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Non-traumatic Rotator Cuff Injury, What Is It, And How Do I Know If I Need Surgery?

What is the rotator cuff?


The rotator cuff is a group of 4 muscles that provide strength and support of the shoulder. See the image below. All of the muscles originate on the scapula (shoulder blade), and attach to the humerus in a cuff (like the seam of your shirt). The names of the muscles are supraspinatus, infraspinatus, subscapularis, and teres minor.


The shoulder is a unique joint, in that it doesn’t have much stability from the bones or ligaments. This is due to the amazing mobility of the joint, which makes good coordination of the muscles even more important!





Common symptoms/complaints


  • Onset: Many people will start to experience shoulder pain that will gradually worsen with daily activities and when just raising the arm. More often than not, there isn’t a specific reason the shoulder pain began, it just started one day and is becoming worse. The older you are, the more likely you are to tear the rotator cuff without trauma.


  • Pain location: over the anterior (front) or lateral (side) of the shoulder, and may radiate down the arm toward the elbow.


  • Pain with movement: especially over shoulder height, when reaching behind the back, and across the body. Sleeping is often painful as well.


  • Weakness: will also be noticed along with the pain, especially during functional tasks such as reaching, lifting, tucking in a shirt, pushing or pulling.


  • Abnormal movement patterns: when someone is moving their arm and it looks different than normal. Examples include a shoulder shrug when raising the arm (most common), along with leaning to the side or backwards to achieve that shoulder motion that is lacking. Normally, you should be able to raise the arm without elevation of the shoulder. If there is pain or weakness, compensation patterns will occur.


Are there other causes for shoulder pain, or is it always the rotator cuff?


Shoulder pain can be caused by other anatomic structures in the shoulder that may have been irritated or compromised. Some of these include: biceps tendon, subacromial bursa, acromioclavicular (AC) joint, labrum, capsule of the shoulder (frozen shoulder), shoulder instability, and even neck pain can radiate into the shoulder.


Whew! Is your head spinning after all of those options? Doctors and physical therapists can sift through the options to find the cause of your pain.


How can I find out what is going on in my shoulder?


A physical therapist will perform an in depth physical exam including testing, and measuring your motion and strength. We will also discuss your history and any other compounding issues you may also have (previous injuries or neck pain). You will receive a customized exercise program to restore your shoulder strength, motion, and ability to perform your daily activities. After all, our bodies were designed for movement!


Utah is a direct access state, which means you can be evaluated by a physical therapist first, without seeing your doctor. We have good working relationships with the top surgeons in the area, and can easily decide if/when you should be referred. A therapist can also order imaging such as a MRI.


The doctor may perform some physical tests and/or order some imaging (x-ray, MRI). You may be offered an injection into the joint, which can decrease pain or inflammation. Medications to manage your symptoms may also be offered. Some insurances require several visits/weeks in physical therapy before approving a MRI.



Do I need surgery?


The decision to undergo surgery is ultimately yours to make. Many people really don’t want to have surgery, and are happy to put in the effort with a physical therapist to avoid it. Many do very well in physical therapy, and are able to avoid surgery altogether. You will be advised by a surgeon and/or a physical therapist about your options.


It is generally recommended to try all conservative options before having surgery. That would include medications, injections, and physical therapy. If a small tear is suspected, it usually heals well with therapy alone.


What can I expect if I do have surgery?


If you do have a tear, it is usually categorized according to size/severity.


  • Small <1 cm

  • Moderate 1-3 cm

  • Large 3-5 cm

  • Severe greater than 5 cm


A rotator cuff repair is a very common procedure, and usually has a good end result (with physical therapy).


The recovery after a rotator cuff repair can be longer than most people expect. It is broken into 3 phases. You will usually meet with your surgeon at the onset of each phase to make sure you are ready to proceed.


  • Phase I: You will be in a sling for 6 weeks, and not allowed to move the arm. This is important, because you had muscles repaired. Time is needed for your body to produce a good “scar” to hold the repair securely.

  • Phase II: your sling will be removed, and you will be allowed to move the arm. Heavy lifting/resistance training is not allowed.

  • Phase III: slowly resistance is introduced, and can be pushed in this phase. Return to sports - such as golf - can begin around 3 months post-operatively.




References:


Fukuda H. The Management of PArtial Thickness Tears of the Rotator cuff. The Journal of Bone and Joint Surgery. 2003; 85(1):3 -11. (1A),


Ainsworth R,Lewis JS. Exercise therapy for the conservative management of full thickness tears of the rotator cuff: a systematic review. British journal of sports medicine. 2007; 41(4): 200-210. (2A)


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