The rotator cuff is a series of four tendons located around the shoulder.
They control the fine movements that are involved with the shoulder’s control, rotation and stabilisation.
These tendons run from their attachments around the shoulder blade, out over the top, back and front of the shoulder joint, known as the humeral head.
Traumatic vs Degenerative Rotator Injuries
While there is a crossover to degenerative injuries, the traumatic rotator cuff injury is usually the result of a fall or a sport’s injury.
A common example of this would be when a young person falls during a sporting game such as rugby, and another player comes down on top of him. The shoulder gets forced across the body and a tendon pulls away from the bone. A traumatic rotator cuff injury could also be associated with a dislocation of the shoulder.
Degenerative rotator cuff injuries occur in older patients. Over time the attachment of the rotator cuff tendons becomes less sound, a bit worn and inflamed, and can actually pull away from the bone without the patient even knowing. This process is called tendonosis.
There can also be a combination of injuries, where a slightly older patient does have some pre-existing damage to the cuff, then they have a big fall. When that happens, the cuff finally gives way.
It is difficult to distinguish between traumatic rotator cuff injuries and degenerative or related injuries, but there are markers with investigations that are done of the shoulder that can help doctors decide whether the cuff had been damaged previously or whether the cuff injury is acute or recent.
What Are the Symptoms of a Rotator Cuff Injury ?
Initial symptoms of a typical rotator cuff injury include pain, usually around the front corner of the shoulder, which often radiates out; it can be up into your neck, down through into your back or down into your upper arm. There is also a limitation in movement; you could find that you can’t lift your arm up to the front.
Patients complain that they can’t reach high shelves or hang up washing, and women struggle with reaching around behind their back to fasten their bra.
Physiotherapy can help you regain the movement, but the pain may not go away completely. Sometimes the rotator cuff tear is of such a significant size, patients won’t regain their movement because the tendon is no longer attached to the bone and can’t pull on it.
People with rotator cuff injuries also complain of night pain – they can’t sleep through the night, they can’t lie on their shoulder, and it often wakes them up at night. If you have ongoing pain, if you have limitation of movement, you should be seeing someone about it.
Most New Zealanders tend to regard everything that happens around the shoulders a bit of a sprain initially, and after a variable period of time, one to two weeks, sometimes several months, they will seek attention when it fails to go away.
The cuff is called a cuff because the tendons, where they attach, tend to attach almost as a continuous attachment. The tendons blend together to some degree. So often there will be a tear of one tendon that extends slightly into the anterior or posterior or front or back border of the tendon adjacent as well.
What Are The Different Types of Injuries?
You can just sprain your rotator cuff, and that’s often only temporary pain that usually goes away with physiotherapy and occasionally a steroid injection. Rotator cuff tears or strains can be associated with bursitis, or inflammation of the bursa.
A bursa is a lubricating bag, designed to allow the rotator cuff to move smoothly underneath the bone and the deltoid muscle. It is normally a very thin layer of fluid in it, but when it is traumatised it can thicken up considerably and become quite painful.
The pain associated with this type of cuff injury can be lessened with a steroid injection and physiotherapy; however, if the pain continues, then a rotator cuff injury is suspected and an investigation is done with x-rays, ultrasound scans and maybe an MRI scan.
The rotator cuff can tear in various patterns. Imagine each rotator cuff tendon to be like the pages of a phone book; it is made up of a series of thin sheets. With a phone book, you can tear off the front page and maybe A through D, or the back cover and Z through W.
This can be done on the rotator cuff, as partial tears, where part of the tendon is still attached, but some of it is delaminated, or lifted up and away. These are called partial thickness tears.
You can also tear the pages in the middle of the phone book and have the front and back covers attached. If this happens to the rotator cuff, it is called an interstitial or intrasubstance tear of the rotator cuff.
Treatment Options for Rotator Injuries
Treatment varies depending on the type of tear, especially for partial thickness tears.
However, the most common injury is a full thickness tear. This is when the tendon has completely pulled away from the bone.
It is very uncommon that the tendon actually pulls out of the muscle – instead, imagine that the muscle is like a spring and the tendon is like a piece of string tied to it. When the piece of string is detached, it is going to recoil, so it pulls away from the bone.
Because of this, rotator cuff tendon tears do not heal on their own accord.
When diagnosing rotator cuff injuries, the first step is analysing the occurrence of the injury.
- How did you do it?
- Was the force that was supplied to the shoulder enough to rupture the rotator cuff tendon?
Lifting a box up is usually not enough to rupture a rotator cuff, but certainly falling off a ladder or being involved in a bad rugby tackle is enough to cause a rupture.
The patient is monitored and the muscles and tendons are tested, which can indicate if the tendons have failed. An x-ray is also considered to ensure there are no fractures, and to check the structure of the shoulder.
If there are changes that occurred on those lumps of bone, or tuberosities, where the tendon attaches, that can give us an indication whether the tear is early or acute, or if it’s been going on for some time. An MRI can also provide information about the thickness of the tear, the degree of retraction of the tear, and the state of the muscles attached to the tendon.
There are a couple of tendons in the shoulder that cannot be seen clearly by a regular ultrasound, but an MRI can pick them up.
Treatment options will vary depending on the nature of the tear, your age, and your functional levels, i.e., if you are a manual worker, drain layer, carpenter, plumber or warehouseman versus if you are an accountant, a school teacher, etc. Age is a factor because as you get older, the rotator cuff tendon does become weaker.
Do All Cuff Injuries Require Surgery?
Treatment tends to be more aggressive in those who are younger and more active.
The specific type of treatment varies depending on the injury. If it’s just bursitis or tendinitis, which is inflammation of the rotator cuff, general physiotherapy, gentle strengthening and steroid injections are advocated.
If you have a full thickness rotator cuff tear, which is at the opposite end of the spectrum, for a younger person it usually means surgery, depending on their other medical problems.
For an older person, they might have the option of non-operative or operative, which can be steroid injections and physiotherapy.
There is no hard and fast rule as to how a rotator cuff tendon is treated; it really depends on the patient, their function, other medical problems, their lifestyle and their wishes.
What Will Happen Following Rotator Cuff Surgery?
For the first 8 to 12 hours after the surgery, your arm will be numb as a result of the anaesthetic. Your shoulder might be uncomfortable after the surgery, but can be managed with pain relief.
You will be in a sling for the first six weeks after surgery, and the exercises you will be doing in those six weeks are often very gentle movements, designed to keep the shoulder just gently moving. This allows for the tendon to start healing.
The implants, the little anchors that are used to tie the tendon back to the bone are very advanced and strong, so it is rare that they fail.
However, the tendon still heals at exactly the same rate it always has, and it is very easy for a patient to pull the repair apart if they are not careful with it.
At the six-week mark, the sling is removed and you begin doing more gentle shoulder exercises, often assisted by the uninjured arm.
Twelve weeks after surgery, patients begin a strengthening program.
Will My Injury Effect My Return To Work and Sports?
Return to work is variable, depending on what you do. If you are a desk-bound worker, returning to work can be very, very quick – within a week or so – depending on your pain levels and the nature of your desk-bound work.
However, somebody who works overhead, like a builder or a plumber, or someone who is involved in a job that involves heavy lifting may not be back at work for four and a half to five and a half months, depending on the nature of their recovery, how strenuous their work is and what supports can be put in place to aid them in their work.
For those who participate in sports, returning to active participation depends on which sport is involved.
For general gym activities, you can usually be back in the gym doing your strengthening program around the three-month mark, and usually back to your normal gym program by five and a half months.
For contact sports such as rugby or rugby league, patients usually remain off the field for approximately six months to allow for substantial healing time so the cuff is less likely to tear again.
To do a revision or to re-do the repair is never quite as good as the first time around, so we try to give you as much time as possible to heal and do it right the first time around.
If you are experiencing any of the symptoms mentioned in this guide please contact Mr Durrants clinic on (09) 523 2765 for more information. If you are in pain from a recent injury please seek immediate medical attention from your nearest accident and emergency clinic.