Shoulder pain - Rotator Cuff Tendonitis vs Tear

Bitterroot Orthopedics and Sports Medicine
A service of Marcus Daly Memorial Hospital
Michael Dolecki, MD
1200 Westwood Drive
Hamilton, MT 59840
(406) 375-4868

Shoulder pain - Rotator Cuff Tendonitis vs Tear
Disorders of the rotator cuff are a common source of shoulder pain. The rotator cuff is a group of 4 muscles (supraspinatus, infraspinatus, teres minor and subscapularis), which attach the scapula or wing bone to the humerus or bone of the upper arm. It allows one to abduct or lift overhead. It also rotates the arm into any throwing motion. Without a good functioning rotator cuff even simple reaching maneuvers can become difficult. Cushioning the rotator cuff is a small sac called a bursa which allows the muscle/tendon unit to glide easily during motion. Irritation or inflammation of the bursa (bursitis) or tendon (tendonitis) can cause shoulder pain. This is generally caused by repetitive reaching overhead or lifting. Eventually the inflammation can lead to tearing or fraying of the tendon, initially as a partial tear but can go on to complete tearing. An acute tear of the rotator cuff tendon can occur with a fall or forceful injury to the shoulder. If one cannot lift their arm overhead after a fall, evaluation of a rotator cuff injury should be done. That evaluation could include a physical examination, X-rays, and most likely an MRI scan. Since the rotator cuff in a soft-tissue structure, it is best evaluated by an MRI. These scans can not only distinguish inflammation/tendonitis from tearing, they can determine the size of the tear and how much the tear has retracted. This will then help determine treatment options which can vary widely from therapy to major reconstructive surgery.

In the case of inflammatory problems like bursitis or tendonitis, initial treatment is conservative and non-surgical. Non-steroid anti-inflammatory medications (NSAID's) like ibuprofen or Naprosyn can be prescribed to decrease inflammation and therefore pain. If ineffective, injections of a steroid, cortisone, can be performed into the inflamed bursa/tendon area. By putting the medicine right where it is needed via an injection, it tends to be more effective. Adding physical therapy for modalities such as ultrasound as well as guided exercises will allow the inflammation to decrease and strength to improve. This process can take 3-4 months to be fully effective.

In the case of rotator cuff tears, they can occur in a variety of shapes and sizes. Small tears of less than 1 cm (1/2 in) are generally treated like tendonitis without surgery. The same protocol of NSAID's and physical therapy can heal smaller tears. If the tear is over a 1 cm in size or if the tendon has retracted or pulled away from its normal attachment, surgery is usually indicated. Surgical repair can be accomplished two different ways - arthroscopic or with traditional open incisional surgery. With arthroscopic surgery a scope is inserted through small incisions to view and repair the torn rotator cuff.

The advantage of arthroscopic surgery is reduced damage to surrounding tissues which can shorten the recovery time. The disadvantage is that some tears are too large or retracted too far to repair through a scope, in those cases performing surgery through an incision works best. With either method of surgery, the torn rotator cuff is typically repaired with anchor devices which re-attach the torn tendon to its proper bone attachment. After the surgery the arm is placed in a sling device for 4 weeks to allow the tendon to heal. After 4 weeks, physical therapy is started to gradually begin moving the shoulder.

Strengthening won't start for 2-3 months, and complete recovery typically takes 6 months. Healing of rotator cuff injuries can be quite long as compared to other Orthopaedic procedures.

Recommendation for surgery is age dependent. If one is over 65 years old or has major health issues, surgery may not be recommended. In that instance, physical therapy is recommended. In the case of a massive rotator cuff tear that cannot be directly repaired and therapy has been ineffective in restoring some function, the final treatment option is called a reverse total shoulder replacement where the shoulder joint is replaced with a metal and plastic device that does not require a rotator cuff for the shoulder to function. In this extreme case, this major reconstructive surgery can restore enough function to perform daily activities. The long term outcome of this procedure is unknown since it has only been performed for the past 5-7 years.

In summary, rotator cuffs disorders can range from inflammation to major tears. The subsequent treatment can vary greatly. If you have a rotator cuff problem, see your local Orthopaedic Surgeon for an evaluation and outline of treatment options.

Questions and or comments regarding this week's health column please contact Michael Dolecki, MD at Bitterroot Orthopedics and Sports Medicine, a service of Marcus Daly Memorial Hospital, 1200 Westwood Drive, Hamilton, MT 59840. Working together to build a healthier community!


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