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Rotator Cuff Disease / Impingement Syndrome
Frequently Asked Questions |
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- What
is the rotator cuff in the shoulder?
- What
is impingement syndrome?
- How
does impingement syndrome relate to rotator cuff disease?
- Why
do some people develop impingement and rotator cuff disease and others
do not?
- Other
than impingement, what else can cause rotator cuff damage?
- What
symptoms does a patient have when the rotator cuff is injured?
- How
is the diagnosis of rotator cuff disease proven?
- What
is the initial treatment for rotator cuff disease and impingement?
- What
is the second line of treatment if pain and weakness persist?
- If
the rotator cuff is already torn, what are the options?
- What
will happen if the rotator cuff is not repaired?
- How
is a major injury to the rotator cuff tendon repaired surgically?
- How
is my shoulder treated after surgery?
- What
is the rehabilitation program after rotator cuff surgery?
- How
successful is rotator cuff surgery?
- 1. What is the rotator cuff in the shoulder?
- The rotator
cuff is a group of flat tendons which fuse together and surround
the front, back, and top of the shoulder joint like a cuff on a shirt
sleeve. These tendons are connected individually to short, but very
important, muscles that originate from the scapula. When the
muscles contract, they pull on the rotator cuff tendon, causing the
shoulder to rotate upward, inward, or outward, hence the name
"rotator cuff."
- 2. What is impingement syndrome?
- The uppermost tendon
of the rotator cuff, the supraspinatus tendon, passes beneath
the bone on the top of the shoulder, called the acromion. In
some people, the space between the undersurface of the acromion and
the top of the humeral head is quite narrow. The rotator cuff
tendon and the adherent bursa, or lubricating tissue, can therefore
be pinched when the arm is raised into a forward position. With repetitive
impingement, the tendons and bursa can become inflamed and swollen and cause the painful situation known as "chronic impingement syndrome."
- 3. How does impingement syndrome relate to rotator cuff disease?
- When the rotator
cuff tendon and its overlying bursa become inflamed and swollen with
impingement syndrome, the tendon may begin to break down near its
attachment on the humerus bone. With continued impingement, the
tendon is progressively damaged, and finally, may tear completely
away from the bone.
- 4. Why do some people develop impingement and rotator cuff disease when
others do not?
- There are many
factors that may predispose one person to impingement and rotator cuff
problems. The most common is the shape and thickness of the acromion (the bone forming the roof of the shoulder). If the acromion has a bone
spur on the front edge, it is more likely to impinge on the rotator
cuff when the arm is elevated forward. Activities which involve
forward elevation of the arm may put an individual at higher risk for
rotator cuff injury. Sometimes the muscles of the shoulder may become imbalanced by injury or atrophy, and imbalance can cause the
shoulder to move forward with certain activities which again may cause
impingement.
- 5. Other than impingement, what else can cause rotator cuff damage?
- In young, athletic
individuals, injury to the rotator cuff can occur with repetitive
throwing, overhead racquet sports, or swimming. This type of injury
results from repetitive stretching of the rotator cuff during the follow-through
phase of the activity. The tear that occurs is not caused by impingement,
but more by a joint imbalance. This may be associated with looseness
in the front of the shoulder caused by a weakness in the supporting
ligaments.
- 6. What kind of symptoms does a patient have when the rotator cuff is
injured?
- The most common
complaint is aching located in the top and front of the
shoulder, or on the outer side of the upper arm (deltoid area).
The pain is usually increased when the arm is lifted to the overhead
position. Frequently, the pain seems to be worse at night, and
often interrupts sleep. Depending on the severity of the injury, there
may also be weakness in the arm and, with some complete rotator cuff
tears, the arm cannot be lifted in the forward or outward direction
at all.
- 7. How is the diagnosis of rotator cuff disease proven?
- The diagnosis of
rotator cuff tendon disease includes a careful history taken
and reviewed by the physician, an x-ray to visualize the anatomy
of the bones of the shoulder, specifically looking for acromial spur,
and a physical examination. Atrophy may be present, along with
weakness, if the rotator cuff tendons are injured, and special impingement
tests can suggest that impingement syndrome is involved. An MRI (magnetic resonance imaging) scan frequently gives the final proof of
the status of the rotator cuff tendon. Although none of these tests
is guaranteed accurate, most rotator cuff injuries can be diagnosed
using this combination of exams.
- 8. What is the initial treatment for rotator cuff disease and impingement?
- If minor impingement
or rotator cuff tendinitis is diagnosed, a period of rest coupled
with medicines taken by mouth, and physical therapy will
frequently decrease the inflammation and restore the tone to the atrophied
muscles. Activities causing the pain should be slowly resumed only when
the pain is gone. Sometimes a cortisone injection into the bursal
space above the rotator cuff tendon is helpful to relieve swelling and
inflammation. Application of ice to the tender area three or
four times a day for 15 minutes is also helpful.
- 9. What is the second line of treatment if the rotator cuff pain and
weakness persist?
- If there is a thickened
acromion or acromial bone spur causing impingement, it can
be removed with a burr using arthroscopic visualization. This
procedure can often be performed on an outpatient basis, and
at the same time, any minor damage and fraying to the rotator cuff tendon
and scarred bursal tissue can be removed. Often this will completely
cure the impingement and prevent progressive rotator cuff injury.
- 10. If the rotator cuff is already torn, what are the options?
- When the tendon
of the rotator cuff has a complete tear, the tendon often must be repaired
using surgical techniques. The choice of surgery, of course,
depends on the severity of the symptoms, the health of the patient,
and the functional requirements for that shoulder. In young working
individuals, repair of the tendon is most often suggested. In some older
individuals who do not require significant overhead lifting ability,
surgical repair may not be as important. If chronic pain and disability
are present at any age, consideration for repair of the rotator cuff
should be given.
- 11. What will happen if the rotator cuff is not repaired?
- In some situations,
the bursa overlying the rotator cuff may form a patch to close
the defect in the tendon. Although this is not true tendon healing,
it may decrease the pain to an acceptable level. If the tendon edges
become fragmented and severely worn, and the muscle contracts and atrophies,
repair at that point may not be possible. Sometimes in this situation,
the only beneficial surgical procedure would be an arthroscopic operation to remove bone spurs and fragments of torn tissue that catch when the
arm is rotated. This certainly will not restore normal power or strength
to the shoulder, but often will relieve pain.
- 12. How is a major injury to the rotator cuff tendon repaired surgically?
- The arthroscope
is extremely helpful when repairing rotator cuff tendons, but sometimes
it is necessary to add a "mini-open" procedure if the tendon
is completely torn. Using the arthroscope at the beginning of the case
allows visualization of the interior of the joint to facilitate trimming
and removal of fragments of torn cuff tendon and biceps tendon. The
next step utilizes the arthroscope to visualize the spur and thickened
ligament beneath the acromial bone, while they are removed with miniature
cutting and grinding instruments. If it is necessary to suture a rotator cuff tear which has pulled off the bone, a two-inch incision
can be made directly over the tear that has been visualized and localized
using the arthroscope. The deltoid muscle fibers can be spread apart
so that strong stitches can attach the rotator cuff tendon back to the
bone. If the tear is minimally retracted, small suture screw anchors
may be used arthroscopically or open.
- 13. How is my shoulder treated after surgery?
- In a minor operation
for impingement, the shoulder is placed in a simple sling. If
a full thickness tear of the rotator cuff was present and repaired,
then the shoulder will be supported by an UltraSling or a AASTHA
postoperative brace. The brace is very helpful because it will allow
exercise of the elbow, wrist, and hand at all times, and places
the arm in a position that promotes better blood circulation and relieves
stress on the repaired rotator cuff tissues. In addition, the shoulder
can be exercised in the brace much easier than when it is at the side
in an immobilizer.
- 14. What is the rehabilitation program after rotator cuff surgery?
- Depending on the
type of surgery performed, the program will allow a period of time for
healing of the soft tissues followed by time to regain range of motion and then strengthen the shoulder muscles, but particularly the rotator
cuff. In minor tendinitis and impingement syndrome, the program
takes approximately two to three months. If the rotator cuff
tendon has been completely torn, it may take six months or more
before the atrophied muscles can resume their function and the range
of motion of the arm is restored. Frequently, pain relief is much quicker
and return to daily activities is often possible by two to three months.
- 15. How successful is rotator cuff surgery?
- Again, every case
is unique. In the young, healthy person with a minor rotator cuff impingement,
surgery is predictably successful. As the injury becomes more severe,
such as with a large bone spur and fragmentation of the tendon, then
a perfect result cannot be expected. Since it is necessary to trim back
the unhealthy tendon before reattaching it to the bone, a decreased
range of motion of the shoulder will often result. Despite this, pain
relief and return of strength are usually well worth the
minor decreased mobility. The final outcome often depends on the willingness and ability of an individual patient to work on their postoperative
physical therapy program.
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