Rotator Cuff

What is the Rotator Cuff and Rotator Cuff Pathology?

As illustrated in Figure 1, the rotator cuff is the confluence of the tendons of four muscles that encompass the ball joint (humeral head) of the shoulder.The muscles originate on the shoulder blade (scapula) and insert on the humeral head. The rotator cuff has two functions. First, it provides stability to the shallow shoulder joint. Its second function is to provide motors (muscles) to move the shoulder. As time passes and we age, so does the rotator cuff. The rotator cuff undergoes wear and tear as it rubs between the acromion (tip of the shoulder blade) and the humeral head. It may become thickened and inflamed which diminishes function. Changes can vary from microscopic tears and bursitis inflammation to large tears (See Figure 2).The symptoms include pain, weakness, restricted motion, a feeling of instability, catching, and locking.

Who gets it?

Anybody is at risk for developing rotator cuff problems. Rotator cuff pathology is really a spectrum of abnormalities ranging from a normal, asymptomatic aging process to end stage arthritis and instability caused by large tears. These are generally more common as you age. Many people over 50 have some spurring of the bone at the level of the acromion. However, many of those people do not have symptoms. Symptoms can develop slowly or can have rapid onset. Generally, overhead activity including lifting activities will cause or aggravate the condition. Additionally, overhead sport activities such as pitching, throwing or playing tennis or racquetball can worsen symptoms.

How is Rotator Cuff Pathology Diagnosed?

Initial diagnosis is through history and physical examination. Pain with overhead activities, as well as night pain and difficulty sleeping on the affected shoulder are often common symptoms. On examination, pain is generally reproduced by lifting the arm overhead. X-rays will be obtained in order to evaluate for bone spurs, calcifications, arthritis or other problems. Often, an MRI is necessary to fully assess the rotator cuff. In some patients, a diagnostic injection of lidocaine can be helpful to differentiate rotator cuff pathology from other shoulder problems or neck problems that can mimic shoulder symptoms.

What are the treatment options?

Rotator cuff inflammation without a tear usually responds to conservative (non-surgical) treatment. This treatment includes the use of antiinflammatory medication, physical therapy to strengthen the rotator cuff, and in many cases cortisone injections. Ninety percent of people with rotator cuff inflammation, but no tear, will have resolution of their symptoms with the treatments described above. In those patients without tears who do not have full resolution of their symptoms, removing the undersurface of the acromion and the end of the distal clavicle creates a decompression that is very effective in treating the condition (See Figure 3). Patients who already have tearing of the rotator cuff are more likely to need surgical treatment. While some small tears can be treated conservatively, larger tears of the rotator cuff lead not only to pain, but also to weakness. Additionally, untreated rotator cuff tears can lead to increasing pain as well as arthritis in the shoulder.

Surgical treatment of a rotator cuff tear involves first decompressing the undersurface of the acromion and the distal clavicle in the same manner that is used for surgical treatment of rotator cuff disease without a tear (See Figure 2).Then the rotator cuff tear is repaired. This often involves putting an anchor into the bone of the humeral head to allow repair of the rotator cuff back to its insertion. Some rotator cuff disease and rotator cuff tears can be treated arthroscopically while others require open surgical treatment.

After surgery, a postoperative rehabilitation period, including physical therapy, is always necessary. In patients who have no tear on the rotator cuff or only a small tear, immediate physical therapy can begin.This minimizes stiffness in the shoulder joint and allows early return to normal function. In patients with large rotator cuff tears, a period of immobilization is necessary, which can be as long as six weeks. The period of immobilization allows rehealing of the rotator cuff tear. After the healing has occurred, physical therapy is necessary to regain motion and strength.