Shoulder injuries are common in both young, athletic people and the aging population. In each of these age groups, there are numerous causes of shoulder pain. Two of the most common problems occur in the narrow space between the bones of the shoulder. Irritation in this area may lead to a pinching condition called impingement syndrome, or damage to the tendons known as a rotator cuff tear. These two problems can exist separately or together. It is likely that rotator cuff tears are the result of impingement syndrome and age related changes within the rotator cuff tendons.
What does the inside of the shoulder look like?
The shoulder is the most mobile joint in the human body, with a complex arrangement of structures working together to provide the movement necessary for daily life. Unfortunately, this great mobility comes at the expense of stability. Several bones and a network of soft tissue structures (ligaments, tendons, and muscles), work together to produce shoulder movement. They interact to keep the joint in place while it moves through extreme ranges of motion. Each of these structures makes an important contribution to shoulder movement and stability. Certain work or sports activities can put great demands upon the shoulder, and injury can occur when the limits of movement are exceeded and/or the individual structures are overloaded.
What is impingement syndrome?
Shoulder impingement syndrome occurs when the tendons of the rotator cuff and the subacromial bursa are pinched in the narrow space beneath the acromion. This causes the tendons and bursa to become inflamed and swollen. This pinching is worse when the arm is raised away from the side of the body. Impingement may develop over time as a result of a minor injury, or as a result of repetitive motions that lead to inflammation in the bursa.
Particular shapes of the acromion may make certain individuals more susceptible to impingement problems between the acromion and the bursa. With age and the onset of arthritis, the acromion may develop bone spurs that further narrow this space. Impingement caused by bone spurs on the acromion is common in older patients who participate in sports or work activities that require overhead positions. Spurs may also result if one of the ligaments in the coracoacromial arch becomes calcified.
Impingement is classified in three grades:
- Grade I is marked by inflammation of the bursa and tendons
- Grade II has progressive thickening and scarring of the bursa
- Grade III occurs when rotator cuff degeneration and tears are evident
What is a rotator cuff tear?
Continual irritation to the bursa and rotator cuff tendons can lead to deterioration and tearing of the rotator cuff tendons. The tendon of the supraspinatus muscle is the most commonly involved tendon among the rotator cuff muscles. This muscle forms the top of the cuff and lies in the narrow space beneath the acromion. It is subject to the most pinching of all the rotator cuff muscles.
Rotator cuff tears can be the result of a traumatic injury or deterioration over time. Symptoms may be present, but in many cases, the patient experiences no symptoms at all. In young active people, full thickness rotator cuff tears are fairly uncommon. When they do occur, they are usually the result of a high-energy injury to the rotator cuff that is associated with throwing or overhead sporting activities. In older people, rotator cuff tears tend to be the result of wear and tear over time. Several scientific studies have shown that up to 2/3 of the population at age 70 have rotator cuff tears; many of these people had no symptoms.
What are the causes of Rotator Cuff Tendinopathy?
The exact cause of rotator cuff tendinopathy remains unknown. So far, many causes have been explained, and, as a result, the disease appears to be multifactorial.
Mostly, extrinsic factors of the disease lead to compression of the tendons and narrowing of the subacromial space. These risk factors include:
- Postural abnormalities such as keeping the arms overhead for a long time
- Decrease in performance of shoulder muscles
- Muscle overuse in people who play sports or have an occupation that involves repetitive overhead movements
- Acromyan or subacromial anatomical variations
On the other hand, Intrinsic factors which lead to degeneration and wear and tear of the tendons are as follows:
- Changes in biology, morphology, vascularity, and mechanical properties
- Genetics and family history
- Old age
- Trauma
- Increase in load on the tendon (obesity)
Symptoms
The pain associated with a rotator cuff injury may:
Be described as a dull ache deep in the shoulder
Disturb sleep
Make it difficult to comb your hair or reach behind your back
Be accompanied by arm weakness.
When the problem becomes severe, the following symptoms are present
- Pain at night that wakes the person up or requires them to change position
- Sharp pain when reaching behind the back or lifting something up
- Loss of joint strength and mobility
Diagnosis
During the physical exam, your doctor will press on different parts of your shoulder and move your arm into different positions. He or she will also test the strength of the muscles around your shoulder and in your arms.
In some cases, he or she may recommend imaging tests, such as:
- X-rays. Although a rotator cuff tear won’t show up on an X-ray, this test can visualize bone spurs or other potential causes for your pain — such as arthritis.
- Ultrasound. This type of test uses sound waves to produce images of structures within your body, particularly soft tissues such as muscles and tendons. It allows dynamic testing, assessing the structures of your shoulder as they move. It also allows a quick comparison between the affected shoulder and the healthy shoulder.
- Magnetic resonance imaging (MRI). This technology uses radio waves and a strong magnet. The images obtained display all structures of the shoulder in great detail. The quality of the images depends greatly on the quality of the equipment used.
Treatment of Rotator Cuff Tendinopathy:
For minor to mild conditions, doctors recommend the following non-surgical treatments.
- Take non-steroidal anti-inflammatory drugs like ibuprofen, naproxen when symptoms flare-up
- Rest, and especially avoid activities that cause pain
- Apply ice to the shoulder for fifteen minutes, three or four times a day
- Apply heat once the pain goes away to lessen stiffness in the shoulder
- Avoid sleeping on the sore shoulder
Sometimes, a person may also benefit from over-the-counter analgesic ointments, creams, or patches such as menthol, capsaicin, and methyl salicylate.
What are interventional pain management options?
If RC tendinopathy is severe, doctors recommend a steroid injection into the shoulder joint. It relieves pain, improves sleep, and helps keep doing daily activities. But a steroid injection is a temporary solution and may weaken the joint in the long run.
Other than this, platelet-rich injection is a very good choice and more modern and preferable treatment for RC tendinopathy. Because it repairs the damaged tendon, it gives long-term results compared to intraarticular steroid injection.
Platelet Rich Plasma (PRP) Therapy: PRP therapy involves injecting platelets from the patient’s own blood to rebuild a damaged tendon or cartilage. It has been successful in not only relieving the pain, but also in jumpstarting the healing process. The patient’s blood is drawn and placed in a centrifuge for 15 minutes to separate out the platelets. The platelet-rich plasma is then injected into the damaged portion of the tendon or cartilage.
How to make a diagnosis of Rotator Cuff Tendinopathy?
Indeed, doctors make a diagnosis based on the following:
- Symptoms, their start, their occurrence, and their progression
- Medical history, recent falls, or any injuries
- Physical examination of the shoulder to check for tenderness, abnormalities, range of motion, etc.
- Strength of the shoulder joint by asking the patient to press against their hand
- X-ray to check for bone spur
- MRI or ultrasound to check for inflammation and signs of tearing or degeneration
Mostly, the imaging tests are usually performed to rule out other possible conditions.
Prognosis of Rotator Cuff Tendinopathy:
Recovery from the disease depends upon its severity. Usually, people see improvements within six to twelve weeks of rehabilitation. The minimum recovery time from a small tear is generally two to four weeks. But large tears may take months to recover. Ultimately, the aim is to reduce inflammation and compression of the tendon.
RC tendinopathy may cause long-term disability and chronicity if combined factors are involved. It badly affects the quality of life and may be associated with substantial morbidity.
Exercises for Rotator Cuff Tendinopathy:
Physical therapy is one of the first treatments doctors recommend. You may also see a physical therapist. Doctors or physical therapists recommend the following exercises:
- The weighted pendulum exercise w to reduce pressure on the rotator cuff muscles
- The crossover shoulder exercise
- Muscle strengthening exercises
- Stretching shoulder throughout the day
Surgery
Most of the time, medication, rest, ice, and physical therapy is all that are needed to treat RC tendinopathy. Surgery is rarely performed and is the last resort. Its appropriateness depends upon age, the severity of the injury, physical demands, and overall health. Surgeries include tendon repair, tendon transfer, or shoulder replacement. Surgery has its own risks of anesthesia and surgical procedures and costly also. That is why non-surgical treatments are always preferable.
Prognosis
If you are at risk of rotator cuff injuries or if you’ve had a rotator cuff injury in the past, daily shoulder strengthening exercises can help prevent future injury.
Most people exercise the front muscles of the chest, shoulder and upper arm, but it is equally important to strengthen the muscles in the back of the shoulder and around the shoulder blade to optimize shoulder muscle balance. Your doctor or a physical therapist can help you plan an exercise routine.