The rotator cuff is a group of tough, flexible fibers (tendons) and muscles in the
shoulder. Rotator cuff disorders occur when tissues in
the shoulder get irritated or damaged. Rotator cuff disorders include:
Inflammation of
the tendons (tendinitis) or of a bursa (bursitis). In
the shoulder, a bursa is a small, fluid-filled sac that serves as a cushion
between the tendons and the bones.
Impingement, in which a tendon
is squeezed and rubs against bone.
Calcium buildup in the tendons,
which causes a painful condition called calcific tendinitis.
How does the shoulder work, and what does the rotator cuff do?
The shoulder is a joint with three
main bones: the upper arm bone (humerus), the collarbone (clavicle), and the
shoulder blade (scapula). The bones are held together by muscles, tendons, and
ligaments. The rotator cuff keeps the upper arm bone
in the shoulder socket and lets you raise and twist your arm.
The
shoulder is a ball-and-socket
joint. The ball at the top of the upper arm bone fits
into the socket of the shoulder blade. This socket is shallow, which lets you
move your arm in a wide range of motion. But it also means that the muscles and
tendons of the rotator cuff have to work hard to hold the bones in place. As a
result, they are easy to injure and are prone to wear and tear.
What causes rotator cuff disorders?
Most rotator cuff disorders are caused by a combination of:
Normal wear and tear. Using your shoulder for
many years slowly damages the rotator cuff. As you age, everyday activities can
lead to changes in the rotator cuff, such as thinning and fraying of the
tendons and reduced blood supply.
Overuse. Activities in which you
use your arms above your head a lot-such as tennis, swimming, or house
painting-can lead to rotator cuff problems. Even normal motions made often over
a long period can stress or injure the rotator cuff.
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.
What are the symptoms?
Symptoms of a rotator cuff
disorder include pain and weakness in the shoulder. Most often, the pain is on
the side and front of the upper arm and shoulder. It may hurt or be impossible
to do everyday things, such as comb your hair, tuck in your shirt, or reach for
something. You may have pain during the night and trouble sleeping.
How are rotator cuff disorders diagnosed?
To diagnose a rotator cuff disorder, doctors ask about any shoulder
injuries or past shoulder pain. They also do a physical exam to see how well
the shoulder works and to find painful areas or activities. Moving your arm in
certain ways can help a doctor learn about the condition of the rotator cuff.
You may have an
X-ray to check the bones of the shoulder. If the
diagnosis is still unclear, the doctor may order an imaging test, such as an
MRI or an
ultrasound.
How are they treated?
It is important to treat a rotator cuff problem.
Without treatment, your shoulder may get weaker and you may not be able to lift
up your arm.
For most rotator cuff disorders, doctors recommend
these steps first:
Rest the shoulder. Use the arm, but do so
carefully. Don't keep the shoulder still with a sling or brace. This can lead
to stiffness or even a frozen shoulder (adhesive capsulitis).
Use ice or heat on
the shoulder, whichever feels better.
Take anti-inflammatory drugs (NSAIDs) to relieve pain and
reduce swelling and inflammation. Examples include ibuprofen (such as
Advil) and naproxen (such as Aleve). Or try acetaminophen (such as Tylenol). It can help with pain but will not reduce swelling or inflammation. Be safe with medicines. Read and follow all instructions on the label.
Avoid positions and
activities that are uncomfortable, such as lifting or reaching overhead. Stop
any activity that hurts the shoulder.
The doctor may also suggest
physical therapy. Physical therapy can reduce pain and
help make your shoulder stronger and more flexible. In physical therapy, you
learn exercises to stretch and strengthen your shoulder. After you learn the
exercises, you can do them at home.
It is important to give
treatment time to work. It may take from a couple of weeks to several months to
get good results.
If other treatments don't help, your doctor may
give you shots of steroid medicine in the shoulder. The shots probably don't
cure rotator cuff disorders. But they can help relieve pain and inflammation so
you are able to do exercises to strengthen the shoulder. The shots may also
help your doctor find out if your shoulder pain is from your rotator cuff. If a
steroid shot near the rotator cuff relieves your pain, even if the pain comes
back later, it means the rotator cuff-not some other shoulder problem-is
causing the pain.
Most rotator cuff disorders aren't treated with
surgery. But doctors may do surgery if a rotator cuff tendon is torn or if
several months of other treatments have not helped.
Surgery may be a good choice if you are young
and your rotator cuff has been in good shape. Surgery may not work as well if
your tendons are weak and frayed.
Surgery is not a substitute for
physical therapy. Even after surgery, you may need months of physical therapy
to have a full recovery.
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 a Doctor
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 immediately 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 have had a shoulder problem in the past and you have
shoulder pain.
Your shoulder pain or stiffness is getting worse.
Home treatment is not helping.
Watchful waiting
Watchful waiting is a period of time during
which you and your doctor observe your symptoms or condition
without using medical treatment. A watchful waiting period may vary from a few
days to weeks or possibly months. Watchful waiting is not appropriate
if:
Pain in your shoulder is
unbearable.
Your shoulder is deformed.
You have loss of feeling in the shoulder.
The skin around your shoulder is pale, cold, or bluish.
Who to see
Health professionals who can diagnose and manage
rotator cuff disorders include:
Primary care health professionals who are
familiar with shoulder injuries. These include:
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:
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 .
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.
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.
Ask your doctor if it would be helpful to take an anti-inflammatory medicine
before activities that may stress your shoulder.
Home Treatment
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:
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.
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.
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.
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
Gerdesmeyer L, et al. (2003). Extracorporeal shock wave therapy for the treatment of chronic calcifying tendonitis of the rotator cuff. JAMA, 290(19): 2573-2580.
Other Works Consulted
American Academy of Orthopaedic Surgeons and American Academy of Pediatrics (2010). Impingement syndrome. In JF Sarwark, ed., Essentials of Musculoskeletal Care, 4th ed., pp. 295-300. Rosemont, IL: American Academy of Orthopaedic Surgeons.
Bannuru RR, et al. (2014). High-energy extracorporeal shock-wave therapy for treating chronic calcific tendinitis of the shoulder: A systematic review. Annals of Internal Medicine, 160(8): 542-549. DOI: 10.7326/M13-1982. Accessed September 3, 2014.
Lin KC, et al. (2010). Rotator cuff: 1. Impingement lesions in adult and adolescent athletes. In JC DeLee et al., eds., DeLee and Drez's Orthopaedic Sports Medicine, Principles and Practice, 3rd ed., vol. 1, pp. 986-1015. Philadelphia: Saunders Elsevier.
Wiesel BB, Carroll RM (2010). The shoulder. In SW Wiesel, JN Delahay, eds., Essentials of Orthopedic Surgery, 4th ed., pp. 323-351. New York: Springer.
Credits
ByHealthwise Staff Primary Medical ReviewerWilliam H. Blahd, Jr., MD, FACEP - Emergency Medicine Adam Husney, MD - Family Medicine Kathleen Romito, MD - Family Medicine Specialist Medical ReviewerKenneth J. Koval, MD - Orthopedic Surgery, Orthopedic Trauma
Gerdesmeyer L, et al. (2003). Extracorporeal shock wave therapy for the treatment of chronic calcifying tendonitis of the rotator cuff. JAMA, 290(19): 2573-2580.
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