Rotator Cuff Injury

ROTATOR CUFF INJURY

 

 

Rotator cuff injury

The rotator cuff is a group of muscles which work together to provide the Glenohumeral (shoulder) joint with dynamic stability, helping to control the joint during rotation (hence the name). The rotator cuff muscles include:

  • Supraspinatus
  • Infraspinatus
  • Teres Minor
  • Subscapularis

Due to the function of these muscles, sports which involve a lot of shoulder rotation – for example, bowling in cricket, pitching in baseball, swimming, kayaking – often put the rotator cuff muscles under a lot of stress.
A rotator cuff injury is an injury to these 1 or more of the 4 muscles in the shoulder. This shoulder injury may come on suddenly and be associated with a specific injury such as a fall (acute), or it may be something that gets progressively worse over time with activity that aggravates the muscle (chronic).

The type of injury can range from an inflammation of the muscle without any permanent damage, such as tendinitisto a complete orpartial tear of the muscle that might require surgery to fix it.

Causes

Acute Tear

Sudden powerful raising of the arm against resistance, often in an attempt to cushion a fall (examples: heavy lifting, a fall on the shoulder)

Injury usually associated with a significant amount of force if person is younger than 30 years

This tends to happen as a result of a sudden, powerful movement. This might include falling over onto an outstretched hand at speed, making a sudden thrust with the paddle in kayaking, or following a powerful pitch/throw.

The symptoms will usually include:

Sudden, tearing feeling in the shoulder, followed by severe pain through the arm

Limited movement of the shoulder due to pain or muscle spasm

Severe pain for a few days (due to bleeding and muscle spasm) which usually resolves quickly

Specific tenderness (“x marks the spot”) over the point of rupture/tear

If there is a severe tear, you will not be able to abduct your arm (raise it out to the side) without assistance

Chronic Tear

Usually found on the dominant side

More often an affliction of the 40+ age group

Found among people in occupations or sports requiring excessive overhead activity (examples: painters, baseball pitchers)

Variations in the shoulder structure causing narrowing under the outer edge of the collarbone

Pain is worse at night, and can affect sleeping

Gradual worsening of pain, eventually some weakness

Eventually unable to abduct arm (lift out to the side) without assistance or do any activities with the arm above the head

Some limitations of other movements depending on the tendon affected

Inflammation

More common in women aged 35-50

Characteristic ache in the shoulder which feels like it is coming from “deep inside”

Tenderness over particular areas, less specific than a tear

Usually a gradual onset of pain, which “flares up” if using the arms over the head or out to the side

Can sometimes lead to a chronic tear if untreated

Tendinitis

Degeneration (wearing out) of the muscles with age

Repetitive trauma to the muscle by everyday movement of the s

Rotator Cuff Injury Symptoms

Chronic tear

Occur more often in a person’s dominant arm

More commonly found among men older than 40 years

Pain usually worse at night and interferes with sleep

Worsening pain followed by gradual weakness

Decrease in ability to move the arm, especially out to the side

Able to use arm for most activities but unable to use the injured arm for activities that entail lifting the arm as high or higher than the shoulder to the front or side

Acute tear

Sudden tearing sensation followed by severe pain shooting through the arm

Motion limited by pain and muscle spasm

Acute pain from bleeding and muscle spasm (often goes away in a few days)

Point tenderness over the site of rupture

With large tears, inability to raise the arm out to the side, although this can be done with help

Tendinitis

More common in women aged 35-50 years

Deep ache in the shoulder also felt on the outside upper arm

Point tenderness

Pain comes on gradually and becomes worse with lifting the arm to the side or turning it inward

May lead to a chronic tear

What should I expect when I visit a healthcare professional with a possible Rotator Cuff problem?

A detailed history of your general health, past problems and injuries, and what happened to cause this injury will be taken

Both shoulders will be looked at and compared (you will need to partially undress for this) both visually and using palpation (feeling)

Your neck, elbows and wrists will be checked to make sure they are not contributing to the problem

Range of movement will be assessed, you’ll be asked to do certain movements and the clinician will observe and ask you to report any pain (but will not be done if a fracture is suspected)

Passive range of movement will be assessed – you will be asked to lie on a couch while the clinician moves your shoulder (but will not be done if a fracture is suspected)

Sensation and strength in the arm will be assessed

Some specific tests will be done which can help to identify which tendon is causing the problem and confirm if it is a rotator cuff tear, or due to inflammation or some other cause.

Assessment of shoulder for rotator cuff injury

Empty Can Test

You will be asked to put your arms out in front of you with your thumbs pointing to the floor (as if holding an empty can) and hold them there while gentle pressure is applied to the top of your arm

This is biased towards the Supraspinatus tendon

Drop Arm Test (Codman’s Test)

Your arm will be moved out to the side, and you’re asked to gently lower your arm to your side

If you can’t do this slowly, or have very severe pain in doing so, it suggests a tear in the rotator cuff

Abrasion Sign

You will be asked to sit and raise your arm to your side with the elbow bent

You will be asked to rotate your arm forwards and backwards

If there is any crunching noise (crepitus) there may be some inflammation or degenerative changes.

Neer’s Sign

Your arm will be moved forwards until it is above your head

If you experience pain or discomfort, it might be possible that you have inflammation of the Supraspinatus and possibly the tendon of the biceps muscle.

Hawkins-Kennedy Test

Your arm will be raised in front of you to 90° and the elbow bent, and the arm will be turned towards the middle of your bod

If this causes pain you probably have a problem with Supraspinatus.

What can I do to help my rotator cuff muscles recover?

Rest the shoulder

Ice can be used at least 3 times a day and is useful for the first couple of days following an injury

Apply ice for no more than 15-20 minutes ensuring you use an appropriate ice bag, or wrap the ice in a towel to prevent ice burn

Warmth may be useful after the first few days to help with the pain

Medication may be helpful to help control the pain – speak to your doctor if you think you require stronger than what you might usually take

Physoline’sTreatment for an Acute Rotator Cuff Tear

Apply ice to reduce swelling as above

Control the pain with appropriate medications

Rest the arm – a sling can sometimes be quite useful if you still need to go to work/school, which can be removed at night

You may require imaging studies (x-ray, MRI, CT Scan) to identify what the problem is and rule out any fractures

Consider consulting a physiotherapist who can assist you with rehabilitating the injury

If the injury is quite severe and you are young and active, you might require an operation to fix the tear.  This needs to be done within 3 weeks.  Indications include:

Under 60 years old

Complete tears of the tendon/muscle

Failure of other treatments after 6 weeks

Professional/keen sports people

If your job requires constant shoulder use

Physioline’s Treatment for a Chronic Rotator Cuff Tear

Control pain

Apply ice as above, heat may also be beneficial

Sometimes you might be referred for an injection of steroid medication directly into the site of the problem to help reduce any inflammation and allow you to proceed with rehabilitation

Shoulder exercises which can be provided by a physiotherapist

You may require surgery, the indications as above

Physioline’s Treatment for Rotator Cuff Inflammation

Apply ice initially as above

Rest the arm for short periods, but it is important to keep the shoulder moving to prevent stiffness and further reduced movement.

You may benefit from a course of anti-inflammatory medications

You may need to have an injection of steroid medications directly to the site of the inflammation, as explained above.

Heat and massage may help once things start to improve a bit

Small pendular movements when leaning forwards may provide some relief and help to improve the shoulder movement.  Consult with a physiotherapist for a personalised exercise plan.

Walking your fingers up a wall or door can help to improve shoulder movement.  Also, holding a stick with both hands and using the better shoulder to move in a circular fashion can help, as this moves the painful shoulder with minimal stress on the rotator cuff muscles

How long will it take to get better?

Depending on several factors, conservative treatment has a 40-90% success rate at fixing the problem.

Surgery often has good results, with some studies citing a 94% satisfaction rate with the surgery, resulting in lasting pain relief and improved function.  Very extensive tears often have a poor surgical outcome, however this injury is thankfully quite rare.

If you are older, it will take you longer to heal due to differences in your physiology.

Prevention

Avoiding a direct landing on the shoulder in sports or falls is the surest prevention but may be easier said than done.

Seek early medical attention if shoulder pain develops because of overuse.