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Shoulder Rotator Cuff Injuries and Impingement Syndrome

Rotator cuff tears are a common cause of pain and disability among adults. In 2008, close to 2 million people in the United States went to their doctors because of a rotator cuff problem. At Nirschl Orthopaedic Center we see a tremendous number of rotator cuff injuries.

A torn rotator cuff will weaken your shoulder. This means that many daily activities, like combing your hair or getting dressed, may become painful and difficult to do.

Shoulder injuries are common in both young, athletic people and the aging population. In both of these age groups, there are numerous causes of shoulder pain. The most common problem occurs in the narrow space between the bones of the shoulder. Irritation in this area may lead to a pinching condition called impingement syndrome, or damage to the tendons known as a rotator cuff tendonitis or tear. These two problems can exist separately or together. It is likely that rotator cuff tears are the result of age related changes within the tendons, tension stretch, or pinching of the rotator cuff.

The rotator cuff is made up of a group of four muscles and tendons that converge around the top of the humerus, the upper arm bone. These muscles and tendons connect your upper arm with your shoulder blade. Together, they form a ''cuff'' that both holds the ball of your shoulder firmly in place, and allows the shoulder to move in different directions. The shoulder is the most mobile joint in the human body, with a complex arrangement of structures working together to provide the movements necessary for daily life. Unfortunately, this great mobility comes at the expense of stability. Too much stress on the shoulder can cause small tears and swelling in the tendons of the rotator cuff called tendonitis. Abrupt stress may even cause one of the tendons to pull away from the bone or tear in the middle of the tendon. Chronic irritation or impingement can then develop into tendinosis or tendon failure with partial or complete tears.

What is Shoulder impingement syndrome? Dynamic vs. Static

Shoulder impingement syndrome when the tendons of the rotator cuff and the subacromial bursa are pinched in the narrow space beneath the acromion. The bursa is a cushion between the rotator cuff and the acromion bone. This causes the tendons and bursa to become inflamed and swollen. This pinching is worse when the arm is raised away from the side of the body. Impingement may develop over time as a result of a minor injury, or as a result of repetitive motions that lead to inflammation in the bursa. In addition, weakness in the muscles of the rotator cuff and shoulder complex can allow the shoulder to ride up in the socket causing a dynamic narrowing of the space leading to dynamic impingement.

With age and the onset of arthritis, the acromion may develop bone spurs that further narrow this space. Impingement caused by bone spurs on the acromion is common in older patients who participate in sports or work activities that require overhead arm positions. Spurs may also result if one of the ligaments in the coracoacromial arch becomes calcified. This form of impingement is static e.g. Not dependent upon abnormal upward mobility of the ball of the shoulder.

Impingement is classified in three grades:

  • Grade I is marked by inflammation of the bursa and tendons
  • Grade II has progressive thickening and scarring of the bursa
  • Grade III occurs when rotator cuff degeneration and tears are evident

What are the Signs and Symptoms of Shoulder Impingement Syndrome?

Most often the onset of symptoms is related to an episode of overuse. In many patients, the episode occurred sometime in the past and the shoulder failed to return to normal.

Impingement symptoms are marked by onset of pain and/or a decrease in range of motion:

  • The pain is often gradual in onset and may be sharp and intermittent in its early stages.
  • As impingement progresses, the pain becomes more of a constant ache.
  • Although pain is usually present after impingement sets in, the original event that led to symptoms is often relatively minor and not remembered as painful.
  • Once inflammation starts, simple movements may become painful.
  • Overhead motions tend to increase the pain. There is less space for the bursa when the arm in this position, causing more compression of the bursa.
  • Arm movements at waist level are not painful. In this position, there is more space for the bursa, and therefore it is less compressed.
  • Pain usually increases at night for two reasons. First, inflammation and swelling tend to get worse as the shoulder is used during the day, and this can lead to more pain in the evening. Second, the mind is usually less occupied in the evening, allowing pain to become a major focus of attention. Rolling over on the shoulder is especially painful.

What is a Rotator Cuff Tear?

Continual irritation to the bursa and rotator cuff tendons can lead to deterioration, fraying and tearing. As the damage progresses, the tendon can tear completely. The tendon of the supraspinatus muscle is the most commonly involved tendon among the rotator cuff muscles. This muscle forms the top of the cuff and lies in the narrow space beneath the acromion. It is subject to the most pinching of all the rotator cuff muscles. In older people, rotator cuff tears tend to be the result of wear and tear over time. Several scientific studies have shown that up to 2/3 of the population at age 70 have rotator cuff tears. Many of these people had no symptoms.

Tears that happen suddenly, such as from a fall, lifting heavy objects or as a result of a high-energy injury associated with throwing or overhead sporting activities, usually occur in an already weakened tendon and can cause intense pain. There may be a snapping sensation and an inability to raise the arm or lift it against gravity.

Tears that develop slowly due to overuse also cause pain and arm weakness. You may have pain in the shoulder when you lift your arm to the side, or pain that moves down your arm. At first, the pain may be mild and only present when lifting your arm over your head, such as reaching into a cupboard. Over-the-counter medication, such as aspirin or ibuprofen, may relieve the pain at first. Over time, the pain may become more noticeable at rest, and no longer goes away with medications. You may have pain when you lie on the affected side at night. The pain and weakness in the shoulder may make routine activities, such as combing your hair or reaching behind your back, more difficult.

Athletes prone to rotator cuff tears include:

  • Gymnasts
  • Throwers-Baseball, Softball, Shot Put, Javelin
  • Weight Lifters
  • Rowers
  • Volleyball Players
  • Tennis Players
  • Swimmers

High-demand events causing rotator cuff tears in an already weakened tendon include:

  • Falling on your shoulder/
  • Using an arm to break a fall
  • Repetitive overhead arm activities
  • Lifting heavy weights
  • Lifting improperly

What Are the Signs and Symptoms of a Rotator Cuff Tear?

  • Pain and tenderness in your shoulder, especially when reaching overhead, reaching behind your back, lifting, pulling or sleeping on the affected side
  • Shoulder weakness
  • Difficulty moving the shoulder/loss of motion
  • Inclination to keep your shoulder inactive
  • Snapping or crackling sounds when moving the shoulder

To diagnose a rotator cuff tear, your doctor will give you a thorough physical exam. He or she will want you to move your arm in different directions to see what causes pain, as well as check the strength of the rotator cuff and surrounding muscles. In addition, your doctor might want to order the following tests:

  • A diagnostic injection can help the doctor distinguish between impingement syndrome and a full thickness rotator cuff tear. A local anesthetic is injected into the inflamed bursae to eliminate the pain. If strength in the shoulder returns once the pain is blocked, it is likely that the weakness was due to pain and the rotator cuff tendons are not torn. A rotator cuff tear is suspected if strength does not return while the pain is blocked.
  • X-rays can reveal signs of arthritis, fractures, and bone spurs. These images are frequently negative in the early stages of injury since x-rays show bone structure but not soft tissue.
  • MRI (Magnetic Resonance Imaging)- can also give your doctor a better idea of how "old" or "new" a tear is because it can show the quality of the rotator cuff muscles.
  • Arthrogram, a special type of X-ray or MRI done after a dye is injected into joint; this will allow your doctor to see more detail. (determine if other tissue was damage as a result of the tear)
  • Musculoskeletal Ultrasound, this can better show soft tissues like the rotator cuff tendons. It can show the rotator cuff tear, as well as where the tear is located within the tendon and the size of the tear.
  • Arthroscopy, a minimally invasive surgical procedure in which a tiny camera is inserted into the shoulder joint to look at the rotator cuff. Arthroscopy is usually not done unless it is likely that you will need a surgical repair as determined by other non-surgical tests.

Non-Operative Treatment of Rotator Cuff Injuries

If you have a rotator cuff tear and you keep using your arm despite increasing pain, you may cause further damage. A rotator cuff tear can get larger over time. Early treatment can prevent your symptoms from getting worse. It will also get you back to your normal routine that much more quickly.

The goal of any treatment is to reduce pain and restore function. There are several treatment options for a rotator cuff tear, and the best option is different for every person. In planning your treatment, your doctor will consider your age, activity level, general health, and the type of tear you have. There is no evidence of better results from surgery performed near the time of injury versus later on. For this reason, many doctors first recommend nonsurgical management of rotator cuff tears using physical therapy.

1. Strengthening Exercises and Physical Therapy
Physical therapy is the most important step in treating rotator cuff injuries. Flexibility exercises to restore movement and strengthening exercises for the entire shoulder complex is extremely important to maintain normal shoulder function. Non-operative treatment is similar for both impingement and rotator cuff tears. The physical therapist can also try treatments to relieve pain and inflammation including ultrasound, electric stimulation, cold laser, and other treatments.

2. Activity Modification
The way we move our shoulders, carry objects, and sleep at night can all place strain on the rotator cuff. Learning proper ways to use the shoulder can place less strain on the rotator cuff muscles. The rotator cuff only accounts for four of the many muscles that surround the shoulder joint. Working with a physical therapist, you can learn to properly strengthen and use the other muscles of the shoulder and rely less on the rotator cuff muscles.

3. Anti-inflammatory Medication
Anti-inflammatory medication may be prescribed to help reduce pain and inflammation. Many patients with rotator cuff tears can function quite well once the pain and inflammation are controlled with medication and physical therapy. This is especially true for the elderly and those with low demands on the shoulder.

4. Cortisone Injections
Cortisone injections can be very helpful at limiting the acute inflammation of a rotator cuff tear and allowing the patient to begin therapy. *Cortisone does not heal, but can help provide pain relief so you may continue to do your therapeutic exercises in an effective comfortable manner.

It is important to participate in the therapy and exercises even if the shoulder feels better after an injection. While the cortisone can help settle down the shoulder inflammation, the therapeutic exercises given to you by the physical therapists will help prevent a recurrence of rotator cuff tear symptoms. The goal is to increase blood supply and healing as well as strength and flexibility.

Will Non-Surgical Treatments Work for Rotator Cuff Injuries?

Non-surgical treatments can provide relief of symptoms of a rotator cuff tear in some, but not all, people. While different studies have found different rates of success, about 50% of people who try non-surgical treatments will find relief of symptoms. Some of the variables that can affect the likelihood of successful treatment include the size of the rotator cuff tear, the length of time you have been experiencing symptoms and your age. Therapeutic exercise brings new blood vessels to the injured tendons and also strength to the adjacent tendons and muscles which can compensate for the strength deficiencies of the injured section of the rotator cuff.

When is Surgery Necessary for Rotator Cuff Injuries?

The answer to this question depends on the condition of the other shoulder muscles and the age of the patient. Many older patients have no symptoms with a rotator cuff tear and continue to function without pain or disability. The goal of physical therapy is to maximize the function of the remaining tendons, and hopefully avoid surgery. In the younger age groups, particularly when tears are caused by a sudden injury, early surgery may be a better choice especially if high demand sports activity is desired. The decision for surgery is ultimately a quality of life determination.

Surgical Treatment

Your doctor may recommend surgery if your pain, flexibility and strength do not improve with nonsurgical methods. Continued pain and loss of function are the main indication for surgery. If you are very active and use your arms for overhead work or sports, your doctor may also recommend surgery.

Surgery may be a good option for you include if:

  • Your symptoms have lasted 6 to 12 months
  • You have a large tear (more than 3 cm)
  • You have significant weakness and loss of function in your shoulder
  • Your tear and symptoms were noted after a recent, acute injury

Surgery to repair a torn rotator cuff most often involves re-attaching the tendon to the head of humerus (upper arm bone). There are several options for repairing rotator cuff tears. Your orthopaedic surgeon will discuss with you the best procedure to meet your individual health needs. Arthroscopic or small open incisions may be considered which ever in your doctor's opinion offers the best result. Large tears may also require on extra tissue patch graft for a more secure repair. Although considered an important part of surgery in years past extensive bone surgery (e.g. acromioplasty) is no longer recommended by the surgeons at Nirschl Orthopaedic Center. A cleaning out of the bursal area is usually indicated. The surgery is generally outpatient surgery (i.e. usually no need for an overnight hospital stay).


Rotator cuff recovery is generally slow and requires supervision. In order to achieve a full and rapid recovery, for smooth and possibly better post-operative results, surgery might be delayed until the patient has full range of motion and has gained good muscle strength from a physical therapy pre surgery pre-habilitation program. After surgery, the patient follows a closely monitored program:

  • Therapy is carefully controlled in the first 6 - 12 weeks while the tendons heal back to the bone.
  • The first goal is to regain full motion within 2 months after surgery. A therapist will assist in the early stages with gradual recovery of motion.
  • During the first 6 weeks, there is limited active use of the shoulder in order to protect the surgical repair.
  • Once initial healing is achieved, a progressive strengthening program should begin.
  • Full recovery can take 4-6 months or longer. Some patients may require more time to regain muscle strength and complete the healing process. Time and quality of recovery is very dependent upon the blood supply and the quality of the tendons at the time of repair.

Companion Problems:

Occasional companion issues may be present. These can include arthritis of the A-C joint (the small joint of the shoulder), labral tears (a rubber like ring of tissue around the socket of the joint), frozen shoulder (scar thickening of the joint lining) and biceps tendon tears. If present these issues may also require some intervention at the same time.

If you have an orthopaedic injury, contact the experts at Nirschl Orthopaedic Center in Arlington, Virginia. Schedule an appointment with an orthopaedic surgeon today by calling 703-525-2200.

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