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THE ROTATOR CUFF
Introduction

Your rotator cuff is made up of the muscles and tendons in your shoulder. Four major muscles (subscapularis, supraspinatus, infraspinatus and teres minor) and their tendons connect your upper arm bone (humerus) with your shoulder blade. They also help hold the ball of your upper arm bone firmly in your shoulder socket, as if holding a golf ball on a tee. The combination results in the greatest range of motion of any joint in your body.

Rotator cuff injuries are fairly common. Causes of the injury may include falling, lifting and repetitive arm activities, especially those done overhead. These activities may include throwing a baseball, reaching up to work on a car on a rack or placing items on shelves above your head. The injury is also common among people whose jobs or hobbies include heavy demands on their shoulders, such as athletes, archers and people in the construction trades. Poor posture, especially as related to your shoulders hunched forward, also can contribute to rotator cuff injury. As you get older, your risk of a rotator cuff injury increases.

Most of the time, treatment involves self-care measures or exercise therapy. Other treatments include steroid injections and surgery.

Signs and symptoms

    Signs and symptoms of a rotator cuff injury may include:
  • Pain and tenderness in your shoulder, especially when reaching overhead, reaching behind your back, lifting, pulling or sleeping on the affected side
  • Shoulder weakness
  • Loss of shoulder range of motion
  • Inclination to keep your shoulder inactive
  • The most common symptom is pain. You may experience it when you reach up to comb your hair, bend your arm back to put on a jacket or carry something heavy. Lying or sleeping on the affected shoulder also can be painful. If you have a severe injury, such as a large tear, you may experience continuous pain and muscle weakness.

    What is shoulder bursitis?

    Many patients seek medical attention for shoulder pain, and a common diagnosis given is 'shoulder bursitis,' or 'shoulder tendonitis.' The doctor will then often state that identifying which of these diagnosis is the true cause of pain is not important because the treatment is the same. This is true. Shoulder bursitis and rotator cuff tendonitis are all ways of saying there is inflammation of a particular area within the shoulder joint that is causing a common set of symptoms. The best terminology for these symptoms is 'impingement syndrome.' Impingement syndrome occurs when there is inflammation of the rotator cuff tendons and the bursa that surrounds these tendons.

    Where is the problem that causes shoulder bursitis?

    The shoulder is interesting in that several bones, muscles, and ligaments contribute to this complex joint. Impingement syndrome, or shoulder bursitis, occurs when there is inflammation between the top of the humerus (arm bone) and the acromion (tip of the shoulder). Between these bones lies the tendons of the rotator cuff, and the bursa that protects these tendons. Normally, these tendons slide effortlessly within this space. In some people this space becomes too narrow for normal motion, and the tendons and bursa become inflamed. Inflammation leads to thickening of the tendons and bursa, and contributes to the loss of space in this location. Eventually, this space becomes too narrow to accommodate the tendons and the bursa, and every time these structures move between the bones they are pinched--this is the impingement.

    What causes this problem?

    Impingement syndrome is a descriptive term of pinching of the tendons and bursa of the rotator cuff between bones. In many individuals with this problem, the shape of their bones is such that they have less space than most others. Therefore, small thickenings of the tendons or bursa can cause symptoms.

    Often there is an initial injury that sets off the process of inflammation. Thereafter, the problem can be self-exacerbating. Once there is an initial injury, the tendons and bursa become inflamed. This inflammation causes a thickening of these structures. The thickening then takes up more space, and therefore the tendons and bursa become are pinched upon even more. This causes more inflammation, and more thickening of the tendons and bursa, and so on.

    What are the symptoms of shoulder bursitis/impingement syndrome

    Common symptoms include:
  • Pain with overhead activities (arm above head height)
  • Pain while sleeping at night
  • Pain over the outside of the shoulder/upper arm

    Impingement syndrome and a rotator cuff tear are different problems, and although they are related, the treatment is different. Impingement syndrome is a problem of inflammation around the rotator cuff tendons. A rotator cuff tear is an actual tear within the tendons. The best signs that differentiate these problems area the strength of the rotator cuff muscles. Your orthopedic doctor will be able to specifically isolate these muscles to better determine if a rotator cuff tear is present. A MRI can also show the tendons of the rotator cuff and help determine if a tear is present.
Causes
    A rotator cuff injury involves any type of irritation or damage to your rotator cuff muscles or tendons, including:
  • Tendinitis. Tendons in your rotator cuff can become inflamed due to overuse or overload, especially in athletes who perform a lot of overhead activities, such as tennis or racquetball players. In some people, the space where the rotator cuff resides can be narrowed due to the shape of different shoulder bones, including the outside end of the collarbone or shoulder blade.
  • Bursitis. The fluid-filled sac (bursa) between your shoulder joint and rotator cuff tendons can become irritated and inflamed.
  • Strain or tear. Left untreated, tendinitis can weaken a tendon and lead to chronic tendon degeneration or to a tendon tear. Stress from overuse also can cause a shoulder tendon or muscle to tear.

    Common causes of rotator cuff injuries include:

  • Normal wear and tear. Increasingly after age 40, normal wear and tear on your rotator cuff can cause a breakdown of fibrous protein (collagen) in the cuff's tendons and muscles. This makes them more prone to degeneration and injury. With age, you may also develop calcium deposits within the cuff or arthritic bone spurs that can pinch or irritate your rotator cuff.
  • Poor posture. When you slouch your neck and shoulders forward, the space where the rotator cuff muscles reside can become smaller. This can allow a muscle or tendon to become pinched under your shoulder bones, including your collarbone, especially during overhead activities, such as throwing.
  • Falling. Using your arm to break a fall or falling on your arm can bruise or tear a rotator cuff tendon or muscle.
  • Lifting or pulling. Lifting an object that's too heavy, or doing so improperly — especially overhead — can strain or tear your tendons or muscles. Likewise, pulling something, such as an archery bow of too heavy poundage, may cause an injury.
  • Repetitive stress. Repetitive overhead movement of your arms can stress your rotator cuff muscles and tendons, causing inflammation and eventually tearing. This occurs often in athletes, especially baseball pitchers and tennis players. It's also common among people in the building trades, such as painters and carpenters.

    When to seek medical advice

    See your doctor as soon as possible if you have severe shoulder pain or you're unable to use your arm. Call your doctor if you've had shoulder pain that has lasted for more than a week

    Treatment

    Most of the time, treatment for rotator cuff injuries involves exercise therapy. Your doctor or a physical therapist will talk with you about specific exercises designed to help heal your injury, improve the flexibility of your rotator cuff and shoulder muscles and provide balanced shoulder muscle strength. Depending on the severity of your injury, physical therapy may take from three weeks to several months.

    Other treatments may include:

    Steroid injections. Depending on the severity of your pain, your doctor may use a corticosteroid injection to relieve inflammation and pain.
  • Surgery. If you have a large tear in your rotator cuff, you may need surgery to repair the tear. Sometimes during this kind of surgery, doctors may remove a bone spur or calcium deposits. The surgery may be performed as an open repair through a 6- to 10-centimeter incision, or as an arthroscopic repair with the aid of a small camera inserted through a smaller incision.
  • Arthroplasty. Some long-standing shoulder muscle tears may contribute to the development of rotator cuff arthropathy, which can include severe arthritis. In such cases, your doctor may discuss with you more extensive surgical options, including partial shoulder replacement (hemiarthroplasty) or total shoulder replacement (prosthetic arthroplasty).
  • A unique treatment option now available involves the use of a reverse ball-and-socket prosthesis. This reverse shoulder prosthesis is most appropriate for people who have very difficult shoulder problems. These include having arthritis in the joint, along with extensive tears of multiple muscles and tendons (rotator cuff) that support the shoulder, or having extensive rotator cuff tears and a failed previous shoulder joint replacement.

    Self-care

    A minor injury often heals on its own, with proper care. If you think you've injured your rotator cuff, try these steps:
  • Rest your shoulder. Stop doing what caused the pain and try to avoid painful movements. Limit heavy lifting or overhead activity for four to seven days until your shoulder starts to feel better.
  • Apply ice and heat. Putting ice on your shoulder helps reduce inflammation and pain. Use a cold pack, a bag of frozen vegetables or a towel filled with ice cubes for 15 to 20 minutes at a time. Do this every couple of hours the first day or two. After about two or three days, when the pain and inflammation have improved, hot packs or a heating pad may help relax tightened and sore muscles. Limit heat applications to 20 minutes.
  • Take pain relievers. Over-the-counter (OTC) nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen (Advil, Motrin, others) or naproxen (Aleve), may help reduce pain. Acetaminophen (Tylenol, others) also may help relieve pain. Follow label directions and stop taking the drugs when the pain improves.
  • Keep your muscles limber. After one or two days, do some gentle exercises to keep your shoulder muscles limber. Total inactivity can cause stiff joints. In addition, favoring your shoulder for a long period of time can lead to frozen shoulder, a condition in which your shoulder becomes so stiff you can barely move it. Once your injury heals and you have good range of motion in your shoulder, continue exercising. Daily shoulder stretches and a balanced shoulder-strengthening program can help prevent a recurrence of your injury.In addition, daily exercises can help prevent an injury if you use your rotator cuff often. Your doctor or a physical therapist can help you plan an exercise routine.