Rotator cuff injuries

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VOL 104 / NO 7 / JULY 1998 / POSTGRADUATE MEDICINE

When it comes to joint flexibility, the shoulders win hands down--and hands up, hands behind your back, wherever you choose to reach. But the shoulder's outstanding range of motion also sets it up for wear, tear, and injury. If you have had a sore shoulder, you know how painful it can be to do something as simple as putting on your coat.

How does this joint work, anyway?
The shoulder is held together by four muscles and their attached tendons, which form a structure called the rotator cuff. The muscles connect the upper arm bone (humerus) to the shoulder blade and hold the ball of the humerus firmly in the shoulder socket.

We hear a lot about rotator cuff injuries in athletes, especially baseball pitchers, tennis players, and swimmers, but actually everyone is at risk. Rotator cuff injuries are common in older adults and people whose jobs or hobbies involve overhead lifting or reaching, such as carpenters and painters. Fortunately, most rotator cuff injuries can be treated with exercise and simple pain-relief measures. Very few injuries require surgery.

What are the most common types of injury?
Irritation or damage to the cuff muscles or tendon can cause a number of problems. The most common are:

• Bursitis, or inflammation of the fluid-filled sac (bursa) between the shoulder blade and the rotator cuff tendons
• Tendinitis, or inflammation of the tendons in the rotator cuff, which may be caused by repetitive stress or by calcium deposits in the cuff. The tendons can also become "pinched" under the shoulder bones, creating the problem called impingement syndrome.
• Tears, which can occur when untreated tendinitis weakens a tendon. Stress from overuse or from a fall can also tear a tendon or muscle.

Pain is the most common symptom. Your shoulder hurts when you lie on it, put on a shirt or coat, comb your hair, or carry something heavy. Shoulder tenderness, weakness, and loss of movement are also common. With severe injuries, such as large tears, pain may be constant.

What are the risks for damaging the cuff?
Several factors increase the risk of shoulder injury. Some can be avoided, others cannot. Among these factors are:

• Normal aging. After age 40, normal wear and tear on the rotator cuff can break down protein (collagen) in the tendons and muscles, increasing the risk of inflammation. Calcium deposits in the cuff or bone spurs that pinch or irritate the rotator cuff are also more common as we get older.
• Poor posture. Slouching the neck and shoulders can lead to pinching of muscles and tendons.
• Improper lifting. Carrying something heavy or lifting (especially overhead lifting) can strain or tear tendons and muscles.
• Muscle stress. Repeated overhead movement of your arms can stress your rotator cuff muscles and tendons, causing inflammation and eventually tearing.
• Falls. Falling on or breaking a fall with your arm can bruise or tear a rotator cuff tendon or muscle.

When should you get help?
Check with a doctor right away if you have severe shoulder pain or can't use your arm. With less severe but nagging shoulder pain, see your doctor if the problem lasts more than a week. Physical therapy or a steroid injection near the injury sometimes helps.

If the cause of the pain is not clear, your doctor may recommend tests, such as a shoulder x-ray, magnetic resonance imaging (MRI), or an arthrogram. For an arthrogram, dye is injected into the shoulder to outline the rotator cuff, and then an x-ray is taken.

With large tears in the rotator cuff or when bone spurs or calcium deposits cause the pain, surgery may be needed. Most of the time, though, exercise therapy does the trick. Your doctor or a physical therapist can give you specific exercises that promote healing, improve flexibility, and build muscle strength. Depending on the severity of the injury, physical therapy may take from 3 weeks to several months.

Once the injury is healed, it's important to continue exercising the joint. Daily shoulder stretches help prevent recurrence of the injury. Your doctor or a physical therapist can help you plan an exercise program.

Caring for your sore shoulder

With proper care, a minor shoulder injury often heals by itself. If you think you may have injured your rotator cuff, these tips might help:

Rest those muscles. Stop doing whatever causes pain and avoid painful movements. Be very careful about lifting and overhead activity for a couple of days until your shoulder feels better.

Apply ice first, then heat. Immediately after an injury, place a cold pack, a towel filled with ice cubes, or even a bag of frozen food on the sore spot for 15 or 20 minutes. Repeat this every 2 hours or so for 1 or 2 days. Once the pain starts to go away (usually in about 2 days), switch to a heating pad or hot packs to relax the sore muscles. Use heat for only about 20 minutes several times a day.

Try over-the-counter medications. The anti-inflammatory drugs, such as aspirin, ibuprofen, or naproxen, may reduce pain and inflammation. Always follow label directions, and stop taking the drugs as soon as the pain improves.

When the pain is better, try some easy exercises. After a couple of days, begin gentle shoulder stretches to keep the muscles limber. Total inactivity can lead to joint stiffness or a more serious problem called "frozen shoulder" when the shoulder becomes so stiff you can barely move it.

This information is not a substitute for medical treatment.

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