Because the shoulder isn’t a weight-bearing joint, though it sustains a good deal of force from lifting and repetitive activity, it is still likely to be affected by the same type of wear-and-tear degeneration that leads to osteoarthritis in the hips and knees. It is also less likely to be affected by rheumatoid arthritis than many other joints.
The most common shoulder problems affect the soft tissues that enclose the joint, which can be damaged by sudden injury or, more frequently, by repetitive motion such as in sports and various kinds of physical labour, especially those involving overhead motion. Injury to the shoulder’s soft tissues can lead to synovitis (inflammation of the synovium), tendonitis (inflammation of a tendon), or bursitis (inflammation of the bursa). Tears of the rotator cuff can also occur.
Rotator cuff tears may occur at virtually any age, but they’re most common in those over 40, as a result of acute trauma or repetitive overhead work or sports activity. The rotator cuff weakens with age and this may be a factor in the development of tears.
An acute rotator cuff tear as a result of trauma can occur on its own or in conjunction with another shoulder injury, such as a fracture or dislocation. An acute tear usually causes a sharp pain in the front of the shoulder that radiates down the side of the arm.
Rotator cuff tears caused by repetitive overhead activity or by wear and degeneration of the tendon usually have a more gradual onset of symptoms. In such cases, the pain may at first be mild and only present with overhead activities such as reaching or lifting, but as time passes, pain may result from little or no stressful activity at all, including just lying in bed on the affected side at night. Stiffness and loss of motion are also common, making it difficult to perform simple daily tasks such as combing your hair or twisting your arm behind your back to fasten a button on a blouse, or reaching up to adjust a hat or the hood of a coat.
Some of the signs of a rotator cuff tear include thinning (atrophy) of the shoulder muscles and pain or weakness when you lift your arm or when you lower it from a fully raised position. There may also be a crackling sensation (crepitus) when the shoulder is moved in certain ways.
Despite all the clues, diagnosing a rotator cuff tear isn’t always easy, because a number of conditions in the bones and soft tissues of the shoulder can present with similar symptoms, and a number of tests may be required for a conclusive diagnosis. A doctor will begin by taking the medical history, then perform a physical examination, looking for tender areas, deformity, and restrictions in strength and motion. The physician may also examine the patient’s neck to ensure a “pinched nerve” in the cervical spine isn’t the pain source and to rule out other conditions, such as osteo- or rheumatoid arthritis.
Beyond that, he or she may request imaging tests, usually beginning with x-rays. Other tests may be ordered, including an ultrasound or a CT scan (computerized tomography) or MRI (magnetic resonance imaging), all of which can better visualize soft tissue structures such as the rotator cuff tendon.
An MRI is the gold standard, since it can even distinguish between a complete (full thickness) tear of the tendon and a partial tear, and whether the tear is within the tendon itself, or if the tendon is detached from the bone.
Once a diagnosis of rotator cuff tear has been made, patients should discuss with their surgeon the most effective treatment approach for their individual needs. For some people – for example, those who aren’t particularly active, don’t play sports or don’t have a physically demanding job – non-surgical treatment can often provide pain relief and improve shoulder function.
A typical program might include:
- rest and limiting overhead use of the shoulder
- use of a properly fitted sling
- a course of non-steroidal anti-inflammatory drugs (NSAIDs, such as ASA or ibuprofen)
- perhaps a cortisone injection into the shoulder joint and
- a program of directed strengthening exercise and physical therapy.
It’s not a quick-fix approach. It may take six months to a year to restore shoulder strength and mobility, and it’s not a guaranteed solution for everyone. Accordingly, an orthopaedic surgeon may recommend surgery if:
- non-operative treatment fails to relieve symptoms,
- the tear is acute and painful,
- the tear affects the dominant arm of an active individual, or
- someone who needs maximum strength in his or her arm for overhead work or sports.
The type of surgery performed depends on the size, shape and location of the tear. A partial tear may require only trimming or smoothing, a procedure called “debridement.” A complete tear within the substance of the tendon is repaired by suturing the two sides of the tendon. If the tendon is torn loose from its insertion on the greater tuberosity of the humerus, it can be reattached directly to the bone. In most cases, a decompression of the cuff is also performed, removing any bone spurs that might be causing impingement or pressure on the cuff.
In years past, the standard procedure for a tear requiring surgery was an “open rotator cuff repair,” which began with a 6- to 10-cm incision over the outside of the shoulder the muscle beneath the skin was then separated to expose the rotator cuff, so that it could be inspected and repaired.
However, while the injury may have been repaired, the operation could be quite painful and occasionally caused problems with stiffness and weakness of the muscles that are cut as part of the surgical exposure.
Despite this, in certain cases, the traditional open surgical incision may still be the best option – such as when the tear is large or complex, or if additional reconstruction is required.
Such cases are the exception, though. More recent techniques and instruments have permitted surgeons to perform complete rotator cuff repairs through smaller incisions, typically four to six cm.
In fact, with the advent of the arthroscope, surgeons are more likely to perform what some call a “mini-open rotator cuff repair” or even an all arthroscopic repair with stitches inserted through small puncture wounds. The arthroscope – once known as “the needle with an eye”- allows surgeons to both see and operate on damaged tissue without making a major incision. A surgeon can insert a flexible tube equipped with a miniature camera and a light source into a small incision to examine the joint via a television monitor. The problem is usually easily identified. Through a second incision, the surgeon inserts another tube equipped with a surgical tool to effect a repair. Arthroscopic procedures are often done on an outpatient basis.
After surgery, the arm is immobilized to allow the tear to heal. The length of immobilization depends upon the severity of the tear. You will be given an exercise program to help regain motion and strength in the shoulder. This begins with passive motion. It advances to active and resistive exercises. Your orthopaedic surgeon may recommend that you work with a physiotherapist. Complete recovery will take at least several months.
A strong commitment to rehabilitation is important to achieve a good surgical outcome. The doctor will advise you when it is safe to return to overhead work and sports activity.