I see many patients every week with shoulder pain. The diagnosis of the cause of your shoulder pain and determining what the actual pain generator is in shoulder is not always straight forward. The most common causes of shoulder pain will vary with age, your activities and whether or not you have suffered any trauma. Rotator cuff injuries are only one of the many sources of pain in the shoulder.
Shoulder Pain by Age
“Young” Adults and “weekend warriors” tend to have shoulder pain due to rotator cuff injuries or rotator cuff changes (tendinosis). Tendinosis and other degenerative changes within the rotator cuff occur as a result of genetics, activities, and aging. In this age group rotator cuff injuries may also occur as a result of trauma or injuries, but degeneration is the most common cause we see in our office.
Seniors tend to have shoulder pain due to arthritis, loss of cartilage, and small, medium or even very large chronic (old) rotator cuff tears from a lifetime of wear and tear. Sometimes the torn rotator cuff tendon will upset the tissues around the tendon and cause a bursitis. This secondary bursitis is the most common cause of pain and discomfort.
In adults, the most common source of shoulder pain are injuries of the rotator cuff … a series of 4 small muscles that coordinate the motion of the shoulder. This post on “what is the rotator cuff will clear many questions about its structure and function. This video on shoulder anatomy may assist you as well. BUT… not all rotator cuff pain is because of a rotator cuff tear. Confused? Most patients, once they hear the words rotator cuff automatically assume the worst… that their rotator cuff is torn. This is usually not the case. The most common cause of shoulder pain is actually rotator cuff tendinosis, or (age related, activity related, genetic or post-traumatic) degeneration of the tendon — I suggest you check out the description herehttp://goo.gl/Ngzd .
If your examination reveals certain characteristic findings we may order an imaging study. That can be an Ultrasound or an MRI.
What if my MRI shows a rotator cuff tear?
Do all rotator tears require surgery?
No. Do some tears *require* surgery? Yes… Which ones, why and when?
Let’s go to the video tape
Good morning I am Howard Luks, this is your orthopedic minute. So today we are going to talk about the rotator cuff, that’s right cuff, CUFF. A lot of people say rotator cup, that’s not entirely accurate. We call it a (rotator) cuff because there are four muscles that sort of come together as they approach the outside of your shoulder and become one and that cuff then it inserts on the top of your shoulder bone. So it completely encapsulates the shoulder in muscle and tendon. Collectively all four muscles are known as the rotator cuff muscles but yet there are four individual muscles. Now they can be injured in many different ways. Usually its just life long list of activities as opposed to one traumatic event. Most rotator cuff issues are simply related to the fact that our tissues wear out, with age— things change, its natural. Sometimes you fall from a bike or fall down or get into a car accident and the tissue can rip or tear acutely. But the majority of injuries are based on your genetics and just based on your activities and the majority of symptoms even if you have a small tear of simply going to get better with rest activity modification and occasionally a course of physical therapy. Initially, there is no rush to get an MRI of your rotator cuff injury unless there is significant weakness and or persistent dislocations. Talk to your orthopedic surgeon, take it slow and good luck, bye.
Rotator Cuff Tears
Let’s talk about rotator cuff tears (injuries). A lot of people say rotator cup tears— but it’s actually rotator cuff (C-U-F-F) tears.
What is the rotator cuff?
The rotator cuff are four small muscles located around your shoulder and they link together to form a cuff that literally sits on top of the top of your humerus. It’s beneath your deltoid so you can’t actually see or feel the rotator cuff. The purpose of the rotator cuff is to take all the energy or strength derived from the larger muscles such as the deltoid or latissimus or your pec major or your chest muscles and turn it into meaningful motion or rotational motion so you can move the arm out, move the arm up, any way you want to place it in space.
What causes rotator cuff tears?
With time, sometimes with usual activities, sometimes with trauma, our tissues wear out, degenerate or tear. The vast majority of rotator cuff tears that we see in the office are attributed to attrition. Your tissues just wore out. Think of your favorite pair of blue jeans that you’ve had since high school if you could still fit in them that — think about the knees on the front of your jeans that that denim just wore out one day. You felt a breeze and looked down and there was a hole there. A portion of your rotator cuff tissue is not very different than that. It goes through a process of degeneration or something we call tendinosis which you can look up on my website. Tendinosis can progress from degeneration to fraying of the surface to a partial tear to a full-thickness tear where a portion of the tendon has detached from the bone.
Traumatic rotator cuff tears versus degenerative rotator cuff tears
There are also situations where you have a normal rotator cuff or a cuff with slight degeneration. You go outside. You play sports. You get tackled and knocked down or you slipped on the ice and fall on that shoulder or as you’re falling you reach for something to hold onto it and you yank your shoulder. Those situations can cause acute traumatic ruptures of the rotator cuff. Is there a difference between attritional and traumatic rotator cuff tears? Absolutely.
Most of us, and I mean academic physicians, believe that attritional rotator cuff tears can be managed in the majority of situations – non-operatively (without surgery). That means with physical therapy or doing nothing if doesn’t bother you too much, occasional injections, etc. If those non-operative modalities are unsuccessful in alleviating your pain AND you have significant pain with use or severe pain at night when you’re trying to sleep, then surgery is an option. But it is YOUR decision. Some tears will grow in size with time. So even if your tear feels better after therapy, you should see your surgeon every 4-6 months for a follow-up to see if the tear has become larger.
Acute or traumatic rotator cuff tears are a different story. Those should generally be repaired. (Again, not all acute tears need surgery and once again, my disclaimer applies and this is not medical advice. You should talk to your orthopedist.) But if you slip and fall and tear your rotator cuff, the likelihood of it being a large tear is fairly high. Those rotator cuff tears have a very good chance of healing after surgery. Should acute rotator cuff tears be fixed sooner rather than later? Yes.
Can I delay my rotator cuff surgery?
Yes, assuming you understand the implications of that decision. A few issues to consider.
(1) Retraction. The rotator cuff is like a loaded rubber band, all right? Imagine a rubber band between my two fingers. I release it on one end. What’s gonna happen? It’s gonna shoot over towards the other finger. The muscle is no different. If the rotator cuff retracts or pulls far enough away from the bone, it will make the repair difficult and the likelihood of a successful repair when all is said and done much lower.
The other issue with waiting: Fatty atrophy. Atrophy is simply put — picture a leg that goes into a cast. You take the cast off in four weeks and that leg has shrunk. What has happened? The muscles have atrophied or become smaller. What happens with rotator cuff muscles that are no longer attached to the bone? The body changes the muscle to fat. It’s very cruel because if you re-establish continuity of the tendon, it doesn’t turn the fat back into muscle. So if you wait on a large, retracted, acute rotator cuff tear and that tissue turns to fat, then it doesn’t matter if you get it fixed later, because you’re fixing a piece of fat and it no longer functions as a muscle.
Night Pain and Rotator Cuff Tears
Most patients with rotator cuff tears simply have pain. A few may have weakness and loss of motion as well. Rotator cuff pain can be activity related — such as trying to reach overhead: trying to wash your hair; for women, trying to put on a bra; for men, trying to put on a belt, or even trying to reach back and pull something out of the backseat of your car.
What brings the majority of patients into an office for small rotator cuff tears? Night pain. You can’t get comfortable at night or you’re waking up at night. Larger rotator cuff tears that encompass at least one or two complete tendons — will complain of weakness. They simply can’t lift the arm up or if they do, they can’t lift it far.
It will take an examination by an orthopedist and perhaps an ultrasound or an MRI to determine the actual size of the tear. X-rays may be useful to reveal changes that we can see in the bone that are secondary to rotator cuff disease as well.
So, bottom line take-home message:
Do all rotator cuff tears need to be “fixed”?
The answer is no. You can go much slower on the small attritional rotator cuff tears where the tissue simply wore out and try a course of therapy, injections, etc., However, we need to consider being much more aggressive with large acute traumatic tears after a significant incident or traumatic event.
We would love to see you if you have any lingering questions about your rotator cuff or shoulder injury:
Any questions? Please feel free to post them in the comments.
Remember, this for informational purposes and is not medical advice. Evidence changes frequently which make some of these comments out-dates in the future and since it is a transcription I will not change them.