Rotator cuff injury is the most common cause of shoulder pain with age and affects a large portion of the population. Rotator cuff pathology primarily affects the tendons of the shoulder, although in advanced cases the articular cartilage may be secondarily affected, known as “cuff arthropathy”.
What are the causes of rotator cuff injuries?
The spectrum of pathology affecting the shoulder tendons ranges from mild tendinosis or degeneration to much more severe complete tears and retractions. The main cause of tendon deterioration is age-related degeneration, which is usually aggravated by repetitive activities such as those related to physical labor or intense sports activities.
However, shoulder tendon ruptures – for the most part – do not have a traumatic or definite onset in time, but rather the tendon ruptures gradually, little by little, even over years, so that the patient is not aware of when it ruptured, only when the shoulder started to hurt.
The following factors can increase the risk of a rotator cuff injury:
- Age. As you get older, your risk of rotator cuff injury increases. Rotator cuff tears are more common in people over the age of 40.
- Some sports. Athletes who regularly perform repetitive arm motions, such as baseball pitchers or tennis players, are at increased risk for rotator cuff injury.
- Construction work. Some trades, that of a painter or carpenter, require repetitive arm movements that can damage the rotator cuff over time.
- Family history of rotator cuff injury.
- Genetic factors or chronic diseases such as diabetes, rheumatic diseases, cancer treatments, high cholesterol and tobacco use.
Although not all tears are the same, most rotator cuff injuries begin in a specific location. Specifically, they occur one centimeter behind the anterior part of the supraspinatus tendon, and from there they gradually progress and enlarge, creating a kind of hole, albeit very slowly.
It is estimated that half of the ruptures progress in an identifiable manner in the following two years, the largest ones being those with the greatest risk of progression.
On the contrary, there is a lower group of patients who suffer a traumatic tear related to a definite injury, either due to a fall -usually with the arm in separation- or due to an eccentric contraction, after which they notice difficulty in raising the arm.
What is the incidence of rotator cuff injuries?
Although it sounds surprising, a rotator cuff tear is much more common than one might think. In fact, among the general population, it is estimated that 15-20% of people over the age of 60 have complete tears of some tendon of the rotator cuff, usually the supraspinatus.
The incidence of rotator cuff injuries increases with age, so that over the age of 80 years half of the people have ruptured at least one of the tendons of the shoulder, even without noticing symptoms.
By the time a patient over 65 years of age feels pain in the shoulder and is shown to have a rotator cuff tear, in 50% of the cases he or she will have a similar injury in the opposite shoulder, despite having no symptoms.
Symptoms of rotator cuff injury
The pain produced by a rotator cuff injury can:
- Be described as a dull ache in the deeper area of the shoulder.
- Disrupt sleep, especially if the patient sleeps on the affected shoulder.
- Make it difficult to touch the back or comb the hair.
- Be accompanied by weakness in the arm.
In other more advanced phases, the pain can appear even if the patient does not move the shoulder, being also very common the nocturnal pain, which can be only postural or more intense, making impossible the conciliation of the sleep. In other cases, apart from pain, patients report loss of mobility associated with pain and in cases of large tears, loss of strength.
As such, there is no correlation between the intensity of the pain and the severity of the tear, since it is common to see patients with very small non-retracted tears who present a lot of pain and functional limitation, as opposed to others with larger tears who maintain good functionality in the arm.
The most serious situation that can be reached in these cases is a pseudoparalytic shoulder, in which the patient cannot raise the arm, although few patients reach this situation, since most of the ruptures are compensated with the function of the rest of the tendons.
With what tests is a rotator cuff injury diagnosed?
If the pain in the shoulder is due to a fall and is accompanied by a loss of strength, it is recommended that not much time passes before a medical consultation, since fractures or dislocations can be ruled out, and if bone involvement can be ruled out by means of radiographs, it is then when a rotator cuff injury can be suspected.
Occasionally, a physical examination already highlights the loss of strength suggesting the presence of a tendon rupture, although if there are doubts, diagnostic tests such as ultrasound or magnetic resonance imaging are recommended. Most acute traumatic ruptures should be repaired with surgical treatment.
However, it is more common for patients to come for consultation because they feel progressive pain without a clear trigger. In this case, a systematic evaluation of the patient’s personal and medical history, an approximate onset, the time of evaluation, things that relieve or aggravate the discomfort… In the exploration, the physician will locate the pain, the range, the movement pattern or strength, among others; and from here he will answer the question of whether the pain really comes from the shoulder and the degree of functional affectation.
Once the examination has been performed, the relevant diagnostic tests are requested to confirm the diagnostic suspicion, with ultrasound and MRI being the tests used.
In the case of the resonance, they provide more complete information, not only on the tendons, but also on the possible atrophy of the musculature, the state of the cartilage… It is usual that an X-ray is also requested, which provides complementary information.
Once other causes of shoulder pain have been ruled out, the possible tendon involvement will be evaluated. The spectrum in this field ranges from tendinosis to complete or partial ruptures, which may involve more than one tendon.
How are rotator cuff injuries treated?
Initially, the initial treatment of rotator cuff injuries does not require surgery, and may include any of the following options:
- Rest avoiding overhead movements.
- Physiotherapy to strengthen the musculature.
- Anti-inflammatory medications to control pain.
- Infiltrations of cortioids or PRP.
When non-surgical treatments are unsuccessful, there are several surgical options to repair rotator cuff tears.
The main treatment is arthroscopy, which consists of suturing the ruptured tendon or tendons and bringing them back to their usual area, which has been previously prepared. Surgery is most often performed arthroscopically, through four or five small incisions, although sometimes open surgery may be required.
To repair the damaged tendons, a series of anchors that remain in the bone and that do not cause discomfort are usually used. In addition to repairing the ruptured tendons, other things are done in surgery to improve the symptomatology, such as removing the bursa or acting on the biceps tendon, which may be deteriorated and can be a source of pain. It may be necessary to simply cut it, which eliminates the pain without impairing the function of the arm, or to perform a tenodesis, that is to say, to cut it and fix it lower down.
On other occasions, older patients also present with acromioclavicular osteoarthritis, which may require resection of the distal end of the clavicle. Whatever the case, these secondary interventions are performed at the same operation if necessary.
What should I do after rotator cuff surgery?
It is essential that the patient adequately follow all postoperative indications that the surgeon has prescribed, thus helping the recovery and avoiding possible complications.
- One day of hospitalization.
- Several weeks with analgesic treatments.
- Six weeks with passive exercises.
- Ten to twelve weeks with assisted movements.
- Around three months of strengthening exercises of the area.
- About three to four months after the operation, the patient will feel much better than before the operation.
- By one year after surgery, the patient will have regained strength, although this may not be complete.
For more information, consult a specialist in Traumatology and Orthopedic Surgery.