CONDITION

The rotator cuff is made up of four muscles and tendons that surround the ball and socket joint of the shoulder (Figure 1). The muscles lift and rotate the arm. Tendons are thick bands of fibrous tissue that connect muscle to bone.

Figure 1

• Injuries to the rotator cuff most often affect the top muscle, or supraspinatus.
• The main injuries affecting the cuff include a tendon tear (strain) or tendinopathy (inflammation and degeneration of tendons).
• Sometimes, tendon problems come from shoulder or rotator cuff impingement. Impingement happens when the upper part of the rotator cuff gets pinched between the ball at the end of the upper arm bone (humerus) and the bones above it. This results in a lot of friction, especially during overhead motion.
• A condition called bursitis occurs when fluid builds up between the upper part of the rotator cuff and the bones above it.
• Tears are more common in adults than in younger athletes. Older people, especially those over age 50, are especially at risk.

CAUSES

• Rotator cuff tears and/or immediate inflammation usually occur:
  • after a fall on the arm, especially an outstretched arm
  • with a blow or hit to the outside of the shoulder or upper arm, especially if the impact comes from the side.
  • with heavy lifting, especially if you are lifting something out and away from your body or over your head
  • with sports injuries such as a shoulder dislocation.
• Overuse of the shoulder with certain repetitive motions, such as reaching above the head or shoulder and lifting out away from the body, can lead to tendinopathy, impingement and bursitis.
• Throwing sports, lifting weights, swimming, golf and certain repetitive motions at work or home may cause rotator cuff problems.
• Arthritis of the bones above the rotator cuff can also cause problems.
• Tendinopathy, especially if you’ve had it for a long time, increases your risk of tearing your rotator cuff.
• Shoulder inflexibility, weakness and fatigue may increase your risk of rotator cuff injury.
• Shoulder arthritis, especially affecting the shoulder blade/collarbone joint above the rotator cuff, can lead to tendinopathy and tears.
• Having had multiple steroid injections in the shoulder increases the risk of tearing.

Shoulder pain also can be caused by other problems:

• It may be the result of problems in the neck such as a pinched nerve or a herniated disc (when the gel-like disc between spine bones bulges against spinal cord and nerves). This is especially true if you also have numbness, tingling or problems with feeling in your arm or hand.
• The source of shoulder pain that extends below the elbow is not usually the shoulder and is more likely coming from the neck.
• Fractures of the shoulder bones, which may occur after falls or sports injuries, can produce symptoms similar to those of a rotator cuff injury.
• Rarely, blood vessel or blood clot problems can cause shoulder pain. However, these also usually cause swelling in your forearm and hand, dusky or grey skin color, a feeling of heaviness in your arm or problems feeling your arm.
• Lung problems such as an infection or a tumor can refer pain to the shoulder.

SYMPTOMS AND SIGNS

• Tears happen suddenly and usually cause immediate, severe pain at the top of the shoulder, all around the shoulder and, sometimes, down to the outside of the shoulder or down the upper arm.
• If you have had longstanding shoulder pain that suddenly increases, you may have a tear that can occur with chronic tendon problems.
• Pain, weakness or the inability to move your arm out away from your body or above shoulder level can signal a tear.
• Shoulder pain that wakes you up at night is probably a tear.
• Overuse tendon problems (tendinopathy) often start slowly and get worse over time. That pain is similar to pain that occurs with a tear but may be less intense. You may also feel a crunching, grinding and catching in your upper shoulder.

WHEN TO CALL YOUR DOCTOR

Call 911 if:

• You are alone, in severe pain and cannot get yourself to the hospital.
• You have problems feeling your arms or have weakness in both shoulders and arms after a neck injury.
• You have other severe injuries that are cause for concern.

Call your doctor right away (day or night) if:

• You have severe shoulder pain that started immediately after a fall or injury, especially if you can’t lift your arm up or out away from your body
• You have numbness, tingling or problems feeling your affected arm, especially if you also have neck pain.
• Your whole arm feels weak or heavy.
• You have other injuries that concern you.

Call your doctor during regular office hours if you have shoulder pain and:

• Your pain is not severe and you want advice on diagnosis and treatment.
• Your pain has been there for weeks or months and is only slowly getting worse or simply not going away.
• You have no problems with numbness, tingling, feeling your arm, or a lot of arm or shoulder weakness.
• You don’t have arm or hand swelling or other symptoms.

SELF-CARE AT HOME

• If you fell or injured your shoulder and have severe pain, consider using an arm sling and avoid lifting the arm up or out away from the body. Your arm should be bent at a right (90-degree) angle when in a sling.
  • Arm slings are often available at drug stores.
  • A homemade sling can be made by wrapping a sheet or large handkerchief around the arm and your neck and then tying the ends together around your neck. Trim off any excess material with scissors.
• If your pain is mild to moderate, avoid doing things that increase the pain. These may include lifting your arm up, out and away from your body; putting it above your head or reaching behind you.
• Avoid lifting things until your doctor looks at your shoulder.
• Wrap an ice pack or cold pack around the front of your shoulder and hold it in place with plastic wrap or an elastic wrap. Do this three times daily for 20 minutes at a time.
• You may take ibuprofen (Advil® or Motrin®). (See the labels for dose and risks.)
• If you can’t find a comfortable position in your bed, try sleeping in a recliner.
• You can do a few shoulder exercises, provided they don’t cause much pain.
  • Maintain shoulder motion by bending over at the waist and hanging your arm loosely down toward the floor. Swing your arm gently in small circles. Progress gradually to larger circles for one to two minutes in each direction. Do this two times daily.
  • If you have only mild to moderate pain, you may “walk” your fingers up the wall, pulling your arm with them (Figure 2). Stand facing the wall with your arm straight out in front of you. As your fingers pull your arm up the wall, move closer to the wall until your arm is above your head as far as pain will allow it to go. Return to your original position by walking your fingers back down the wall. Repeat the exercise, this time facing away from the wall (your body should be at a right angle to the wall), with your injured arm out to the side. Do the exercise five to 10 times in both positions once or twice a day.

  Figure 2

  

PREVENTION

• Keeping your shoulder flexible and strong with exercises can help prevent injuries.
• A preseason throwing program can help prevent shoulder injuries in throwing sports.

FOR MORE INFORMATION

• American Family Physician: Management of Shoulder Impingement Syndrome and Rotator Cuff Tears
  • http://www.aafp.org/afp/980215ap/fongemie.html
• American Medical Society for Sports Medicine: Rotator Cuff Tendonitis
  • http://www.newamssm.org/Handouts/RotatorCuff.pdf
• MayoClinic.com: Rotator Cuff Injury
  • http://www.mayoclinic.com/health/rotator-cuff-injury/DS00192
• American Academy of Orthopedic Surgeons: Rotator Cuff Tears
  • http://orthoinfo.aaos.org/fact/thr_report.cfm?Thread_ID=127

REFERENCES

• Hutton K, Julin M: Shoulder injuries. In Mellion M, Walsh WM, Madden C: The Team Physician’s Handbook, Hanley & Belfus, Inc, Philadelphia, p397-417, 2002.
• Sports Medicine Clinical Consult
• Krabak B, Sugar R, McFarland E: Practical nonoperative management of rotator cuff injuries. Clinical Journal of Sport Medicine. 13(2):102-105, 2003.

Authored by Christopher Madden, M.D.

Favorably reviewed by The American Medical Society for Sports Medicine

http://amssm.org


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