A Multifaceted Approach To Treat Pain And Maintain Function
Rotator Cuff Injuries
By Frank Rodriguez Jr., M.D.
Rotator cuff injuries are a common shoulder disorder, especially for people age 40 or older. The rotator cuff refers to muscles and tendons that surround the shoulder joint and hold it in place. Repetitive injury to the shoulder or a single traumatic event may tear the rotator cuff. Overhead activities such as painting a ceiling or strenuous “overhand” arm motions from sports such as baseball often contribute to these injuries. Poor posture, heavy lifting, or extending an arm to break a fall can play roles, too. Aging also increases the risk of a rotator cuff tear as bone spurs can develop that irritate rotator cuff tissue and degenerative changes can affect tendons and muscles.
Rotator cuff tears typically occur in a person’s dominant arm. With a partial-thickness rotator cuff tear, only a portion of the tendon is severed. A full-thickness tear means the tendon has torn completely. Rotator cuff tears result in persistent pain, weakness, and limited range of motion. The pain may prevent the patient from sleeping on the injured side. The patient may also notice a clicking or grinding in the shoulder or a feeling of instability, fatigue, or weakness.
The worst thing a person can do when this injury occurs is ignore it. Some attempt to play or work through the pain but ignoring the symptoms and continuing to stress the tissues can only worsen the tear.
Diagnosis
To assess a rotator cuff tear, physicians inquire about the patient’s medical history, when the symptoms began, and if he or she sustained any recent injuries. During the physical exam, the physician pays close attention to the shoulder area, assessing muscle strength and range of motion. He or she asks the patient to move the arm in many different directions and hold each position. The physician may also inject an anesthetic into the joint to help with moving the arm to evaluate the condition.
X-rays can identify problems with the bones but do not show soft-tissue injuries, such as those associated with muscle or tendon tears. To assess damage to these tissues, physicians may order magnetic resonance imaging, an ultrasound, or an arthrogram. An arthrogram is a special X-ray taken injecting a contrast fluid that outlines structures within the joint that may be damaged. Arthrograms and ultrasounds are used less often than magnetic resonance imaging.
Treatment
Initially, physicians take a multifaceted approach to managing the pain from rotator cuff tears and maintaining shoulder function. Minor tears may heal without intervention. In such cases, the patient is asked to rest the shoulder and refrain from overhead activities until the physician gives approval to resume such movement, usually about a week after the shoulder begins to feel better. Patients often use cold packs during the first two days to help decrease inflammation and pain.
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Physicians might order nonsteroidal, anti-inflammatory drugs or a pain reliever to control discomfort. They may also recommend injecting a corticosteroid drug into the joint. Other treatments include rehabilitation programs to help stretch and strengthen the surrounding muscles, which can speed the recovery and help prevent subsequent injury. This physical therapy might include ultrasound treatments.
Full-thickness tears and partial tears that do not respond to conservative treatment typically require surgical repair. The size, depth, and location of the tear dictate the possible options. For small tears, a surgeon may perform an arthroscopic procedure, inserting a scope and instruments through tiny incisions. He or she can also combine an arthroscopic technique with a small open incision, which allows a full-thickness repair. For more severe cases that require tissue transfers or tendon grafts, an open procedure provides greater access to the area. Joint replacements are another option for some patients.
The final step after surgery is rehabilitation. It may take six months to regain full shoulder function after an operation. The patient’s active participation in a physical therapy program is essential for a good outcome.