Ask the Osteopath:Rotator cuff injuries

rotator cuff muscles

Most common cause of shoulder disability stems from the rotator cuff muscles in the shoulder and it will affect millions of people around the world. It is most common between the ages of 58.7 – 67.8 years. (Hsu&Kenner,2015) However, many of these cases will be asymptomatic and not everyone will feel any pain. It is common to have a small tear, which later on can develop into a full thickness tear with age. There is a very strong link to the affects of degeneration and aging especially in regards to rotator cuff tears. Sambanfam et al (2015)

Anatomy:

You shoulder is made up of three bones your humerus (the bone in your upper arm), shoulder blade or scapula and your collarbone or clavicle. The joint is a ball and socket joint.

The rotator cuff is a group of 4 muscles that help to keep your arm firmly in its socket. They all go from the shoulder blade to the humerus (funny bone) just in different places and slightly different directions to create a layered horseshoe shape. Matthewson et al (2015) The muscles and tendons of the rotator cuff, work together to provide movement as well as the majority of the stability for the shoulder joint. The main function of the shoulder is to provide as much movement as possible so that we can use our hands most effectively. It actually has the greatest range of movement of any joint in our body but means it is also a relatively unstable joint compared to say the pelvis. The rotator cuff muscles are like a bunch of good friends if one of them is hurt then they will all work together to help the others out. Due to the large variety of different movements you ask of your shoulder it is often requires co-ordination involving many different muscles to do one basic movement. Therefore if you have a tear in one of the rotator cuff muscles it is very likely that it will affect all of them to a certain degree as they work to help compensate for the injury. Drake et al (2010)

Supraspinatus: Supraspinatous fossa :(shoulder blade) to superior greater tubercle. It mainly helps the deltoid in being your arm out to the side but it can also help in flexing the arm.
Infraspinatus: Infraspinatus fossa (scapular) to the middle great tubercle. Its main function is to prevent your arm from dislocating from the back of your shoulder it also try to help in rotating your hand outwards.
Subscapularis: sub scapular fossa to the lesser tubercle it also joins part of the capsule of the shoulder. It help rotates your arm towards the centre of your body as well as stabilising the shoulder joint.
Teres Minor: Mid lateral border scapular to the inferior greater tubercle, its main function it to rotate your arm outwards.

 

rotator cuff injuries
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Bursa: The bursa is a fluid filled sac, which is located between your rotator cuff muscles and the acromion, which is the bone at the top of the shoulder that can be quite pointy in some people. The bursa helps to reduce friction and to allow your arm to move freely in the joint. Then the tendons are damage this can often affect the bursa as well.

Labrum: This is a cuff of cartilage that surrounds the joint like a collar to form a cup for the ball or head of the humerus to sit in. The socket in the shoulder is quite small compared to the head of the humerus or the ‘ball’ and actually only covers 1/3 of the ball. The labrum is used to help deepen the socket to help support the head and add a bit more stability.

Injuries associated with the rotator cuff muscles:

Tears: This is when the tendon is weakened or torn; there are many different degrees of tears. The different types include a partial tear, which will damage the tendon, but not enough to rupture it. A full thickness tear or a complete tear is when the tendon is completely severed.
Tendonitis: Inflammation of the tendon normally due to overuse injuries normally involving overhead movements. These are very common and generally build up over time.
Impingement: When the tendons of the rotator cuff are squeezed and partly tapped by the acromion (the bony bit on the top of people’s shoulders. They often create a pain arc movement which is when you bring your hand out to the side it will get more painful as you bring it up but then after a certain point it will ease off again.
Frozen Shoulder (Adhesive Capsulitis): When adhesions build up around the humerus on to the shoulder blade often cause pain and stiffness. There are three stages: freezing, frozen, thawing each phases can last at least 6 months.
Sub-acromial bursitis: Inflammation of a small fluid sac called a bursa. The bursa acts as cushion to prevent friction similar to a blister. (Elshewy, 2016)
Calcification: This is when there is calcium deposits within the rotator cuff tendons, it is very common and is normally associated with degeneration. It is most common between the ages of 50-60 years.

Symptoms:

• Pain often a deep dull ache but can be sharp, it is also very common at night especially if you lie on it
• Pain on lifting or rotating your arm
• Reduced movement: depending on which muscle is affected more it will depends on which movements will be affected more
• Weakness in lifting or rotating the arm
• Crepitus or clicking of the shoulder
• The feeling of instability within the shoulder.

Tears of the rotator cuff:

Acute/Traumatic: This is when you fall down, lift something or a FOOSH which is (fall on an outstretched hand). These type of tears are more common in the dominant arm for obviously reasons. Furthermore if you have a problem with one shoulder you are also more at risk for a minor tear in the opposite side even if you have no pain.

Degenerative: Anterior supraspinatus adjacent to the biceps tendon more recent research suggested that there is actually more involvement from posterior biceps tendon than supraspinatus. Kim et al (2010)

Causes:

• Trauma:normally lifting, catching or falling on to a outstretched hand
• Poor blood supply to the area – this will also occur naturally as we age and will not only affect your risk of developing a problem but also slow your recovery time.
• Weakness of the tendons of the shoulder
• Overuse or inactivity of the shoulder joint

Risk factors to tears:

• Muscle degeneration
• Genetics
• Hand dominance
• Smoking
• Other medical conditions such as diabetes
• Age:the incidence increases with age, commonly over 40years.
• Repetitive lifting or overuse from occupational or recreational factors most commonly overhead movements or sports such as baseball, tennis and weightlifting.
• Size + location of tear
• Posture particularly if you have rounded shoulders or are more hunched over.
• Increase in women after the menopause but even until then.
• History of trauma to the shoulder

Degeneration:

Degeneration is a natural part of aging and luckily it is normally asymptomatic. As many people do not experience any pain it’s harder to identify as many tears. However research is proving that tears that are degenerative in nature are normally in both shoulders even if one is painful therefore they are starting to scan the asymptomatic side build up some more data. Furthermore you can actually maintain a normal range of movement with it and often have no idea you have it. Degeneration is one of the major risk factor to rotator cuff injuries and around 50% have an asymptomatic tear by the age of 66. Moreover 50% degeneration tears will progress in size within a 5yr period. Degeneration of the tendon and the muscle belly can cause slower rates of healing and is most common in the biceps tendon.

A feature of degeneration is often bone spurs. As apart of the repair process when you get injuries or have arthritis your body will try and regrow more bone to replace the older and worn bone. This can reduce the amount of space within the joint as well as weaken the tendons over time. For more information on bone spurs and osteophytes read my guide to Osteoarthritis.

Progression of tears:

They normally progress from partial to full thickness tears over time. This is normally due to muscle retraction, atrophy of the muscle mostly due to reduce use and increase in fatty deposits within the muscle. These changes can all lead to less movement and elasticity within the tendon.

48.7 years: Bilateral intact cuffs
58.7 years: Unilateral cuff tears
67.8 years: Bilateral cuff tears

(Yamaguchi et al. 2006)

Investigations:

MRI:
This is the gold standard test for the rotator cuff as it will give you very detailed pictures of the muscles and the tendons involved as well as more information such as the bones, fat pads or bursas.

X-ray:
Helpful to see the general state of the shoulder, for example if there is any arthritis or bony spurs but wont give much information in regards to the rotator cuff muscles.

CT:
This will take multiple x-ray pictures of the shoulder to create a detailed image. It will give you more information than a normal x ray but not as much as an MRI would.

Ultrasound:
This uses high frequency sounds waves to generate a picture of the muscles and tendons.

Treatment:

Surgery:

If you have traumatic tear especially if you are active the guidelines state you should be recommended for a surgical repair with 3 weeks to 4 months. The sooner you get the surgery the superior outcomes you’ll have as it will influence the quality of the tissue, healing time as well as prevent any further damage, scar tissue or fatty deposits to build up round the tear. These factors can all lead to degeneration or complications further down the line. Petersen & Murphy (2011) Surgery is normally recommended to patients under the age of 60 yearrs while no operative alternatives are normally first point of call for patients over this age.

Manual therapy:

Manual therapy such as an Osteopath or phyiso will work with you to try to increase the range of movement at the joint, decreased the muscular guarding and tendon around the joint. As a part of their management plan they should give you some advice and exercises to get you back on track. Your manual therapist may also use stretching techniques to work into the capsule of the joint to get to the ball of the humerus, moving better in the socket. The rehabilitation programme should be cantered around increasing the range of movement that you have at your shoulder as well as strengthen the movement and stability of the shoulder bade. Rudzki & Shaffer (2008)

Injections:
Corticosteroid injections are the most common and they are normally involved the chemical cortisone but there is other alternatives. The idea is to give you a large does of anti-inflammatory to bring down the pain, and inflammation that has built up in the joint. This should give your body the boost it needs to recovery quicker and enable you to get some more movement in the joint and to increase your rehab.

Drugs: You will often be prescribed drugs by your doctor these will include NSAIDS (non-steroidal anti inflammatories) such as ibuprofen.

References:

ElShewy MT. (2016) Calcific tendinitis of the rotator cuff. World Journal of Orthopedics 7(1): 55-60

Drake, R., Vogl, W., Mitchel, A.W.M (2010) Gray’s anatomy for students. 3rd edition. Churchill Livingstone, Elsevier Health

Yamaguchi, K, Ditsios K, Middleton WD, Hildebolt CF, Galatz LM, Teefey SA. (2006) The demographic and morphological features of rotator cuff disease. A comparison of asymptomatic and symptomatic shoulders. The Journal of bone and joint surgery.

Petersen, SA., Murphy, TP. (2011) The timing of rotator cuff repair for the restoration of function Journal of Shoulder and Elbow Surgery , Volume 20 , Issue 1 , 62 – 68

Matthewson, G, Beach, C.J, Nelson A.A, Woodmass, J.M, Ono, Y., Boorman, R.S, Lo. I.K, Thornton, G.M (2015) “Partial Thickness Rotator Cuff Tears: Current Concepts,” Advances in Orthopedics, Article ID 458786 

Kim, H,M, Dahiya, N., Teefey S.A, Middleton, W.D, Stobbs, G., Steger-May, K.,Yamaguchi, K., Keener, J.D (2010) Location and Initiation of Degenerative Rotator Cuff Tears Journal of Bone and Joint Surgery 92 (5) 1088-1096;

Rudzki JR, Shaffer B. (2008;) New approaches to diagnosis and arthroscopic management of partial-thickness cuff tears. Journal of Clinical Sports Medicine 27:

Sambandam SN, Khanna V, Gul A, Mounasamy V. (2015) Rotator cuff tears: An evidence based approach. World Journal Orthopedics 6(11): 902-918

Hsu, J., & Keener, J. D. (2015). Natural History of Rotator Cuff Disease and Implications on Management. Operative Techniques in Orthopaedics25(1), 2–9. 

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