Tendinitis: Tendons in the rotator cuff can become inflamed
due to overuse or overload, especially in athletes who
perform a lot of overhead activities. In some people, the
space where the rotator cuff resides can be narrowed
due to the shape of different shoulder bones, including
the outside end of the collarbone or shoulder blade.
Bursitis: The fluid-filled sac (bursa) between the shoulder
joint and rotator cuff tendons can become irritated and
Strain or tear: Left untreated, tendinitis can weaken a
tendon and lead to chronic tendon degeneration or to a
tendon tear. Stress from overuse also can cause a
shoulder tendon or muscle to tear.
A ripping of one or more of the tendons
Result when a sudden eccentric force applied to the
rotator cuff resulting in failure of the tendon.
Uncommon under the age of 40 but strains do occur.
In the population over 40 years of age, supraspinatus
tears occur and less commonly, infraspinatus tears.
Tears in the subscapularis tendon are uncommon and
are often the result of a shoulder dislocation.
Repetitive stress: Repetitive overhead movement of the arms can
stress the rotator cuff muscles and tendons, causing inflammation
and eventually tearing. This occurs often in athletes, especially
baseball pitchers,cricket players and tennis players. It's also
common among people in the building trades, such as painters and
Impingement: Falls or incorrect throwing techniques or arm
movements and weak shoulder muscles may cause the humerus to
move up and trap the tendon. This may also happen in persons who
over-train or have a sudden change in arm or shoulder activity.
Normal wear and tear: The rotator cuff tendons can degenerate due
to ages (starting around the age of 40) . This can cause a breakdown
of fibrous protein (collagen) in the cuff's tendons and muscles.
Calcium deposits: Calcium may deposit in the tendons due to
decreased oxygen and poor blood supply. These deposits may cause
irritation and inflammation
Poor posture: When a person slouches the neck and shoulders
forward, the space where the rotator cuff muscles reside can
become smaller. This can allow a muscle or tendon to become
pinched under the shoulder bones, including the clavicle,
especially during overhead activities, such as throwing.
Falling: Using the arm to break a fall or falling on the arm can
bruise or tear a rotator cuff tendon or muscle.
Lifting or Pulling: Lifting an object that's too heavy, or doing
so improperly (especially overhead) can strain or tear the
tendons or muscles. Pulling something, such as an archery
bow of too heavy poundage, may cause an injury.
Pain in the shoulder or arm , especially with arm movement
(reaching overhead, reaching behind your back, lifting,
pulling or sleeping on the affected side.
Radiation of the pain to the upper, lateral arm
Pain at night
Patient may not be able to move the arm well, especially
away from the body.
The shoulder may feel weak, numb, or tingly.
Loss of shoulder range of motion
Inclination to keep the shoulder inactive
Lying or sleeping on the affected shoulder also can be
The physical examiner must detect the torn muscle by
isolating the muscles through manual testing. Perform
following with patient seated:
External rotation - with elbow at right angles and held into side,
turn the arm outwards as far as possible.
Internal rotation - with elbow held into side, raise arm as far as
possible up patient's back.
Internal rotation with 90° forward flexion - support elbow and
shoulder with elbow at right angles pointing vertically
downwards and palm facing backwards, turn the forearm as far
backwards as possible.
Forward flexion - start with arm at patient's side and lift arm
forwards and upwards as far as possible.
Extension-with arm by the patient's side, lift the arm back wards
as far as possible.
Abduction-with arm at patient's side, lift arm away from the body
as far as possible, continuing past the horizontal by allowing the
shoulder to externally rotate, bringing the hand behind the head.
Adduction-draw the arm across the anterior chest wall as far as
Abduct the patient's shoulder to 90° and ask the patient to lower the arm
slowly to the side in the same arc of movement. Severe pain or inability
of the patient to return the arm to the side slowly indicates a positive test
result.A positive result indicates a rotator cuff tear.
Neer impingement test
The shoulder is forcibly forward flexed and internally rotated, causing
the greater tuberosity to jam against the anterior inferior surface of the
acromion. Pain reflects a positive test result and indicates an overuse
injury to the supraspinatus muscle and possibly to the biceps tendon
Hawkins-Kennedy impingement test
With force internally rotate the shoulder. Pain indicates a positive test
result and is due to supraspinatus tendon and greater tuberosity impingement
under the coracoacromial ligament and coracoid process.
Abduct the arm 90° and fully externally rotate while placing anteriorly
directed force on the posterior humeral head from behind. The patient
becomes apprehensive and resists further motion if chronic anterior
instability is present.
Diagnosis is usually made after a physical
examination. X rays are also sometimes used in
diagnosis as well as an arthrogram. However,
the arthrogram is an invasive procedure and
may be painful afterwards. For this reason,
magnetic resonance imaging (MRI) is preferred
to determine tendon tears as it also shows
greater detail than the arthrogram.
Arthrogram: A test done by injecting dye into the
shoulder joint and then taking x-rays. Areas where the
dye leaks out indicate a tear in the tendons.
Magnetic Resonance Imaging (MRI) Scan
Initial Care: Treatment will depend on thesymptoms and the
duration. Limitation of activity on
the affected shoulder to decrease stress on the tendon may help
prevent further damage, decrease pain, and promote tendon heal.
primary treatment is resting the shoulder and, for minor tears and
inflammation, applying ice packs.A sling can be applied to keep
the shoulder from moving.
Medicines: Anti-inflammatory medications may also be prescribed.
soon as pain decreases, physical therapy is usually started to help
normal motion. If pain persists after several weeks, the physician may
inject cortisone into the affected area.
Surgery: If there is a large tear in the rotator cuff, surgery may be needed to
repair the tear. Sometimes during this kind of surgery, bone spur or calcium
deposits may also beremoved. The surgery may be performed as an open
repair through a 6- to 10-centimeter incision, or as an arthroscopic repair with
the aid of a small camera inserted through a smaller incision. An arthroscope
is used to view the shoulder joint and confirm the presence of a tear. It can
also remove any bone spurs that may be present in the shoulder area. The
arthroscopic procedures usually involves 2in incision in the outer shoulder.
During this time the torn rotator edge may be reattached to the humerus with
Arthroplasty: Some long-standing shoulder muscle tears may contribute to the
development of rotator cuff arthropathy, which can include severe arthritis. In
such cases, more extensive surgical options, including partial shoulder
replacement (hemiarthroplasty) or total shoulder replacement (prosthetic
arthroplasty)may be required. A unique treatment option now available
involves the use of a reverse ball-and-socket prosthesis. This reverse shoulder
prosthesis is most appropriate for people who have very difficult shoulder
problems. These include having arthritis in the joint, along with extensive
tears of multiple muscles and tendons (rotator cuff) that support the shoulder,
or having extensive rotator cuff tears and a failed previous shoulder joint
1. Ice: Apply ice to the top and back part of the shoulder as much as
possible (at least 30 minutes every hour) during the first 24 to 48
hours after surgery (if a cyrocuff was prescribed, it should be used
continuously during this period. Make sure that the cuff remains
cold). This will help limit swelling. After the first few days use the
ice/cyrocuff as you feel necessary. The ice should be placed in a
sealed plastic bag to keep the surgical dressing from getting wet.
2. Dressing: The shoulder may have been filled with sterile fluid with a
pump during the operation. The shoulder, therefore, will be very
swollen and drainage will occur from the wounds
3. Activity: Wear a sling to immobilize and unload the shoulder. You
should remove it periodically to move the elbow. This will help
avoid cramping pain and stiffness. Unless instructed otherwise the
sling may be removed when sitting in a chair, eating, or lying in bed.
4. Exercise: Begin elbow range of motion immediately. Begin posture
(shoulder shrugs) and cervical spine flexibility exercises the first
post-op day as tolerated. Begin shoulder pendulum exercises and
isometric strengthening exercises at 24 to 48 hours as tolerated.
5. Medication: The injured patient will have a prescription for a strong
painkiller. Use it as prescribed during the post-operative period.
After several days, Tylenol or Ibuprofen may provide the pain relief.
6. Potential Problems: Call the office if:
-If drainage continues after 24 hours or you think the drainage is excessive.
-If you have a temperature greater than 101 degrees on more than one
hours or more after surgery.
-If swelling increases or you develop any persistent numbness in the hand.
-If severe pain remains 48 hours after surgery.
Rehabilitation is crucial to restore the rotator cuff strength. The length
of recovery depends of the severity of the tear.
Rehabilitation can be divided into three phases:
Phase I: Pain control: Use of non-steriodal antiflammatory agents,
cryotherapy, protection of the injured tissue through the use of a sling
or shoulder immobilizer. Exercises such as the pendulum can be
performed. This is important for preservation of strength, which will
speed recovery time.
Phase II: 5 to 7 days after injury: In an overuse problem, this phase begins
when pain diminishes. Range of motion is fully restored. Progressive
resistive exercises are initiated to establish normal strength. Some
examples of exercises are rotator cuff strengthening and strengthening
of the scapular stabilizers. Restoration of strength and mobility of the
shoulder is vital to allow for a successful return to sports.
Phase III: Sports Specific Training: To return an
athlete to a level of full recovery and maximal
performance, the exercises need to be tailored
to the specific sport. For example, an interval
throwing program is used for the throwing
Shoulder Pendulum: Let arm move in
a circle clockwise, then
counterclockwise by rocking body
weight in a circular pattern. Repeat 5
times and complete 3 to 4 sessions
Lay on stomach on a table or bed.
Put your arm out shoulder level with
your elbow bent to 90 degrees and
your hand down. Keep your elbow
bent and slowly raise your hand.
Stop when your hand is level with
your shoulder. Lower the hand
Shoulder Shrugs: scapular
stabilizing exercise of
retraction and elevation.
Lie on your right side with a rolled-up
towel under your right armpit. Stretch
your right arm above your head. Keep
your left arm at your side with your
elbow bent to 90 degrees and the
forearm resting against your chest, palm
down. Roll your left shoulder out,
raising the left forearm until it is level
with your shoulder.
Warm-up stretching and strengthening of the shoulder
The shoulder exercises for treatment are great for a
general conditioning program.
When shoulder injury symptoms begin, early
evaluation and treatment can prevent mild
inflammation from becoming full blown rotator cuff
impingement, or worse, a tear of the rotator cuff.
A program of twenty minutes a day of shoulder
stretches and muscle strengthening exercises is
recommended to increase performance and decrease
Return to play criteria should be individualized. The athlete
should experience no pain with rest or activity, full strength in
muscles across the affected joint, pain-free shoulder range of
motion and negative provocative tests (Neer impingement
test, Hawkins impingement test). An athlete who returns to
his or her sport too soon tends to alter throwing mechanics
and risks injuries not only to the same shoulder, but also to
the elbow, hip, and spine. Resumption of activities should be
gradual, and the intensity of the activity may need to be
modified. Imaging findings alone should not be used to
determine return to play.