Ouch my Shoulder Hurts!

Got a terrible ache while you lift your arm and rotate it and wondered what was wrong with it? The cause of this pain is often due to the rotator cuff. It commonly occurs in people beyond 40 years.Incidence figures of 0.9-2.5% were found for different age groups. At any given point in time the prevalence figures differ from 6.9 to 26%.The different causes can be anything from periathritis (frozen shoulder), impingement (when the tendons of the rotator cuff are inflamed and irritated) or a tear of the cuff.Impingement and rotator cuff tear can be considered as two ends of a spectrum of shoulder disorders affecting the rotator cuff.Here are some questions and answers that will help you to understand the Rotator Cuff (RC) and its associated pathologies much better.

What is the rotator cuff (RC)?

The muscles controlling various movements of the shoulder (supraspinatus, teres minor and subscapularis) before attaching at the shoulder joint coalesce to form a sheet or cuff like structure known as the rotator cuff.

What is the function of the rotator cuff?

The muscles of the cuff primarily function to stabilize the shoulder joint and to ensure its efficient functioning. The individual muscles also function to move the shoulder in various directions that include elevation, external rotation and internal rotation.The normal functioning of the cuff is ensured by its continuity and integrity as well as by smooth gliding of this sheet in the narrow space of the shoulder joint which in turn is facilitated by lubricating tissues known as the bursa.What can go wrong with the rotator cuff?The pathologies of the rotator cuff can range from inflammation (RC tendinits), degeneration (RC tendinosis) or to tear (partial or complete RC tear). There may be a component of each one in any presenting pathology. Inflammation of the cuff leads to swelling, thickening and micro tears in the cuff interfering with its smooth gliding in the narrow space of the shoulder. This causes pain during shoulder movements especially elevation. This is known as external impingement.

The above figure shows inflamed and swollen bursa and RC cause impingement in smooth gliding of the cuff.

RC Tear

  Loss of continuity of the cuff may be partial or complete. This leads to weakening of the shoulder and the inability of the cuff to stabilize the shoulder joint and perform specific movements caused by the different muscles forming the cuff.

How do I know that there is a problem with my rotator cuff?

Patients with RC pathologies generally present with pain in the shoulder which is aggravated while moving it (most commonly elevation and internal rotation) of the shoulder (Figures 5, 6).The pain may also disturb your sleep. There may also be weakness in certain movements of the shoulder like elevation, external rotation or internal rotation if the pathology involves a tear in the RC. Shoulder pain is the most common symptom in RC problems.

   

The Figure shows pain during overhead activity more commonThe diagnosis can be confirmed after a clinical examination and imaging studies like X ray, ultrasound and MRI/ MRA.

How does the rotator cuff problem develop?

RC tears are uncommon in people younger than 40 years unless the cuff is avulsed or torn with a fragment of bone at its insertion. This usually follows a fall on an outstretched hand or a direct impact on the shoulder. Young patients are more commonly affected with RC tendinitis. Patients older than 40 years especially those with multiple conditions like diabetes mellitus, gout, smoking, alcoholic more commonly have tears of the RC. It occurs with undue rapidity when an already compromised RC (having tendinitis, tendinosis) gets injured directly or indirectly. 

Live snap of arthroscopic shoulder surgery

What are the treatment options available?

Cases of RC tendinitis or tendinosis can be treated conservatively with anti inflammatory medications and rest followed by RC strengthening. Some partial thickness RC tears may heal with rest; others need surgery for repair of the torn cuff. The surgery can be done via open, mini open or the arthroscopic approach .

Schematicdiagram of arthroscopic shoulder surgery

What is the recovery time after an RC repair?

Active shoulder movements including overhead movements may be started after 6 weeks of surgery. Routine office work can be started after 2-3 months from surgery. Return to sports is only advisable after 8 – 9 months provided the proper physiotherapy protocol has been followed.

Do all RC tears need surgery?

A complete tear of RC cannot heal without repair. Some (not all) partial thickness tears of RC may heal with rest. It is advisable for young and active people to get their RC tears assessed by a doctor and most likely repaired earlier (preferably within 3 months) for good results.

 How are the results of surgery?

The results of the surgery are variable and depend on a number of factors. In general individual with healthy tissues, i.e. those not suffering from diabetes, thyroid disorders, rheumatoid arthritis, non smokers etc. have a good to excellent outcome after surgery. On the other hand individuals with poor general health or suffering from or having habits mentioned above may not have equally good results.

Ortho One, the Super Speciality Orthopaedic Hospital, the Best Ortho Hospital in South India offers physiotherapy, knee surgery, joint replacement, arthroscopy, spine surgery, sports injury treatment, shoulder surgery, paediatric orthopaedics etc with affordable cost.

For more information,

Website : www.ortho-one.in

E-mail : orthocaretamilnadu@gmail.com 

This blog is written by,
Dr. David V. Rajan, MS (Orth) MNAMS (Orth) FRCS (G), 
Shoulder arthroscopic surgeon at Ortho One, Centre of excellence shoulder surgery in India.