ROTATOR CUFF INJURY OVERVIEW

Tendons are tough bands of tissue that connect muscles to bones. Repetitive activities and overuse can injure tendons and lead to pain and impaired function. This is called tendinitis or tendinopathy. Although the most common cause of tendinitis is overuse, it can also be caused by other conditions.

Tendinitis is a common problem that is more likely as people age and in people who routinely perform activities that require repetitive movement that increase stress on susceptible tendons. Rotator cuff disease is the most common cause of shoulder pain, particularly in people over age 30. Treatment focuses on resting the injured tendon to allow healing, decreasing inflammation, and correcting imbalances that caused stress on the injured area. In most people, tendinitis resolves with treatment. In some cases, it goes away without treatment.

Tendinitis can affect many different tendons in the body. Other types of tendon injury are discussed separately. (See "Patient information: Biceps tendinitis or tendinopathy (Beyond the Basics)" and "Patient information: Elbow tendinopathy (tennis and golf elbow) (Beyond the Basics)".)

WHAT IS THE ROTATOR CUFF?

The rotator cuff is composed of four muscles, each of which has a tendon that attaches to the upper arm bone (the humerus).

• Supraspinatus
• Infraspinatus
• Teres minor
• Subscapularis

These tendons form a cuff around the head of the upper arm bone (humerus) (figure 1A-C). These tendons attach to the front and side of the humerus and the greater and lesser tubercles (part of the upper humerus). The muscles associated with these tendons are located in the upper back, where they are attached to the shoulder blade (scapula).

The largest component of the rotator cuff is the supraspinatus tendon, which is essential for lifting the arm. The infraspinatus and teres minor rotate the arm outward, while the subscapularis rotates the arm inward.

Rotator cuff tendinitis — Rotator cuff tendinitis occurs when the tendons are injured, usually as a result of repetitive overhead reaching, pushing, or lifting with outstretched arms. Athletes who perform overhead activity, such as swimming, tennis, throwing, golf, weightlifting, volleyball, and gymnastics, are also at risk. Tendinitis is usually treated with ice, antiinflammatory drugs, and physical therapy. (See 'Rotator cuff injury treatment' below.)

Rotator cuff tear — The rotator cuff tendon(s) may be torn as a result of injury, chronic tendinopathy, or a combination of both. Typically the injury is caused by a fall, direct blow, or a rapid use of force (pulling on a starter cable, for instance).

The goals of treatment for a torn rotator cuff are to recover lost strength, improve the function of the shoulder, and treat any underlying tendinitis. Conservative treatment is adequate in the vast majority of people, although younger people with a medium- to large-sized tear, particularly affecting the dominant arm, may be candidates for surgical repair. Surgery may also be recommended for older people who have significant pain related to a rotator cuff tear. (See 'Surgical repair of rotator cuff tears' below.)

People with small- to medium-size tears usually improve with physical therapy exercises, stopping painful activities, and, in some cases, injection of a steroid. If shoulder strength and function do not improve after completing three to six months of physical therapy, surgical repair may be considered.

ROTATOR CUFF INJURY SYMPTOMS

Tendinitis — People with rotator cuff tendinitis typically complain of shoulder pain at the tip of the shoulder and the upper, outer arm. Specialists often refer to tendinitis as tendinopathy because there is no evidence of inflammation with this injury. The pain is often aggravated by reaching, pushing, pulling, lifting, positioning the arm above the shoulder level, or lying on the side. Painful daily activities may also include putting on a shirt or brushing hair. The pain may prevent comfortable sleep, or awaken a person from sleep, particularly if he or she sleeps on or rolls onto the shoulder.

Tear — Symptoms of rotator cuff tear often include pain and weakness of the shoulder, although some people have few or no symptoms. In addition, the severity of the tear does not necessarily correlate with the severity of a person's pain; in other words, a person with a partial tear may have severe pain while a person with a complete tear may have little or no pain.

ROTATOR CUFF INJURY TESTS

The diagnosis of rotator cuff tendinitis or tear is usually based upon the person's symptoms and a physical examination.

To differentiate rotator cuff tendinitis from tear, the healthcare provider may inject the shoulder joint with a local anesthetic. In people with tendinopathy, the anesthetic will relieve pain and the muscle strength is usually normal. In people with a tear, the anesthetic will relieve the pain, although the muscles are usually weak.

In most cases, x-rays and other imaging tests are not needed to diagnose tendinopathy. However, if the person's symptoms do not improve after a course of conservative treatment, an imaging test (eg, x-ray, ultrasound, and/or MRI) may be recommended to confirm the diagnosis.

If a rotator cuff tear is suspected, an imaging test (ultrasound or MRI) is usually recommended to confirm the tear. Initially, smaller tears are treated conservatively, with rest, ice, stretching, and strengthening exercises.

If the pain or weakness does not improve or if a large tear is confirmed with an imaging test, most people are referred to a specialist (orthopedic surgeon) for further evaluation and management. (See 'Surgical repair of rotator cuff tears' below.)

ROTATOR CUFF INJURY TREATMENT

Treatment of rotator cuff injuries focuses on decreasing pain and swelling of the tendon, preserving normal range of motion, and strengthening the shoulder muscles. The first goal of treatment is to preserve the ability to move the shoulder. In many people, a decreased ability to move the shoulder means that they use the joint less frequently, which can further reduce range of motion and lead to a frozen shoulder. (See "Patient information: Frozen shoulder (Beyond the Basics)".)

There are two basic options for treatment: conservative, non-surgical treatments and surgery. Conservative treatment is discussed here while surgical treatment is discussed later (see 'Surgical repair of rotator cuff tears' below).

Conservative treatment usually includes:

Ice — Ice can be used to reduce the inflammation that often occurs in rotator cuff injuries. Ice can be applied over the upper and outer portion of the shoulder muscle for 15 to 20 minutes every four to six hours. The response to ice is variable since the rotator cuff tendons are located deep within the shoulder.

Rest — Rest means avoiding activities that aggravate symptoms, including all overhead activities. Avoiding painful activities in general will alleviate strain on the injured area. An example of these activities includes lifting, overhead reaching, and reaching behind (eg, reaching into the backseat or putting on a coat). It is safest to keep the arm down, in front of, and close to the body. Use of an arm sling is not recommended because this may lead to a frozen shoulder.

Some general rules to decrease shoulder strain with activities include:

• Lift objects close to the body.
• Only lift light weights and limit lifting to below shoulder level.
• Do sidestroke or breaststroke when swimming.
• Throw balls underhand or sidearm.
• Avoid pushing exercises at the gym (eg, pushups, bench press, flys, shoulder press)
• Do not serve overhand in tennis.
• Maintain good posture with writing, assembly work, and other tasks by keeping the shoulder blades down and back

Reduce inflammation — A nonsteroidal antiinflammatory medication (eg, ibuprofen or naproxen) is often used to reduce pain and inflammation. The dose of medication needed to reduce inflammation is higher than that recommended for pain relief. You should check with your healthcare provider before using high dose NSAIDs. (See "Patient information: Nonsteroidal antiinflammatory drugs (NSAIDs) (Beyond the Basics)".)

Heat and massage — Heat and massage help prepare the tissues for range of motion exercises and are recommended before performing these exercises. The best method to warm the tissues is to take a warm shower or bath for 10 to 15 minutes. Local heat (eg, with a moist heating pad or a hot pack warmed in a microwave) is an alternative, although local heat is generally not as effective because of the deep location of the rotator cuff tendons.

Light massage to the surrounding tissues is a very effective way to prepare the area for range of motion and strength exercises.

Stretching and range of motion exercises — Range of motion exercises are recommended early in the recovery period to help maintain joint mobility and flexibility of the muscles and tendons in the shoulder. Stretching exercises should be performed once per day every day.

Exercises should not cause more than a mild level of pain. If you experience pain, decrease the intensity of the stretch or the number of repetitions; anyone who feels sharp or tearing pain should stop exercising immediately and consult with their healthcare provider.

Pendulum stretch — The pendulum stretching exercise helps to stretch the space in which the tendons pass, and helps to prevent the development of a frozen shoulder. This exercise can be started almost immediately after a shoulder injury, or after receiving a steroid injection into the shoulder joint. The exercise is performed as follows (figure 2):

• Relax your shoulder muscles
• While standing or sitting, keep your arm vertical and close to your body (bending over too far may pinch the rotator cuff tendons)
• Allow your arm to slowly swing forward to back, then side to side, then in small circles in each direction (no greater than 1 foot in any direction). Only minimal pain should be felt.
• Stretch the arm only (without added weight) for three to seven days. Increase the stretch by adding 1 to 2 lbs (0.5 to 1 kg) per week and gradually increase the diameter of the movements (not to exceed 18 to 24 inches/45 to 60 cm).

Wand exercises — The goal of this exercise is to fully extend the arm at shoulder height, 90º from the body. You will need a long wooden rod (or broom stick).

• Hold the end of the rod with the hand on the injured side (right in this example) as the left hand holds the rod in the middle.
• Use the left hand to guide the rod so that the right arm is extended away from the body, until the right hand is at shoulder height (or lower, if pain is felt). Keep the right arm straight at all times.
• Slowly lower the right arm until it is next to the body. Rest as needed and repeat 15 to 20 times each day.

To vary the stretch, use the rod to direct the hand in front of the body (no higher than shoulder height) and slightly behind the body. Do not proceed if this stretch causes pain.

Once you are able to fully extend the arm at shoulder height, you can try a modified version of this same exercise.

• Start by lying on your back holding the rod against the abdomen with both elbows straight and hands shoulder-width apart.
• Keeping elbows straight, lift arms up to shoulder height while keeping shoulder blades squeezed down and back together.
• Return wand to rest on abdomen.

Perform 5 to 10 repetitions, lifting the wand to 90 degrees (shoulder height), then if there is no pain, move the wand through a full range of motion (over the head). Increase to two sets of 10 repetitions with a 2-3 second pause at the end of the motion.

Posterior capsule stretching — Tightness in the ligaments/capsule of the shoulder can develop in people with rotator cuff injuries. This tightness can contribute to further movement abnormalities and pain in the shoulder. Tightness is caused by any of the following:

• Injury to the shoulder including rotator cuff strains, partial tears or tears
• Poor posture (forward shoulder posture)
• History of repetitive throwing or racquet sports
• Guarded movement as when protecting the shoulder

Although the posterior capsule is most effectively stretched passively by a skilled professional, there are 2 ways to stretch the posterior capsule yourself.

• Reach your affected arm across your body at chest height. Use your other hand to pull your arm closer to your body. Hold for 30 seconds. Do this regularly throughout the day.
• Sleeper stretch – Lie on your back and extend both arms out in front of you, towards the ceiling. Bend your elbows and hold the wrist of your affected arm (right arm in this example) with your left hand. Roll onto your right side with the right hand pointing towards the ceiling. Using your left hand to hold the right wrist, push your right arm down, towards the floor, until you feel a stretch in your right shoulder. Hold for 5 seconds. Repeat 15 to 20 times. As your range of motion increases, you should be able to push your arm down closer to the floor.

Muscle strengthening exercises — Muscle strengthening exercises are necessary to improve shoulder muscle strength and help to prevent further injury. You can begin strengthening the shoulder once your shoulder has full range of motion, including overhead activities, with minimal pain. Consult with your provider or physical therapist to determine when to begin strengthening exercises.

As pain improves, the level of difficulty of these exercises should be increased. Increased difficulty is necessary to improve muscle strength to a degree that reduces the risk of re-injury. Mild soreness is expected with these exercises, although pain should not continue for more than 24 hours. Sharp or severe pain during or after exercising may indicate a flare of the underlying problem; stop these exercises for a few days if this occurs.

Preparing for strengthening exercises — Before performing these exercises, stretch the injured shoulder with the pendulum stretch or wand exercise, described above (see 'Pendulum stretch' above).

Rest after stretching for two or three minutes, then perform 15 to 20 repetitions of each exercise slowly, holding for one to two seconds during each exercise. Flexible rubber tubing, a bungee cord, or a large rubber band can be used for each exercise (figure 3).

Do not perform ANY exercise below if you experience any amount of discomfort or pain in the shoulder. Strengthening exercises should not cause ANY pain.

Scapular squeezes — Lie on your back with your knees bent and feet flat (picture 1). Your arms should be straight out, 6 to 12 inches (15 to 30 cm) away from the side of your body, with palms facing upward. Keeping your low back flat against the ground, squeeze your shoulder blades downward and towards each other, towards the spine. Make a conscious effort not to shrug your shoulders and keep the neck relaxed. You should feel the lower muscles between your shoulder blades contracting. Hold for five seconds. Rest as needed then repeat 10 to 15 times. Do this exercise two to three times per day.

The difficulty can be increased by performing the squeezes while sitting. Hold a piece of tubing in each hand and pull the hands apart while squeezing the shoulder blades together, as described above.

Outward rotation exercise — Hold your elbows at 90 degrees, close to your sides; holding a towel between your torso and the inside of your elbow will cue you to keep your elbow by your side. Hold one end of a long rubber band (eg, Theraband®) in each hand and rotate the affected forearm outward two or three inches, holding for five seconds (picture 2). Repeat 10 to 15 times.

Perform the exercise through all available pain-free ranges of motion. Keep the shoulder blades squeezed down and back while performing this exercise.

Inward rotation exercise — Hold your elbow at 90 degrees, close to your side. Hook a rubber band (eg, Theraband®) onto a door handle and grasp with only one hand. Rotate your forearm towards the body two or three inches and hold for five seconds (picture 3). The forearm swings like a door. Repeat 10 to 15 times.

Abduction exercise — Bend your elbow to 90 degrees. Place the rubber band near the elbows. While keeping your shoulder blades squeezed down and backwards, lift your arms up four or five inches away from the body, holding for five seconds (picture 4). Repeat 10 to 15 times. Avoid shrugging the shoulders while performing this movement.

Scapular strengthening — For these exercises, you should lie face down on an elevated surface, like a bed, exercise bench, or large exercise ball. The head should be held in line with the body, hanging over the edge of the bed or bench. Let the arms rest below the body. Extend the arms next to the head to form a "Y"; make sure your thumbs are facing up (picture 5) . Hold the position for a second or two, then let the arms return to the floor. Repeat 10 to 15 times. Movements should be steady, smooth, and pain-free.

Using the same body position, squeeze your shoulder blades down and backwards towards the spine while moving the arms to form a "T." Raise the arms straight out to each side, parallel to the floor (picture 6). This can be done with the thumbs up or down. Hold for a second or two, then return the arms to the starting position; repeat 10 to 15 times.

Position the arms to form a "W." Hold the arms bent with elbows pointed towards the feet and hands pointed towards the head (picture 7). Squeeze the shoulder blades and raise the arms until they are parallel with the floor, hold for a second or two, then return arms to the starting position; repeat 10 to 15 times.

Position the arms to form an "L." Hold arms bent with upper arms parallel to the floor and hands pointed towards the floor (picture 8). Rotate the arms such that the forearms become parallel with the floor. Hold for a second or two, then return to the starting position; repeat 10 to 15 times.

To increase the difficulty of these exercises, increase the number of repetitions to 20 to 30 times. Using 1 pound weights can further increase the difficulty.

Maintenance exercises — Once rehabilitation is complete, it is important to keep the shoulder muscles strong to maintain fitness and prevent a recurrence of pain. Non-athletes may continue to perform the exercises.

Athletes may perform exercises that are similar to those required in their sport. As examples, a tennis player may perform a service-type motion using a five pound dumbbell, while a pitcher may perform a throwing motion using a three pound dumbbell.

Anyone who performs frequent overhead activities needs to maintain strong shoulder blades and rotator cuff muscles to prevent overuse injuries of these areas. These muscles are essential in preventing aggravation to the tendons.

Return to activities — Most people with rotator cuff tendinitis see improvement in pain and function after 6 to 12 weeks of rehabilitation.

IF PAIN PERSISTS

If shoulder pain does not improve after several weeks of physical therapy exercises, most clinicians will recommend further evaluation (see 'Rotator cuff injury tests' above).

If tendinitis is confirmed with an imaging study, some clinicians will inject a steroid/local anesthetic mixture into the joint. Although clinical studies of steroid injections do not show that the injection is helpful in all cases, some people do benefit. In these people, pain and inflammation may improve quickly, usually within a few days. If the injection is helpful, it can be repeated once per month for up to three months.

If you have another cause for your pain (eg, rotator cuff tear, nerve impingement), you will usually be referred to an orthopedic surgeon for further evaluation and treatment.

SURGICAL REPAIR OF ROTATOR CUFF TEARS

The need to surgically repair a torn rotator cuff depends upon your age, activity level, and the severity of your tear. (See 'Rotator cuff tear' above.)

• Surgical repair is usually recommended for people with a complete rotator cuff tear, especially if the person is young and/or active. Surgery is usually recommended soon after the injury, if possible, to prevent the tendon and muscle from shrinking.
• Conservative treatment is usually recommended first if you do not have a complete rotator cuff tear or are older, less active, or if there is minimal pain. Conservative treatments (eg, stretching and strengthening exercises, injection of a steroid) are usually recommended first.
• Surgery may be recommended if you do not improve after stretching and strengthening exercises and you have persistent pain, limited strength, have arthritis or spurs that cause pain and interferes with rehabilitation, or if a new injury occurs and you have a previous rotator cuff injury.

There are several ways to repair the rotator cuff, including open and arthroscopic techniques.

• Open repairs require a 3 to 4 inch incision in the skin over the shoulder.
• Arthroscopic surgery requires several (2 or 3) smaller incisions, through which a telescope-like device with a camera and light (called an arthroscope) and other instruments are inserted.

The advantage of arthroscopic surgery is that there is usually less pain and a faster return to normal activities, including sports.

Most surgeries are performed in a hospital or surgical center, after you are given general anesthesia. The surgery takes one to two hours. Most people can go home several hours after the surgery is completed.

Return to activities — After surgical repair, most people require 6 months of rehabilitation before strength and shoulder function return to normal. Post-surgical rehabilitation is necessary and use of the shoulder must be limited. Immediately after surgery, you will be allowed to use the affected arm with your elbow at your side for eating, using the keyboard, using the telephone, and driving. Above-the-shoulder activities are not usually allowed for three months after surgery.

Sporting activities can be gradually restarted, including golfing at four months, light weight lifting at four months, swimming at five months, and throwing and tennis playing at five to six months.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient information: Rotator cuff injury (The Basics)
Patient information: Biceps tendinopathy (The Basics)
Patient information: Frozen shoulder (The Basics)
Patient information: Elbow tendinopathy (tennis and golf elbow) (The Basics)
Patient information: Shoulder impingement (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient information: Biceps tendinitis or tendinopathy (Beyond the Basics)
Patient information: Elbow tendinopathy (tennis and golf elbow) (Beyond the Basics)
Patient information: Frozen shoulder (Beyond the Basics)
Patient information: Nonsteroidal antiinflammatory drugs (NSAIDs) (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Evaluation of the patient with shoulder complaints
Frozen shoulder (adhesive capsulitis)
Presentation and diagnosis of rotator cuff tears
Rotator cuff tendinopathy

The following organizations also provide reliable health information.

• National Library of Medicine

     (www.nlm.nih.gov/medlineplus/healthtopics.html)

• American Academy of Orthopaedic Surgeons

     (http://orthoinfo.aaos.org/)

• National Institute of Arthritis and Musculoskeletal and Skin Disease

     (www.niams.nih.gov)

• American Physical Therapy Association

     (www.apta.org)

• Arthritis Foundation

     (www.arthritis.org)

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