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Shoulder Problems

Rotator Cuff

Full thickness rotator cuff tears

Overview:

The rotator cuff is a group of 4 muscle with their tendons, namely the supraspinatus, infraspinatus, subscapularus and teres minor. These muscles and tendons attach the humerus to the scapula and allow for movement of the shoulder. Their function is to stabilise the ball shaped humerus in the cup shaped glenoid fossa and to keep the joint surfaces together through a wide range of motion during which the humeral head otherwise dislocate.

Rotator cuff injuries can occur through local irritation and trauma. Acute tears can occur when excessive stress is placed on the rotator cuff by jerky lifting of heavy objects, use of the arm to break a fall or where the shoulder dislocates. Degenerative or chronic tears occurs through normal wear and tear of the tendon by bony outgrowth associated with arthritis, weak muscles, weak posture, weak blood supply to the tendons or repetitive strenuous movements during work. Inflamation of the tendons or the bursa that lies between the rotator cuff and overlying bone can further narrow the space and increase impingement as the tendon moves through this space. This contributes to pain, wear and tear and degeneration of the tendon.

Partial tear of the rotator cuff refers to a situation where fraying or defect of the rotator cuff tendon occurs that has not progressed to a point where the damage has taken place through the full thickness of the tendon.

Symptoms:

Weakness, continuous pain, tenderness and inability to take the shoulder through the full range of motion are usually present. Pain is most intense when the arm is elevated to the front or to the side or with push ups with the hands behind the back. Degenerative tears usually start with mild pain that progress over time. Night pain occurs when the tendon is damaged or weakened. Acute full thickness tears usually cause severe pain and can be associated with a snapping feeling in the shoulder during the injury as the tendon ruptures.

Classification:

Injury to the tendons is classified according to the degree of damage that has taken place, the location of the tear, whether it involves a part or the full thickness of the tendon and the specific tendons of the rotator cuff that is involved.

Treatment:

Pain relief and improvement of function is the aim of treatment and treatment is adjusted to the patient's specific injury and the grade thereof. Partial tears can be treated conservatively with rest, limitation of activities that causes pain, anti-inflammatory medication and exercises to strengthen the shoulder girdle, mobilise the joint and improve range of motion.

Where there is no sufficient response to conservative treatment the use of a corticosteroid injection is controversial. When pain continues despite the above treatment and when the tears enlarge as observed by ultra sound examination, surgery might be indicated to debride the involved tendon ends, stitch them back to bone and decompress the tendons by removing a certain amount of overlying bone. Repair of the tendons take place by specialised bone anchors, or through drill holes through the bone.

Download Full thickness rotator cuff tears document.

More information: http://www.orthoinfo.org/topic.cfm?topic=A00064

Partial tear of the rotator cuff

Overview:

The rotator cuff is a group of 4 muscles with their tendons, namely the supraspinatus, infraspinatus, subscapularus and teres minor. These muscles and tendons attach the humerus to the scapula and allow for movement of the shoulder. Their function is to stabilise the ball shaped humerus in the cup shaped glenoid fossa and to keep the joint surfaces together through a wide range of motion during which the humeral head otherwise dislocate. Partial tear of the rotator cuff refers to a situation where fraying or defect of the rotator cuff tendon occurs that has not progressed to a point where the damage has taken place through the full thickness of the tendon.

Rotator cuff injuries can occur through local irritation and trauma. Acute tears can occur when excessive stress is placed on the rotator cuff by jerky lifting of heavy objects, use of the arm to break a fall or where the shoulder dislocates.

Degenerative or chronic tears occurs through normal wear and tear of the tendon by bony outgrowth associated with arthritis, weak muscles, weak posture, weak blood supply to the tendons or repetitive strenuous movements during work or sport. Infection of the tendons or the bursa that lies between the rotator cuff and overlying bone can further narrow the space and increase impingement as the tendon moves through this space. This contributes to pain, wear and tear and degeneration of the tendon.

Symptoms:

Weakness, continuous pain, tenderness and inability to take the shoulder through the full range of motion are usually present. Pain is most intense when the arm is elevated to the front or to the size or with push ups with the hands behind the back. Degenerative tears usually start with mild pain that progresses over time. Night pain occurs when the tendon is damaged or weakened.

Classification:

Injury to the tendons is classified according to the degree of damage that has taken place, the location of the tear, whether it involves a part or the full thickness of the tendon and the specific tendons of the rotator cuff that is involved.

Treatment:

Pain relief and improvement of function is the aim of treatment and treatment is adjusted to the patient's specific injury and the grade thereof. Partial tears can be treated conservatively with rest, limitation of activities that causes pain, anti-inflammatory medication and exercises to strengthen the shoulder girdle, mobilise the joint and improve range of motion.

Where there is no sufficient response to conservative treatment the use of a corticosteroid injection is controversial. When pain continues despite the above treatment and when the tears enlarge as observed by ultra sound examination, surgery might be indicated to debride the involved tendon ends, stitch them back to bone and decompress the tendons by removing a certain amount of overlying bone. Repair of the tendons take place by specialised bone anchors, or through drill holes through the bone.

Download Partial tear of the rotator cuff document.

More information: http://www.orthoinfo.org/topic.cfm?topic=A00064

Rotator cuff impingement

Overview

Impingement refers to the changes that takes place in the rotator cuff due to strain, mechanical pressure and rub of the rotator cuff underneath the acromion and can lead to rotator cuff tears. Part of the rotator cuff is surrounded by bone. Where the injury of the rotator cuff takes place, it start swelling and start rubbing against the nearby bone. This leads to irritation of these tendons. Over time it can lead to degeneration and eventually a rotator cuff tear.

Causes:

The most common place of impingement is the supraspinatus tendon. During high elevation of the arm, the supraspinatus tendon and bursa rubs against the under surface of the acromion and coraco-acromion ligament. This pinch of the tendon can cause inflammation and when it continues it can damage the tendon where repetitive movements are performed. This can lead to thickening of the tendon, further limiting the space for the tendon to move through. Blood supply to the tendon is reduced. Bony outgrows on the bone can rub against the tendon and muscle and create further irritation, inflammation and fraying.

Symptoms

Rotator cuff impingement typically starts with a gradual onset of pain that is brought on when the arm is elevated above shoulder height and the arm is rotated externally or internally at the same time. The pain of rotator cuff syndrome occurs in front of the shoulder and it radiates over the outer part of the arm towards the elbow. This pain can eventually cause limitation of every day activities and can wake you up at night.

Classification:

More than one classification is present. The common one that is used is the one by Neer which is based on the different stadia of impingement. Stadium 1 occurs in persons in their mid twenties and is usually reversible. Stadium 2 is the further development of stadium 1 and is more common in people in their mid thirties to forties and comprise of irreversible changes in the tendon. Stadium 3 is usually encountered in people of 40 years and older. It follows on chronic inflammation over years and tendon rupture can develop in these cases.

Treatment:

Adjustment of activities, rest, ice packs on the shoulder, non-steroid anti-inflammatory medication and exercises that improve range of motion and strengthen the shoulder girdle is first line treatment. When pain continues, corticosteroid injections can be applied to limit inflammation that is caused by impingement.

It might take several weeks for symptoms to improve. When the symptoms did not clear up after several months, surgery might be indicated. Surgical techniques are aimed at relieving the impingement of the bone on the tendon and to remove diseased tissue. Often a piece of the overlying bone must be removed and when a tear is present, repair of this tear will be indicated.

Download Rotator cuff impingement document.

 

Subacromial bursitis

Overview:

A fluid filled sack between the acromion and the rotator cuff limits friction and serves as a shock absorber between the rotator tendon and the bone. When the bursa is injured or irritated, inflammation occurs and fluid is secreted in the bursa. This leads to lowering of the shock absorbing properties of the bursa. The bursa can also become inflamed due to rotator cuff impingement that causes swelling of the tendon and narrowing of the space between the tendon and the bone. The bursa is pinged between the tendon and the bone with every movement and this leads to shoulder pain. Chronic bursitis can occur when the inflammation process repeats and thickening and scar formation in the bursa takes place, up to a point where range of motion is limited. It can even lead to frozen shoulder.

Causes

Bony anatomy that limits the space between the rotator cuff and the acromion can cause bursitis. Inflammation of the rotator cuff tendons causes swelling of these tendons and limits the space even further. Injury to the bursa or the tendon through repetitive shoulder movement can cause a cycle of pain, inflammation and irritation and a so-called over use injury can occur. Arthritis, gout, rheumatoid arthritis and infection can also bring it on.

Symptoms

It usually starts as a vague, nagging pain in the front and to the side of the shoulder that limits range of motion. Activities with the hand above the head are limited. Pain is also present during rest and can be so severe that it wakes the person up during the night, especially when lying on the shoulder. A feeling of weakness can also be present.

Classification

It is classified by its cause namely inflamation through rotator cuff impingement or inflammation due to underlying medical conditions.

Treatment

It often responds to rest and anti-inflammatory medication, adjustment of activities, ice, strengthening exercises of the shoulder girdle and if this does not work corticosteroid injection can be added.

Symptoms can become chronic despite of non-operative treatment in which case a subacromial decompression operation might be indicated after 3 to 6 months. During this procedure the inflamed bursa is removed and space for the tendon is enlarged by removing some of the bone on the lower surface of the acromion.

Download Subacromial bursitis document.

More information: http://www.orthoinfo.org/topic.cfm?topic=A00032