The rotator cuff is a cuff of muscles and tendons which sits around the socket of the shoulder joint. These are the fine tuning muscles (like guy ropes) rather than the bulk movers such as the deltoid and trapezius which are easier to build up and look more obvious. The function of these muscles and tendons is very important, but the tendons themselves have rather a poor blood supply which, particularly in the middle aged (40-50) age group, can often give us trouble. Either with an isolated injury or just through a bit of over-use, the tendon will often become a little bit degenerate and swollen and they will start to rub on the under surface of the flat plate of bone on top of the shoulder blade which sits above them. As they rub they swell more which makes them rub more and eventually they can tear completely.
Impingement & Injections
Whilst impingement is not an emergency, and the majority settle with exercises under the supervision of an expert physiotherapist, decompression (acromioplasty) is sometimes required to allow the shoulder to settle. Sometime we can tide patients over while nature is healing these tendons with an injection of steroid (or more recently autologous conditioned plasma or platelet rich plasma variants), but this should not be done on more than two or three occasions as it does tend to weaken the tissues. NICE has produced some patient information on blood product injections.
Extracorporeal shock wave therapy is a very effective and safe new treatment for certain tendonopathies, but requires rather expensive & specialised equipment. We now have access to this routinely and are starting to see the benefits. NICE has produced patient information on this.
The physiotherapy works probably by strengthening and re-co-ordinating the muscles to prevent the rubbing of the tendon on the top of the shoulder and is very commonly successful.
If operation is necessary this is now done invariably with a key hole procedure and just a one night stay, but again there is a fairly prolonged rehabilitation after it and I usually tell patients that they feel 80% of the benefit in three months and they will be continuing to improve beyond one year.
In the End.....
At the end of the spectrum of wear and tear in the rotator cuff tendons is a complete tear of the tendon. This most commonly occurs in the older age group. In fact, of people in their sixties who have a completely normal shoulder as far as they are concerned and a completely normal shoulder to examination by an expert, it is known that 25% will have a full-thickness perforation of the tendon on the top of the shoulder. This means that it is a effectively a normal variant in the ageing process, and simply seeing a tear on an MRI scan does not mean that it is the source of the symptoms. This is the reason for a careful clinical assessment of patients before recommending surgery on the basis of any imaging. If the symptoms are coming from elsewhere (for example the neck), then it is a complete waste of time having treatment including surgery to a tendon which has a perforation which had been there for years & is not causing any trouble!
I usually say to patients that a small perforation of the tendon is not necessarily of any significance in the same way as a small hole in a belt which allows the buckle to fasten does not mean that the belt stops working. When the hole in the tendon or belt gets bigger and extends right across the side then it usually will become significant in that your trousers (or in this case your shoulder) will fall down.
The typical symptoms of rotator cuff problems are of an aching pain, particularly with work above shoulder height and I am afraid typically the pain is at night which makes it particularly disabling. Patients are unable to sleep on the affected shoulder and this is a major interference with their quality of life.
The situation is a bit more complicated in that impingement does occur in young athletes, but it is almost always secondary to subtle instability and the underlying instability needs to be treated as well for a long-tern cure. This is because the ball is poorly centred and controlled in the socket and as it wanders around it throws more strain on the tendons which are tying to control it. The tendons then become worn and swollen and run into secondary injury impingement problems. For this, the primary treatment needs to be directed at the underlying cause rather than at the rotator cuff and the impingement itself.