Rotator Cuff Tears

Pathophysiology

The rotator cuff is a group of 4 muscles which control shoulder stability and rotational movements. Rotator cuff tears are often present with no symptoms with 40-50% of those aged over 60 having a rotator cuff tear but 70% of these having no pain or symptoms.

During normal aging the rotator cuff will degenerate and may then be unable to meet the demands asked of it. It is not the tear itself that causes the pain but the altered biomechanics and therefore irritation as a result. Tears can either be traumatic (from an accident) or degenerative (from normal ageing). Evidence suggests there is no difference between outcomes of surgical intervention compared to physiotherapy treatment.

Symptoms

  • Pain generally at the front of the shoulder which can radiate to the biceps region
  • Can be after an accident- may be bruising
  • May be unable to lift the arm by itself, but with support may be able to move 
  • Pain and difficulty in tasks e.g. putting on coat, reaching behind your back or brushing hair
  • Being unable to lie on the shoulder
  • Often no pain with full thickness tears but problems with movement or function

Management

  • Activity modification
  • Ice or heat
  • Pain relief
  • Physiotherapy- to include range of movement exercises, stability exercises and a gradual strengthening programme

Investigations

  • In traumatic cases may be referred to orthopaedics for investigations including imaging and sometimes surgical repair

Rotator Cuff Tendinopathy

Pathophysiology

Irritation of the rotator cuff tendon is one of the most common causes of shoulder pain. Tendinopathy is an umbrella term that covers a number of conditions that present and respond to treatment in similar ways. Often tendinopathy follows a period of overload or trauma, such as a strain or prolonged compression. Rotator cuff tendinopathy is often the correct diagnosis in misdiagnosed frozen shoulders. 

Tendinopathy results in the tendon becoming painful, this can either be intermittent following certain movements or loads or constant in some cases. Often there will be little pain at rest or when doing activities with a tendinopathy, but you may experience your symptoms later the same day or the next day. This is normal in tendinopathy.

  • Pain generally at the front and side of the shoulder
  • Can be after trauma, compression or overuse (overload)
  • Can come on slowly over time or quickly
  • Pain in certain positions or following activity/exercise
  • Limitations in function e.g. putting on coat, reaching behind your back or brushing hair
  • Inability to lie on the shoulder
  • Painful in the second half of the night

Management

  • Activity modification
  • Ice and/or heat
  • Pain relief or anti-inflammatory medication as advised by your health professional
  • A graded exercise programme is the best evidenced initial treatment in managing rotator cuff tendinopathy – it can take several months to improve
  • Injections can be considered if exercise is not helpful
  • Surgery is normal only a consideration if other treatments are not successful

Investigations

  • In some cases ultrasound or magnetic resonance imaging can be useful, these are only considered if it will guide treatment
  • Your GP may consider blood tests

Calcific Tendonitis

Pathophysiology

Irritation of the tendons around the shoulder can lead to calcium deposits to form within the rotator cuff tendons. This can cause a build-up of pressure and chemical irritation which leads to pain. The calcium deposit can reduce the space between the rotator cuff and the bony process above, this is worse with overhead activities. Tends to be more common in those aged 30-60 years, it does disappear completely on its own but this can take several years to resolve. 

Symptoms

  • Generalised pain around the shoulder joint, often intense
  • Pain may refer down the arm to the elbow
  • Pain with overhead activities
  • Pain at night, lying on sides may be worse

Management

  • Activity modification
  • Ice or heat
  • Pain relief
  • Physiotherapy
  • Orthopaedic option of steroid injection, surgical removal or Barbotage to break up calcium deposits

Investigations

  • X-ray can pick up calcium deposits as can ultrasound scans which make it easier to assess the size of the deposit in all directions.

Exercises to try:

Wall Press Up

Wall Press

Standing with your hands on a wall or door, shoulder width apart

Step back with both feet 

Slowly bend both elbows to bring your chest towards the wall

Push back up to the starting position

ADP

Anterior Deltoid Exercise

Lying on your back with a pillow for your head

Raise your arm up towards the ceiling 

(If this is difficult you can use your other arm to help)

Once raised move slowly in a small range up and down or in circles

Cat and Camel

Cat and Camel

Kneeling on all fours, hands under shoulders and knees hip width apart

Arch through your back, looking underneath you

Then tilt your pelvis and dip your back down whilst looking forwards

Repeat slowly, keeping your elbows straight

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