Rotator Cuff Conditions & Injuries

Introduction

The shoulder is a ball and socket joint comprising the humeral head (ball) and glenoid (socket). The rotator cuff is a group of muscles and tendons around the shoulder joint that helps keep the humeral head within the shallow socket of the glenoid. There are 4 actual muscles and tendons that make up the rotator cuff, and each moves the shoulder in its own unique way. 
Rotator cuff tears are common with increasing age, and most happen during repeated overhead movements. Progressive wear and tear of the tissue over time, as well as the reduced water content of these tendons with age, contribute to the injury. Certain overhead sports and jobs further increase the risk of rotator cuff injuries.
Patients often experience pain during daily shoulder movements such as dressing, carrying something and sleeping on their side. 

The 4 muscles and tendons that make up the rotator cuff are the subscapularis, supraspinatus, infraspinatus and teres minor.

Clinical examination and investigations

Your orthopaedic surgeon will first take a history of your shoulder pain. This includes details such as the duration of pain, what makes it better or worse and what sorts of treatments you’ve had for the pain and stiffness. 
Some may also have associated neck pain that accompanies the shoulder symptoms. 
A clinical examination will be performed to assess your general range of motion of both your shoulders and strength of movements, as well as specific impingement tests to ascertain where exactly the pain is coming from. 
An MRI scan is usually organised to assess the soft tissue envelope around the shoulder. MRI scans are safe even for pregnant ladies and give detailed information about the state of the muscles, tendons and ligaments around the shoulder. For medical facilities without MRI machines, an ultrasound scan may also be done to assess for rotator cuff injuries. 

MRI investigation for rotator cuff injuries

• Tendinosis describes a degeneration of the tendon due to chronic overuse. There is no actual tendon tear, but the tendon is unhealthy from repetitive strain injury.
• Tendonitis is described as a swollen and inflamed tendon. Patients may experience pain, swelling and discomfort from rotator cuff tendonitis. Similar to tendinosis, there is no actual tear of the tendon.

Tear of the supraspinatus is the most common rotator cuff tear. 

Treatment options

• Conservative treatments include rest, ice and physical therapy. Patients are also advised to avoid movements, sports or activities that worsen the shoulder symptoms. Anti-inflammatory medications may also be taken to help reduce pain and swelling in the shoulder. 
• Physical and physiotherapy are important modalities for maintaining the general range of motion of the shoulder without worsening the injury. They also help strengthen the surrounding muscles to support the shoulder's function better. 
• Injections may also be given around the shoulder and into the shoulder joint in selected patients, such as those with rotator cuff tendinosis or swelling without a tear. This helps to reduce pain and inflammation, as well as facilitate a better range of motion during physiotherapy. These injections commonly contain a local anaesthetic and a small dose of steroids. In patients with tears of their rotator cuff who may require surgery, steroid injections are not given as they may weaken the tendon and undermine the success of surgery. 

Surgery for rotator cuff tears

Patients experiencing significant painful symptoms from rotator cuff tears despite rest, medication and physiotherapy may benefit from surgery. These key-hole surgical techniques aim to reattach the tendon back to the bone.
Patients are usually under general anaesthesia for the procedure. The orthopaedic surgeon makes about 2 or 3 small skin incisions on the back, front and occasionally side of the shoulder to gain access. Using an arthroscope, the surgeon is able to have a good view of the shoulder joint and document any injuries to the shoulder cartilage, labrum, tendons and muscles that hold the shoulder together. Intra-operative photos are taken, and these are shared with the patient after surgery so that they may better understand their condition. 
  Anchor sutures are a type of implant used to repair tendons to bones. A small hole is made with a drill, and the anchor is inserted into the hole. Several strands of sutures attached to the anchor are then passed through the torn tendon and tied together. The tendon is then allowed to heal over the following months.

Anchor sutures are used to repair rotator cuff tears back to the proximal humerus. 

 Immediate Post-operative care

The operated shoulder is usually kept in an arm sling for a few weeks. This is to protect the repair and allow it to heal.

Patients are usually kept in the hospital overnight and are discharged the following morning. While in the hospital, they are given some antibiotics to prevent any infection as well as medication for pain. 

A simple arm sling is used to allow the repair to heal before greater range of motion exercises are started. 

Timeline for Shoulder Recovery

During the first few weeks, patients are encouraged to do minor shoulder pendular movements to prevent frozen shoulder. They are not allowed to do overhead movements too early as this may compromise the repair before it has had enough time to heal.

Once the orthopaedic surgeon is satisfied that the tendon repair site has healed, he will allow the physiotherapist to do a greater range of motion as well as strengthening exercises for your shoulder. Your relationship with the physiotherapist is important as they will facilitate your timely return to function and sports. 
Physiotherapy aims to achieve a certain range of motion, strength and function at different milestones during your recovery. Every patient is different and each rehabilitation program will be tailored to your needs. 

Common Challenges and How to Manage Them

It is important to take anti-inflammatory medications during the initial recovery phase. This helps with pain and reduces swelling. The icing of the shoulder is also essential to reduce swelling. 
While surgery only takes 2 hours, the rehabilitation may take three or more months. It is, therefore, very important to stay motivated through the recovery process. Your surgeon and physiotherapist are there to help you along the way. 
Patients are encouraged to participate in different rehab techniques to help with recovery. This includes physiotherapy, going to the gym and even swimming. Daily stretching helps break up any adhesions or scar tissue in the shoulder, and this improves flexibility. 

Physiotherapy is crucial to any shoulder injury, whether or not the patient requires surgery.

Returning to Daily Activities and Sports

Each patient will have different goals for rehabilitation. Some may want to return to high-level racket sports, while others may be satisfied just being able to put on a t-shirt. Whatever your goals are, it is important that you discuss this with your physiotherapist so that your rehab activities are tailored to your needs. For those returning to sports, the physiotherapist will also make formal assessments of your shoulder to determine if you are fit to return to your sport. This is also to prevent an early repeat injury of your shoulder. 

Conclusion

If shoulder pain is affecting your daily life, it is advised that you seek professional medical care to determine the cause of your symptoms. Rotator cuff injuries are common and may not be the only shoulder injuries we commonly see. An MRI Scan will be able to determine the cause of the pain, and there are many techniques to deal with it. Surgery is always the last resort, and most patients have good outcomes after surgery.