Rotator Cuff

The rotator cuff is a large tendon in the shoulder, which is important for normal movement of the shoulder, particularly lifting the arm from the side and turning the arm behind the back. Disorders of the rotator cuff tendon are the commonest cause of shoulder pain and can affect people at all times of life.

The commonest problems are:

  • Inflammation caused by injury or over-use of the shoulder.
  • Tearing of the tendon, usually caused by a fall or by a sudden movement of the arm. This most commonly happens in later life, beyond the age of 50.
  • Calcium formation, known as “calcific tendonitis”, with the formation of a calcium deposit within the tendon, which can cause local inflammation and interfere with free movement of the shoulder.

 
The term “impingement” is often used when describing problems caused by inflammation of the rotator cuff tendons. Impingement is not a diagnosis, but describes mechanical catching or rubbing of the tendon against the bony edges of the shoulder blade (the acromion process) when the arm is lifted above the head. Impingement of the tendon can cause inflammation and a large part of the treatment of rotator cuff disorders involves reducing the inflammation and preventing the tendon from impinging when the arm is used.

Symptoms of rotator cuff disorders can present in several ways, but most commonly develop either after injury or over-use of the arm, particularly when the arm is used above the head for long periods (decorating the spare bedroom for example!). Sometimes, there is no history of injury or over-use of the arm but the symptoms develop gradually over a period of days and weeks, until the pain is more persistent than disturbing sleep or lying on the affected side. Pain arising from the rotator cuff is usually felt in the upper arm between the shoulder and the elbow. It is an aching discomfort which is more severe when the arm is used, particularly above shoulder level and often there is a sense of something “catching” when the arm is lifted above the head, or once again when the arm is lowered to the side. This is referred to as “painful arc”.

Confirming the diagnosis of a rotator cuff problem is usually based on a clinical assessment and X-rays can be helpful, usually to exclude calcification of the tendon and any other problems, such as arthritis of the shoulder joint. Further investigations which are commonly used are an ultrasound scan of the tendon or an MRI scan, both of which are very sensitive investigations which can be used to look for a tear of the rotator cuff.

Treatment depends on the underlying cause of the pain. When inflammation is caused by injury or over-use, the principal objective is to reduce inflammation and to improve the function of the shoulder by performing exercises. Anti-inflammatory drugs can be helpful, particularly in the early stages, as can an injection of steroid (cortisone) in the space around the tendon, which is very effective in reducing inflammation. This is normally combined with an exercise programme to overcome stiffness in the shoulder and to strengthen the muscles, which help to eliminate impingement. This exercise is commonly called a “stretching and strengthening” exercise programme. In most cases, this form of treatment will be pursued for at least six months before considering surgical treatment. Surgery is usually “keyhole” to remove inflamed tissue from around the tendon and to increase the space between the tendon and bone to reduce impingement. The operation is termed “an arthroscopic subacromial decompression” and would be performed normally under a general anaesthetic as a day care surgery procedure in hospital.

After surgery, exercises are required to prevent stiffening of the shoulder and in most cases the shoulder pain will diminish gradually over a period of three to six months. In well over 90% of cases normal shoulder function will be re-established.

When there is calcium formation within the tendon, this can be investigated in more detail by performing an ultrasound scan and a radiologist can needle the calcium deposit using the ultrasound probe as a guide. If this is ineffective and symptoms persist, keyhole surgery can also be used to examine the tendon to remove the calcium deposit. This will leave a small, shallow ulcer in the surface of the tendon, which will take three to six months to heal.

When the rotator cuff tendon is torn, a surgical repair is usually required. A tear of the rotator cuff tendon will be diagnosed by performing an ultrasound or MRI scan. To assess the size of the tear andto look for changes in the muscles. The tendon can be repaired either by keyhole surgery or an open operation, depending upon the size of the tear and the surgeon’s preference.

Following surgery (which is usually performed as a day care operation under general anaesthetic), the arm is rested temporarily to allow the tendon to heal. This usually takes about one month. Physiotherapy will be required to re-establish normal shoulder function, but in most cases normal shoulder movement and strength will recover gradually but the rate of recovery will depend upon the size of the tear and how long the symptoms have been present before surgery was performed. When the tear is very large, repairing the defect can be very difficult and sometimes it is not possible. In these circumstances unfortunately shoulder function will not return to normal, however the shoulder pain may be less.

It is important to emphasise that rehabilitation, working closely with the physiotherapist, is an essential part of this treatment following shoulder surgery.

RWN’s View

Rotator cuff disorders are by far the commonest cause of symptoms described by patients attending the shoulder clinic. In younger patients, this is nearly always due to inflammation and impingement of the tendon, which in most cases will be effectively treated by anti-inflammatory medication (often a steroid injection) and physiotherapy. I cannot emphasise enough the importance of the physiotherapy exercises, which performed several times a day, are essential in overcoming stiffness and improving strength of the muscles in the shoulder.

I recommend arthroscopic subacromial decompression for persistent impingement and calcific tendonitis when the symptoms have not responded to up to six months or appropriate non-surgical treatment. Once again, I always emphasise the importance of the exercises after the operation. The longer the patient keeps the arm in the sling and immobile, the more difficult it will be to recover normal shoulder movements. It is also important to be patient with the recovery of the shoulder as pain and function rarely recovers to normal within three months and for most patients it will take six months before the shoulder is working normally again.

Treatment of rotator cuff tears is usually surgical. It is important to perform scans to assess the size of the tear so that the appropriate surgical approach can be used. Keyhole surgery is effective in treating rotator cuff tears but for larger, more complex tears it is my preference to perform an open repair of the rotator cuff. Once again, the rehabilitation aspects are very important. After a period of rest, cooperation with the physiotherapist is the key to a good recovery.