The Rotator Cuff (see shoulder anatomy)
The rotator cuff is a group of four muscles and their tendons that attach around the top of the arm bone (humerus) forming a ‘hood’. The rotator cuff holds the ball in the socket providing stability and mobility. By keeping the ball in the socket, it allows the outer muscle (deltoid) to move the shoulder joint in a co-ordinated way.
Above the rotator cuff is a shelf of bone (acromion) which is an extension of the shoulder blade (scapula). This acromion forms a joint (acromioclavicular joint; ac joint) with the end of the collarbone (clavicle). Between the rotator cuff and the acromion there is a bursa or cushion of fluid, which allows for smooth movement when the rotator cuff moves against the acromion as the arm is lifted up. Soft tissue thickening or bony prominences (spurs) under the acromion and acromioclavicular joint can result in irritation of the rotator cuff as it moves under and against the acromion.
Rotator Cuff Inflammation
Narrowing of the space above the rotator cuff can result in mechanical wear and tear. This can lead to inflammation of the rotator cuff and thickening resulting in pain as it moves against the shelf of bone (acromion) when the arm is lifted up. This process is called
ROTATOR CUFF IMPINGEMENT
The condition may start after a simple motion such as lifting an object from the back seat of the car. This position with the arm extended backwards may cause the rotator cuff to abrade against the acromion and initiate the condition. It may happen from overuse with arms above shoulder height e.g. cutting a hedge. It is fairly commonly seen as an overuse injury e.g. excess lifting such as when moving house or lifting cases on a trip. It may also occur after an injury but in many cases it starts spontaneously.
How is the diagnosis made?
This is made from the history and examination. Pain is the most common presenting complaint and is usually sited over the shoulder joint itself and can radiate down the arm, into the neck or into the shoulder blade. Some patients only feel the pain over the midpart of the arm with no pain felt in the shoulder itself. Pain is related to movements of the shoulder and in particular movements with the arm overhead, behind the back, when stretching out or when lifting anything heavy.
Most patient feel the pain at night, which disturbs their sleep and can be very distressing. Patients may feel that the arm is weak.
The examination is aimed at reproducing the pain and testing the strength of the rotator cuff muscles.
X-rays are taken to look at the bony configuration of the shoulder joint, acromion and acromioclavicular joint. A spur of bone may be present. The rotator cuff can be viewed with the use of Ultrasound, which can help to diagnose the presence or absence of a rotator cuff tear. Occasionally MRI is used to aid in the diagnosis but in most cases is not necessary.
What is the treatment?
Physio is aimed at stretching exercises to loosen up the capsule or lining of the joint. Strengthening of the rotator cuff muscles and the muscles that stabilse and move the scapula ( shoulder blade).
Tightness of the back of the capsule is implicated in the causation of impingement. Tightness of the posterior capsule leads to the ball or humeral head being pushed forward which results in impingement when the arm is elevated. Stretching of the back of the capsule is important in helping resolve it.
Standing or sitting. Take the hand of you affected arm across your body towards the opposite shoulder. Give gentle assistance with your other arm.
Repeat 10 to 30 times and do 2 to 3 times a day.
Strengthening of the Rotator Cuff Muscles
The function of the rotator cuff muscles is to stabilise and mobilise the shoulder. They keep the ball (humeral head) in the socket. If there is any weakness of the rotator cuff muscles then the humeral head may move slightly abnormally resulting in rotator cuff impingement.
Strengthening of the rotator cuff muscles will help prevent or resolve impingement. This is done by strengthening the muscles that turn the arm outwards (external rotation) and the muscles that turn the arm inwards (internal rotation)
STRENGTHENING OF EXTERNAL ROTATION (shown for left arm)
Sitting or standing with your elbow bent. Keep your elbow IN your side.
Hold one end of elastic band – other end fixed. Start with your hand in front of your stomach and pull hand outwards until it is in front of you.
CONTROL the movement on return. Repeat 30 times
STRENGTHENING OF INTERNAL ROTATION (shown for left arm)
With your forearm elbow bent and held against your side; you forearm and hand straight out in of your body. Hold rubber elastic band – other end of band fixed. Pull your hand towards your stomach. Keep the elbow in. Control the movement on return.
Repeat 30 times.
Strengthening of internal and external rotation can also be done with dumbbells in the following way:
STRENGTHENING OF EXTERNAL ROTATION
Repeat 30 times
STRENGTHENING OF INTERNAL ROTATION
Repeat 30 times
STRENGTHENING OF SCAPULAR MUSCLES
The scapula function is often altered in impingement with resultant winging of the scapula and altered scapulothoracic rhythm. Strengthening of the muscles that control scapula movement is important and can be done as follows:
With your feet 3 feet apart and keeping the elbows straight, adjust the rope so the weight is just resting on the ground. Now shrug your shoulders so the weight is lifted off the ground.
With your feet 2 feet apart and hands on the wall in front, bend your elbows till your face almost touches the wall.
Start with doing 10 repetitions and then moving to do 30 repetitions.
You should do all these exercises 2 to 3 times per day.
If this treatment is unsuccessful, then local anaesthetic and cortisone injections may be given.
A maximum of 3 of these injections in one course (i.e.: 3 to 4 weeks apart).
These conservative measures will resolve the condition in up to 50% of cases.
Surgery involves shaving of bone from the undersurface of the acromion to increase the ‘space’ between the tendons and acromion. The end of the collarbone (clavicle) may need to be removed if it has been identified as a source of pain.
Use pain-killers and/or ice packs to reduce the pain before you exercise.
Do short frequent sessions (eg: 5-10 minutes, 4 times a day) rather than one long session.
It is normal to feel aching, discomfort or stretching sensations when doing these exercises. However, intense and lasting the pain (ie: > 30 minutes) is an indication to change the exercise by doing it less forcefully or less often.
Continue to do these exercises until you get the movement back, or you see the physiotherapist.
Lean forwards, let your arm hang freely. Start with small movements. Swing your arm: forwards & backwards side to side in circles
Repeat each movement 5 times
Sitting or standing. Lift shoulders upwards towards your ears. Let them relax down.
Repeat 5 times
Sitting or standing. Keep your arms relaxed. Roll your shoulder blades back and downwards. Hold it for 10 seconds.
(Do not let your back arch).
Sitting or standing, elbow to your side. Hand near stomach. Take hand away from stomach. (This twists the shoulder joint.) Can support/add pressure with a stick held between your hands.
Repeat 10 times.
Lying on your back on bed/ floor. Support your operated arm and lift up overhead. Gradually remove the support. Then progress to trying the movement sitting or standing.
Repeat 10 times.
Will it be painful?
Although the operation is done to relieve pain, it may several weeks until you begin to feel the benefit. The local anaesthetic block will last for between 8 and 24 hours. After this you will be given pain-killers. You will be given pain killers to take home with you on your discharge (or a script as some medical aids do not pay for ‘take home’ medication). Although the operation is done with arthroscopy (key hole surgery), it is still an operation inside and may be very painful.
An ice packs over the shoulder is often helpful. Leave this on for 10 to 15 minutes and repeat several times a day.
Much spasm and pain maybe felt over the biceps muscle and this can be alleviated by taking off the sling and simply straightening the elbow.
Different people recover at different rates so never compare yourself to someone who has had a similar operation.
Complete recover may take up to 6 months with some patients taking up to a year. Most patients will feel improvement by 6 week and complete recover by 3 months.
Yes! You will be shown exercises by the physiotherapist in the hospital the day after the operation and you will need to continue with the exercises once you go home. They aim to stop your shoulder getting stiff and to strengthen the muscles around your shoulder.
The physiotherapist will arrange an appointment to see you as an outpatient or will refer you back to your own physio or one near your home.
Waterproof dressing will be applied to the small wounds on the day after the operation and you will be able to wash and shower with these on.
Avoid using spray deodorant, talcum powder or perfumes near or on the wounds until they are well healed (usually by 10 days).
Patients progress at different rates. The discomfort from the operation will gradually lessen over the first few weeks. You should be able to move your arm comfortably below shoulder height by 2 – 4 weeks and above shoulder height by 6 weeks.
The things that take the longest to improve are night pain, being able to sleep on that side and getting your hand up your back (i.e. to fasten your bra).
Complete relief pain may take up to 6 months (80% of people have complete relief by 6 months according to research). However, there may be improvements for up to 1 year.
This will depend on the type of work you do. If you have a job involving arm movements close to your body you may be able to return within a week (i.e. using a computer). Most people return within 2 weeks of the operation but if you have a heavy lifting job or one with sustained overhead arm movements you may require a longer period off work. Please discuss this further with the surgeon or physiotherapist if you feel unsure.
Your ability to start these activities will be dependent on pain, range of movement and strength. Nothing is forbidden, but it is best to start with short sessions involving little effort and then gradually increase the effort or time for the activity. However, be aware that sustained or powerful overhead movements (e.g. trimming a hedge, some DIY, racket sports etc.) will put stress on the subacromial area and may take longer to become comfortable. You may be unable to do these for 4 months post operation.