Shoulder pain is a common musculoskeletal problem among patients today. One of the most common causes of shoulder pain revolves around the rotator cuff. Each year, approximately 2 million people in the US will be diagnosed with a rotator cuff problem. It is important for patients to be able to identify common symptoms and potential treatment options for rotator cuff tendon inflammation and tears.
The shoulder is made of three bones: humerus, scapula, and clavicle. These bones are held together with a series of ligaments, tendons, and muscles to form the shoulder joint. The shoulder is a ball-and-socket joint. It is unique because the ball is larger than the socket. This allows for more motion, but less stability of the joint. Therefore the rotator cuff muscles and tendons are needed to hold the ball into the socket. They also aid the shoulder with rotation and elevation of the arm.
Figure 1. Normal shoulder anatomy. Rotator cuff muscles/tendon: Supraspinatus, infraspinatus, teres minor, and subscapularis
There are three types of injuries to the rotator cuff tendons: tendinitis, partial tear, or full thickness tear. Tendinitis means that there are no tears of the rotator cuff tendons, but the tendons are aggravated and inflamed. Partial tears (or incomplete) mean that the tears are damaged, but not completely severed. Full thickness (or complete) tears imply that there is a hole going through the tendon or that it is detached from the humerus completely.
Figure 2. (Left) Normal rotator cuff. (Right) Full thickness rotator cuff tear
Most rotator cuff tears are from normal wear-and tear associated with aging. Patients greater than 40 years old are the most common patients with rotator cuff tears. Patients performing repetitive work or overhead activities are also at risk. Regarding the younger patient population, it is more common to have rotator cuff tendinitis associated with athletes, rather than large tears; however an athlete with a traumatic fall or collision (e.g. football, hockey) should be evaluated for rotator cuff injuries, among other things.
Pain along the outside portion of the shoulder is most common. Many patients experience significant weakness in raising their arm overhead, but this is not a requirement for rotator cuff tears. Overhead activity and rotating the arm can reproduce the pain. The pain can be present at night while asleep as well. Remember that there can be other causes of pain that can mimic rotator cuff symptoms. Neck pain, nerve pain, and even atypical heart attacks can be similar to rotator cuff pain.
There are a variety of treatments for rotator cuff injuries. Treatment should be individualized for each patient. Age, general health, activity requirements, work demands, and social/family demands should all be considered in designing a treatment plan for all patients. Nonoperative treatment can be successful in treating about 70-80% of all rotator cuff injuries. These include rest, activity modification (avoiding activities that cause pain), NSAIDs (over the counter medications such as ibuprofen or naproxen), rehab exercises performed with a therapist or just at home, and steroid injections. The primary advantage for nonoperative treatment is that it avoids surgical risks such as anesthesia complications, stiffness, infection, and a lengthy recovery. The disadvantage is that while tears can become asymptomatic, it is uncommon for them to heal and the size of the tear may increase over time.
If surgery is required, each surgeon has a different philosophy regarding their approach to rotator cuff tears. Most surgeons will try to identify the tear with a scope and fix the tear using anchors and sutures. The biggest disadvantage to surgery is the potential for a lengthy recovery. Full recovery can take up to 4-12 months depending on the size of tear and the surgical requirements needed to fix it.
Rotator cuff injuries are a common cause of pain in the shoulder. Majority of injuries can be treated successfully with nonoperative treatment. Treatment plans should be individualized to each patient. Surgery can be successful if nonoperative treatment fails, but it may take several months for a full recovery.