It could be a torn rotator cuff
When you hear the words “rotator cuff injury,” you probably think of professional baseball pitchers and tennis players. It’s true that this injury frequently affects athletes whose sports require an overarm motion. The rotator cuff—the broad tendon and muscle that surrounds the “ball” part of the “ball and socket” shoulder joint—helps stabilize the shoulder and is involved in lifting and rotating the arm.
What you may not know: It’s also easy for nonathletes to tear a rotator cuff, and you can even do so without realizing it. If you’ve noticed decreased strength and mobility or recurrent pain in your shoulder, you may have torn your rotator cuff. Studies suggest that up to 70% of people age 80 and older have a tear in one or both rotator cuffs. Among people in their 60s and 70s, more than 50% have rotator cuff tears.
One reason these tears are so common in older people is that even under the best of conditions, the shoulder joint gets a limited supply of blood. As we age, the shoulder’s blood supply diminishes even further, causing tendons to become less elastic—and more prone to damage. A single traumatic event such as a fall can cause a rotator cuff injury, but most are the long-term result of everyday wear and tear.
IS IT TORN?
Do you experience weakness when lifting or rotating your arm…a crackling sensation in your shoulder…and/or pain in the front and outside of your shoulder? The pain may be constant or intermittent, and it may feel worse when you lean on your elbow, reach up for something or lie on the affected shoulder at night.
These are all indicators of a torn rotator cuff, and you should see an orthopedic surgeon, who can diagnose the problem. Other possible causes of shoulder pain include arthritis, tendonitis (inflammation of the rotator cuff tendon) and bursitis (inflammation of the bursa, a pad of soft tissue inside the shoulder joint).
When I examine someone with a shoulder ailment, I check for shoulder weakness by having the patient lift his/her arm away from the body at a 90-degree angle while resisting my downward pressure. If there’s no weakness, the pain is most likely due simply to inflammation. In that case, I generally recommend that the patient try to avoid exacerbating activities (overhead sports, reaching, sleeping with that arm extended over the head) for two to three weeks, take anti-inflammatory medication, such as ibuprofen or naproxen (possibly including a cortisone shot in the affected joint), and perform shoulder-strengthening exercises (see below) once the pain subsides.
But if my test reveals shoulder weakness, that usually indicates a tear in the rotator cuff tendon, which requires much more aggressive treatment. The next step is to do an MRI or ultrasound scan of the shoulder to check for a tendon tear.
TREATING AN INJURY
No rotator cuff tear, big or small, will ever heal on its own. If the tear is small and the patient is over 65, I’ll usually recommend two weeks of anti-inflammatory medication along with physical therapy to see if strengthening the remaining rotator cuff muscles will compensate for the small tear. In younger patients—who tend to be more active and who have more years ahead of them during which the tear will increase and become more symptomatic and difficult to repair—surgery is recommended.
Helpful exercises involve working the four muscles around the shoulder joint using a TheraBand (an elastic band that provides resistance when you pull it, available at sporting-goods and fitness supply stores), or light (one- or two-pound) weights.
Examples: Tie the TheraBand to a doorknob. Stand with your affected shoulder away from the door, holding one end of the band with that same hand. Pulling the band for resistance, extend your arm out to the side (keeping your elbow against your body). Repeat 10 to 15 times.
Next, stand with the affected shoulder toward the door, hold the band with the same hand and pull your arm across your body 10 to 15 times (again keeping your elbow in).
Finally, stand with the front of your body facing the door. Holding the band, lift the affected arm with the palm up and the elbow straight 10 to 15 times.
Do three sets of these exercises every other day. By the tenth lift, the arm should be tired.
WHEN SURGERY IS NECESSARY
If a patient’s pain continues, or if the rotator cuff tear is large, I generally recommend surgery to repair the tendon. Reason: As already mentioned, tears tend to get worse over time—especially large ones. In the worst cases, the attached muscles lose function and start to atrophy.
For this same reason, I’ll also periodically reevaluate patients with small tears to make sure that the tears haven’t progressed to where surgery is required. In these follow-up exams, I check not just the affected shoulder but also the other shoulder. Reason: Many people also have tears on their “good” side. In a recent ultrasound study of nearly 600 patients with shoulder pain, researchers found that one-third had tears in both rotator cuffs—even though most had pain in just one shoulder.
Today, rotator cuff surgery is usually done arthroscopically, using a scope and cutting tool that are inserted through two or three tiny incisions. The surgeon typically removes a spur of bone from the top of the shoulder joint to make more space for the rotator cuff and trims away any chronically inflamed tendon tissue. The tear is sewn up and, usually, reattached to the top of the humerus bone using a small anchor made of metal or of a bioabsorbable material that looks like plastic.
The procedure is generally very successful provided the patient does shoulder-strengthening exercises under the guidance of a physical therapist during recovery. It typically takes six weeks for the tendon to heal, but can take up to 12 months to regain maximum strength. Return of strength is far less predictable than pain relief.
Once a patient has completed physical therapy, the shoulder will be reassessed to determine the need for any restrictions. Most patients return to full activity.
Future hope: Two promising medications may speed healing. Early studies indicate that application of certain healing substances derived from blood platelets or engineered in a laboratory promotes earlier absorption of diseased tissue and replacement by strong tendon. Other promising techniques include use of platelets isolated from the patient’s own blood to deliver growth factors to a tendon repair site…and pulsed ultrasound, which speeds healing by improving local blood circulation.
Source: Sabrina Strickland, MD, sports medicine specialist, Hospital for Special Surgery, New York City, where she treats orthopedic conditions of the shoulder, knee, elbow and ankle. She is also chief of orthopedics at the James J. Peters VA Medical Center, Bronx, New York, and a clinical instructor at Weill Medical College of Cornell University, New York City.
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Publication Bottom Line Tomorrow
Original publication date June 1, 2008
