Impingement Syndrome

A Patient’s Guide to Impingement Syndrome

Introduction

The shoulder is a very complex piece of machinery. Its elegant design gives the shoulder joint great range of motion, but not much stability. As long as all the parts are in good working order, the shoulder can move freely and painlessly.

Many people refer to any pain in the shoulder as bursitis. The term bursitis really only means that the part of the shoulder called the bursa is inflamed. Tendonitis is when a tendon gets inflamed. This can be another source of pain in the shoulder. Many different problems can cause inflammation of the bursa or tendons. Impingement syndrome is one of those problems. Impingement syndrome occurs when the rotator cuff tendons rub against the roof of the shoulder, the acromion.

This guide will help you understand

  • what happens in your shoulder when you have impingement syndrome
  • what tests your doctor will run to diagnose this condition
  • how you can relieve your symptoms.

Anatomy

What part of the shoulder is affected?

Impingement Syndrome

The shoulder is made up of three bones: the scapula (shoulder blade), the humerus (upper arm bone), and the clavicle (collarbone).

Impingement Syndrome

The rotator cuff connects the humerus to the scapula. The rotator cuff is formed by the tendons of four muscles: the supraspinatus, infraspinatus, teres minor, and subscapularis.

Tendons attach muscles to bones. Muscles move the bones by pulling on the tendons. The rotator cuff helps raise and rotate the arm.

Impingement Syndrome

As the arm is raised, the rotator cuff also keeps the humerus tightly in the socket of the scapula, the glenoid. The upper part of the scapula that makes up the roof of the shoulder is called the acromion.

Impingement Syndrome

A bursa is located between the acromion and the rotator cuff tendons. A bursa is a lubricated sac of tissue that cuts down on the friction between two moving parts. Bursae are located all over the body where tissues must rub against each other. In this case, the bursa protects the acromion and the rotator cuff from grinding against each other.

Related Document: A Patient’s Guide to Shoulder Anatomy

Causes

Why do I have problems with shoulder impingement?

Usually, there is enough room between the acromion and the rotator cuff so that the tendons slide easily underneath the acromion as the arm is raised. But each time you raise your arm, there is a bit of rubbing or pinching on the tendons and the bursa. This rubbing or pinching action is called impingement.

Impingement occurs to some degree in everyone’s shoulder. Day-to-day activities that involve using the arm above shoulder level cause some impingement. Usually it doesn’t lead to any prolonged pain. But continuously working with the arms raised overhead, repeated throwing activities, or other repetitive actions of the shoulder can cause impingement to become a problem. Impingement becomes a problem when it causes irritation or damage to the rotator cuff tendons.

Raising the arm tends to force the humerus against the edge of the acromion. With overuse, this can cause irritation and swelling of the bursa. If any other condition decreases the amount of space between the acromion and the rotator cuff tendons, the impingement may get worse.

Impingement Syndrome

Bone spurs can reduce the space available for the bursa and tendons to move under the acromion. Bone spurs are bony points. They are commonly caused by wear and tear of the joint between the collarbone and the scapula, called the acromioclavicular (AC) joint. The AC joint is directly above the bursa and rotator cuff tendons.

Impingement Syndrome

In some people, the space is too small because the acromion is oddly sized. In these people, the acromion tilts too far down, reducing the space between it and the rotator cuff.

Symptoms

What does impingement syndrome feel like?

Impingement syndrome causes generalized shoulder aches in the condition’s early stages. It also causes pain when raising the arm out to the side or in front of the body. Most patients complain that the pain makes it difficult for them to sleep, especially when they roll onto the affected shoulder.

A reliable sign of impingement syndrome is a sharp pain when you try to reach into your back pocket. As the condition worsens, the discomfort increases. The joint may become stiffer. Sometimes a catching sensation is felt when you lower your arm. Weakness and inability to raise the arm may indicate that the rotator cuff tendons are actually torn.

Related Document: A Patient’s Guide to Rotator Cuff Tears

Diagnosis

What tests will my doctor run?

The diagnosis of bursitis or tendonitis caused by impingement is usually made on the basis of your medical history and physical examination. Your doctor will ask you detailed questions about your activities and your job, because impingement is frequently related to repeated overhead activities.

Impingement Syndrome

Your doctor may order X-rays to look for an abnormal acromion or bone spurs around the AC joint. A magnetic resonance imaging (MRI) scan may be performed if your doctor suspects a tear of the rotator cuff tendons. An MRI is a special imaging test that uses magnetic waves to create pictures that show the tissues of the shoulder in slices. The MRI scan shows tendons as well as bones. The MRI scan is painless and requires no needles.

An arthrogram may also be used to detect rotator cuff tears. The arthrogram is an older test than the MRI, but it is still widely used. It involves injecting dye into the shoulder joint and then taking several X-rays. If the dye leaks out of the shoulder joint, it suggests that there is a tear in the rotator cuff tendons.

In some cases, it is unclear whether the pain is coming from the shoulder or a pinched nerve in the neck. An injection of a local anesthetic (such as lidocaine) into the bursa can confirm that the pain is in fact coming from the shoulder. If the pain goes away immediately after the injection, then the bursa is the most likely source of the pain. Pain from a pinched nerve in the neck would almost certainly not go away after an injection into the shoulder.

Treatment

What treatment options are available?

Nonsurgical Treatment

Doctors usually start by prescribing nonsurgical treatment. You may be prescribed anti-inflammatory medications such as aspirin or ibuprofen. Resting the sore joint and putting ice on it can also ease pain and inflammation. If the pain doesn’t go away, an injection of cortisone into the joint may help. Cortisone is a strong medication that decreases inflammation and reduces pain. Cortisone’s effects are temporary, but it can give very effective relief for up to several months.

Related Document: A Patient’s Guide to Joint Injections for Arthritis

Your doctor may also prescribe sessions with a physical or occupational therapist. Your therapist will use various treatments to calm inflammation, including heat and ice. Therapists use hands-on treatments and stretching to help restore full shoulder range of motion. Improving strength and coordination in the rotator cuff and shoulder blade muscles lets the humerus move in the socket without pinching the tendons or bursa under the acromion. You may need therapy treatments for four to six weeks before you get full shoulder motion and function back.

Surgery

If you are still having problems after trying nonsurgical treatments, your doctor may recommend surgery.

Subacromial Decompression

The goal of surgery is to increase the space between the acromion and the rotator cuff tendons. Taking pressure off the tissues under the acromion is called subacromial decompression. The surgeon must first remove any bone spurs under the acromion that are rubbing on the rotator cuff tendons and the bursa. Usually the surgeon also removes a small part of the acromion to give the tendons even more space. In patients who have a downward tilt of the acromion, more of the bone may need to be removed. Surgically cutting and shaping the acromion is called acromioplasty. It gives the surgeon another step to get pressure off (decompress) the tissues between the humerus and the acromion.

Resection Arthroplasty

Impingement may not be the only problem in an aging or overused shoulder. It is very common to also see degeneration from arthritis in the AC joint. If there is reason to believe that the AC joint is arthritic, the end of the clavicle may be removed during impingement surgery. This procedure is called a resection arthroplasty.

The most common procedure for AC joint osteoarthritis is resection arthroplasty. A resection arthroplasty involves removing a small portion of the end of the clavicle. This leaves a space between the acromion (the piece of the scapula that meets your shoulder) and the cut end of the clavicle, where the joint used to be. Your surgeon will take care not to remove too much of the end of the clavicle to prevent any damage to the ligaments holding the joint together. Usually only a small portion is removed, less than one cm (about three-eighths of an inch). As your body heals, the joint is replaced by scar tissue. Remember, the AC joint doesn’t move much, but it does need to be flexible. The scar tissue allows movement but stops the bone ends from rubbing together.

This procedure can be done in two ways. Today, it is more common to do this procedure using the arthroscope. An arthroscope is a slender tool with a tiny TV camera on the end. It lets the surgeon work in the joint through a very small incision. This may result in less damage to the normal tissues surrounding the joint, leading to faster healing and recovery.

Related Document: A Patient’s Guide to Osteoarthritis of the Acromioclavicular Joint

Arthroscopic Procedure

Today, acromioplasty is usually done using an arthroscope.

Impingement Syndrome

An arthroscope is a special type instrument designed to look into a joint, or other space, inside the body. The arthroscope itself is a slender metal tube smaller than a pencil. Inside the metal tube are special strands of glass called fiberoptics. These small strands of glass form a lens that allows one to look into the tube on one end and see what is on the other side – inside the space. This is similar to a microscope or telescope. In the early days of arthroscopy, the surgeon actually looked into one end of the tube. Today, the arthroscope is attached to a small TV camera. The surgeon can watch the TV screen while the arthroscope is moved around in the joint. Using the ability to see inside the joint, the surgeon can then place other instruments into the joint and perform surgery while watching what is happening on the TV screen.

The arthroscope lets the surgeon work in the joint through a very small incision. This may result in less damage to the normal tissues surrounding the joint, leading to faster healing and recovery. If your surgery is done with the arthroscope, you may be able to go home the same day.

To perform the acromioplasty using the arthroscope, several small incisions are made to insert the arthroscope and special instruments needed to complete the procedure. These incisions are small, usually about one-quarter inch long. It may be necessary to make three or four incisions around the shoulder to allow the arthroscope to be moved to different locations to see different areas of the shoulder.

Impingement Syndrome

A small plastic, or metal, tube is inserted into the shoulder and connected with sterile plastic tubing to a special pump. Another small tube allows the fluid to be removed from the joint. This pump continuously fills the shoulder joint with sterile saline (salt water) fluid. This constant flow of fluid through the joint inflates the joint and washes any blood and debris from the joint as the surgery is performed.

Impingement Syndrome

There are many small instruments that have been specially designed to perform surgery in the joint. Some of these instruments are used to remove torn and degenerative tissue. Some of these instruments nibble away bits of tissue and then vacuum them up from out of the joint. Others are designed to burr away bone tissue and vacuum it out of the joint. These instruments are used to remove any bone spurs that are rubbing on the tendons of the shoulder and smooth the under surface of the acromion and AC joint.

Open Procedure

Impingement Syndrome

In other cases, an open incision is made to allow removal of the bone. Usually an incision about three or four inches long is made over the top of the shoulder. The surgeon removes any bone spurs and a part of the acromion. The surgeon then smooths the rough ends of the bone. If necessary, the surgeon will do a resection arthroplasty on the AC joint. If you have open surgery, you may need to spend a night or two in the hospital.

View animation of bone spur removal

Rehabilitation

What should I expect after treatment?

Nonsurgical Rehabilitation

Even if you don’t need surgery, you may need to follow a program of rehabilitation exercises. Your doctor may recommend that you work with a physical or occupational therapist. Your therapist can create an individualized program of strengthening and stretching for your shoulder and rotator cuff.

It is important to maintain the strength in the muscles of the rotator cuff. These muscles help control the stability of the shoulder joint. Strengthening these muscles can actually decrease the impingement of the acromion on the rotator cuff tendons and bursa. Your therapist can also evaluate your workstation or the way you use your body when you do your activities and suggest changes to avoid further problems.

After Surgery

Rehabilitation after shoulder surgery can be a slow process. You will probably need to attend therapy sessions for several weeks, and you should expect full recovery to take several months. Getting the shoulder moving as soon as possible is important. However, this must be balanced with the need to protect the healing muscles and tissues.

Your surgeon may have you wear a sling to support and protect the shoulder for a few days after surgery. Ice and electrical stimulation treatments may be used during your first few therapy sessions to help control pain and swelling from the surgery. Your therapist may also use massage and other types of hands-on treatments to ease muscle spasm and pain.

Therapy can progress quickly after a simple arthroscopic procedure. Treatments start out with range-of-motion exercises and gradually work into active stretching and strengthening. You just need to be careful to avoid doing too much, too quickly.

Therapy goes slower after open surgery in which the shoulder muscles have been cut. Therapists will usually wait up to two weeks before starting range-of-motion exercises. Exercises begin with passive movements. During passive exercises, your shoulder joint is moved, but your muscles stay relaxed. Your therapist gently moves your joint and gradually stretches your arm. You may be taught how to do passive exercises at home.

Active therapy starts four to six weeks after surgery. You use your own muscle power in active range-of-motion exercises. You may begin with light isometric strengthening exercises. These exercises work the muscles without straining the healing tissues.

At about six weeks you start doing more active strengthening. Exercises focus on improving the strength and control of the rotator cuff muscles and the muscles around the shoulder blade. Your therapist will help you retrain these muscles to keep the ball of the humerus in the socket. This helps your shoulder move smoothly during all your activities.

Some of the exercises you’ll do are designed get your shoulder working in ways that are similar to your work tasks and sport activities. Your therapist will help you find ways to do your tasks that don’t put too much stress on your shoulder. Before your therapy sessions end, your therapist will teach you a number of ways to avoid future problems.

Labral Tears

A Patient’s Guide to Labral Tears

Introduction

Labral Tears

Since orthopedic surgeons began using a tiny TV camera called an arthroscope to diagnose and treat shoulder problems, they have discovered several conditions that no one knew existed. One of these conditions is an injury to a small structure in the shoulder called the labrum. A labral tear can cause pain and a catching sensation in the shoulder. Labral tears can be very difficult to diagnose.

This document will help you understand:

  • where and what the labrum is
  • what tests your doctor will run to diagnose the problem
  • what you can do to relieve your pain

Labral Tears

Anatomy

What is the labrum?

The shoulder is made up of three bones: the scapula (shoulder blade), the humerus (upper arm bone), and the clavicle (collarbone).

Labral Tears

A part of the scapula, called the glenoid, makes up the socket of the shoulder. The glenoid is very shallow and flat. The labrum is a rim of soft tissue that makes the socket more like a cup. The labrum turns the flat surface of the glenoid into a deeper socket that molds to fit the head of the humerus.

The rotator cuff connects the humerus to the scapula. The rotator cuff is formed by the tendons of four muscles: the supraspinatus, infraspinatus, teres minor, and subscapularis.

Tendons attach muscles to bones. Muscles move the bones by pulling on the tendons. The rotator cuff helps raise and rotate the arm. As the arm is raised, the rotator cuff also keeps the humerus tightly in the glenoid of the scapula.

Labral Tears

The soft labral tissue can be caught between the glenoid and the humerus. When this happens, the labrum may start to tear. If the tear gets worse, it may become a flap of tissue that can move in and out of the joint, getting caught between the head of the humerus and the glenoid. The flap can cause pain and catching when you move your shoulder. Several tendons and ligaments attach to the labrum that help maintain the stability of the shoulder. So when the labrum tears, the shoulder often becomes much less stable.

Related Document: A Patient’s Guide to Shoulder Anatomy

Causes

What causes labral tears?

Labral tears are often caused by a direct injury to the shoulder, such as falling on an outstretched hand. The labrum can also become torn from the wear and tear of activity, a condition called overuse. An injured labrum can lead to shoulder instability. The extra motion of the humerus within the socket causes additional damage to the labrum. An extremely unstable shoulder may slip or dislocate. This can also cause the labrum to tear.

Related Document: A Patient’s Guide to Shoulder Instability

Labral Tears

The biceps tendon attaches to the front part of the labrum. The biceps is the large muscle on the front of your upper arm. Sports can cause injuries to the labrum when the biceps tendon pulls sharply against the front of the labrum. Baseball pitchers are prone to labral tears because the action of throwing causes the biceps tendon to pull strongly against the top part of the labrum. Weightlifters can have similar problems when pressing weights overhead. Golfers may tear their labrum if their club strikes the ground during the golf swing.

Related Document: A Patient’s Guide to Biceps Tendonitis

Symptoms

What does a labral tear feel like?

The main symptom caused by a labral tear is a sharp pop or catching sensation in the shoulder during certain shoulder movements. This may be followed by a vague aching for several hours. At other times, the tear may not cause any pain. Shoulder instability from a damaged labrum may cause the shoulder to feel loose, as though it slips with certain movements.

Diagnosis

What tests will my doctor run?

Your doctor may suspect a labral tear based on your medical history. You will be asked questions about your pain and past injuries to your shoulder that may suggest labral damage.

In the physical examination, there are several shoulder movements that can bring on the symptoms. You may feel a catching sensation as your arm is raised, and there may be pain when the arm is held overhead. If your arm is held in front of your body, with the palm of the hand facing downward, you may feel pain when your doctor tries to push down on your arm.

Labral Tears

Labral tears are difficult to see, even in a magnetic resonance imaging (MRI) scan. An MRI scan is a special imaging test that uses magnetic waves to show the tissues of the shoulder in slices. The MRI scan shows soft tissues such as tendons and ligaments as well as bones.

Labral tears may be seen using computed tomography (CT) scan and a special dye. A CT scan is an older test that uses computer-enhanced X-rays to show slices of the shoulder. The soft tissues do not show up in a CT scan, but the special dye does. The dye shows the outline of the labrum. If there is a tear, the dye may leak into it and show up on the CT scan.

Labral Tears

However, MRI and CT scans are not very accurate in detecting labral tears. Confirming the diagnosis of a labral tear can be extremely difficult. A surgeon may need to look into your shoulder using an arthroscope. The arthroscope is a small TV camera that is inserted into the shoulder joint through a very small incision. The surgeon can then see pictures of the joint on a TV screen. This allows the surgeon to look directly at the labrum to see if it is torn.

Treatment

What treatment options are available?

Nonsurgical Treatment

Your doctor’s first goal will be to control your pain and inflammation. Initial treatment for pain control is usually rest and anti-inflammatory medication, such as aspirin or ibuprofen. Your doctor may suggest a cortisone injection if you have trouble getting your pain under control. Cortisone is a strong anti-inflammatory medication. It can provide good relief, although its effects are temporary.

Related Document: A Patient’s Guide to Joint Injections for Arthritis

Your doctor will probably have a physical or occupational therapist direct your rehabilitation program. Your first therapy treatments will try to ease pain and inflammation by using such treatments as heat or ice. Hands-on treatment and various types of exercises are used to improve the range of motion in your shoulder and the nearby joints and muscles.

Later, you will do strengthening exercises to improve the strength and control of the rotator cuff and shoulder blade muscles. Your therapist will help you retrain these muscles to keep the ball of the humerus in the glenoid. This will improve the stability of your shoulder and help it move smoothly during all your activities.

You may need therapy treatments for four to six weeks. Most patients are able to get back to their activities with full use of their arm within this amount of time.

Surgery

If your symptoms don’t go away, you may need surgery. Surgical treatment for this condition is still evolving. Surgeons have not known about the problem long enough to adequately evaluate the results of different treatments.

Labral Debridement

The arthroscope is commonly used to treat many labral tears. If the tear is small and is mostly getting caught as you move the shoulder, simply removing the frayed edges and any loose parts of the labrum may get rid of your symptoms. This is called labral debridement.

Labral Repair

If the tear is larger, the shoulder may also be unstable. If this is the case, the labral tear may need to be repaired, rather than simply removed. Several new techniques allow surgeons to place “anchors” into the bone around the shoulder joint and reattach the labrum using the arthroscope. There are many variations of these anchors, but most are drilled into the bone and have sutures (stitches) attached that are then used to tie the labrum down to the bone and enable the labrum to heal back in the appropriate position.

Open Procedure

Open procedures are rarely used today for repair of labral tears. The arthroscopic techniques have become increasingly refined and are today the preferred method of treatment.

Labral Tears

If for some reason the tear is repaired open, the surgeon will need to make an incision in the front of the shoulder. The main drawback of making the larger incision is that it will probably take you longer to recover from surgery.

Rehabilitation

What should I expect after treatment?

Nonsurgical Rehabilitation

Even nonsurgical treatment requires a rehabilitation program. Some evidence suggests that shoulder instability may eventually make labral tears worse. The goal of therapy will be to strengthen the rotator cuff muscles to make the shoulder more stable. At first you will do exercises with the therapist. Eventually you will be put on a home program of exercise to keep the muscles strong and flexible. This should help you avoid future problems.

After Surgery

Rehabilitation after surgery is more complex. You will probably need to wear a sling to support and protect the shoulder for several weeks after surgery. A physical or occupational therapist will probably direct your recovery program. Depending on the surgical procedure, you will probably need to attend therapy sessions for one to two months, and you should expect full recovery to take up to four to six months if you are expecting to participate in athletics.

Getting the shoulder moving as soon as possible is important. However, this must be balanced with the need to protect the healing tissues. The first few therapy treatments will focus on controlling the pain and swelling from surgery. Ice and electrical stimulation treatments may help. Your therapist may also use massage and other types of hands-on treatments to ease muscle spasm and pain.

Therapy proceeds quickly after a simple arthroscopic surgery to clean up the frayed edges or loose parts of the labrum. Sessions start with range-of-motion exercises and gradually work into active stretching and strengthening. Overhand athletes start their sports gradually within four to six weeks. They can usually return to competition within three months.

After surgery to repair the labrum, therapists usually begin with passive exercises. In passive exercises, the shoulder joint is moved, but your muscles stay relaxed. Your therapist gently moves your joint and gradually stretches your arm. You may also be taught how to do passive exercises at home.

Active therapy starts about six weeks after repair surgery. Active range-of-motion exercises help you regain shoulder movement using your own muscle power. Light isometric strengthening exercises are started about this time. These exercises work the muscles without straining the healing joint.

By about the tenth week, you will start more active strengthening. Exercises will focus on improving strength and control of the rotator cuff muscles. They help tighten the ball of the humerus in the glenoid socket and can improve the stability of the shoulder. A stronger and more stable shoulder helps keep the ball of the humerus centered in the socket during all your activities.

Some of the exercises you will do are designed get your shoulder working in ways that are similar to your work tasks and sport activities. Your therapist will help you find ways to do your tasks that don’t put too much stress on your shoulder. Before your therapy sessions end, your therapist will teach you a number of ways to avoid future problems.

Rotator Cuff Tears

A Patient’s Guide to Rotator Cuff Tears

Introduction

The shoulder is an elegant and complex piece of machinery. Its design allows us to reach and use our hands in many different positions. However, while the shoulder joint has great range of motion, it is not very stable. This makes the shoulder vulnerable to problems if any of its parts aren’t in good working order.

The rotator cuff tendons are key to the healthy functioning of the shoulder. They are subject to a lot of wear and tear, or degeneration, as we use our arms. Tearing of the rotator cuff tendons is an especially painful injury. A torn rotator cuff creates a very weak shoulder. Most of the time patients with torn rotator cuffs are in late middle age. But rotator cuffs tears can happen at any age.

This guide will help you understand

  • what the rotator cuff is
  • how it can become torn
  • what treatments are available for a torn rotator cuff

Rotator Cuff Tears

Anatomy

What is the rotator cuff, and what does it do?

The shoulder is made up of three bones: the scapula (shoulder blade), the humerus (upper arm bone), and the clavicle (collarbone).

The rotator cuff connects the humerus to the scapula.

Rotator Cuff Tears

The rotator cuff is formed by the tendons of four muscles: the supraspinatus, infraspinatus, teres minor, and subscapularis.

Tendons attach muscles to bones. Muscles move the bones by pulling on the tendons. The rotator cuff helps raise and rotate the arm.

Rotator Cuff Tears

As the arm is raised, the rotator cuff also keeps the humerus tightly in the socket of the scapula. The upper part of the scapula that makes up the roof of the shoulder is called the acromion.

Rotator Cuff Tears

A bursa is located between the acromion and the rotator cuff tendons. A bursa is a lubricated sac of tissue that cuts down on the friction between two moving parts. Bursae are located all over the body where tissues must rub against each other.

In this case, the bursa protects the acromion and the rotator cuff from grinding against each other.

Related Document: A Patient’s Guide to Shoulder Anatomy

Causes

What causes the rotator cuff to tear?

The rotator cuff tendons have areas of very low blood supply. The more blood supply a tissue has, the better and faster it can repair and maintain itself. The areas of poor blood supply in the rotator cuff make these tendons especially vulnerable to degeneration from aging.

The degeneration of aging helps explain why the rotator cuff tear is such a common injury later in life. Rotator cuff tears usually occur in areas of the tendon that had low blood supply to begin with and then were further weakened by degeneration.

This problem of degeneration may be accelerated by repeating the same types of shoulder motions. This can happen with overhand athletes, such as baseball pitchers. But even doing routine chores like cleaning windows, washing and waxing cars, or painting can cause the rotator cuff to fatigue from overuse.

Excessive force can tear weak rotator cuff tendons. This force can come from trying to catch a heavy falling object or lifting an extremely heavy object with the arm extended. The force can also be from a fall directly onto the shoulder. Sometimes injuries that tear the rotator cuff are painful, but sometimes they aren’t. Researchers estimate that up to 40 percent of people may have a mild rotator cuff tear without even knowing it.

The typical patient with a rotator cuff tear is in late middle age and has had problems with the shoulder for some time. This patient then lifts a load or suffers an injury that tears the tendon. After the injury, the patient is unable to raise the arm. However, these injuries also occur in young people. Overuse or injury at any age can cause rotator cuff tears.

Symptoms

What does a rotator cuff tear feel like?

Rotator Cuff Tears

Rotator cuff tears cause pain and weakness in the affected shoulder. In some cases, a rotator cuff may tear only partially. The shoulder may be painful, but you can still move the arm in a normal range of motion. In general, the larger the tear, the more weakness it causes.

In other cases, the rotator cuff tendons completely rupture. A complete tear makes it impossible to move the arm in a normal range of motion. It is usually impossible to raise the arm away from your side by yourself.

Most rotator cuff tears cause a vague pain in the shoulder area. They may also cause a catching sensation when you move your arm. Most people say they can’t sleep on the affected side due to the pain.

Diagnosis

What tests will my doctor run?

Your doctor will ask questions about your medical history, your injury, and your pain. Your doctor will then do a physical examination of the shoulder. The physical exam is most helpful in diagnosing a rotator cuff tear. A complete tear is usually very obvious. If your doctor can move the arm in a normal range of motion, but you can’t move the arm yourself, you most likely have a torn rotator cuff.

X-rays won’t show tears in the rotator cuff. However, your doctor may want you to have a shoulder X-ray to see if there are bone spurs, a loss of joint space in the shoulder, or a down-sloping (hooked) acromion. These findings are associated with tears in the rotator cuff. An X-ray can also show if there are calcium deposits in the tendon that are causing your symptoms, a condition called calcific tendonitis.

Related Document: A Patient’s Guide to Calcific Tendonitis

Your doctor will probably also want to do an arthrogram test. An arthrogram involves injecting dye into the shoulder joint and taking several X-rays. If the dye leaks out of the shoulder joint, there is probably a tear in the rotator cuff.

Your doctor may ask you to have a magnetic resonance imaging (MRI) scan.

An MRI scan is a special imaging test that uses magnetic waves to create pictures of the shoulder in slices. The MRI scan shows tendons as well as bones. This test is painless and requires no needles or injections.

Treatment

What treatment options are available?

Nonsurgical Treatment

Rotator Cuff Tears

Your doctor’s first goal will be to help control your pain and inflammation. Initial treatment is usually rest and anti-inflammatory medication, such as aspirin or ibuprofen. This medicine is used mainly to control pain. Your doctor may suggest a cortisone injection if you have trouble getting your pain under control. Cortisone is a very effective anti-inflammatory medication.

Your doctor will probably have a physical or occupational therapist direct your rehabilitation program. At first, treatments such as heat and ice focus on easing pain and inflammation. Hands-on treatments and various types of exercises are used to improve the range of motion in your shoulder and the nearby joints and muscles.

Later, you will do strengthening exercises to improve the strength and control of the rotator cuff and shoulder blade muscles. Your therapist will help you retrain these muscles to keep the ball of the humerus in the socket. This will help your shoulder move smoothly during all of your activities.

You may need therapy treatments for six to eight weeks. Most patients are able to get back to their activities with full use of their arm within this amount of time.

Surgery

A complete rotator cuff tear will not heal. Complete ruptures usually require surgery if your goal is to return your shoulder to optimal function. The exception is in elderly patients or patients who have other diseases that increase the risks of surgery. There is some evidence that repairing the rotator cuff within three months of the injury results in a better outcome. You will need to work with your surgeon to determine when is the best time to do the surgery.

Certain types of partial rotator cuff tears may not require surgical repair. If you have a partial tear, your surgeon will most likely want to further evaluate the situation and determine how much the tendon is torn and where the tendon is damaged. This information will be used to decide whether surgery should be recommended or whether you may want to consider non-surgical care for the partial tear of the tendon.

Today, the MRI scan is the most common test used to evaluate the shoulder and determine whether surgery is necessary. Your surgeon will be looking for details of your rotator cuff tear and checking for other problems. As mentioned earlier, a tear usually doesn’t occur unless the rotator cuff is already weakened by some other problem. Other potential problems include acromioclavicular (AC) joint osteoarthritis and impingement syndrome. Your surgery may need to address these conditions as well.

Related Document: A Patient’s Guide to Osteoarthritis of the Acromioclavicular Joint

Related Document: A Patient’s Guide to Impingement Syndrome

Arthroscopic Repair

In the past,

Rotator Cuff Tears

repair of the rotator cuff tendons usually required an open incisionthree or four inches in length. As surgeons have become more comfortable using the arthroscope to work in and around the shoulder joint, things have changed. Today, it is much more common to repair tears of the rotator cuff using the arthroscope.

An arthroscope is a special type instrument designed to look into a joint, or other space, inside the body. The arthroscope itself is a slender metal tube smaller than a pencil. Inside the metal tube are special strands of glass called fiberoptics. These small strands of glass form a lens that allows one to look into the tube on one end and see what is on the other side – inside the space. This is similar to a microscope or telescope. In the early days of arthroscopy, the surgeon actually looked into one end of the tube. Today, the arthroscope is attached to a small TV camera. The surgeon can watch the TV screen while the arthroscope is moved around in the joint. Using the ability to see inside the joint, the surgeon can then place other instruments into the joint and perform surgery while watching what is happening on the TV screen.

The arthroscope lets the surgeon work in the joint through a very small incision. This may result in less damage to the normal tissues surrounding the joint, leading to faster healing and recovery. If your surgery is done with the arthroscope, you may be able to go home the same day.

Rotator Cuff Tears

To perform the rotator cuff repair using the arthroscope, several small incisions are made to insert the arthroscope and special instruments needed to complete the procedure. These incisions are small, usually about one-quarter inch long. It may be necessary to make three or four incisions around the shoulder to allow the arthroscope to be moved to different locations to see different areas of the shoulder.

A small plastic, or metal, tube is inserted into the shoulder and connected with sterile plastic tubing to a special pump. Another small tube allows the fluid to be removed from the joint. This pump continuously fills the shoulder joint with sterile saline (salt water) fluid. This constant flow of fluid through the joint inflates the joint and washes any blood and debris from the joint as the surgery is performed.

Rotator Cuff Tears

There are many small instruments that have been specially designed to perform surgery in the joint. Some of these instruments are used to remove torn and degenerative tissue. Some of these instruments nibble away bits of tissue and then vacuum them up from out of the joint. Others are designed to burr away bone tissue and vacuum it out of the joint. These instruments are used to remove any bone spurs that are rubbing on the tendons of the shoulder and smooth the under surface of the acromion and AC joint.

Once any degenerative tissue and bone spurs are removed, the torn rotator cuff tendon can be reattached to the bone. Special devices have been designed to reattach these ligaments. These devices are called suture anchors.

Rotator Cuff Tears

Suture anchors are special devices that have been designed to attach tissue to bone. In the past, many different ways were used to attach soft tissue (such as ligaments and tendons) to bone. The usual methods have included placing stitches through drill holes in the bone, special staples and screws with special washers – all designed to hold the tissue against the bone until healing occurred. Most of these techniques required larger incisions to be able to see what was going on and to get the hardware and soft tissue in the right location.

Rotator Cuff Tears

Today, suture anchors have simplified the process and created a much stronger way of attaching soft tissue to bone. These devices are small enough that the can be placed into the appropriate place in the bone through a small incision using the arthroscope. Most of these devices are made of either metal or a special plastic-like material that dissolves over time. This is the “anchor” portion of the device. The anchor is drilled into the bone where the surgeon wished to attach the soft tissue. Sutures are attached to the anchor and threaded through the soft tissue and tied down against the bone.

Open Repair

In some instances, open surgery is necessary. In open surgery, the surgeon gets to the rotator cuff tendon by cutting through muscles and tissues on the front of the shoulder. After repairing the tendon, the muscle on the front is reattached to the bone.

Graft Method

It is not possible to repair all rotator cuff tears. Sometimes the tendon has been torn for too long a period of time. The tendons and muscles become contracted and can’t be stretched enough to be reattached. In these cases, the surgeon may use a length of tendon graft to span the distance from the tendon stump of the torn rotator cuff to the humerus.

Salvage Procedure

In other cases, the tendon tissue has simply worn away, and the remaining tendon is not strong enough to hold the necessary stitches. In these instances, simply removing all the torn tissue and fixing any other problems in the shoulder may reduce your pain. But this will probably not increase the strength or motion of your shoulder. It may actually decrease your range of motion.

Rehabilitation

What should I expect after treatment?

Nonsurgical Rehabilitation

Even if you don’t need surgery, you may need to follow a program of rehabilitation exercises. Your doctor may recommend that you work with a physical or occupational therapist. Your therapist can create an individualized program to help you regain shoulder function. This includes tips and exercise for improving posture and shoulder alignment. It is also very important to improve the strength and coordination in the rotator cuff and shoulder blade muscles. Your therapist can also evaluate your workstation or the way you use your body when you do your activities and suggest changes to avoid further problems.

After Surgery

Rehabilitation after rotator cuff surgery can be a slow process. You will probably need to attend therapy sessions for two to three months, and you should expect full recovery to take up to six months. Getting the shoulder moving as soon as possible is important. However, this must be balanced with the need to protect the healing tissues.

Your surgeon will most likely have you wear a sling to support and protect the shoulder for several weeks (generally four to six weeks) after surgery. Ice and electrical stimulation treatments may be used during your first few therapy sessions to help control pain and swelling from the surgery. Your therapist may also use massage and other types of hands-on treatments to ease muscle spasm and pain.

Therapy can progress quickly after arthroscopic procedures. Treatments start out with range-of-motion exercises and gradually work into active stretching and strengthening. You just need to be careful about doing too much, too quickly.

Therapy goes slower after surgeries where the front shoulder muscles have been cut. Exercises begin with passive movements. During passive exercises, your shoulder joint is moved, but your muscles stay relaxed. Your therapist gently moves your joint and gradually stretches your arm. You may be taught how to do passive exercises at home.

Active therapy usually starts six weeks after surgery. You use your own muscle power in active range-of-motion exercises. You may begin with light isometric strengthening exercises. These exercises work the muscles without straining the healing tissues. Formal strengthening exercises will be delayed until 12 weeks.

Exercises focus on improving the strength and control of the rotator cuff muscles and the muscles around the shoulder blade. Your therapist will help you retrain these muscles to keep the ball of the humerus firmly in the socket. This helps your shoulder move smoothly during all your activities.

Some of the exercises you’ll do are designed to get your shoulder working in ways that are similar to your work tasks and sport activities. Your therapist will help you find ways to do your tasks that don’t put too much stress on your shoulder. Before your therapy sessions end, your therapist will teach you a number of ways to avoid future problems.

If all of these efforts to improve your shoulder condition fail, there are a few other options. Tendon grafts and muscle transfers, for example, may help you regain use of your shoulder. However, these procedures are very complex and are rarely necessary.