Rotator cuff injury

Rotator cuff injuries are the most common source of shoulder problems. They can range from minor sprains causing impingement type symptoms, to massive tears resulting in severe loss of function and pain. They commonly occur as a result of acute injuries (sports, falls), chronic overuse (repetitive loading) or due to gradual aging.

Anatomy of shoulder

The shoulder joint (glenohumeral joint) is the most mobile joint in the human body. It comprises of the humeral head (top portion of upper arm bone) which fits in the glenoid cavity of the scapula (shoulder blade) to create a ball and socket configuration. This anatomical configuration results in limited bony contact between the humeral head and the glenoid fossa, which reduces the stability of the joint.

Several passive and active structures stabilize and maintain proper biomechanics of the shoulder joint.

• Passive stabilizers include the ligaments, joint capsule, cartilage and the bony concavity of glenoid fossa. Thick cartilage known as labrum lines the glenoid fossa to further deepen the groove by about 50% which is advantageous in stabilizing the shoulder joint during the articulation.

• Dynamic stabilizers of the glenohumeral joint is gained from the coordination of rotator cuff muscles that compress the passive structures providing stability and mobility as whole.

The rotator cuff muscles include:

• supraspinatus

• infraspinatus

• subscapularis

• teres minor

 

 

Injury to any or all these four muscles, including the tendons that attach the muscles to bone can result movement dysfunction and severe pain.

Other important joints of the shoulder complex include:

• sternoclavicular joint

• arcomioclavicular joint

• scapulothoracic joints

Types of rotator cuff pathology

Tendinitis and Tendinosis

More often than not the term tendinitis and tendinosis are interchangeably used to describe a similar tendon pathology. However, the factor that differentiates the two is the time of injury (acute or chronic).

Tendinitis results from acute injury to the tendon which sets off an inflammatory process characterized by pain, swelling, and redness. On the other hand, tendinosis is a chronic pathology that does not involve an inflammatory process. It is characterized by degeneration of collagen fibers in response to persistent micro-trauma, vascular compromise and aging.

Acute rotator cuff tear

• Acute tears result from sudden forceful lifting of the arm against resistance or in an attempt to cushion a fall (for example, heavy lifting or a fall on the shoulder).

Chronic injuries

• Most commonly resulting from occupational or sports requiring excessive repetitive overhead activity.

Signs and symptoms

Symptoms of a rotator cuff injury are due to the inflammation that accompanies the strain. Swelling that forms within the small space of the joint prevents the normal mechanics of the shoulder, resulting in the clinical picture of pain and decreased range of motion.

• Acute rotator cuff tears
  Tearing sensation
  Immediate severe localised pain
  Reduced strength
  Symptomatic clicking
  Reduced and worsening pain with movements
  Affects daily activities (personal care, lifting, reaching etc)

• Chronic rotator cuff tears
  Generalized deep dull ache, sharp onset of pain with movements
  Global shoulder weakness
  Reduced movements and daily activities (especially moving to the side, reaching behind back)

When to seek medical treatment

See your doctor or a physiotherapist if you experience any of the following symptoms in the shoulder:

• Pain, especially pain that does not improve with rest

• Swelling, redness or tenderness around the joint

• Shoulder weakness

• Reduced shoulder movement

For more severe rotator cuff injuries, you may require immediate medical attention.

Seek immediate medical attention if you experience the following symptoms:

• Sudden, severe pain

• Visible joint deformity

• Inability to move or use your shoulder joint

• Sudden swelling, discoloration

Diagnosis

To diagnoses an injured rotator cuff, your physiotherapist will begin with a thorough subjective and physical examination of your shoulder.

• Subjective assessment

Your physiotherapist will begin with a thorough subjective assessment inquiring about your signs and symptoms of an acute injury as well as any symptoms that may suggest a more long-term problem.

• Physical assessment

The physical examination often involves observation to look for muscle wasting, deformities, and/or changes in appearance of the injured shoulder to the unaffected side. Your physiotherapist will also palpate different areas of the shoulder complex to find the area of pain or tenderness. Further examination will involve assessment of movement and strength to establish injury to muscles or tendons.

• Radiology

In addition, your physiotherapist may refer you for imaging tests to diagnosis the cause of your symptoms:

• Ultrasound: examines soft-tissue structures (muscles, tendons, bursa)

• X-rays: examines bone health, calcification

• MRI: provides detailed imaging of areas injured (referred by doctors, specialists or surgeons)

Treatment

Early diagnosis and treatment of a rotator cuff tear may prevent symptoms such as loss of strength and loss of motion from setting in.

Initial treatment of rotator cuff tendinitis involves managing pain and swelling to promote healing. This can be done by:

• avoiding activities that cause pain

• applying cold packs to your shoulder three to four times per day

• taking anti-inflammatory medications like ibuprofen and naproxen

Rehabilitation plays a critical role in both the nonsurgical and surgical treatment of a rotator cuff tear.

When a tear occurs, there is frequently atrophy of the muscles around the arm and loss of motion of the shoulder. An individualized physiotherapy program is necessary to regain strength and improve function in the shoulder.

Physical therapy

Physiotherapy will initially consist of passive exercises to help restore range of motion and ease pain.

Once the pain is under control, your physiotherapist will prescribe exercises to help regain strength in your arm and shoulder.

Steroid injection

If you have persisting symptoms, your physiotherapist may recommend a steroid injection. This is injected into the tendon to reduce inflammation, which reduces pain.

Surgery

Surgery is recommended if you have persistent pain or weakness in your shoulder that does not improve with nonsurgical treatment. In which case, your physiotherapist will refer you to surgeon for an opinion of surgical intervention.

Exercises

Range of movement exercise

 

Strengthening exercises with band