Rotator Cuff Injuries
What is the rotator cuff?
The rotator cuff is made up of four muscles. Each muscle has a tendon that combine together to form one common tendon that is called the rotator cuff. The rotator cuff muscles originate from the shoulder blade (scapula) and the rotator cuff tendon inserts onto the top of the arm bone (humerus). The rotator cuff has many functions including elevating the arm, rotating the arm and providing stability to the shoulder joint. The shoulder joint moves more than any other joint in the body and the rotator cuff tendon is an active muscle through a wide range of motion.
How do you injure the rotator cuff?
The rotator cuff can become injured in many ways. The most common source of injury is repetitive damage due to aging and overuse. Often times, the tendon is inflamed from repetitive injury which can lead to rotator cuff tendonitis. If further injury occurs, the normal collagen fibers of the tendon become compromised and gradually these fibers can begin to tear. As multiple fibers begin to fail, the tendon can eventually develop a complete tear over time. This type of tear is described as a chronic rotator cuff tear. In addition to overuse injuries, traumatic injuries like a fall on an outstretched arm or a sudden pull on the arm can result in a rotator cuff tear. These types of sudden injuries are described as an acute rotator cuff tear. Typical symptoms of a rotator cuff injury include weakness, pain in the outside of the arm, night pan and decreased overhead range of motion.
Rotator cuff tears can involve any of the four rotator cuff muscles and often vary in size and severity. Tears are graded based on the dimensions of the tear as small (<1cm), medium (between 1 and 2 cm), large (between 2 and 3 cm) and massive (>3cm). As important as the size and location of the tear is the status of the rotator cuff muscle. Often with chronic rotator cuff tears, the muscle will undergo atrophy (loss of muscle volume) and fatty infiltration (muscle will be replaced by fat). If your doctor suspects a rotator cuff tear, they may order an MRI scan of your shoulder to visualize the tendon and the rotator cuff muscle.
How are rotator cuff injuries treated?
Treatment for rotator cuff injuries depends on many factors including the extent of injury to the tendon. For rotator cuff tendonitis or small and partial rotator cuff tears, many times physical therapy and anti-inflammatory medications will alleviate the symptoms. For more advanced inflammation or significant repetitive injury, your physician may recommend a cortisone injection. An injection should provide you with relief of your symptoms and allow you to perform the physical therapy more easily.
If conservative management is unable to restore your shoulder to full health or if you have a significant rotator cuff tear, your doctor may recommend surgical treatment. Depending on the extent of damage, your injury may be able to be treated using a minimally invasive technique called shoulder arthroscopy. With shoulder arthroscopy, a small camera is used to enter the joint along with small instruments to repair damaged structures in your shoulder. In some more advanced cases of rotator cuff damage with arthritis, shoulder replacement can be an option to improve pain and improve range of motion.
What is shoulder instability?
The shoulder joint is a ball and socket joint. The ball portion of the joint is called the humeral head and the socket is called the glenoid and together they are referred to as the glenohumeral joint. The glenohumeral joint is a large ball on a small socket similar to a golf ball on a golf tee. The anatomy of the shoulder allows it to have more motion than any other joint in the body. With this freedom of motion comes the risk of instability of the joint. Fortunately, we have ligaments in the shoulder that help to stabilize the joint. In addition to the ligaments, the socket is further stabilized by a rim of fibrous tissue called the labrum. The labrum deepens the glenoid socket and provides an insertion point for the ligaments that stabilize the joint.
Occasionally, when the joint is moved beyond where the ligaments, labrum and bony structures can allow, the humeral head can move completely out of the socket which is known as a dislocation. Also, the humeral head can move slightly out of its normal alignment without a complete dislocation which is referred to as a subluxation of the joint. When a normal shoulder dislocates or has a significant subluxation, often times the ligament and labrum are damaged. The shoulder can be unstable towards the front (anterior) or back (posterior) aspect of the joint. Depending on the direction of instability, corresponding structures will be injured.
In some individuals, the shoulder joint is inherently loose and the joint can have multiple episodes of instability without any ligament or joint damage. This type of instability is known as multi-directional instability and is more commonly seen in teenage girls. How does the shoulder become unstable?
The shoulder can become dislocated from a traumatic event and the direction of instability depends on the position of the arm at the time of injury. Specifically, when the arm is forced upward and excessively rotated outward, the shoulder joint typically becomes unstable anteriorly. Conversely, when the arm is internally rotated and forced backwards the shoulder becomes unstable posteriorly. An example of an anterior dislocation is when a basketball player goes for a rebound and his arm is forced upward and rotated outward. An example of a posterior dislocation is a football lineman that holds their arm internally rotated and is hit by an oncoming player causing the shoulder to move backwards. How is shoulder instability treated?
Shoulder instability can be a very disabling problem causing pain and inability to participate in sports. Treatment will depend on the type of injury, age, type of sport, and degree of instability. Minor subluxations and multidirectional instability are often treated with physical therapy and bracing for return to contact sports. If a significant injury is diagnosed and your examination shows significant laxity with a history of recurrent dislocations, surgery may be recommended. Surgery can be performed using arthroscopic techniques to repair injured structures in the shoulder. In cases with significant bone loss or recurrent dislocations after previous surgery, open reconstructive procedures may be recommended.
What is biceps tendonitis?
The biceps is a muscle in the front of the arm that functions mostly to turn your forearm palm up (supination) and it also aids in flexing the elbow joint. The biceps has a single attachment at the elbow, however, it has two attachments in the shoulder region. The two separate attachments of the biceps are the short and long head of the biceps. The long head of the biceps tendon originates from within the shoulder joint as it attaches directly to the top of the socket (glenoid). It is unclear as to the exact function of the long head of the biceps tendon, but it is believed that it helps to stabilize the shoulder joint especially with high velocity rotation of the arm as is seen in throwers. The short head of the biceps originates outside of the shoulder joint on a bone called the coracoid and it is not a commonly injured tendon. The long head of the biceps is more commonly injured as it is a cord like tendon that exits the shoulder joint at an acute angle and then enters the biceps groove where it can become damaged and inflamed. The repetitive strain on the tendon can cause damage to the tendon resulting in tendon fraying, subluxation (moved out of place), or even complete rupture.
How does biceps tendonitis occur?
Biceps tendonitis is most commonly seen in association with other problems around the shoulder especially injury to the rotator cuff tendon (see Rotator Cuff Injuries). As the rotator cuff becomes inflamed the biceps tendon also becomes irritated and inflamed. Common activities that cause biceps tendonitis include overhead throwing, repetitive lifting, and racket sports. Typical symptoms include pain in the front of the shoulder and difficulty lifting the arm directly in front of the body.
How is biceps tendonitis treated?
Most often biceps tendonitis is treated with a course of rest, anti-inflammatories, stretching exercises and physical therapy. If the biceps tendon remains inflamed, sometimes a cortisone injection will be placed directly into the biceps groove to alleviate the inflammation. In more advanced cases or when the tendon has moved out of the groove or torn, surgery maybe indicated. Surgery for the biceps tendon usually involves an arthroscopic assisted procedure to release the damaged long head of the biceps tendon (biceps tenotomy) and sometimes performing a reattachment of the tendon to the arm outside of the shoulder joint (biceps tenodesis).
What is lateral epicondylitis?
The lateral epicondyle it the bony prominence on the outside (lateral) aspect of the elbow. The lateral epicondyle serves as the origin for the muscles of the forearm that extend the wrist and fingers. These muscles attach to the lateral epicondyle through a common extensor tendon. Specific portions of the common extensor tendon become damaged over time and result in microscopic tears in the tendon. Due to poor blood supply to the injured tendon the process of healing these small tears is not complete and can result in progressive injury over time as more fibers become injured with overuse.
How do you get lateral epicondylitis?
Lateral epicondylitis is usually caused by repetitive lifting with the elbow extended. Injury can also occur by sudden increased stress to the extensor muscles of the forearm. Many racket sports including tennis have been linked to lateral epicondylitis and that is why lateral epicondylitis is commonly referred to as “tennis elbow.” Any activities requiring repetitive use of the muscles that extend the wrist can cause or exacerbate lateral epicondylitis. Typical symptoms of lateral epicondylitis include pain and tenderness over the outside of the elbow. Patients will often complain of difficulty lifting a gallon of milk or lifting groceries out of the car trunk due to lateral elbow pain.
How is lateral epicondylitis treated?
Lateral epicondylitis is initially treated with activity modification. This may include complete rest, but often requires altering the activity causing the problem to avoid injury. In the case of tennis, racket size and grip may need to be changed to fit the player better or a swing change can be used to avoid the pain (i.e. changing form a one handed to a two-handed back hand). Often times the workspace can be modified to accommodate the limitations (i.e. adjusting keyboard and chair height to avoid typing with the wrist in an extended position). If simple modifications are not helping, a home stretching program is prescribed along with a forearm strap to improve the tendon flexibility and ease tension on the tendon. In addition, anti-inflammatories and formal physical therapy are used to decrease any inflammation around the elbow and improve strength of the tendon. Finally, on occasion a cortisone injection can be used to treat pain associated with lateral epicondylitis. Cortisone injections do not, however, cause the tendon to heal or usually eliminate the problem all together.
Although the vast majority of patients will improve without any further intervention, several options have been described to treat persistent lateral epicondylitis. These interventions include percutaneous release, ultrasound guided debridement, open release/repair, and arthroscopic release of the damaged tendon. Many factors determine the best option for each patient and your doctor can discuss what the best option is for you.