Posted by: wockhardthospitals | August 6, 2009

Rotator Cuff Injuries : Symptoms, Diagnosis and Treatment

Anil Kumble, Shane Warne, Muthaiah Muralitharan,

image source:chicagonow

image source:chicagonow

Javagal Srinath…have two things in common– fast bowling cricketing prowess and Rotator Cuff Injuries! Since the sport they are into involves a lot of shoulder rotation, their rotator cuff muscles are often put into a lot of stress. Thus they are prone to rotator cuff injuries.

The shoulder bones are held together by a group of muscles called the rotator cuff muscles. Sports which involve repeated shoulder rotation (like bowling in cricket, pitching in baseball, swimming, kayaking) put the rotator cuff muscles under stress. The rotator cuff muscles are not meant to function under stress with the arm above a line parallel to the ground. If the shoulder joint is continually stressed with the arm in this overhead position, the rotator cuff muscles begin to stretch out. This allows the head of the joint to become loose within the shoulder socket.


As such, a shoulder is a very shallow ball-and-joint socket where the ball can slide very easily out. Since the shoulder only has a shallow socket and lacks ligaments, any weakness of the small rotator cuff muscle makes it easy for the head of the shoulder to slide part way out of the socket, which is a partial dislocation, or subluxation. Or it may slide all the way out, which is a full dislocation.


Rotator Cuff injuries can be classified into two categories:


  • Tears of the tendons/musclesacute or chronic, and

  • Inflammation of structures in the joint

Acute tear is a result of a sudden, powerful movement

image source : emedx.com

image source : emedx.com

of outstretched hand at speed. It often gives a tearing feeling in the shoulder, followed by severe pain through the arm. It restricts movement of the shoulder due to pain, muscle spasm or specific tenderness. In severe cases, the person with the tear would need assistance to raise the shoulder out to the side.


Chronic tear mostly affects people in the 40 plus age group. There is gradual worsening of pain on the dominant side of the shoulder. The person develops weakness and limitation of other movements depending on the tendons affected around the shoulder.


The inflammation type of Rotator Cuff injuries is more common in women in the age group of 35 to 40 years. It is usually a gradual onset of pain that flares up with overuse or repeated rotator movements. If untreated, the inflammation can lead to a chronic tear. Symptoms include pain coming from deep within with tenderness in specific areas of the shoulder.


DIAGNOSIS AND ASSESSMENT: A Rotator Cuff injury does demand a visit to the doctor for a detailed assessment of the shoulder. The visit may be immediate if the pain limits your ability to work, persists for more than 2-3 days, unable to reach up/sideward with the affected arm even after some days following a shoulder injury, and so on.


Diagnosis of a possible rotator cuff injury involves a detailed history of your general health, past problems and injuries, and reasons that caused the injury; physical examination of both the shoulders to compare disparities, examination of the neck, elbows and wrists to make sure they are not contributing to the problem, etc. Unless a fracture is suspected, the doctor will assess the range of motion and certain other movements of the shoulders. Some specific tests will be done which can help to identify which tendon is causing the problem and confirm if it is a rotator cuff tear, or due to inflammation or some other cause.


TREATMENT: In the past, a torn rotator cuff often resulted in permanent disability. Now, tearing the rotator cuff muscles is not as serious in consequences due to improved rehabilitation programs and better surgical technique. A torn rotator cuff is initially treated by means of a rehabilitation programme. A thorough exercise programme ensures strengthening of the rotator cuff muscles sufficiently so that the head of the shoulder is held firmly in place and will not slip out of the socket. With no slipping, the tendons will no longer be inflamed or irritated.


With a good exercise programme, many tears will heal without surgery. Since the surgery is difficult, it should be avoided unless absolutely necessary. Surgery should only be considered if rehabilitation fails. The doctor might suggest an x-ray, MRI or a CT scan to identify the exact problem and rule out any fractures. If the tear is not large, a simple surgery through a lighted tube (arthroscope) may be possible. Arthroscopic surgery, which has proved so successful in knee treatment, is now used in treatment of the shoulder. Repairing the rotator cuff muscles through the arthroscope offers a less invasive way to treat injuries.


A potential problem with rotator cuff tears develops during the recovery period. When the shoulder is rested, as is necessary for 4 to 6 weeks following surgery, the shoulder loses its ability to move properly. This can result in a partially frozen shoulder with limited motion. This necessitates a carefully constructed rehabilitation program, with a long and painful process of restoring the full range of motion.


Conservative treatment to help rotator cuff muscles – for both acute and chronic rotator cuff tears –recover includes adequate rest to the shoulder with a possible sling, ice therapy at least three times a day for the first couple of days following an injury, heat therapy, medication such as anti-inflammatory drugs and sometimes steroid injections.


A physiotherapist would suggest shoulder exercises and a personalized exercise plan for rehabilitation. For example, small pendular movements when leaning forwards may provide some relief and help to improve the shoulder movement. Walking your fingers up a wall or door can help to improve shoulder movement. Also, holding a stick with both hands and using the better shoulder to move in a circular fashion can help, as this moves the painful shoulder with minimal stress on the rotator cuff muscles.


Depending on several factors, conservative treatment has a 40-90% success rate at fixing the problem. However, if the injury is quite severe and you are young and active, you might require an operation to fix the tear. This needs to be done within 3 weeks.  The criteria would be that the patient for a shoulder surgery should be less than 60 years of age, suffering from complete tendon/ muscle tear where other treatment options would have significantly failed. Surgery often has good results. Very extensive tears often have poor surgical outcomes, but thankfully, such injuries are rather rare. If you are older, it will take you longer to heal due to differences in your physiology.


Questions To Ask Your Doctor about Rotator Cuff Injuries:


  • Do you recommend anti-inflammatory drugs?

  • Will these drugs be taken over a long period of time?

  • What are the risks and side effectsof the drugs?

  • What do you suggest to minimize strain on the muscles?

  • Will exercises help/ what kind of exercises do you recommend?

  • Is a referral to a physical therapist called for?

  • When can normal activities be resued?

by Dr. Sachin Bhonsle, Consultant Orthopedics, Joint Replacements & Arthroscopic Surgeon, Wockhardt Hospitals

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