Case Review of Rotator Cuff Injury - Dr. Kelly Cunningham

Rotator Cuff Tendonitis Fundamentals

The rotator cuff is a group of four tendons that covers the humeral head and controls arm rotation and elevation. These muscles and their tendons work together with the deltoid muscle to provide motion and strength to the shoulder for all waist-level and shoulder-level or above activities.

Rotator cuff tendonitis is an inflammation of a group of muscles in the shoulder together with an inflammation of the lubrication mechanism called the BURSA.

This condition is often caused by or associated with repetitive overhead activities such as throwing, raking, washing cars or windows and many other types of highly repetitive motions. It may also occur as a result of an injury. Rotator cuff injuries are the most common cause of shoulder pain and limitation of activities in sports in all age groups. Rotator cuff tendonitis is the mildest form of rotator cuff injury.

The shoulder has a unique arrangement of muscle and bone. The rotator cuff (which is muscle) is sandwiched between two bones much like a sock lies between the heel and the edge of a shoe. In the same way that repeated walking eventually wears out the sock, the rotator cuff muscles fray with repeated rubbing on the bone. As the muscle begins to fray, it responds to the injury by becoming inflamed and painful. With continued fraying, like a rope, it may eventually tear.

What are the symptoms?

The classic symptoms include a ‘toothache’ like pain radiating from the outer arm to several inches below the top of the shoulder.Pain may also occur in the front and top of the shoulder. It may interfere with sleeping comfortably. It may even awaken people from a sound sleep with a nagging pain in the upper arm.

The symptoms are usually aggravated by raising the arms overhead or in activities that require reaching behind the body, such as retrieving an object from the back seat of a car. Furthermore, reaching behind the back to fasten underclothing or to pass a belt may aggravate the arm and shoulder pain.

A clicking in the shoulder may occur when raising the arm above the head.

What are my treatment options?

A thorough history and physical exam will nearly always lead to a correct diagnosis. X-rays will often show changes on the arm bone where the rotator cuff muscles attach, but an MRI provides the definitive diagnosis. This test clearly shows the muscles and indicates if the muscle is inflamed, injured or torn.

Medical

The following steps should be taken as a conservative approach to treating rotator cuff tendonitis:

• Stop or markedly decrease the activity that required the use of the shoulder at or above shoulder level.
• Apply ice to the affected area.
• Take anti-inflammatory medication to reduce arm and shoulder pain.
• Begin an exercise program to maintain flexibility.
• Avoid carrying heavy objects with the affected arm or using shoulder-strap bags on the affected side.

In the early phases, over-the-counter anti-inflammatory medications may provide benefit. However, to allow the inflammation to resolve, it is vital to curtail any repetitive activity and it is equally important to try to keep the elbow below the shoulder level when using the arm.

Daily stretching while in a hot shower is also beneficial. If shoulder pain becomes more severe, prescription strength medication or a cortisone type injection may help.

Cortisone injections can be very effective in the treatment of the pain. When used, injections should be done in conjunction with a home exercise program for flexibility and strengthening, modification of activities and ice. Other pain controlling options include heat, ice, ultrasound and therapeutic massage.

For a young patient under the age of 30 and with a first time episode of rotator cuff tendonitis that is treated immediately with the above protocol, the average length of time for rehabilitation is two to four weeks. For those with recurrent episodes of tendonitis and some risk factors, rotator cuff tendonitis may take months to heal and in rare cases may require surgery.

Surgical

If symptoms persist, surgery to remove a spur on the acromion can increase the space available for the inflamed tendon and may prevent further fraying or complete rupture. If an MRI shows a complete muscle injury, surgical repair may be required.

Surgery for recurrent rotator cuff tendonitis (bursitis) is occasionally performed to:

• Remove a prominence or spur on the undersurface of the acromion.
• Remove chronically inflamed, thickened and fibrotic bursal tissue.
• Inspect the tendons and tidy up and sometimes repair a tear in the tendons.

These procedures are often done in combination. This can be done either through an open or an arthroscopic approach with the start of an early rehabilitation program one or two days after surgery and advancing to a more comprehensive program between two and five weeks after surgery. The initiation and progression of these exercises is dependent upon the patient’s findings at surgery, surgical procedure and rate of healing.

"Complete rotator cuff tears can be augmented with stem cell and growth factors to aid in healing.
Studies show that, after repair of the rotator cuff defect (as shown in the videos), stem cells injected into the repair site result in a higher healing and a lower re-tear rate. Another example of cutting edge treatment applied to a common sports medicine problem." Says Dr. Cunningham.

Dr. Kelly Cunningham

Author

Dr. Kelly Cunningham Physician