Shoulder
Rotator Cuff Problems
What is the rotator cuff?
All muscles are made up of a fleshy muscle (meat) part and a non fleshy tendon
part. It is the tendon part that connects the muscle to bone.
There is a group of muscles in the shoulder that rotate (and lift) the arm at the shoulder.
They are known as a group as the "shoulder rotators". The tendons of the shoulder
rotator muscles come together and combine to form a single common sheet of tendon through
which they all attach together to bone. This common sheet of tendons is called the
rotator cuff because it surrounds (cuffs) the top and back of the ball in the shoulder
and serves the muscles that rotate the shoulder.
Where is the rotator cuff?
The rotator cuff develops problems precisely because of where it is located in the shoulder
and how the shoulder is constructed.
The rotator cuff is between two bony surfaces. Above it is the bony "roof" of the
shoulder made up of the acromion and clavicle. Below it is the round ball of the humerus
(arm) bone. Throughout life, whenever a person lifts his/her arm to reach up for something,
the rotator cuff is repeatedly rubbed and pinched between those two bone surfaces.
This constant rubbing of the rotator cuff between the two bony surfaces causes irritation and
"wear and tear" of the tendon tissue.
If you rub your hand on your thigh once or twice, nothing much happens. But if you kept
rubbing your hand on your thigh for a long time, your thigh skin would get sore. Similarly
after periods of repeated overhead use of the arm (repeated pinching of the rotator cuff)
the tendon can become inflamed. This is the so called rotator cuff tendonitis
(or bursitis). Years of rubbing causes a hole to wear through the tendon, just like you
can wear a hole in the leather sole of your shoe over time. This is a known as a
degenerative tear of the rotator cuff. Here the word "tear" is like in "wear and tear".
What is a rotator cuff tear?
A rotator cuff tear can be an actual real tear during an injury, or it can be a
gradual degenerative tear as explained above. The degenerative tear is much more
common.
Most tears do not detach the entire tendon from the bone. These partial tears cause
symptoms mainly of pain, but not significant strength loss. Sometimes, however, the tear can
be massive enough so that enough muscle is detached from the bone that the person can
no longer lift the arm up. In such massive tears, even when the pain disappears, the power
loss persists.
What are the symptoms of rotator cuff disease?
These include pain in the shoulder and sometimes weakness and inability to
lift the arm.. Reaching overhead or upwards pinches the rotator cuff (see above).
Therefore if the rotator cuff is already inflamed this pinching increases or causes pain.
However, many conditions can mimic a rotator cuff problem. These can include neck
problems, pinched nerves, frozen shoulder syndrome and arthritis. In rare cases even
conditions such as gall-bladder disease, heart attacks, and even tumors can cause shoulder
symptoms. It is therefore important to be examined by an experienced physician to establish
the diagnosis.
Treatment of Rotator Cuff Disease
TREATMENT
Non-surgical treatment is successful in the majority of cases. For this reason it should
always be tried first. The only exception to this may be the case of a complete rotator
cuff tear, because here the patient will never be able to lift the arm unless the
completely detached rotator cuff is reattached.
NON-SURGICAL TREATMENT
The main cause of pain in most rotator cuff problems is the inflammation, not the tear.
Therefore treatment is aimed at reducing the inflammation. This is done by:
Anti-inflammatory drugs:
Use of anti-inflammatory drugs while simultaneously avoiding things that increase the inflammation
The most useful of these are the NSAIDs. These are taken by mouth and it is important to take
them as prescribed to achieve the aimed for anti-inflammatory effect.
Injections:
Steroids (cortisone, prednisone) are the most potent anti-inflammatory medications available
but have many complications when taken by mouth for the necessary period of time that
would be needed to affect a cure. However, fortunately cortisone injections, as long
as they do not exceed 3-4 a year, can be used safely because the amount then used is too
little to cause problems.
Injections can have a dramatic effect in relieving rotator cuff pain, frequently
before the patient leaves the examining room. Sometimes only one injection is needed,
though frequently it might take 2 or 3.
Activity modification:
Since reaching overhead compresses the rotator cuff and contributes more irritation,
it is very useful to avoid this motion until the inflammation has subsided.
Ice:
Ice packs helps reduce the pain and the inflammation of rotator cuff disease. Heat on the
other hand will make things worse.
SURGICAL TREATMENT
If conservative treatment fails, or there is significant muscle weakness it becomes
necessary to consider surgical options.
It is too complicated to discuss the surgical options here, but essentially we are talking
about procedures to decompress the rotator cuff (making more room for the rotator
cuff) and repairing tears in the rotator cuff.
Decompression surgery can be performed "open" through a 1.5 inch incision or
arthroscopically through 2-3 half inch incisions. Both have advantages and the jury
is still out as to which is better. This is something that needs to be discussed with your
surgeon as to which might be best for you. The good thing to remember is that fortunately
both techniques work well.
Repairing a tear in the rotator cuff can also be performed open or arthroscopically
though here the arthroscopic technique is still too new and not as good as it will become in
the future.
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