Leesa M. Galatz, MD
Professor and System Chair
Leni and Peter W. May Department of Orthopaedic Surgery
Icahn School of Medicine at Mount Sinai
Chair of Orthopaedic Surgery
Mount Sinai Health System
Got Shoulder Pain? Rotator Cuff Injuries 101
When an elite athlete like basketball legend Kobe Bryant or tennis icon Maria Sharapova suffers a rotator cuff injury, we all hear about it. But as my patients and I can vouch, sports stars aren't the only ones who deal with this common cause of shoulder pain. According to the American Academy of Orthopaedic Surgeons, nearly two million people saw their doctors for rotator cuff problems in 2008.
What is the Rotator Cuff?
The rotator cuff is a group of four small muscles and tendons that connect the shoulder blade to the top of the shoulder and head of the upper arm bone -- the ball part of the ball-and-socket shoulder joint. The rotator cuff gives the shoulder strength and stability while keeping the ball centered on its socket.
How it Gets Injured
The tendons of the rotator cuff are susceptible to age-related "wear and tear" that may result in their thinning and tearing. Traumatic injury, such as from a car accident or fall, can cause the rotator cuff to tear. It is also prone to overuse, as we use it whenever reaching overhead or outstretching our arm; that's why athletes like baseball players, swimmers, and tennis players are at greater risk for overuse injuries, including tendinitis (inflammation of a tendon) and tears. Painters, electricians, and others who frequently work with their arms in an overhead position are vulnerable, as well.
Even people with sedentary jobs can have rotator cuff pain. For example, merely sitting with poor posture at your desk with your arms outstretched typing for extended periods may cause tendinitis.
Symptoms
The primary symptom of rotator cuff injuries is pain along the side of the shoulder or upper arm (pain rarely travels below the elbow). It can interfere with everyday activities, such as reaching up to a high shelf, pulling on a coat, or lifting heavy objects. Soreness may be more noticeable when you are trying to sleep, especially when lying on the injured side.
Resting and icing the shoulder may help relieve pain, as may anti-inflammatory medications, such as ibuprofen, naproxen, or aspirin. I discourage patients from taking narcotic medication, except after surgery.
Initial Treatment
Rotator cuff injuries are diagnosed through a physical examination and ultrasound or MRI imaging study. Initial treatment options include physical therapy and other non-surgical measures.
Physical therapy. The first treatment step is physical therapy, including a directed and supervised program of shoulder-friendly exercises to strengthen and condition the muscles. The goal is to get them working as efficiently as possible to reduce the risk of shoulder pain. For people with desk jobs, postural training and adjusting the workspace to promote ergonomic positioning are also important.
Cortisone shots. If the pain continues and is so bad it disrupts your sleep, the next step is often an injection of cortisone and numbing medication into the shoulder joint to reduce inflammation and break the cycle of pain. The duration of relief varies, from several weeks to long-term.
Platelet-rich plasma injections. This new treatment, which employs the cells of a patient's own blood to stimulate healing, is gaining popularity, particularly among professional athletes. However, while it may be of some benefit and probably won't hurt you, there is insufficient scientific evidence to support its routine use.
Debridement. Most people with tendinitis but no tear will get better without surgery. On the rare occasions they don't, debridement--a minimally invasive procedure to remove damaged tissue from the shoulder joint--often helps.
Surgical Repair of Rotator Cuff Tears
For those with tears, surgery to repair the rotator cuff usually produces very good results. Whether surgery is recommended depends on various factors, including a patient's age, severity of pain, and response to non-operative treatment.
Some complex cases may require open surgery, but most rotator cuff tears are repaired using a minimally invasive surgical approach called arthroscopy. In this outpatient procedure, an arthroscope (thin tube with tiny camera attached) and miniature instruments are inserted through small incisions into the shoulder joint, where the surgeon reattaches tendon to bone with screw-like anchors and sutures.
A technique called interscalene block is often used to manage pain both during and after surgery. Prior to surgery, numbing medication is delivered through a catheter to the group of nerves that control movement and sensation in the upper extremities, allowing for lighter anesthesia during the operation. Continued for a couple days after surgery, it also helps patients through the worst cycle of post-surgical pain, decreasing or eliminating the need for narcotic painkillers.
The recovery time is substantial, with patients wearing a sling for four to six weeks followed by several months of physical therapy.
Prevention
Maintaining good posture and exercising regularly are things everyone can do to guard against rotator cuff problems. To avoid overuse injuries, people who frequently engage in overhead activities may benefit from a directed exercise program to keep the rotator cuff as strong as possible. And, if you work at a desk, improving your posture and maintaining an ergonomic workspace are essential prevention measures (the U.S. Department of Labor website offers many useful tips on this topic). As the adage goes, "an ounce of prevention is worth a pound of cure."