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Throwing a ball or lifting the groceries, doing your household chores, or working on a computer, all your daily grind involves the shoulder. The movement may look easy, but it is a complicated one, involving many joints. The shoulder is the most flexible as well as complex joint in the human body. An important part of the shoulder movement is done by the rotator cuff muscles.
Reports suggest that every year, almost 2 million people in the United States seek medical help for rotator cuff injury. A rotator cuff injury affects about 30% of people over the age of 60, and this number jumps to 62 percent by the age of 80. Let’s discuss in detail rotator cuff injury, complications, and management strategies in this blog. Before that, understanding about the anatomy of the shoulder and the rotator cuff muscles would be compelling.
The shoulder is made up of three bones called the upper arm bone or humerus, the shoulder blade or scapula, and the collarbone or clavicle. It is a ball-and-socket joint, where the ball, or head, of the upper arm bone, fits into a shallow socket in the shoulder blade. Imagine a golf ball sitting on a golf tee.
There are approximately 20 muscles supporting the shoulder that allows it to turn, rotate and exhibit a full range of motion. One of those is the rotator cuff, which is a group of four muscles that acts together as tendons. It keeps the humerus centered in the shoulder socket.
The following are the important muscles that form the rotator cuff.
This muscle originates from supraspinous fossa of the scapula and inserts on the greater tubercle of the humerus. It maintains the upper arm stable and helps in lifting the arm.
This muscle initiates from the infraspinous fossa of the scapula and inserts on the greater tubercle of the humerus. The main action of the muscle is the rotation and extension of the shoulder.
- Teres Minor
This muscle originates from the posterior surface of the scapula and inserts on the greater tubercle of the humerus. It is the smallest muscle comprising the rotator cuff muscle. It aids in the lateral rotation of the arm.
This muscle initiates from the subscapular fossa on the costal surface of the scapula and inserts on the lesser tubercle of the humerus. It helps in holding the upper arm bone to the shoulder blade and in medial rotation of the arm
Types of Rotator Cuff Injuries
Rotator cuff injuries can be classified based on the cause, and the type of tear involved
Based on the Cause
A rotator cuff injury may be acute or chronic depending on the factor causing the tear
- Acute Injuries: A tear or a strain to the rotator cuff due to a traumatic event such as an accident is called an acute injury. Healing of these type of injuries is easy with rest and proper treatment.
- Chronic Injuries: Chronic injuries occur due to the overuse or impingement of the rotator cuff. It is commonly reported in sportsmen and a certain groups of workers. Healing time for chronic rotator cuff injuries is longer than acute injuries.
Based on the Type of Tear
Rotator cuff tears can be classified into two based on the extent of the tear. They are
- Partial Tear: It is an incomplete tear where the tendon would be damaged, but not completely.
- Full-Thickness Tear: It is a complete tear in which all of the tendons gets separated from the bone, making a cavity in the tendon.
Risk Factors Associated with a Rotator Cuff Tear
A rotator cuff injury could be an aftermath of a traumatic event, shoulder arthritis or a degenerative issue. Traumatic events refer to personal injuries, sports injuries, etc. Common personal injuries resulting in rotational cuff tear include motor vehicle accidents, lifting heavyweight, workplace injuries, slip and fall, etc.
Individuals practicing overhead sports such as baseball, basketball, tennis, golf, and swimming are more prone to rotator cuff tears. Football, lacrosse, and ice hockey players can also sustain shoulder injuries leading to rotator cuff injuries.
Individuals suffering from shoulder arthritis are more prone to shoulder instability, muscle weakness, and bony cysts, which are called osteophytes. This condition where arthritis leads to rotator cuff injury is termed cuff tear arthropathy.
Degenerative events occur over time. It may be age-related or an occupational injury. Degenerative rotator cuff injury is generally reported in aged people. Studies report that 15-30% of people over age 70 have rotator cuff tears. The common occupations causing rotator cuff injuries include carpentry, hammering, painting, etc. which demands repetitive movement of the shoulder.
Symptoms of Rotator Cuff Injury
A minor rotator cuff injury may initiate as a dull ache in the shoulder, but gradually develop into severe pain and difficulty in moving the arm. Signs and symptoms may differ depending upon the age, factor involved in the tear, and the type of injury. In a rotator cuff injury involving degenerative issues, symptoms may appear even after months or years. The following are the frequently reported rotator cuff injury symptoms.
- Shoulder pain and tenderness
- Disturbed sleep
- Weakness in the shoulder and arm
- Difficulty in reaching behind the back
- Difficulty in lying on the affected shoulder
- Difficulty in lifting or rotating your arm
- Snapping sensation in the upper arm
- avoiding certain activities because they cause pain
- Difficulty in achieving full range of shoulder motion
- Crackling sensation when moving the shoulder in certain angles
- Pain while doing normal household chores.
Diagnosis of Rotator Cuff Injury
The primary diagnosis of a rotator cuff tear involves a physical examination and a rotator cuff injury test. A detailed discussion may reveal the medical history of the patient. The following are the common functional tests performed by physicians and physiotherapists to diagnose a rotator cuff injury.
- Apley scratch test
- Hornblower’s sign test
- Bear hug test
- Neer’s sign
- Hawkins’ test
- Drop-arm test
- Cross-arm test
- Spurling’s test
- Apprehension test
- Sulcus sign
- Jobe’s test (empty can test)
- Yergason test
- Speed’s maneuver
- Clunk test
Depending upon the preliminary diagnosis, the physician may order imaging studies like X-rays, ultrasound, and MRI.
Management and Treatment of Rotator Cuff Tears
Strategies used to treat rotator cuff injury may imply either nonsurgical treatment or surgical treatment depending upon the type, severity of the tear, and age, general health condition of the patient. Any treatment that could help the patient manage pain and restore function would be preferred by the physician.
The following are the non-surgical interventions used to manage a rotator cuff injury. It may be either used individually or used as a combined management strategy.
- Arm sling and rest – This is used in minor rotator cuff injuries to prevent movement of the shoulder and to help the rotator cuff heal.
- Steroid injections– An injection of a local anesthetic and a cortisone preparation may help the patient to manage pain, inflammation and swelling of the rotator cuff.
- Nonsteroidal anti-inflammatory drugs (NSAIDs) – Medications like ibuprofen, and naproxen help in relieving pain and swelling.
- Physical therapy – Physical therapy may help the patient in muscle strengthening, stretching, and exercises for rotator cuff injury.
Surgical interventions are recommended when there is a partial or a complete tear in the rotator cuff which cannot be managed by non-surgical methods. Arthroscopy is the commonly used procedure where tiny instruments are inserted into small incisions in the shoulder. Bone spurs are removed and the tendon is reattached to the upper arm bone. When the tear is partial, trimming and debridement procedures may be done to prevent further tearing.
Rotator cuff injury heal time would be around 4-6 weeks depending upon the procedure done. A combination of shoulder immobilizer, sling, pain medication, and physical therapy may be suggested even after the surgery.
How to Prevent Rotator Cuff Injury?
The following preventive measures could be followed to avoid rotator cuff tears.
- Maintain good posture
- Exercise to strengthen rotator cuff muscles
- Avoid repetitive overhead arm activities
- Maintain a healthy weight
- Avoid sleeping on your side with the arm stretched overhead
“A torn rotator cuff is a cancer for a pitcher and if a pitcher gets a badly torn one, he has to face the facts, it’s all over baby”. This was quoted by Los Angeles Dodgers Hall of Famer Don Drysdale. The “Big D” had to retire from his baseball career in 1969 at age of 32 with a severe rotator cuff injury.
A rotator cuff injury causes inflammation and shoulder pain making the shoulder movement very difficult. Rotator cuff injury can hinder the daily living of an individual. It’s a myth that rotator cuff injuries are sustained only by professional athletes, such as pitchers and tennis players. Any shoulder injury, over time, could lead to degenerative issues and rotator cuff tear.
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