Rotator Cuff Injuries
A rotator cuff injury is a tear or other injury to the supporting muscles and tendons that protect and move the shoulder. It is common in athletes and statistics shows that adult athletes over the age of 60 are at the highest risk of this type of injury than other age groups. Other statistics show an increase in the injury frequency after the age of 40.
In fact, 70 percent of those over the age of 80 are found to have had a torn rotator cuff, and even those who are sedentary are at risk for the injury. Seventy-five percent of people with a relatively large rotator cuff tear or complete tear will reinjure and re-tear the muscle following surgical repair.What is an injury to the Rotator Cuff?
A rotator cuff is a group of four muscles and tendons that surround the head of the humerus in the shoulder. They act together to form a “cuff” that keeps your arm in the proper position and allows the shoulder to move in all the movements it does. The shoulder is considered one of the most mobile joints of the body and it can only do so with the cooperation of the rotator cuff. Unfortunately, the shoulder is rather weak so that a sudden stressor can tear one of the tendons away from the bone. The other outcome is a tear in the middle of the rotator cuff tendons.
Athletes are highly prone to getting rotator cuff tears, especially pitchers in baseball, tennis players, swimmers, and football players. The average person can get a rotator cuff injury if they fall directly onto the shoulder, lift heavy weights, or use their arm to break a fall. Any repetitive motion of the arm, particularly with the arms raised above the head, can cause a rotator cuff tear.
The injury doesn’t have to involve a tear in the tendons. It can involve irritation, such as a tendonitis of one or more of the tendons or a tear in the muscle. Tendons are normally tough and thick bands of tissue that connect the shoulder muscles to the bone. Tendonitis can happen with repetitive injury overuse of the muscle group attached to the tendon. Tendonitis of the rotator cuff increases with age. Often the only management is anti-inflammatory medication, steroid injections, rest and determining ways to rebalance the way the extremity moves so one tendon does not receive excessive pressure.
An injury to the rotator cuff involves damage to at least one of the tendons that belong to these four muscles:
- Teres minor
The tendons connect around the head of the humerus and attach on the fronts and sides of the humerus bones and on the greater and lesser tubercles. The muscles attached to the above tendons are located in various places in the upper back. They also attach to the shoulder blade.
The supraspinatus tendon is the biggest; it is necessary for lifting the arm. The teres minor and the infraspinatus tendons help the arm rotate outward. The subscapularis tendon and muscle help the shoulder rotate inward.
A rotator cuff injury is one of the most common causes of disability among adults. Almost 2 million people per year visit their doctors because of a problem with their rotator cuff. When the rotator cuff tears, there will be problems with activities of daily living such as combing one’s hair or reaching up to grab something off a shelf.
Symptoms of a rotator cuff injury
The symptoms of an injury to the rotator cuff can come on gradually or all of a sudden, depending on the nature of the injury that caused the tear. If you sustain a serious injury that causes a rotator cuff tear, you will feel a pop in the shoulder area associated with intense pain and a sudden weakness in the affected arm.
Once the tendon has torn, the following symptoms can be experienced:
- Pain in the arm and shoulder, which can be moderate to severe, depending on how serious the rotator cuff tear was.
- Weakness of the shoulder, especially with lifting the shoulder above the level of the armpit
- Tenderness in the shoulder in the location of the torn tendon
- Difficulty moving the shoulder, especially if you are trying to lift the arm above the level of the shoulder
- A snapping sound or crackling sound when the shoulder is moved
- A problem trying to sleep on that side of your body
There are two major causes of a rotator cuff injury. These are “acute” and “chronic”. The mechanisms of injury can be either intrinsic or extrinsic to the tendon.
Acute tears most likely occur during sporting events. They happen as a result of a sudden high-stress impact or motion and include events like falling on the outstretched hand or lifting something heavy with a jerking motion. You can also get a rotator cuff tear with injuries that cause a broken collarbone or a dislocated shoulder.
In chronic tears, the injury happens over time. It happens when a person suffers from a muscular imbalance in the shoulder or poor biomechanics in lifting or carrying things. Most chronic tears do not have to be the result of specific movements but are rather the aging process taking its toll on the joint doing normal daily activities. This is why the tears most likely occur in the dominant arm.
There are several different factors that contribute to degeneration of the rotator cuff. Repetitive motion is the greatest factor leading to rotator cuff injury. Things like weightlifting, rowing, or overhead throwing, when done in a repetitive fashion, can cause injury.
Another factor causing an increased chance of rotator cuff injuries is a decrease in the blood supply to the area, which blocks the ability of the tendons to repair themselves.
The last factor in rotator cuff injury is called an impingement syndrome. This is when the tendon fibers pass through the subacromial space, the passage beneath the acromion in the shoulder joint. Those tendons and muscles get irritated in this small space. The subacromial space gets even narrower when the shoulder is raised so that the chronic irritation results in pain and tears in the tendons.Risk Factors for Rotator Cuff Injury
There are some people who are at greater risk for rotator cuff injuries than others. These include:
- Being an athlete older than age 40.
- Having a known case of impingement syndrome
- Having tightness in the muscles or the joint
- Having poor posture
- Repetitive motion of the shoulder
- Being a swimmer
- Being a baseball pitcher
- Playing football
Before any formal testing is done, the doctor must get a detailed history of the patient’s use of the shoulder. That includes sports, occupational, and recreational use of the shoulder on a repetitive basis.
Then the doctor assesses the joint, including finding areas of tenderness, doing strength testing and assessing the neurological function of the arm. Any deformity should be noted. Remember that neck pain can be felt in the shoulder so shoulder pain may not be from the shoulder itself.
The doctor could do a plain film x-ray of the shoulder to rule out a bony pathology but, since the soft tissue of the muscles and tendons do not show up on x-ray, it is not a good test to diagnose the injury. In addition, CT scan of the shoulder would be equally unhelpful in detecting a rotator cuff injury. A plain film can show the presence of bone spurs, which are sure signs that some chronic rotator tendon injury is going on.
The best test for detecting a rotator cuff injury is the MRI scan. This test can often pick up on soft tissue injuries and can show both the location and size of the tear. It is usually also able to tell if the rotator cuff tear is complete or only partial.Treatment of the injury
Because using a shoulder in the presence of increasing pain from a rotator cuff tear can further damage the shoulder and enlarge the tear, it is wise to have some kind of treatment for the injury. There are two types of treatments for rotator cuff tear: a nonsurgical approach and a surgical approach.
The goal of the treatment of these types of injuries is to lessen the pain and restore normal function. The best course of treatment to achieve these things varies from person to person. Rehabilitation and surgery depend on your age, your general health, the type of tear you have, and your activity level. Most doctors prefer a nonsurgical approach.
In nonsurgical rehabilitation, about half of all people will have pain relief and will have an improvement in function of the affected shoulder. It should be noted that the strength of the shoulder does not get any better without having surgery.
Nonsurgical treatment of rotator cuff injuries includes:
- Rest, with an avoidance of overhead activities. A sling might be used to keep the shoulder temporarily immobilized.
- You should avoid any activity that makes the pain worse.
- You should begin to take nonsteroidal anti-inflammatory medication to treat the inflammation of the tendons.
- You should undergo physical therapy in which you strengthen the shoulder and bring the range of motion back to a normal position.
- You could have a steroid injection into the tendon to ease the inflammation in the joint.
The advantage that nonsurgical methods have over surgery is the avoidance of surgical complications such as:
- Anesthesia complications
- Long recovery times
- Permanent shoulder stiffness
The disadvantages of nonsurgical methods include:
- A lack of improvement in shoulder strength
- The size of the tear may get larger
- There may be a permanent activity limitation
In some cases, surgery is recommended, especially for those people who are active and rely on their shoulder for a sporting career. Doctors use the following criteria to determine if you are a candidate for surgery:
- The symptoms have been present for at least 6-12 months.
- There is significant loss of function or weakness in the shoulder
- The tear is greater than 3 centimeters
- The tear was caused by an acute injury in the recent past.
Surgery to repair a rotator cuff tear usually involves the reattachment of the tendon onto the head of the humerus. There are several types of approaches to a rotator cuff tear repair. These include:
- Open Repair. This involves opening the skin in a several centimeter long incision. The deltoid muscle on the chest is detached in order to have access to the tendon that is torn. Bone spurs are removed if they are present and the tendon is repaired. This is the preferred technique to use if the tear is very big or requires a complex repair. It leaves a bigger scar than the other surgery types but it may be necessary for some situations.
- Arthroscopic Repair. This involves using a small incision in which a camera and instruments are inserted. The doctor uses the camera images to find the tear and repair it without having to see it in real life. It is best used in smaller tears that are easy to fix. This can be done as an outpatient and does not disrupt the rest of the shoulder tissue.
- Mini-Open Repair. This repairs the tendon using an incision that is 3-5 centimeters long. Arthroscopy is also used to assess the damage to the rotator cuff. This means the doctor does not have to detach the deltoid in the process of doing the surgery. Bone spurs can be trimmed to make more room to repair the damaged tendon. Because there is an open incision, the actual tendon repair happens with direct viewing rather than through the arthroscope.
Most people have a satisfactory outcome from their rotator cuff surgery. Those things that negatively influence the outcome include:
- Very large tears
- Smoking history
- Poor tissue quality
- Patient age greater than 65 years
- Ongoing workman’s compensation claim
I'm Ed Smith, a Sacramento Personal Injury Lawyer. If you or a loved one has suffered a rotator cuff injury as a result of someone else's negligence and would like to discuss your legal options with an experienced Personal Injury Attorney, contact us online or call us at 916.921.6400 to set up a FREE consultation.
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