Due to increased fitness activities and more active lifestyles, our clinic is treating numerous patients suffering from rotator cuff injuries. The rotator cuff is a group of muscles and their tendons, which act together to elevate and rotate the shoulder. It consists of four muscle groups: the supraspinatus, the infraspinatus, the teres minor, and the subscapularis.

Currently, there is some confusion in the medical community concerning the pathology and treatment of rotator cuff injuries. Through extensive research published by the NOSC, we have found that what many doctors commonly refer to as tendonitis is actually tendinosis. Tendonitis is defined as an inflammation of the tendon. Tendinosis is an overuse injury resulting from multiple micro-traumatic events, which over time accumulate and lead to the eventual degeneration of the tendon. Dr. Nirschl describes this as tendinosis, a distinctly non-inflammatory, degenerative, avascular (lacks blood supply) process. This painful tendon abnormality might be thought of as a heart attack of the tendon. Our research has proven through examination of the tendon using a high-powered microscope that there is not inflammation in the tendon and therefore tendinitis is not present. This is an important distinction because it impacts how to treat and cure the injury.

In addition, it is incorrectly believed that damage to the rotator cuff is most commonly the direct result of pressure, or impingement, from the bone which is located on top of the cuff, the acromion. Various medical studies have indicated that this is not accurate, and that the rotator cuff is most commonly damaged by tension overload, repetitive micro trauma, and fatigue. As this tendinosis of the rotator cuff progresses, partial thickness tears in any of the four muscle - tendon groups may occur. This may also lead to a full thickness rotator cuff tear if appropriate treatment is not initiated.

Symptoms of Rotator Cuff Tendinosis

• Usually gradual onset of pain with minor inciting traumatic event

  Dull, aching pain at rest

  Pain localized outside, in front, or behind the shoulder

  Pain with overhead activity

  Weakness and/or pain with lifting objects

Treatment of Rotator Cuff Tendinosis

Conservative

The first step is pain relief. We use medication in our clinic as a helpful means of enhancing the healing process. Medication alone does not promote healing, but enables you to get comfortable and proceed to the rehabilitation or healing phase of treatment. Towards this end, Dr. Nirschl advocates the use of non-steroidal anti-inflammatory drugs (e.g. Ibuprofen, Motrin). The use of cortisone injections are reserved for the rare cases when the patient's discomfort is so pervasive as to preclude activities of daily living. It is important to note that steroid (cortisone) injections cannot be used long term because of potentially damaging side effects. You should never receive more than 3 injections in a one-year span. Rest and medication alone is not an acceptable form of curative treatment. Comfort or pain control alone does not specifically improve the injured tendon tissue.

Physical therapy is an integral part of the treatment of rotator cuff disorders. It is important to Retain a normal range of motion of the shoulder in order to prevent a complicating problem called "frozen shoulder." Therapy also will help to strengthen the rotator cuff and surrounding muscles. Through our research, we have found sensory level electrical stimulation the most effective modality of physical therapy. Tendons, which attach muscles to bones, do not receive the same amount of oxygen and blood that muscles do, so they heal more slowly. Electric stimulation helps increase blood supply to the tendon, thus increasing healing and decreasing any swelling or discomfort. Ice is also used to provide relief from pain and decrease any swelling in the shoulder. It is important to use ice after exercise and after any activity that causes discomfort.

While rest is important to encourage healing it does not specifically initiate the healing process. Rest is also best defined as the absence from the abusive activity, not absence of activity. "Absolute rest is rust" says Dr. Nirschl. All tissues, particularly injured tendons, require tension and motion to maintain health. Total immobilization is contra-indicated as it results in muscle atrophy, weakness, and decreased blood vessel supply. More specifically, immobilization in limited extensibility, joint stiffness, fibrous adhesions and abnormal alignment of collagen fibers.

The key to tendon healing is rehabilitation exercises whose goal is promote optimal healing of the injured tissue. Absolute rest and pain relief by injection or medications offer no direct stimulation to heal the injured tissue. Injured tendons must be nourished by increased blood supply, in association with the production of new protein, which matures into healthy tissue. Rehabilitation exercises are the key to the curative process as they also promote strength, flexibility and endurance to the injured area.

A major goal of rehabilitating the rotator cuff / shoulder is total arm strength and endurance including the muscles of the upper back. Incidence of injury increases as the body fatigues. Exercise of the elbow, shoulder, and upper back muscle groups, therefore are an important concept in avoiding injury. Dr. Nirschl stresses to his patients that "you should get in shape to play your sport, not play a sport to get in shape".

Most patients will have their pain and discomfort reduced significantly with conservative treatment and will not require surgical intervention.

Surgical Treatment

Surgical treatment is considered if a course of quality rehabilitation proves unsuccessful. Failure to receive a quality program or months of rest without rehabilitative exercise, do not justify surgical intervention. In addition, if muscles are not strengthened and range of motion is not maximized prior to surgery, it will prolong postoperative rehab time.

Operative treatment for tendinosis or a partial tear of the rotator cuff involves a shoulder arthroscopy. Surgery is focused on the removal of the damaged portion of the rotator cuff tendon. This abnormal tendinosis tissue weakens the tendon and is pain producing. By surgically removing this tissue, the blood supply is stimulated to produce new collagen proteins, which strengthen the tendon and therefore reduce the pain.

Furthermore, since studies have shown that it is not the impingement of the bone (acromion) above the rotator cuff causing the problem, it is unnecessary and often harmful to remove portions of this bone. In fact, the acromion and its surrounding space have been found to be normal in many cases of rotator cuff tendinosis and by performing bone removal (an acromioplasty), there may be increased bleeding and scarring in the shoulder. This may lead to further pain, limitation of motion, and abnormal shoulder mechanics.

Following the procedure, a sling is used for 2 or 3 days for post-op comfort and support. Rehabilitation including motion exercises can often begin 2-3 days after surgery to improve strength and range of motion.

If there is a full thickness tear of the rotator cuff, an open procedure may be performed. Through an open incision, the damaged part of the tendon is removed, and the tear of the rotator cuff is repaired. Again, it is usually unnecessary to perform an acromioplasty (cutting of the bone) as this procedure can lead to further complications postoperatively. The rehabilitation process for a full thickness rotator cuff tear also starts in 2-3 days but the time to maximum benefit is somewhat longer than partial thickness tears.