Shoulder Pain and Rotator Cuff Tears
by Dr. Scott Stephens
Shoulder pain can have a significant effect on an individual’s quality of life. It can make common daily activities challenging or even impossible. The shoulder consists of three main bones (humerus-arm bone, scapula-shoulder blade, and clavicle-collar bone) that form a ball and socket joint. The surrounding anatomy allows for the most motion of any joint in the body. Shoulder motion relies on the surrounding muscles that attach to the bone through their respective tendons. Although there are many different causes of shoulder pain, one of the most commonly seen conditions by an orthopedic shoulder surgeon is a tear of the rotator cuff tendons.
The rotator cuff is a group of four muscles (subscapularis, supraspinatus, infraspinatus and teres minor) that come together as tendons to form a cuff over the top of the humerus. The attachment of these tendons helps to lift and rotate the arm that that allows not only for the simple activities of daily life such as fixing your hair, eating, or grabbing an item of the top shelf but also for athletic endeavors such as throwing a ball or climbing a rock. These tendons can be torn from traumatic injuries like a fall or simply tear from a lifetime of daily repetitive stresses placed on the body or from bone spurs that rub against the tendon and cause impingement. Regardless of how they are torn, the end result is typically the same with pain that radiates down your arm, weakness, loss of function, and a common complaint of pain at night as a result of laying on the shoulder.
When one or more of these tendons are damaged, it may result in simple tendinitis, a partial tear in which a portion of the tendon is still attached to the bone or a full thickness tear in which the entire tendon has torn off the bone. Patients who have full thickness tears of one or more of their rotator cuff tendons can be most concerning as these tears risk becoming larger over time and weakening or tearing the surrounding rotator cuff tendons. The common symptoms experienced by patients who have a rotator cuff tear are:
- pain at night when lying on the shoulder
- pain when lifting your arm above your head
- weakness when lifting objects
- cracking and popping as you lift your shoulder.
Over time as the tendon tear enlarges, the pain may become more noticeable at rest and no longer relieved by anti-inflammatories.
Although these tears can be frustrating to an active patient, nonsurgical treatment options can improve the function of the shoulder and potentially diminish pain. Different types of conservative treatment options include modifying your activities, anti-inflammatory medications such as ibuprofen or Aleve, physical therapy and strengthening exercises, and potentially a steroid injection if it is simple tendinitis. If your symptoms do not improve with these non-surgical options then surgery may be an option. This is typically considered if symptoms have persisted, it is a large rotator cuff tear, significant weakness, or had an acute injury from a fall and then the loss of function. Prior to surgery, a shoulder surgeon will obtain an MRI to see the size of the tear.
Surgery to repair a torn rotator cuff simply involves re-attaching the tendon to the top of the humerus (arm bone). Originally this surgery consisted of an open procedure with a large incision that disrupted an important shoulder muscle, the deltoid muscle. As technology has advanced these procedures are now performed minimally invasive by using a small arthroscopic camera and instruments to improve the outcomes and allows a faster recovery. An all arthroscopic procedure is commonly performed today and requires a surgeon specifically trained in shoulder surgery to provide the best results. This procedure has progressed to an outpatient procedure where the pain is controlled through a pre-operative nerve block and postoperative pain medications.
Rehabilitation plays an essential role in returning to activities that a patient was able to enjoy prior to the rotator cuff tear. Recovery involves a sling for the first 4-6 weeks following surgery with basic passive motion. After this time frame, the sling is removed and active motion of the shoulder is started with physical therapy. After approximately 8-12 weeks you will begin strengthening exercises. Following the recovery period, patients tend to be extremely satisfied with improved shoulder strength and decreased pain.
If you have injured your shoulder or have had chronic pain you should see an orthopedic surgeon that specializes in shoulder surgery to optimize your care. Early diagnosis and treatment can help prevent the loss of strength seen with muscle atrophy if the muscle is not attached to the bone. These injuries can be debilitating and prompt care with a physical exam and imaging can help restore your shoulder function and allow you to return to activities that you enjoy.