The rotator cuff is a group of four muscles that surround the humeral head (ball of joint). The muscles are referred to as the "SITS" muscles-Supraspinatus, Infraspinatus, Teres minor and Subcapularis. The muscles function to provide rotation and elevate the arm and give stability to the shoulder joint (glenohumeral joint). The supraspinatus is most frequently involved in degenerative tears of the rotator cuff. More than one tendon can be involved. There is a bursa (sac) between the rotator cuff and acromion that allows the muscles to glide freely when moving. When rotator cuff tendons are injured or damaged, this bursa often becomes inflamed and painful.
Rotator cuff tendinitis is an inflammation (irritation and swelling) of any of the 4 tendons of the rotator cuff muscles of the shoulder. The most common ones injured are supraspinatus and infraspinatus. Often the patient can develop what is known as “impingement syndrome”.
What causes impingement syndrome?
Repeated movement of the arm overhead can cause the rotator cuff to contact the outer end of the shoulder blade where the collarbone is attached, called the acromion. When this happens, the rotator cuff becomes inflamed and swollen, a condition called tendonitis. The swollen rotator cuff can get trapped and pinched under the acromion. All these conditions can inflame the bursa in the shoulder area. A bursa is a fluid-filled sac that provides a cushion between a bone and tissues such as skin, ligaments, tendons, and muscles. An inflammation of the bursa is called bursitis
Neer developed a system of categorizing rotator cuff tendonitis/impingement syndrome. Stage I is when there is edema and swelling but is completely reversible. Stage II is when there is thickening of the tendon; there may be spurs on the undersurface of the acromion and the condition is irreversible. Stage III has all the characteristics of Type II but there is now a tear of some sort in the rotator cuff tendon.
Causes, incidence, and risk factors
The shoulder joint is a ball and socket type joint where the top part of the arm bone (humerus) forms a joint with the shoulder blade (scapula). The rotator cuff holds the head of the humerus into the scapula.
Inflammation of the tendons of the shoulder muscles can occur in sports requiring the arm to be moved over the head repeatedly as in tennis, baseball (particularly pitching), swimming, and lifting weights over the head. Chronic inflammation or injury can cause the tendons of the rotator cuff to tear.
The risk factors are being over age 40 and participation in sports or exercise that involves repetitive arm motion over the head (such as baseball).
Pain in the shoulder at night, especially when lying on the affected shoulder
Weakness with raising the arm above the head, or pain with overhead activities (brushing hair, reaching for objects on shelves, etc.)
If they go into late stage II or stage III they may develop loss of range of motion
Signs and tests
A physical examination will reveal tenderness over the shoulder. Pain may occur when the shoulder is raised overhead. There is usually weakness of the shoulder when it is resisted in certain positions. The Neer’s test for impingement is usually positive. Another commmon impingement test is the Hawkins Kennedy test. Both tests place the arm in such a position that it minimizes the subacromial space and if the tissues are enlarged, they will be pinched in these positions causing an increase in pain.
X-rays may show a bone spur, while MRI may demonstrate inflammation in the rotator cuff. If a tear in the rotator cuff is present, this can usually be identified on MRI.
The injured shoulder should be rested from the activities that caused the problem and from activities that cause pain. Ice packs applied to the shoulder and non-steroidal anti-inflammatory drugs will help reduce inflammation and pain.
Physical therapy to strengthen the muscles of the rotator cuff and the scapula should be started; attention to any causative factors such as poor posture should also be addressed. If the pain persists or if therapy is not possible because of severe pain, a steroid injection may reduce pain and inflammation enough to allow effective therapy.
If the rotator cuff has sustained a complete tear, or if the symptoms persist despite conservative therapy, surgery may be necessary. Arthroscopic surgery can remove bone spurs and inflamed tissue around the shoulder. The most common surgery is called a subacromial decompression where they remove the coracoacromial ligament; remove about a third of the width of the acromian or in some cases, remove the distal end of the acromion.
Small tears can be treated with arthroscopic surgery. Newer techniques allow even large tears to be repaired arthroscopically, although some large tears require open surgery to repair the torn tendon.
Rotator Cuff Tears Rotator cuff tears are a common source of shoulder pain. . The incidence of rotator cuff damage increases with age and is most frequently due to degeneration of the tendon, rather than injury from sports or trauma. While the information that follows can be used as a guide for all types of rotator cuff tears, it is intended specifically for complete degenerative tears of the rotator cuff. Treatment recommendations vary from rehabilitation to surgical repair of the torn tendon(s). The best method of treatment is different for every patient. The decision on how to treat rotator cuff tears is based on the patient's severity of symptoms and functional requirements, and presence of other illnesses that may complicate treatment. In consultation with an orthopaedic surgeon, the information that follows is intended to assist patients in deciding on the best management of their rotator cuff tear with the understanding that all patients are unique.
Rotator cuff tears increase in frequency with age, are more common in the dominant arm, and can be present in the opposite shoulder even if there is no pain1,7. The true incidence of rotator cuff tears in the general population is hard to determine because 5 percent to 40 percent of people without shoulder pain may have a torn rotator cuff. This was determined by studies using MRI and ultrasound to image the shoulders of patients with no symptoms. One study6 revealed a 34 percent overall incidence of rotator cuff tears. The highest incidence occurred in patients who were more than 60 years old. This study supported the concept that rotator cuff damage has a degenerative component and, importantly, that a tear of the rotator cuff is compatible with a painless, normal functioning shoulder.
There are intrinsic and extrinsic causes of rotator cuff tears. An example of an intrinsic factor is tendon blood supply. The blood supply to the rotator cuff diminishes with age and transiently with certain motions and activities. The diminished blood supply may contribute to tendon degeneration and complete tearing3,4,5. The substance of the tendon itself degenerates over time. Due to an age related decrease in tendon blood supply, the body's ability to repair tendon damage is decreased with age; this can ultimately lead to a full-thickness tear of the rotator cuff.
An extrinsic cause would be damage to the rotator cuff from bones spurs underneath the acromion. The spurs rub on the tendon when the arm is elevated; this is often referred to as impingement syndrome. Bone spurs are another result of the aging process. The rubbing of the tendon on the bone spur can lead to attrition (weakening) of the tendon. Combining this with a diminished blood supply, the tendons have a limited ability to heal themselves. These factors are at least partly responsible for the age-related increase in rotator cuff disease and the higher frequency in the dominant arm.
What will happen if a torn rotator cuff is not treated with surgery? Will I lose the use of my arm? Will the tear get larger over time? These are common concerns patients have, and the answers are not always clear. In one study, 40 percent of patients with a rotator cuff tear showed enlargement of the tear over a five-year period; however, 20 percent of those patients had no symptoms. Therefore, less than half of patients with a rotator cuff tear will have tear enlargement, but 80 percent of patients whose tear enlarges will develop symptoms7. This data is based on a small group of patients; it is important to realize that once symptoms develop, progression may have already progressed and enlarged.
Surgical and Non-Surgical Options
Treatment options include:
Non-operative (conservative) treatment
Operative - Rotator cuff repair
Non-Operative Treatment Benefits and Limits
Non-surgical treatment typically involves:
Activity modification (avoidance of activities that cause symptoms)
Non-operative management of a rotator cuff tear can provide relief in approximately 50 percent of patients.
Hawkins & Dunlop8
Itoi & Tabata9
Bokor et al.10
Bartolozzi et al.11
Percentage of patients who were satisfied
Percentage of patients with pain relief
These studies show that about half (50 percent) of patients have decreased pain and improved motion, and are satisfied with the outcome of nonsurgical treatment. Surgeons may recommend nonsurgical treatment for patients who are most bothered by pain, rather than weakness, because strength did not tend to improve without surgery. There are a few predictors of poor outcome from nonsurgical treatment:
Long duration of symptoms (more than 6-12 months)
Large tears (more than 3 centimeters)
Nonsurgical treatment has both advantages and disadvantages.
Surgical management is indicated for a rotator cuff tear that does not respond to non-operative management and is associated with weakness, loss of function and limited motion. Because there is no evidence of better results in early versus delayed repairs, many surgeons consider a trial of non-operative management to be appropriate1. Tears that are associated with profound weakness, are caused by acute trauma, and/or are very large (greater than 3cm) on initial evaluation may also be considered for early operative repair. Operative treatment of a torn rotator is designed to repair the tendon back to the humeral head (ball of joint) from where it is torn. This can be accomplished in a number of ways. Each of the methods available has its own pros and cons; all have the same goal--getting the tendon to heal to the bone. The choice of surgical technique depends upon several factors including the surgeon's experience and familiarity with a particular procedure, the size of the tear, patient anatomy, quality of the tendon tissue and bone, and the patient's needs. Regardless of the repair method used, studies show similar levels of pain relief, strength improvement, and patient satisfaction.
The three commonly employed surgical techniques for rotator cuff repair are:
An individual surgeon's ability to repair a torn rotator cuff and achieve a satisfactory result varies by technique. Variation is based on experience and familiarity with the technique. While one surgeon may be capable of achieving a quality repair through all-arthroscopic means, another may have better results with mini-open repair. Prior to surgery, patients should discuss the options available to them with their surgeon. The surgeon can share results of using different techniques so that the most appropriate treatment plan can be designed.
Open repair is performed without arthroscopy. The surgeon makes an incision over the shoulder and detaches the deltoid muscle to gain access to and improve visualization of the torn rotator cuff. The surgeon will usually perform an acromioplasty (removal of bone spurs from the undersurface of the acromion) as well. The incision is typically several centimeters long. Open repair was the first technique used to repair a torn rotator cuff; over the years, the introduction of new technology and surgeon experience has led to development of less invasive measures. Although a less invasive procedure may be attractive to many patients, open repair does restore function, reduce pain and is durable in terms of long-term relief of symptoms12, 13.
As the name implies, mini-open repair is a smaller version of the open technique. The incision is typically 3 cm to 5 cm in length. This technique also incorporates an arthroscopy to visualize the tear, assess and treat damage to other structures within the joint (i.e., labrum and remove the spurs under the acromion. Arthroscopic removal of spurs (acromioplasty) avoids the need to detach the deltoid muscle. Once the arthroscopic portion of the procedure is completed, the surgeon proceeds to the mini-open incision to repair the rotator cuff. Mini-open repair can be performed on an outpatient basis. Currently, this is one of the most commonly used methods of treating a torn rotator cuff; results have been equal to the open repair. The mini-open repair has also proven to be durable over the long-term14.
This technique uses multiple small incisions (portals) and arthroscopic technology to visualize and repair the rotator cuff. All-arthroscopic repair is usually an outpatient procedure. The technique is very challenging and the learning curve for surgeons is steep. It appears that the results are comparable to the mini-open and open repairs15.
Below is a picture of a open repair.
After rotator cuff repair, 80 percent to 95 percent of patients achieve a satisfactory result, defined as adequate pain relief, restoration or improvement of function, improvement in range of motion, and patient satisfaction with the procedure. Certain factors decrease the likelihood of a satisfactory result16:
Poor tissue quality
Large or massive tears
Poor compliance with post-operative rehabilitation and restrictions
Patient age (older than 65 years)
Worker's Compensation claims
Surgical techniques for rotator cuff repair have progressed to more minimally invasive procedures. With each advance in technique, surgeons must undergo a learning curve. Initially, some tears were considered too large to be treated with less invasive techniques. As surgeons become more experienced in using the technique, they are better able to treat most tears with less invasive means. The most recent development is the all-arthroscopic technique. As more surgeons gain experience with this technique, more tears will become amenable to an all-arthroscopic repair.
Each step toward less invasive surgery has benefited the patient by:
Each technique has similar results in terms of satisfactory relief of pain, improvement in function and patient satisfaction. Less invasive surgery results in an easier rehabilitation process and less postoperative pain.
Open repair results:
Range of Motion
Hawkins et al.17
Mini-open repair results:
Range of Motion
Levy et al.20
Paulos et al.21
Blevins et al.22
All-arthroscopic repair results:
Range of Motion
The above studies represent on a few of many papers on this topic. A large review of all published material relating to outcomes from rotator cuff repair surgery was presented in 200330. This paper demonstrated:
Results were equal between open, mini-open, and arthroscopic techniques measured by:
SHOULDER INSTABILITY What is traumatic shoulder instability?
Traumatic shoulder instability begins with a first dislocation that injures the supporting ligaments of the shoulder. The glenoid (the socket of the shoulder) is a relatively flat surface that is deepened slightly by the labrum, a cartilage cup that surrounds part of the head of the humerus. The labrum acts as a bumper to keep the humeral head firmly in place in the glenoid. More importantly, the labrum is the attachment point for ligaments stabilizing the shoulder. When the labrum is torn from the glenoid, the support of these ligaments is lost. The development of recurrent instability depends upon the type and amount of damage that is done to the labrum and the supporting ligaments.
The most common dislocation that leads to traumatic instability is in the anterior (forward) and inferior (downward) direction. A fall on an outstretched arm that is forced overhead, a direct blow on the shoulder, or a forced external rotation of the arm are frequent causes of this type of dislocation. Much less common is a posterior (backward) dislocation, which is usually related to a seizure disorder or electrocution, events in which the muscular forces of the shoulder cause the dislocation.
What are the signs and symptoms of a dislocation?
If the shoulder is dislocated, it is usually very apparent:
The shoulder is quite painful.
Motion is severely restricted.
The shoulder appears to hang down and forward, with a large dimple evident under the acromion (in the area of the collar bone).
The humeral head may be visible as a bump on the front of the shoulder, or in the armpit.
To return the dislocated arm to its socket (called a reduction) usually requires a visit to the emergency department, where expert assistance can be found. Some individuals with recurrent dislocations eventually become experienced at reducing the arm themselves.
How is a dislocation and traumatic shoulder instability diagnosed?
As a rule, a sudden dislocation is quite evident. The patient usually holds the arm against the side, since any attempts at motion cause pain. A large crease under the acromion and a bulge in the armpit are clues to the direction of the dislocation. However, when the shoulder spontaneously relocates into its proper position, the diagnosis can be more difficult. Patients may only report the feeling of having the shoulder "slip" before the spontaneous reduction occurred.
A qualified individual usually can relocate the humerus at the site of the injury occurrence. Once the reduction is performed, there is immediate pain relief. Without medications, some patients may be unable to relax the shoulder muscles enough to allow the reduction to take place. Often, these patients must go to the emergency department to get the reduction accomplished.
X-rays are usually taken to confirm the dislocation, its direction, and to check for a related fracture. After the reduction, follow up X-rays will confirm proper positioning and assess any other injuries. X-rays may reveal a "bony Bankart", which is a fracture of the anterior-inferior glenoid (front, lower portion of the glenoid). The presence of this fracture indicates that the labrum and ligaments in the front part of the shoulder are no longer attached to the glenoid.
If X-rays do not reveal such a fracture, an MRI or arthrogram may be ordered. In this diagnostic test, the status of the labrum and ligaments can be assessed. A Bankart lesion (detachment of the anterior-inferior portion of the labrum from the glenoid) is the most common cause of recurrent instability after an injury.
How is a dislocation and traumatic shoulder instability treated?
The initial reduction of a dislocation can be quite difficult. Contractions of the shoulder muscles can trap the humeral head against the glenoid. Gentle traction, and at times, medication may be needed to accomplish the reduction. Once the shoulder is reduced, a sling is used for a few days to protect it, and relieve discomfort. Physical therapy may help the patient regain motion in the joint.
Initial treatment for recurrent instability of the shoulder centers on physical therapy. Strengthening the rotator cuff muscles and periscapular muscles (those around the scapula) gives stability to the joint. The goal of physical therapy is to help the muscles provide stability to the shoulder that the torn ligaments can no longer supply. The therapy for recurrent instability should be carefully designed for each patient since this condition often causes apprehension about certain arm positions or exercise maneuvers. Very often, physical therapy can help regain lost motion, reduce apprehension, and restore shoulder function.
Surgery is usually recommended if recurrent instability cannot be controlled with physical therapy and activity modification. The goal of surgery is to return stability to the shoulder with the least loss of motion. All shoulder procedures designed to stabilize the shoulder involve some loss of motion. The current procedures for anterior shoulder instability attempt to restore the normal anatomy without over tightening the ligaments. In certain instances, such as in young persons who have a higher risk of re-dislocation and in contact athletes who plan on continuing to participate in sports that put their shoulders at risk, surgery may be performed after the first dislocation.
Open Labral Repair
Currently, the preferred procedure for anterior instability is an open labral repair with an anterior capsular shift. This procedure is performed through a two to three inch incision on the front of the shoulder. The torn labrum is repaired and the stretched-out anterior shoulder capsule is imbricated (overlapped) to make it smaller. This procedure is successful approximately 95% of the time in eliminating recurrent dislocations.
Recently, arthroscopic procedures such asBankart repairhave been used to repair the torn labrum and reduce capsular laxity. Arthroscopic techniques are approximately 80% successful. These procedures are performed with visualization through a small fiberoptic scope. Instruments are inserted into the joint through two or three small incisions to repair the labrum. The surgical technique is similar to the one used in an open repair. A loose capsule is more difficult to address arthroscopically. Procedures using thermal energy to shrink the loose capsule have been developed, and are still being evaluated.
What types of complications may occur?
The major complications of anterior stabilization techniques are recurrent instability and/or loss of motion. The rate of recurrent instability depends largely on the technique used for the repair. The loss of motion can be severe, and is a function of over tightening the anterior capsule. In general, the operative shoulder should lose no more than ten degrees of external rotation. Other small risks (less than 1%) include infection, post-operative stiffness, nerve damage, or blood vessel injury.
Patients who have a first dislocation, and do not develop recurrent instability, will often regain full motion from a four to six week course of physical therapy.
Patients who do develop recurrent instability have a longer rehabilitation course and should concentrate on strengthening the shoulder muscles. Daily exercises in a home program may be recommended to help prevent instability events.
Following either arthroscopic or open operative repair and stabilization:
The patient will usually wear a sling for the first four to six weeks. This immobilization protects the repaired labrum while it heals to the glenoid. Until the ligaments heal, the repair must depend on the sutures used to secure the labrum.
During this immobilization period, elbow and wrist motion are maintained with gentle range of motion exercises.
Once the initial healing process is complete, physical therapy may begin. Exercises stressing range of motion are done for approximately eight weeks after surgery, or until full strength is regained.
Overhead sports, such as baseball or tennis, may resume about three months after surgery.
Thoracic outlet syndrome is actually a collection of syndromes brought about by abnormal compression of the neurovascular bundle by bony, ligamentous or muscular obstacles between the cervical spine and the lower border of the axilla.