Condition Basics

What are rotator cuff disorders?

The rotator cuff is a group of tough, flexible fibres (tendons) and muscles in the shoulder. Rotator cuff disorders include:

• Irritation or damage to the tendons (tendinopathy, sometimes called tendinitis).
• Inflammation or irritation of a bursa (bursitis). In the shoulder, a bursa is a small, fluid-filled sac that serves as a cushion between the tendons and the bones.
• Impingement. This means that a tendon is squeezed or rubbed against bone.
• Calcium buildup in the tendons. The buildup can cause a painful condition called calcific tendinopathy.
• Partial or complete tears of the rotator cuff tendons.

What causes them?

Most rotator cuff disorders are caused by a mix of overuse and normal wear and tear. It usually takes great force to tear a healthy rotator cuff tendon. This can happen during sports, an accident, or a severe fall.

What are the symptoms?

A rotator cuff disorder causes pain and weakness in your shoulder. Most often, the pain is on the side and front of the upper arm and shoulder. It may hurt when you do everyday things, such as comb your hair or reach for something. You may have pain during the night and trouble sleeping.

How are they diagnosed?

To diagnose a rotator cuff disorder, doctors ask about any shoulder injuries or past shoulder pain. They also do a physical exam to check for painful areas or activities. You may have an X-ray to check the bones in the shoulder. If needed, the doctor may order more tests.

How are rotator cuff disorders treated?

Treatment of a rotator cuff disorder depends on your symptoms, your age, and how active you are. Most are treated without surgery. You may get medicines and use home treatment, such as rest and applying cold or heat. You may have physiotherapy. Your doctor may also give you a shot of steroid medicine in the shoulder if other treatments haven't worked.

Cause

Most rotator cuff disorders are caused by a mix of overuse and normal wear and tear.

Overuse.

Activities in which you use your arms above your head a lot—such as tennis, swimming, or house painting—can lead to rotator cuff problems. Even normal motions made often over a long period can stress or injure the rotator cuff.

Normal wear and tear.

Using your shoulder for many years slowly damages the rotator cuff. As you age, everyday activities can lead to changes in the rotator cuff. These changes include thinning and fraying of the tendons and reduced blood supply.

It takes great force to tear a healthy rotator cuff tendon. This can happen during sports, a mishap, or a severe fall. But even a simple movement like lifting a suitcase can cause a rotator cuff tear in an older adult or someone whose shoulder is already damaged.

What Increases Your Risk

Things that may increase the risk of rotator cuff disorders include:

• Aging.
• Holding or moving your arm overhead often. This may include painting, working as a waiter, or playing tennis, baseball, and other throwing sports.
• Previous shoulder injuries. These may include dislocations and broken bones.
• Having a rotator cuff tear in the other shoulder.
• Irregularities of the muscles, tendons, and bones in the shoulder that increase wear on the rotator cuff tendons.
• Having received multiple corticosteroid injections in the shoulder. This may weaken tendons and increase your risk.
• Smoking. This decreases the blood supply and slows healing.
• Shoulder instability.

Prevention

The long-term changes to the shoulder joint from everyday wear and tear can't be totally prevented. But you may be able to prevent some rotator cuff problems if you:

• Keep the muscles in your shoulders flexible and strong. Daily exercises may be the best way to do this and help prevent a rotator cuff disorder.
• Have good posture. Stand straight and relaxed, and don't slump.
• Don't lift objects that are too heavy for you, especially over your head.
• Avoid sports or other activities where forceful contact or falls are likely or common.
• Don't keep your arms out to the side or raised over your head for long periods of time. If you must do these activities:
  • Take breaks often. Ice your shoulder several times a day and at night.
  • Take a non-steroidal anti-inflammatory drug (NSAID) to relieve any swelling and pain in the tissues that are being pinched.

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Symptoms

A rotator cuff disorder causes pain and weakness in your shoulder. It may hurt to do everyday activities, such as combing your hair, tucking in your shirt, or reaching above your head.

Because of the pain, you may try not to use your arm. And that can cause even more weakness and stiffness in the shoulder.

Symptoms of rotator cuff tendinopathy

With tendinopathy (damage or irritation to the tendon), the pain usually starts bit by bit, over the side of the shoulder and the upper arm.

• Your shoulder and arm aren't that weak, but it hurts to use them.
• The pain may spread down the outside of the upper arm, even to the elbow.
• The pain may be worse at night. It may keep you awake, especially if you lie on that side.
• Lifting the arm to the side or to the front makes the pain worse.

Over time, the pain may get worse, or you may have constant pain. In some cases, this is because you actually have one or more small tendon tears.

Symptoms of rotator cuff tears

The most common symptoms of a tear are:

• Pain when you move your arm, especially when you move it over your head or against resistance.
• Pain at night.
• Weakness in your shoulder. But some people don't notice any weakness if the tear is small.

Symptoms of a sudden, severe tear include:

• A popping sound or feeling like something is tearing in your shoulder.
• Sudden pain in your shoulder.
• Weakness and pain when you lift or rotate your arm.
• Limited range of motion and not being able to raise your arm because of pain or weakness.
• Swelling or a bump at the site of the tear.
• In some cases, bruising in your shoulder or upper arm.

You can have a complete tear without symptoms, especially if you are an older adult who is not very active.

What Happens

If the rotator cuff problem isn't checked, wear and tear and limited movement can lead to other shoulder problems. These may include stiffness or frozen shoulder. Doing some activities can lead to problems like bursitis and tendinopathy. Recovery varies. Most people feel better after several weeks of rehabilitation. Some treatments can last longer.

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When to Call a Doctor

Call 911 or other emergency services immediately if shoulder or arm pain occurs with chest pain or other symptoms of a heart attack, such as shortness of breath and nausea.

Call your doctor now if you have an injury to your shoulder and:

• Your shoulder is very painful.
• Your shoulder appears to be deformed.
• You cannot move your shoulder normally.
• You have signs of damage to the nerves or blood vessels, such as numbness; tingling; a "pins-and-needles" sensation below the injury; or pale, cold, or bluish skin.

Call your doctor if:

• You had a shoulder problem in the past and you have shoulder pain.
• Your shoulder pain or stiffness is getting worse.
• Home treatment isn't helping.

Watchful waiting

Watchful waiting is a wait-and-see approach. If you get better on your own, you won't need treatment. If you get worse, you and your doctor will decide what to do next. A watchful waiting period may vary from a few days to weeks or maybe months.

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Examinations and Tests

To diagnose a rotator cuff disorder, doctors ask about any shoulder injuries or past shoulder pain. They also do a physical exam. The exam helps them to see how well the shoulder works and to find painful areas or activities. Moving your arm in certain ways can help the doctor learn about the condition of the rotator cuff.

You may have an X-ray to check the bones of the shoulder. If the diagnosis is still unclear, the doctor may order more tests. This may include an imaging test, such as an MRI, an ultrasound, or sometimes an arthrogram.

Your doctor thinks about your age, job, and activity level when deciding about more tests. A clear diagnosis is important if you are likely to keep doing things that may do more damage to your shoulder.

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Treatment Overview

Treatment depends on your symptoms, your age, and how active you are. Your treatment may include:

• Medicines. Non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are often used for pain and inflammation. If other treatments don't help, your doctor may give you a shot of steroid medicine in the shoulder.
• Home treatment, such as rest and applying cold or heat.
• Physiotherapy to stretch and strengthen the shoulder.

Most rotator cuff disorders aren't treated with surgery. But doctors may do surgery if a rotator cuff tendon is torn. They may also do it if several months of other treatments haven't helped. Whether or not you get surgery will depend on your age, the amount of other damage in the shoulder, and the chances that surgery will be a success in your case. And surgery is not a substitute for physiotherapy. Even after surgery, you may need months of physiotherapy to recover fully.

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Self-Care

Home treatment is often the first treatment for a rotator cuff problem. Treatment can help relieve the pain and keep the problem from getting worse.

• Rest your injured shoulder. Limit repeated movements. And avoid strenuous activity and activities where your arms move above your head.
• Do only the gentle movements that your doctor recommends. It is important that you don't keep your shoulder completely still. That can cause the joint to stiffen or can lead to frozen shoulder.
• Avoid activities or positions that cause discomfort. Stop any activity that hurts your shoulder.
• Take non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen to relieve pain. Or you can use acetaminophen.
• Use ice or heat. Use the one that makes you feel better. For a sudden injury, try ice first. After 2 or 3 days, if you don't have swelling, you can try heat.
• Follow your doctor's advice about exercise and whether you need physiotherapy.

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Medicines

Medicines don't heal rotator cuff disorders. They help with pain and inflammation. This allows you to start exercises to stretch and gradually strengthen the shoulder, which reduces the risk of stiffness or a frozen shoulder.

The types of medicines used to treat a rotator cuff disorder are:

Non-steroidal anti-inflammatory drugs (NSAIDs).

NSAIDs are the most common medicines used to help manage rotator cuff disorders. They are available with or without a prescription. NSAIDs come in pills and in a cream that you rub over the sore area. Or you can use acetaminophen.

Corticosteroid shots.

These are strong medicines that are often only given after a few weeks of other treatment. Your doctor may recommend not having this shot near the time of rotator cuff surgery.

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Surgery

Surgery may be an option if:

• Your rotator cuff injury is very severe or likely to worsen.
• You have severe pain and loss of shoulder function that haven't been helped by other treatment.
• You have shoulder weakness caused by a complete tear.
• You don't have other shoulder problems, such as arthritis.

Surgery mostly is used to repair a torn rotator cuff when there is little sign of other problems. People who have advanced rotator cuff disorders and tendons that are frail and stiff usually do less well with surgery. Surgery may work to repair the tear. But it can't repair all the damage caused by age or degeneration.

Shoulder surgery may include:

• Debridement. This removes loose fragments of tendon and other debris.
• Rotator cuff repair.
• Subacromial smoothing. This shaves bone or removes growths.

Sometimes a rotator cuff tear is too severe to be fixed in the usual ways. Your doctor may suggest surgery to move another tendon, replace the torn tendon, or surgery to replace the shoulder.

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Physiotherapy and Rehabilitation

A physiotherapy (PT) and rehabilitation (rehab) program usually involves exercises to stretch and slowly strengthen the shoulder. Stretching includes range-of-motion exercises. Exercises to strengthen can help you build and keep shoulder function and stability. Some physiotherapists may use other techniques to relieve pain and reduce muscle spasms. These may include massage or ultrasound.

Rehab may be used without surgery. Or it may be part of your recovery after surgery. It can reduce pain in the soft tissues, such as the muscles, ligaments, and tendons. It can also improve function and build muscle strength.

A good recovery depends a lot on how you do with rehab. If you follow your PT plan closely and get help when you need it, you are more likely to restore your shoulder's strength and movement.

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