Health tips: SHOULDER PAIN – ROTATOR CUFF SYNDROME

Dr Tariq Jagnarine
Family Med, Endocrinology/ Diabetes

The rotator cuff is the group of four tendons that stabilise the shoulder joint. The tendons hook up to the four muscles that move the shoulder in various directions. There are four muscles, the tendons of which form the rotator cuff: the subscapularis muscle, which moves the arm by turning it inward (internal rotation); the supraspinatus muscle, which is responsible for elevating the arm and moving it away from the body; the infraspinatus muscle, which assists the lifting of the arm during turning the arm outward (external rotation); and the teres minor muscle, which also helps in the outward turning of the arm.

ROTATOR CUFF SYNDROME (DISEASE)
Rotator cuff disease is damage to the rotator cuff from any cause. It can be from an acute injury or from repetitive strains. This can lead to minor strain injury; partial tear of the tendons; or complete tear of tendons, with loss of shoulder-joint function. Rotator cuff injury is one of the most common causes of shoulder pain.
The rotator cuff can be injured because of degeneration with aging, or inflammation due to tendinitis, bursitis, or arthritis of the shoulder. The rotator cuff is commonly injured by trauma (such as from falling and injuring the shoulder, or overuse in sports). Rotator cuff injury is particularly common in people who perform repetitive overhead motions that can stress the rotator cuff. These motions are frequently associated with muscle fatigue.

RISK FACTORS
Risk factors for rotator cuff disease include any activity that involves sudden strain movements of the shoulder against resistance. These include:
* Lifting weights
* Lifting objects overhead
* Tennis,
* Swimming,
* Sports wherein objects are thrown (baseball or softball pitchers, football quarterbacks, etc.)
* Taking luggage off of racks, etc.
* Work – carpenters, masons, joiners, teachers
* New mothers having to lift babies

SYMPTOMS AND SIGNS
Rotator cuff injuries cause chronic shoulder pain. Symptoms are due to inflammation and swelling in the rotator cuff. Signs of an injury include:
* Pain in the shoulder and upper arm. Pain is felt often at night, when lying on the affected shoulder.
* Pain may also be felt when moving the arm in certain ways. The pain stops before the elbow.
* If the injury is acute, (sudden) pain will be intense and immediate.
* If the injury is degenerative (damage occurs over time), the pain may be mild at first.
* Weakness or loss of motion in the arm or shoulder.
* A grating or snapping sensation or cracking sound when moving the shoulder.
The most common symptom of rotator cuff disease is shoulder pain. The pain is often noticed gradually and may be first noticed even a day after the actual event that may have caused the injury. Sometimes a sudden pain occurs during a sport activity. The pain is usually located to the front and side of the shoulder and is increased when the shoulder is moved away from the body. The pain is usually noted to be more intense at night, and sometimes increases when lying on the affected shoulder. The pain can diminish range of motion and movement of the arm. The inflammation from the rotator cuff disease and the lack of movement due to pain can result in a FROZEN SHOULDER. There can also be tenderness in the area of the inflamed tendons of the injured rotator cuff.

People with rotator cuff disease usually find it difficult to lift the arm away from the body fully. If the rotator cuff disease involves severe tears of the rotator cuff tendons, it can be impossible for the patient to hold the arm up because of pain and decreased function of the tendons and muscles.

DIAGNOSIS
Rotator cuff disease is suggested by the patient’s history of activities and symptoms of pain in the shoulder. In making a diagnosis, signs of increased pain with certain movements of the shoulder are explored. The pain is due to local inflammation and swelling in the injured tendons of the rotator cuff. Additionally, with severe tendon tears of the rotator cuff, the arm falls due to weakness (positive drop arm sign) when moved away from the body.
The diagnosis of rotator cuff disease can be confirmed by radiology testing. Sometimes X-rays can show bony injuries, which suggest long-standing severe rotator cuff disease. An arthrogram involves injecting contrast dye into the shoulder joint to detect leakage out of the injured rotator cuff.
The MRI is a non-invasive imaging test that uses a magnet and computer to produce detailed images of the tissues of the shoulder. An MRI has the added advantage of providing more information than either X-ray or an arthrogram, especially if a condition other than rotator cuff disease is present.

TREATMENT
The treatment of rotator cuff disease depends on the severity of the injury to the tendons of the rotator cuff, and the underlying condition of the patient.

* Mild rotator cuff disease is treated with ice, rest, and anti-inflammatory medications (such as ibuprofen, Diclofenac). Generally, physical therapy using gradual exercise rehabilitation is instituted. Exercises are used that are specifically designed for rotator-cuff strengthening.
* Patients with persistent pain and motion limitation can often benefit by a cortisone injection around the rotator cuff. Repeat injections may be necessary.
* More severe rotator cuff disease can require surgical repair.
* Subacromial decompression is the removal of a small portion of the bone (acromion) and soft tissues (bursa) that surround the rotator cuff. This removal can relieve pressure on the rotator cuff in certain conditions, and promote healing and recovery. This procedure can be done by arthroscopic or open surgical techniques. Both methods have been reported to be equally successful.
* The most severe rotator cuff disease, complete full-thickness rotator cuff tears, usually requires surgery for the best results. These procedures, which can also be done by either arthroscopy or open surgery, involve mending the torn rotator cuff by suturing the tissues back together. Ultimately, recovery from rotator cuff disease often requires extended physical therapy and rehabilitation.

HOME REMEDIES
Mild rotator cuff disease is treated with cold packs, rest, and anti-inflammatory medications such as ibuprofen. It is essential to avoid reinjuring the shoulder by avoiding activities that stress the joint.

COMPLICATIONS
The most serious complication of rotator cuff disease is frozen shoulder. Frozen shoulder is a result of scarring that occurs around the inflamed joint, and leads to loss of range of motion and function of the joint.

PROGNOSIS
Without treatment, the shoulder can permanently lose full function from rotator cuff disease. Minor rotator cuff injuries cause mild to moderate dysfunction; severe rotator cuff injuries can cause complete dysfunction of the shoulder joint. Scarring around the shoulder (adhesive capsulitis) can lead to a marked restriction of the range of shoulder motion (frozen shoulder). Extensive need for rehabilitation and physical therapy is the norm with significant rotator cuff disease. Some patients never recover full function of the shoulder joint.

PREVENTION
Rotator cuff disease can be prevented by avoiding injury to the tendons of the shoulder. Rotator cuff disease can also be prevented by strengthening the rotator cuff muscles with exercises designed for this purpose.
Repetitive strains, especially arm movements over the head, should be limited.
The following week’s article would discuss frozen shoulder.