Rotator Cuff Injury

What are the rotator cuff muscles?

The rotator cuff is a group of muscles which work together to provide the Glenohumeral (shoulder) joint with dynamic stability, helping to control the joint during rotation (hence the name). The rotator cuff muscles include:

• Supraspinatus
• Infraspinatus
• Teres Minor
• Subscapularis

Due to the function of these muscles, sports which involve a lot of shoulder rotation – for example, bowling in cricket, pitching in baseball, swimming, kayaking – often put the rotator cuff muscles under a lot of stress.
Problems with the rotator cuff muscles can be classed into two categories – Tears of the tendons/muscles, and inflammation of structures in the joint.

Acute Tear

This tends to happen as a result of a sudden, powerful movement. This might include falling over onto an outstretched hand at speed, making a sudden thrust with the paddle in kayaking, or following a powerful pitch/throw.

The symptoms will usually include:

• Sudden, tearing feeling in the shoulder, followed by severe pain through the arm
• Limited movement of the shoulder due to pain or muscle spasm
• Severe pain for a few days (due to bleeding and muscle spasm) which usually resolves quickly
• Specific tenderness (“x marks the spot”) over the point of rupture/tear
• If there is a severe tear, you will not be able to abduct your arm (raise it out to the side) without assistance

Chronic Tear

• Usually found on the dominant side
• More often an affliction of the 40+ age group
• Pain is worse at night, and can affect sleeping
• Gradual worsening of pain, eventually some weakness
• Eventually unable to abduct arm (lift out to the side) without assistance or do any activities with the arm above the head
• Some limitations of other movements depending on the tendon affected

Inflammation

• More common in women aged 35-50
• Characteristic ache in the shoulder which feels like it is coming from “deep inside”
• Tenderness over particular areas, less specific than a tear
• Usually a gradual onset of pain, which “flares up” if using the arms over the head or out to the side
• Can sometimes lead to a chronic tear if untreated

When should I seek medical attention for my Rotator Cuff Injury?

Seek medical attention if:

• The pain persists for more than 2-3 days
• You are unable to work due to the pain/limitations
• You are unable to reach up or to the side with the affected arm after 2-3 days
• You are unable to move the shoulder and arm at all
• For any acute injury where you are unable to move the injured shoulder as well as the uninjured shoulder

What should I expect when I visit a healthcare professional with a possible Rotator Cuff problem?

• A detailed history of your general health, past problems and injuries, and what happened to cause this injury will be taken
• Both shoulders will be looked at and compared (you will need to partially undress for this) both visually and using palpation (feeling)
• Your neck, elbows and wrists will be checked to make sure they are not contributing to the problem
• Range of movement will be assessed, you’ll be asked to do certain movements and the clinician will observe and ask you to report any pain (but will not be done if a fracture is suspected)
• Passive range of movement will be assessed – you will be asked to lie on a couch while the clinician moves your shoulder (but will not be done if a fracture is suspected)
• Sensation and strength in the arm will be assessed
• Some specific tests will be done which can help to identify which tendon is causing the problem and confirm if it is a rotator cuff tear, or due to inflammation or some other cause.

Assessment of shoulder for rotator cuff injury

• You will be asked to put your arms out in front of you with your thumbs pointing to the floor (as if holding an empty can) and hold them there while gentle pressure is applied to the top of your arm
• This is biased towards the Supraspinatus tendon

Drop Arm Test (Codman’s Test)

• Your arm will be moved out to the side, and you’re asked to gently lower your arm to your side
• If you can’t do this slowly, or have very severe pain in doing so, it suggests a tear in the rotator cuff

Abrasion Sign

• You will be asked to sit and raise your arm to your side with the elbow bent
• You will be asked to rotate your arm forwards and backwards
• If there is any crunching noise (crepitus) there may be some inflammation or degenerative changes.

Neer’s Sign

• Your arm will be moved forwards until it is above your head
• If you experience pain or discomfort, it might be possible that you have inflammation of the Supraspinatus and possibly the tendon of the biceps muscle.

Hawkins-Kennedy Test

• Your arm will be raised in front of you to 90° and the elbow bent, and the arm will be turned towards the middle of your bod
• If this causes pain you probably have a problem with Supraspinatus.

What can I do to help my rotator cuff muscles recover?

• Rest the shoulder
• Ice can be used at least 3 times a day and is useful for the first couple of days following an injury
• Apply ice for no more than 15-20 minutes ensuring you use an appropriate ice bag, or wrap the ice in a towel to prevent ice burn
• Warmth may be useful after the first few days to help with the pain
• Medication may be helpful to help control the pain – speak to your doctor if you think you require stronger than what you might usually take

Treatment for an Acute Rotator Cuff Tear

• Apply ice to reduce swelling as above
• Control the pain with appropriate medications
• Rest the arm – a sling can sometimes be quite useful if you still need to go to work/school, which can be removed at night
• You may require imaging studies (x-ray, MRI, CT Scan) to identify what the problem is and rule out any fractures
• Consider consulting a physiotherapist who can assist you with rehabilitating the injury

If the injury is quite severe and you are young and active, you might require an operation to fix the tear.  This needs to be done within 3 weeks.  Indications include:

• Under 60 years old
• Complete tears of the tendon/muscle
• Failure of other treatments after 6 weeks
• Professional/keen sports people
• If your job requires constant shoulder use

Treatment for a Chronic Rotator Cuff Tear

• Control pain
• Apply ice as above, heat may also be beneficial
• Sometimes you might be referred for an injection of steroid medication directly into the site of the problem to help reduce any inflammation and allow you to proceed with rehabilitation
• Shoulder exercises which can be provided by a physiotherapist
• You may require surgery, the indications as above

Treatment for Rotator Cuff Inflammation

• Apply ice initially as above
• Rest the arm for short periods, but it is important to keep the shoulder moving to prevent stiffness and further reduced movement.
• You may benefit from a course of anti-inflammatory medications
• You may need to have an injection of steroid medications directly to the site of the inflammation, as explained above.
• Heat and massage may help once things start to improve a bit
• Small pendular movements when leaning forwards may provide some relief and help to improve the shoulder movement.  Consult with a physiotherapist for a personalised exercise plan.
• Walking your fingers up a wall or door can help to improve shoulder movement.  Also, holding a stick with both hands and using the better shoulder to move in a circular fashion can help, as this moves the painful shoulder with minimal stress on the rotator cuff muscles

How long will it take to get better?

• Depending on several factors, conservative treatment has a 40-90% success rate at fixing the problem.
• Surgery often has good results, with some studies citing a 94% satisfaction rate with the surgery, resulting in lasting pain relief and improved function.  Very extensive tears often have a poor surgical outcome, however this injury is thankfully quite rare.
• If you are older, it will take you longer to heal due to differences in your physiology.