Rotator Cuff Syndrome

What is Rotator Cuff Syndrome?

The rotator cuff is a group of muscle and tendon tissues including the supraspinatus (SS), infraspinatus (IS), teres minor (TM), and subscapularis (SubSc), which exist around the shoulder joint (see Image. Shoulder Joint Anatomy). The term “Rotator cuff syndrome” covers a range of issues related with injuries or ageing conditions affecting the rotator cuff. Some well-known conditions include subacromial impingement syndrome (where tendons are trapped and compressed during shoulder movements), bursitis (inflammation of a small fluid-filled sac in the shoulder), rotator cuff tendonitis (swelling of the shoulder tendons), and either partial or complete rotator cuff tears.

Chronic rotator cuff syndrome, or long-lasting rotator cuff problems, can increase the chances of developing glenohumeral degenerative disease, which is essentially wear-and-tear damage to the shoulder joint, and rotator cuff arthropathy, a severe shoulder condition that occurs when there is both a rotator cuff tear and wear-and-tear damage in the shoulder joint. As we age, rotator cuff syndrome becomes increasingly common. It has also been linked with metabolic syndrome, a cluster of conditions such as diabetes, inflammatory arthritis (joint inflammation), and thyroid disease (issues with the thyroid gland, which sits in the neck).

What Causes Rotator Cuff Syndrome?

The relationship between shoulder impingement syndrome and rotator cuff disease can be quite complex, and there’s ongoing debate about it. To fully grasp these conditions, it’s important to first understand the medical terms used and the symptoms they refer to.

‘Rotator cuff tendonitis/tendinosis’ describes conditions where there is damage to the rotator cuff, which can happen due to repeated stress or anatomical risk factors. This repeated stress can lead to weak spots in the rotator cuff, which eventually evolve into different types of injuries.

‘Shoulder impingement’ is often used to describe patients who experience pain or discomfort when raising their arms above their heads.

‘Internal impingement’ is common among athletes who regularly throw objects overhead, like baseball pitchers, and is caused by the rotator cuff hitting against the edge of the shoulder blade when the arm is fully raised and rotated. It results in changes to the athlete’s shoulder, including increased rotation and tightness in the back of the shoulder. These changes can lead to reduced shoulder rotation, predisposing the shoulder to internal impingement.

‘External impingement’ or ‘subacromial impingement syndrome’ involves external compression sources, such as the acromion (part of the shoulder blade), which can cause inflammation and injuries to the rotator cuff.

Over the years, there have been a number of theories about what causes these rotator cuff issues. Historically, most theories revolved around the idea of external pressure damaging the rotator cuff. More recently, some theories focus on the theory of internal impingement where the rotator cuff is pinched between the back edge of the shoulder blade and the upper arm bone at maximum raise. Other theories highlight the natural degeneration of the rotator cuff as primary contributors to these shoulder issues.

Over time, natural wear and tear can weaken the rotator cuff, which can lead to instability of the shoulder joint. As the shoulder becomes less stable, the shoulder blade can rise higher, reducing the space below the acromion, potentially leading to external pressure on the weakened cuff, which can result in further degeneration and tearing.

Many studies have identified regions with poor blood supply in the rotator cuff, which may contribute to its wear and tear. However, this factor is still under debate. Other factors that can contribute to rotator cuff injuries include aging, gender, and genetics, high tensile forces repeatedly placed on the rotator cuff, and environmental factors such as frequent, heavy overhead lifting, manual labor, and repeated arm movements.

Interestingly, smoking has been linked with rotator cuff tears in several studies, suggesting a relationship between smoking and damage to the rotator cuff. Medical conditions such as metabolic syndrome, thyroid disorders, diabetes, and inflammatory arthritides are also considered additional risk factors for rotator cuff issues.

The majority of rotator cuff tears occur in the front half of the supraspinatus tendon, which is a part of the rotator cuff. Poor blood supply in this particular area, which often initiates rotator cuff tears, has led to current understanding that most rotator cuff tears originate at the side.

Risk Factors and Frequency for Rotator Cuff Syndrome

Rotator cuff syndrome and related issues affect millions of people around the world. For instance, in the United States alone, shoulder pain leads to roughly 4.5 million doctor’s office visits and costs about $3 billion in healthcare expenses each year. This health issue affects people of different ages, from 5% to 10% of people 20 and under, to more than 60% of people 80 or older. In the general adult population, about 67% will experience chronic shoulder pain in their lifetime.

The main cause of both sudden and long-term shoulder pain is something called subacromial impingement syndrome. Studies show that both men and women are equally likely to experience rotator cuff syndrome and tears.

Signs and Symptoms of Rotator Cuff Syndrome

If you’re experiencing shoulder pain that’s been lasting for a few days or even a few weeks, it’s possible you could have a condition known as rotator cuff syndrome. This usually shows up as dull, lingering pain in your shoulder, particularly when you’re doing things with your arms up in the air, like lifting or reaching for something. This pain might even wake you up at night. To work out if it is rotator cuff syndrome, a doctor would need to know things like whether this has happened to you before, if you play sports or have a job with a lot of repetitive movement, previous shoulder or neck injuries or operations, and which is your main hand.

Some other physical tests the doctor may do to confirm a rotator cuff syndrome diagnosis include:

• Checking for other possible causes of the pain, like issues with the neck. The doctor might look at how your neck moves, feel for any unusual muscle tension, and check your reflexes.
• A thorough check of your shoulder, looking for anything out of the ordinary in how it looks or moves, and for any signs of past injury like scars.
• Checking if there’s a difference between you moving your shoulder (active movement) versus the doctor moving your shoulder (passive movement). People with rotator cuff syndrome usually struggle with active movement but can move well when someone else is doing the moving.
• Testing the strength of each of the muscles in the rotator cuff. For example, the doctor might do this by asking you to resist their attempts to move your arm in certain directions, or by seeing if your arm ‘drifts’ into certain positions when it’s supposed to be staying still.
• Testing for shoulder impingement, which is where the space in your shoulder joint becomes narrow, pinching the muscles. This can show up as pain when you move your arm in certain ways.

All these checks and tests help the doctor understand what’s going on in your shoulder and design the most suitable treatment for you.

Testing for Rotator Cuff Syndrome

If you’re experiencing either sudden or long-term pain in your shoulder, your doctor may use radiographic imaging – a type of X-ray technology – to get a better idea of what’s causing your discomfort.

A specific type of X-ray, known as the “Grashey” view, can provide a detailed picture of your shoulder joint. To capture this image, you’ll be positioned at an angle between 30 and 45 degrees, while the imaging machine makes adjustments to capture the best possible image. The image will then be used to measure the space between your shoulder blade and upper arm bone, which can help diagnose issues like advanced arthritis and rotator cuff problems.

Additional X-ray images taken from different angles can be useful for detecting further issues. For example, a 30-degree tilt view can help reveal any abnormal bone growth on your shoulder blade, while a “scapular Y” or “supraspinatus outlet” view can provide important information on the shape of your shoulder blade.

The most common changes seen in X-rays for shoulder issues are a decrease in the space between shoulders and upper arm bone to less than 7 mm, and a shift in the position of the upper arm bone. These changes usually signal problems like external impingement syndrome or rotator cuff syndrome.

Advanced conditions may reveal certain bone changes such as the presence of bone spurs (abnormal growths) on the upper arm bone or shoulder blade, the deterioration of the acromioclavicular joint (the joint at the top of the shoulder), or the appearance of a “hooked” acromion, a change in the shape of your shoulder blade – best seen on the supraspinatus outlet view.

Ultrasound is another imaging method that’s particularly good at assessing the condition of the tendons and muscles of the rotator cuff. A 2011 study of over 6,000 shoulders found ultrasounds to be highly accurate in detecting tears in the rotator cuff tendons.

MRI scans can also be valuable for examining the extent and nature of any rotator cuff injuries. Using MRI, your doctor can gain detailed insights about any tears, including their size, location, and degree of retraction (how much they’ve pulled back from where they should be). MRI can also show any fatty degenerative changes in the rotator cuff, particularly when the problem has been present for a long time.

MRI scans also allow doctors to assess the joint at the top of your shoulder, the shape of your shoulder blade and the long head of the biceps tendon, all of which can provide valuable insights. Thoroughly reviewing MRI findings, and combining them with your reported symptoms and clinical examination, is a crucial step in correctly diagnosing and treating your shoulder pain.

Treatment Options for Rotator Cuff Syndrome

Rotator cuff syndrome is a complex condition that often requires different approaches for effective treatment and management.

The first category consists of asymptomatic patients who have rotator cuff tears, which can be full or partial. These tears are often identified through MRI scanning. Even though age increases the probability of rotator cuff disease, there is no clear evidence that surgery prevents the tearing from getting worse or symptomatic. Therefore, doctors usually recommend symptom management through nonsurgical strategies.

The second group comprises patients who have partial rotator cuff tears and are also experiencing outward impingement or subacromial impingement syndrome. Initial treatment for these patients often includes nonsurgical strategies. Deciding the right time to consider surgical intervention differs from one patient to another and can range from 3 to 18 months. This decision is personalized based on the patient’s symptoms, improvement with nonsurgical intervention, and overall health goals.

The third group includes symptomatic patients with chronic rotator cuff tears. The American Academy of Orthopaedic Surgeons (AAOS) advises symptom management through nonsurgical methods due to the limited evidence comparing surgical repair with ongoing nonsurgical treatment for these types of patients. Treatment decisions are based on individual patient assessments and their specific health circumstances.

Main treatments to manage rotator cuff syndrome without surgery include:

1. Physical therapy: This is generally the primary treatment for rotator cuff syndrome and consists of muscle strengthening exercises and range of movement exercises.

2. Anti-inflammatory medications: When combined with physical therapy, nonsteroidal anti-inflammatory drugs (NSAIDs) can help manage symptoms. However, the efficacy of NSAIDs and similar treatments for treating full-thickness rotator cuff tears is not clearly substantiated by clinical practice guidelines.

3. Cortisone injections: Such injections given into the subacromial space often result in rapid pain relief, making physical therapy more comfortable for patients.

4. Rest/activity modifications: Patients are advised to rest and avoid activities that could worsen their condition, such as repetitive overhead motions and heavy lifting.

There are also surgical options for rotator cuff syndrome. This management involves debridement (removal of damaged tissue), subacromial decompression (creating more space in the shoulder joint), and acromioplasty (reshaping the shoulder blade). Surgical treatment is typically considered when patients continue to experience painful symptoms despite 4 to 6 months of nonsurgical treatment. A comprehensive examination of the shoulder joint and careful removal of damaged or calcified tissue are also part of the surgical process. Both open and arthroscopic (keyhole) surgeries have been found to be equally effective, though the latter may allow for a quicker return to work.

Acromioplasty involves shaving the underside of the shoulder blade, particularly beneficial for patients with significant spur development. This surgery improves the shoulder joint environment and creates more space between the acromion and the rotator cuff. Debridement of the hook-shaped acromion area is done in cases with this specific morphology.

For persistent symptoms associated with os acromiale (a condition where the shoulder blade hasn’t fully fused), a two-stage surgical procedure is generally used. The first step includes fusing the os acromiale using bone grafting techniques, followed by acromioplasty once the fusion has healed.

What else can Rotator Cuff Syndrome be?

When dealing with chronic shoulder pain, doctors need to consider many possible causes. Here are some of the potential reasons why someone might be experiencing this discomfort:

• Impingement conditions, like external impingement syndrome, subcoracoid, calcific tendonitis, and internal impingement
• Damage to the rotator cuff
• Conditions related to age and wear, like advanced degenerative joint disease, glenohumeral arthritis, adhesive capsulitis, avascular necrosis, and scapulothoracic crepitus
• Issues with the proximal biceps, like subluxation or tendonitis
• Problems with the acromioclavicular joint, such as separation, distal clavicle osteolysis, and arthritis
• Instability in the shoulder, sometimes associated with an event or dislocation, and also can include injuries to the labrum (a type of cartilage)
• Conditions related to nerves and blood vessels, like suprascapular neuropathy, scapular winging, brachial neuritis, thoracic outlet syndrome, and quadrilateral space syndrome
• Other conditions, such as scapulothoracic dyskinesia, os acromiale (an extra bone), muscle ruptures, and fractures resulting from acute injury, deformities, malunions, or nonunions

Understanding the cause of the pain is the first step to effective treatment. Each of these conditions will require different approaches for long-term relief.

What to expect with Rotator Cuff Syndrome

Most people suffering from rotator cuff syndrome without full-thickness tears (FTTs), which are complete tears through the thickness of the rotator cuff, typically get better with non-surgical treatments. The American Academy of Orthopaedic Surgeons (AAOS) recommends starting with treatments like anti-inflammatory drugs (NSAIDs) and/or exercise programs based on several studies.

Further clarity on the treatment and results of non-traumatic FTTs of the rotator cuff, which are tears that occur without a specific injury, was provided by the MOON shoulder group in 2013.

In a group of about 500 patients, non-surgical treatment was successful, with 75% of patients reporting positive results two years later. For the 25% of patients who chose surgery, this decision was typically made between 6 and 12 weeks after they first started experiencing symptoms.

Possible Complications When Diagnosed with Rotator Cuff Syndrome

Rotator cuff syndrome can sometimes lead to complications. These can be grouped into two categories: those related to non-surgical treatment and those resulting from surgical intervention.

When it comes to non-surgical management, patients may still have ongoing or recurring symptoms. For those with partial thickness tear (PTT) of the rotator cuff, there’s a potential risk of the tear getting larger, the rotator cuff not healing, fatty changes in the muscle, muscle wasting, and muscle retraction. A 2017 survey looked into the factors that can increase the likelihood of these symptoms worsening for patients being managed without surgery. Risk factors include:

• Presence of a full thickness tear (FTT) initially
• Medium-sized tears, between 1 to 3 cm
• Smoking

Interestingly, even though partial thickness tears (PTTs) were taken into account in the study, they were not identified as a risk factor for worsening of the rotator cuff tear.

In the circumstance of longstanding or atrophied rotator cuff tears, especially ones that get larger, patients may develop joint disease and rotator cuff arthropathy (a form of shoulder arthritis).

As for surgical management, it is often recommended for patients whose symptoms have not improved or have worsened after at least 4 to 6 months of comprehensive non-surgical treatments. The typical risks associated with surgery include recurring pain or symptoms, infection, stiffness, injuries to nerves or blood vessels, and complications related to anesthesia.

During surgery, specific procedures may be carried out such as:

• Subacromial decompression/acromioplasty, which could lead to deltoid muscle dysfunction: This can happen when the deltoid repair fails after an open acromioplasty procedure or if too much of the tissue is removed during arthroscopy.

A complication known as anterosuperior escape can occur due to excessive loosening of the part of the rotator cuff that’s affected by arthritis. This can cause damage to the coracoacromial arch and the body’s natural suspension system. This is often seen in patients with large, retracted, and irreparable rotator cuff tears, where the upper arm bone may move upwards and forwards, which can affect the patient’s functional outcomes.

Recovery from Rotator Cuff Syndrome

After a surgery called subacromial decompression/acromioplasty, which is carried out when the rotator cuff in your shoulder is not responsible for any pain or discomfort, patients usually wear a sling for 1 to 2 weeks. During this period, they gradually start moving their arm around without using their muscles, a process known as early passive Range of Motion (ROM) rehabilitation. But it’s essential for healthcare providers to ensure that the arm isn’t kept in the sling for too long, especially if there’s no need for special measures to repair soft tissues. To start with, patients are encouraged to avoid lifting heavy objects and doing intense workouts to let the soft tissues recover from the surgery.

Devices that apply cold therapy are frequently used during the first 10 to 14 days after the operation. Once the patients stop using the sling, they usually start physical therapy. Within 3 to 6 weeks, patients can expect to regain full active ROM, which is the ability to move their arm around using their own muscles. Depending on how well each patient tolerates the rehabilitation, they are usually allowed to go back to physical activities related to their sports around 6 to 8 weeks after surgery.

Preventing Rotator Cuff Syndrome

Patients should be thoroughly informed about their condition. This includes understanding that they may continue to experience chronic pain, even after surgery, for ongoing issues related to their impingement/rotator cuff syndrome symptoms. ‘Impingement’ refers to when a part of the body gets pinched in a certain area, and ‘rotator cuff syndrome’ is a group of conditions affecting the tendons in the shoulder. Surgery is often an option for treating these issues, but it may not always completely relieve the pain.