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
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!