Rotator Cuff Disorders

Cause

In a rotator cuff disorder, tendons that make up the rotator cuff get squeezed and rub against bone. They become damaged and irritated. This causes bleeding and inflammation. The tendons can develop scar tissue, which is not as strong and flexible as normal tendon tissue. Over time, the tendons get weaker and less flexible. Eventually, they can tear.

Normal wear and tear and overuse cause most rotator cuff problems.

It takes great force to tear a healthy rotator cuff tendon. This can happen during sports, an accident, or a severe fall. But even a simple movement like lifting a suitcase can cause a rotator cuff tear in an older adult or someone whose shoulder is already damaged.

Symptoms

A rotator cuff disorder causes pain and weakness in your shoulder. It may be uncomfortable or impossible to do everyday activities, such as combing your hair, tucking in your shirt, or reaching above your head.

Most often, you will feel the pain on the side and front of your upper arm and shoulder. You may have pain during the night and have trouble sleeping on that side. Pain is almost always worse when you make overhead movements.

Because of the pain, you may try not to use your arm. And that can cause even more weakness and stiffness in the shoulder.

The amount of pain usually depends on how much damage there is:

• Minor damage. Pain most often occurs only when you are active and is usually relieved with rest.
• Moderate damage. You will likely notice pain both during and after activity. Pain may also occur at night, especially when you lie on your shoulder.
• Severe damage. You may have continuous pain.

Sometimes the pain isn't directly related to the amount of damage. For example, your rotator cuff may have minor damage, but strength and the loss of range of motion may be severe because it's too painful to move in certain ways. This is especially true if you normally make a lot of overhead movements.

Symptoms of rotator cuff tendinitis

In tendinitis (inflammation in the tendon), the pain usually starts gradually, over the side of the shoulder and the upper arm.

• Your shoulder and arm aren't particularly weak but it hurts to use them.
• The pain may spread down the outside of the upper arm, even to the elbow.
• The pain may be worse at night and may keep you awake, especially if you lie on that side.
• Lifting the arm to the side or to the front makes the pain worse.

Over time, the pain may get worse or you may have constant pain. In some cases, this is because you actually have one or more small tendon tears.

Some people also have tendinitis in other parts of the shoulder. And some people have neck pain from using other muscles to help move the shoulder.

Symptoms of rotator cuff tears

The most common symptoms of a tear are:

• Pain when you move your arm, especially overhead or against resistance.
• Pain at night.
• Weakness in your shoulder, although some people don't notice any weakness if the tear is small.

Symptoms of a sudden, severe tear include:

• A popping sound or tearing sensation in your shoulder.
• Immediate pain in your shoulder.
• Weakness and pain when you lift or rotate your arm.
• Limited range of motion and inability to raise your arm because of pain or weakness.
• Possibly, bruising in your shoulder or upper arm.

You can have a complete tear without symptoms, especially if you are an older adult who is not very active.

In rare cases, shoulder pain may be a sign of a more serious problem with your heart or lungs.

What Happens

The rotator cuff is a group of four tendons. These tendons connect the main muscles of the shoulder to the upper arm. The tendons and muscles stabilize the shoulder joint so you can raise and rotate your arm. Every time you raise your arm above your head, the upper tendon glides under the upper end of your shoulder blade.

Sometimes the shoulder blade is rough or abnormally shaped and rubs or scrapes the tendon. Over time, this can cause tiny tears and bleeding. When these tears heal, the scar tissue is weaker and less flexible than normal tendon, so the whole rotator cuff gets weaker. The weaker the tendon becomes, the greater its chances of tearing.

Without treatment, this cycle of inflammation, wear and tear, and limited use can lead to other shoulder problems, such as stiffness or frozen shoulder. Activities that require repeated overhead arm movements can lead to problems like bursitis and tendinitis.

Here are the things that can gradually lead to rotator cuff problems. They often occur together or overlap:

• Irregularly shaped bones. These can affect how the rotator cuff moves. You may be born with these irregularities, or they may occur after some type of injury, such as a broken bone.
• Aging. As you age, everyday activities and normal wear and tear lead to some changes in the rotator cuff, such as:
  • General thinning, fraying, and tearing of the tendon.
  • Reduced blood supply to the tendons.
• Joint looseness and muscle imbalance in the shoulder. This can damage tissue.
• Repetitive activities. Repeated activities, especially forceful overhead motions, are common in certain sports or occupations, including throwing a baseball, the overhead swing in tennis, swimming, lifting, or painting. These motions can eventually lead to tendons scraping against bone (impingement).
• Overuse. This may occur with or be closely related to repetitive activities. Normal motions made often over a long period can stress or injure rotator cuff tissues. Athletes, including young people, may get tendinitis from overuse in throwing, swimming, and racquet sports.

Sudden tears

It takes tremendous force to tear a healthy rotator cuff tendon. This may happen while you are playing sports or during an accident or a severe fall.

In older, less active adults, even simple movements such as lifting a suitcase can cause a tear.

What Increases Your Risk

Things that may increase the risk of rotator cuff disorders include:

• Aging.
• Having long-standing rotator cuff tendinitis.
• Holding or moving your arm overhead frequently, such as when you regularly paint; work as a waiter; or play tennis, baseball, and other throwing sports.
• Previous shoulder injuries, such as dislocations and broken bones.
• Having a rotator cuff tear in the other shoulder.
• Irregularities of the muscles, tendons, and bones in the shoulder that increase wear on the rotator cuff tendons.
• Having received multiple corticosteroid injections in the shoulder, which may weaken tendons and increase your risk.
• Smoking, which decreases the blood supply and slows the healing process.
• Shoulder instability.

As the rotator cuff and the shoulder weaken, the risk for a partial or complete tear increases.

When To Call

Call 911 or other emergency services immediately if shoulder or arm pain occurs with chest pain or other symptoms of a heart attack, such as shortness of breath and nausea.

Call your doctor now if you have an injury to your shoulder and:

• Your shoulder is very painful.
• Your shoulder appears to be deformed.
• You cannot move your shoulder normally.
• You have signs of damage to the nerves or blood vessels, such as numbness; tingling; a "pins-and-needles" sensation below the injury; or pale, cold, or bluish skin.

Call your doctor if:

• You had a shoulder problem in the past and you have shoulder pain.
• Your shoulder pain or stiffness is getting worse.
• Home treatment isn't helping.

Watchful waiting

Watchful waiting is a wait-and-see approach. If you get better on your own, you won't need treatment. If you get worse, you and your doctor will decide what to do next. A watchful waiting period may vary from a few days to weeks or maybe months.

Exams and Tests

To diagnose a rotator cuff disorder, your doctor will ask about your injury or shoulder pain history and will do a physical exam to see how your shoulder is working.

If your symptoms and exam show that you may have a complete rotator cuff tear, you may have one or more of these tests to confirm the diagnosis:

• X-ray
• MRI
• Ultrasound
• Arthrogram (rare)

Further testing

Your age, job, and activity level are considered when your doctor is deciding about further testing. For example, if you are a competitive athlete or have a job that requires frequent overhead activity, you may need further testing sooner than a relatively inactive older adult. A more complete diagnosis is important if you are likely to continue activities that may further damage your shoulder.

Treatment Overview

Treatment of rotator cuff disorders should begin soon after an injury or soon after symptoms develop, to give you the best chance of restoring flexibility and strength to your shoulder. Without treatment, inflammation and tears can build up, causing pain, weakness, and loss of function.

Treatment depends on your symptoms, age, and activity level, and on whether your symptoms appear to be related to a rotator cuff injury.

Nonsurgical treatment

Most rotator cuff disorders are treated without surgery. Your treatment may include:

• Medicines. For more information, see Medications.
• Home treatment, such as rest and applying cold or heat. For more information, see Home Treatment.
• Physical therapy. For more information, see Other Treatment.

If symptoms don't improve after a few months of nonsurgical treatment, you and your doctor may consider testing (such as X-rays or an MRI) to find out if you have a rotator cuff tear.

Or your doctor may give you a corticosteroid shot.

Surgery

Surgery often is used to repair a torn rotator cuff in a healthy young person, because good results are more likely if there is little or no evidence of degeneration or impingement.

People who have advanced rotator cuff disorders and tendons that are tough, stringy (fibrous), and stiff usually respond less well to surgery. Surgery may successfully repair the tear, but it can't repair all the damage caused by age or degeneration.

But surgery may be considered if:

• You have a rotator cuff tear caused by a sudden injury.
• Your shoulder doesn't get better after 3 to 6 months of other treatment.

For more information, see Surgery.

What to think about

Recovery from a rotator cuff disorder varies with each person. Your physical therapy and home exercise program should continue until your shoulder is as strong and flexible as possible. Some treatments for rotator cuff disorders can last up to a year. Most people can return to their previous activities after several weeks of rehabilitation.

Experts have differing opinions about treating rotator cuff tears.

• Some prefer nonsurgical treatment for people older than 60. But other experts believe that the sooner a rotator cuff tear is surgically repaired, the better the chance of a successful outcome, regardless of age.
• Some believe that small tears do not need surgery. Other experts feel that small tears should be repaired early to prevent further tearing.

Prevention

The long-term changes that occur in and around the shoulder joint because of everyday wear and tear cannot be totally prevented. But you may be able to prevent some rotator cuff problems if you:

• Keep the muscles in your shoulders flexible and strong. Daily exercises to maintain strength and flexibility may be the best defense against rotator cuff disorders.
• Have good posture at all times. Stand straight and relaxed, without slumping.
• Don't lift objects that are too heavy for you—especially over your head.
• Don't catch falling objects.
• Avoid sports or other activities where forceful contact or falls are likely or common.
• Don't keep your arms out to the side or raised over your head for long periods of time, such as when painting a ceiling. If you must do these activities:
  • Take frequent breaks, and ice your shoulder several times a day and at night.
  • Take a nonsteroidal anti-inflammatory drug to relieve any swelling and pain in the tissues that are being pinched. Be safe with medicines. Read and follow all instructions on the label.
  • Ask your doctor if it would be helpful to take an anti-inflammatory medicine before activities that may stress your shoulder.

Self-Care

Home treatment is often the first treatment for a rotator cuff problem. Treatment can help relieve the discomfort and keep the problem from getting worse.

• Rest your injured shoulder, although gentle movement of the shoulder is recommended. Limit repetitive movement, and avoid strenuous activity and activities where your arms move above your head. Be sure to follow your doctor's advice on how long to limit movement. Most people don't rest long enough. The rest period for a rotator cuff disorder may be a couple of days to several weeks. During rest:
  • Avoid putting your arm in a sling. It is important that you don't keep your shoulder completely still (immobilized), because it can cause the joint to stiffen or can even lead to frozen shoulder.
  • Move your arm carefully through its full range of motion several times a day. Progress slowly to avoid injury.
• Avoid activities or positions that cause discomfort, such as playing golf or tennis or carrying heavy bags of groceries. Stop any activity that hurts your shoulder.
• Take nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen to relieve pain. NSAIDs come in pills and in a cream that you rub over the sore area. Be safe with medicines. Read and follow all instructions on the label.

Using ice and heat

People respond to heat and ice differently. Use whichever one makes you feel better. In some cases, heat feels good for a while but may make pain and stiffness worse after 1 to 2 hours. For a sudden injury, don't use heat for the first 48 hours.

At first, ice helps relieve pain and reduce swelling. Try applying ice to your shoulder for the first 48 hours after discomfort begins:

• To avoid harming your skin, place a thin towel between the ice pack and your body, or put a pillowcase over the ice pack.
• Apply ice 2 or 3 times a day, up to 20 minutes at a time.
• Apply an ice pack after exercising your shoulder, to help prevent swelling.

After 2 to 3 days, start moving your shoulder with the aid of moist heat:

• Soak a towel in hot water, and wring it out. Fold the towel to about 8 in. (20 cm) square.
• While holding the towel on your shoulder, relax your shoulder, lean forward so your arm hangs freely, and gently swing your arm back and forth like a pendulum.
• You also can do this exercise standing under a warm shower. Heat relaxes your muscles and tendons by increasing blood flow to them. When combined with gentle motion, heat can ease inflammation.
• Repeat these steps 2 or 3 times a day to reduce the risk of permanent stiffness in the joint.

Exercises

Eventually, your doctor may want you to do more to stretch and strengthen your shoulder. For exercises you can do at home (with your doctor's approval), see:

• Rotator Cuff Problems: Exercises You Can Do at Home.

Medicines

Medicines don't heal rotator cuff disorders. They help with pain and inflammation. This allows you to start exercises to stretch and gradually strengthen the shoulder, which reduces the risk of stiffness or a frozen shoulder.

Medicine choices

• Nonsteroidal anti-inflammatory drugs (NSAIDs). These are the most common medicines used to help manage rotator cuff disorders. NSAIDs are available with or without a prescription. NSAIDs come in pills and in a cream that you rub over the sore area. Or you can use acetaminophen.
• Corticosteroid shots. These are strong medicines that are usually given only after 3 to 4 weeks of other treatment. If the first shot doesn't help much, a second shot may be given to make sure that the first shot was given in the right place. But there is rarely a need for more than a few shots.

Be safe with medicines. Read and follow all instructions on the label.

Surgery

Surgery may be considered if:

• Your rotator cuff injury is very severe.
• You have severe pain and loss of shoulder function that haven't responded to other treatment.
• You have shoulder weakness caused by a complete tear, especially when the rotator cuff is otherwise healthy.

Surgery typically is used to repair a torn rotator cuff in a healthy young person, because good results are more likely if there is little or no evidence of other problems. People who have advanced rotator cuff disorders and tendons that are tough, stringy (fibrous), and stiff usually respond less well to surgery. Surgery may successfully repair the tear, but it can't repair all the damage caused by age or degeneration.

If surgery isn't done right away, repair of a large tear may not be as successful. But it still usually relieves pain and restores enough strength for you to do routine, nonstrenuous activities.

After surgery, a program of physical rehabilitation (rehab) is very important. You may not do as well after surgery if you aren't willing or able to commit to completing a challenging physical rehab program.

• Rotator Cuff Problems: Should I Have Surgery?

Surgery choices

Shoulder surgery for rotator cuff disorders usually involves one or more of the following:

• Debridement
• Rotator cuff repair
• Subacromial smoothing

These procedures may be done arthroscopically, by traditional open surgery, or by a combination of the two approaches.

Sometimes a rotator cuff tear is so severe that it can't be fixed in the usual ways. If this happens in a younger person, the doctor may suggest moving another tendon to substitute for the torn tendon. In an older person, the doctor may suggest a special shoulder replacement.

What to think about

The success of surgery for rotator cuff tears depends on many things, such as:

• The amount of other damage present.
• Your age.
• Other medical conditions. Some may cause you to heal slower.
• Your recovery goals and commitment to and compliance with a physical rehabilitation program.
• Whether you smoke. Smoking decreases the blood supply throughout the body and slows the healing process.

Other Treatment

Physical therapy and rehabilitation

A physical therapy and rehabilitation (rehab) program usually involves exercises to stretch and gradually strengthen the shoulder. Some physical therapists may use other techniques, such as massage or ultrasound, to relieve pain and reduce muscle spasms.

This program of treatment may be used without surgery or as part of recovery after surgery. It can reduce pain in the soft tissues (such as the muscles, ligaments, and tendons), improve function, and build muscle strength.

Common difficulties with rehab programs include:

• Impatience during the long periods of rest needed to let your shoulder heal. Athletes and people whose jobs depend upon the use of their arms may find it hard to be patient with this stage of treatment.
• Not doing exercises as often as prescribed.
• Using incorrect technique when doing exercises.

Although completing a rehab program may be hard, a successful outcome after surgery depends on your commitment to treatment. If you follow your physical therapy plan closely and get help when you need it, you are more likely to restore shoulder strength and movement.

Exercises for rotator cuff disorders include:

• Gentle stretching exercises. These are often the most important part of physical therapy for rotator cuff disorders, especially when stiffness is a major symptom. Stretching includes range-of-motion exercises.
• Strengthening exercises. In general, you won't start these exercises until your rotator cuff has healed and is able to perform the stretching and range-of-motion exercises comfortably. Strengthening exercises can help you build and keep shoulder function and stability.

• Rotator Cuff Problems: Exercises You Can Do at Home (with your doctor's approval)

Treatments being studied

Experts are studying a new treatment for chronic calcifying tendinitis of the rotator cuff. The treatment uses sound waves to create shock waves that destroy calcium deposits in the rotator cuff tendons. This is called extracorporeal shock wave therapy. Some studies show pain relief and increased range of motion. But more studies are needed to see whether these results can be duplicated and to measure long-term results.^{footnote 1}

Other treatments being studied include:

• Acupuncture.
• Hyaluronan, which is injected into a joint to help supplement the natural synovial fluid in the joint.