscles. This risk factor can be decreased or eliminated with shoulder-strengthening exercises, especially for the less commonly strengthened muscles on the back of the shoulder and around the shoulder blades.
Symptoms of a rotator cuff injury are due to the inflammation that accompanies the strain. This inflammation causes swelling, leading to the clinical picture of pain and decreased range of motion. Because the muscles and tendons of the rotator cuff are hidden well below skin level, it may be hard to feel the swelling that accompanies the injury, but that swelling within the small space that makes up the shoulder joint prevents the normal range of motion of the shoulder joint.
Acute rotator cuff tear
Symptoms can be a sudden tearing sensation followed by severe pain shooting from the upper shoulder area (both in front and in back) down the arm toward the elbow. There is decreased range of motion of the shoulder because of pain and muscle spasm.
Acute pain from bleeding and muscle spasm: This may resolve in a few days.
Large tears may cause the inability abduct the arm (raise it out to the side) due to significant pain and loss of muscle power.
Chronic rotator cuff tear
Pain usually is worse at night and may interfere with sleep.
Gradual weakness and decreased shoulder motion develop as the pain worsens.
Decrease in the ability to abduct the arm or move it out to the side. This allows the arm to be used for most activities but the affected person is unable to use the injured arm for activities that entail lifting the arm as high as or higher than the shoulder to the front or side.
Rotator cuff tendinitis
More common in women 35-50 years of age.
Deep ache in the shoulder also felt on the outside upper arm over the deltoid muscle.
Point tenderness may be appreciated over the area that is injured.
Pain comes on gradually and becomes worse with lifting the arm to the side (abduction) or turning it inward (internal rotation).
May lead to a chronic tear: When a rotator cuff tendon becomes inflamed (tend=tendon +itis=inflammation), it runs the risk of losing its blood supply, causing some tendon fibers to die. This increases the risk that the tendon can fray and partially or completely tear.
Not all shoulder pain arises from the shoulder. Sometimes pain from the heart can be referred to the shoulder, and pain from the gallbladder or diaphragm can also be felt in the shoulder region. Pain from a rotator cuff injury is worsened with shoulder movement. If the unexplained shoulder pain is not affected by movement, it is reasonable to seek immediate medical care. If there is concern that the pain is coming from the heart, emergency medical services should be activated (call 911 if available).
If the shoulder pain persists in spite of home care with rest, ice and if tolerated, anti-inflammatory medications like ibuprofen (Advil) or naproxen (Naprosyn).
If shoulder problems (pain) prevent the person from performing routine daily activities or work.
If pain prevents overhead reaching (for example, reaching to get an item in a cabinet above shoulder level).
If the pain prevents playing sports in which an overhead motion is required (for example, throwing, swinging a racquet, or swimming).
It is reasonable to seek emergency medical care if there is worry about a broken bone, if there is numbness or change in sensation in the arm or hand, or if movement in the shoulder is limited.
Most of the time, treatment for rotator cuff injuries involves exercise therapy. Your doctor or a physical therapist will talk with you about specific exercises designed to help heal your injury, improve the flexibility of your rotator cuff and shoulder muscles, and provide balanced shoulder muscle strength. Depending on the severity of your injury, physical therapy may take from several weeks to several months to reach maximum effectiveness.
Other rotator cuff injury treatments may include:
Steroid injections. Depending on the severity of your pain, your doctor may use a corticosteroid injection to relieve inflammation and pain.
Surgery. If you have a large tear in your rotator cuff, you may need surgery to repair the tear. Sometimes during this kind of surgery doctors may remove a bone spur or calcium deposits. The surgery may be performed as an open repair through a 2 1/2- to 4-inch (6- to 10-centimeter) incision, as a mini-open repair through a 1 1/4- to 2-inch (3- to 5-centimeter) incision, or as an arthroscopic repair with the aid of a small camera inserted through a smaller incision.
Arthroplasty. Some long-standing rotator cuff tears over time may contribute to the development of rotator cuff arthropathy, which can include severe arthritis. In such cases, your doctor may discuss with you more extensive surgical options, including partial shoulder replacement (hemiarthroplasty) or total shoulder replacement (prosthetic arthroplasty).
A unique treatment option now available involves the use of a reverse ball-and-socket prosthesis. This reverse shoulder prosthesis is most appropriate for people who have very difficult shoulder problems. These include having arthritis in the joint, along with extensive tears of multiple muscles and tendons (rotator cuff) that support the shoulder, or having extensive rotator cuff tears and a failed previous shoulder joint replacement.
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, a bag of frozen vegetables or a towel filled with ice cubes for 15 to 20 minutes at a time. Do this every couple of hours the first day or two. After about two or three 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 (OTC) nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen (Advil, Motrin, others) or naproxen (Aleve), may help reduce pain. Acetaminophen (Tylenol, others) also may help relieve pain. Follow label directions and stop taking the drugs when the pain improves.
Keep your muscles limber. Try to do some gentle range-of-motion exercises in a pain-free range to keep your shoulder muscles limber. Total inactivity can cause stiff joints. In addition, favoring your shoulder for a long period of time can lead to frozen shoulder, a condition in which your shoulder becomes so stiff you can barely move it. Once your injury heals and you have good range of motion in your shoulder, continue exercising. Daily shoulder stretches and a balanced shoulder-strengthening program can help prevent a recurrence of your injury.