What is the rotator cuff?
The rotator cuff is a group of four muscles (supraspinatus, subscapularis, teres minor, and infraspinatus) and tendons responsible for helping to stabilize and move the shoulder joint.
The rotator cuff tendon is simply the part that attaches muscle to bone (humerus). The rotator cuff muscles are small, stabilizing muscles that provide most of the stability of the shoulder joint and allow precise and coordinated shoulder movement. Of the four rotator cuff muscles, the most commonly injured tendon is the supraspinatus. In advanced ages there is usually calcification because the tendon tends to accumulate deposits of calcium salts.
The supraspinatus initiates the lateral elevation of the arm up to about 20-30º; The second part of the arm raise is performed primarily by the deltoid muscle. The injury or tear in the supraspinatus tendon occurs mainly in throwing sports or in the gym and in the elderly due to the degeneration of the tissues due to a lack of blood supply. The injury usually begins as a partial and incomplete injury that eventually expands to become a complete tear if nothing is done.
Rotator cuff tears can be partial or complete. Although a rotator cuff tear itself does not heal (that is, the ends of the tear do not rejoin), it is possible to return to normal function, even without surgery.
Causes of Rotator Cuff / Supraspinatus Tendon Tears
There are two possibilities (and many times it will be both at the same time):
- The rotator cuff injury can be caused by trauma, the most common is a fall on the arm generating a sudden tension on the tendon or even a shoulder dislocation that causes a sudden stretching of the rotator cuff tendons. The risk of rotator cuff tears is increased when there are calcifications that make the tendon more rigid and brittle.
- Very often, the rotator cuff is damaged over the years, due to repetitive mechanical stress , the rupture of these tendons can be the final consequence of a slow process of chronic inflammation and degeneration due to wear due to friction between the tendon and the acromion. If a person has a distance between the acromion (bone at the top and outside of the shoulder) and the humeral head of less than 1 cm, the supraspinatus has less space available in this situation and the movement causes friction of the tendon with the acromion causing fraying and inflammation, this is called subacromial impingement syndrome. This excess friction is also usually caused by a decompensation of the shoulder muscles, which is often the result of poor function of the liver with respect to the right shoulder or the stomach with respect to the left.
Rotator Cuff Pathology What is it, diagnosis and indicated treatment
we will give you all the information you need if you have a rotator cuff injury: from what the injury is to the surgery that is performed on the rotator cuff injury, as well as including what are the symptoms that are develop around cuff pathology and how to diagnose it.
Symptoms of Rotator Cuff Tear / Supraspinatus Tendon
In general, symptoms very similar to those of tendinitis in the shoulder can occur. The most common symptom of a rotator cuff tear is lateral or anterior-lateral shoulder pain. Occasionally, the pain may radiate down the side of the arm toward the elbow (rotator cuff symptoms will not go past the elbow). Functionally, the most common complaint is pain and limitation of arm movement up and to the sides. If you can’t lift your arm, this could indicate a major rotator cuff tear. Most rotator cuff tears do not require surgery. However, complete tears that lead to significant limitation in the ability to lift the arm often indicate that surgical intervention may be necessary as long as this occurs in a relatively young person.
Daily activities that are often affected by a rotator cuff tear include sleeping on the affected side, reaching and lifting objects such as a milk bottle or an item in a cupboard above the head, and pain when washing or combing. The supraspinatus tendon, more specifically, affects more abduction movements, tying your bra strap, taking your wallet out of your back pocket, combing your hair, putting on a hair tie, etc.
There is an arm injury that often accompanies this supraspinatus pathology which is inflammation of the long head biceps tendon or there may also be subacromial bursitis.
Diagnosis of a Tear of the Supraspinatus / Rotator Cuff Tendon
- The most appropriate instrumental tests are ultrasound compared to the other shoulder and magnetic resonance imaging , since it shows the soft tissues: muscles, tendons and ligaments, while X-rays show only the bones.
- The inspection and painful palpation of the area will provide us with important information.
- The shoulder joint is the most mobile in the human body, because it can make all movements: extension, flexion, abduction, adduction, internal and external rotation, the injury of these tendons usually limits these movements, especially rotations.
- A differential diagnosis must be made with respect to the following pathologies: acromioclavicular injury, cervical radiculopathy, osteoarthritis, rheumatoid arthritis, subscapular nerve entrapment.
Rotator Cuff Tear / Supraspinatus Tendon Treatment
As with all joint tissue, the goals of treatment for a rotator cuff tear or tear include first to reduce inflammation, second to restore range of motion (ROM), and third to restore strength.
When pain is present it often means that inflammation is also present. The use of ice therapy to minimize swelling is very helpful. Ice should be placed directly on the outside of the shoulder for 10 to 15 minutes. Also, anti-inflammatory medications may be recommended (ask your doctor about medications). If the micro-tears have created a chronic inflammatory condition in the shoulder, cortisone infiltrations may be recommended to help minimize the inflammation, although the abuse of these can end up worsening the situation due to the increase in fibrosis and subsequent degeneration of the shoulder zone.
Although the ends of the rotator cuff tear do not rejoin, strength and normal function can be obtained.
If the shoulder is not limited in range of motion, stretching exercises are not necessary. If there is a limitation in range of motion, it is important that range of motion is restored before starting strengthening exercises.
When one of the rotator cuff tendons has been torn, strengthening exercises are used to strengthen the other shoulder muscles. It is important that when performing these strengthening exercises there is no pain. Also, because the rotator cuff muscles are stabilizer muscles, muscular endurance is the goal. Therefore, the emphasis of strengthening exercises should be using the minimum weight and the highest number of repetitions. When the exercises become easy, increase the number of repetitions before increasing the weight of the exercise.
The physical therapist will explain a physical exercise program to help restore range of motion and strength after a rotator cuff tear.
Surgical Treatment of Rotator Cuff Tear / Supraspinatus Tendon Rupture
Repair of a rotator cuff tear is major surgery. Surgery consists of controlling and evaluating the real damage, since the internal situation is not always accurately reflected in the MRI. After seeing the damage, the surgeon cleanses the joint by removing damaged or necrotic tissue, and fixes the tendon to the bone with metal and absorbable anchor wires. This operation is usually associated with an action on the acromion by filing it down to increase the space through which the tendon passes. After surgery, the shoulder is immobilized in a sling for up to six weeks. Rehabilitation after rotator cuff repair is a complicated process that takes up to four months.
Surgery and operation for shoulder tendonitis and subacromial syndrome
Following repair of the rotator cuff tear or tear, active movement is not allowed for approximately six weeks. Controlling pain and swelling in the initial post-surgical period is of paramount importance. The use of ice and pain medication should be used when necessary. For the first six weeks after surgery, passive stretchingand stretching exercises by a physical therapist is necessary. A possible complication after surgery at this stage is the development of a frozen shoulder. It is evident that due to the limitation of active mobility, everyday functional activities can be a challenge. This is especially true if the rotator cuff surgery is on your dominant side. Sleeping can also be a big challenge with many times resorting to sleeping in a recliner to avoid shoulder pressure.
After the first six weeks active movement is allowed. Depending on the speed of restoring active movement, the first strengthening exercises will be determined. Strengthening exercises will include strengthening the muscles around the scapula as well as the rotator cuff muscles. Due to the length of recovery required post-surgery, surgery should be the option of last resort. Surgery should only be considered if you continue to have significant pain, limited use of your arm, and when medications, injections, and physical therapy have failed.
Rotator Cuff Tear Summary
- The rotator cuff is a group of four tendons that function to help provide dynamic stability to the shoulder.
- The most frequently injured rotator cuff tendon is called the supraspinatus.
- Lateral shoulder pain and limited movement of the arm up and to the sides are the most common signs and symptoms associated with a rotator cuff tear.
- Depending on the size of the rotator cuff tear, surgery may not be necessary.
- Typical conservative treatment for a rotator cuff tear includes ice therapy, anti-inflammatory medications, cortisone injections, and physical therapy.
- Rotator cuff repair surgery is a lengthy process and should only be considered after conservative treatment has failed and you continue to experience significant pain and functional limitation.
- To improve shoulder mobility and strength after a rotator cuff tear, your physical therapist will teach you an exercise program.
A rotator cuff tear is not always a surgical situation. Follow the recommendations to help reduce pain and restore mobility to your shoulder.