Overview

Rotator cuff injury is a strain or tear of the rotator cuff. The rotator cuff is made up of four separate tendons that fuse together to surround the shoulder joint.

Causes of a rotator cuff injury include:

• direct blow to the shoulder area
• falling on an outstretched arm
• repetitive overhead motion of the arm such as in swimming, baseball (mainly pitching), and tennis

Risk factors that increase your chance of getting a rotator cuff tear include:

• age: 40 or older
• heavy lifting
• activities that involve repetitive overhead arm motion
• weakened shoulder muscles from inactivity

Diagnosis

Symptoms of a rotator cuff tear include:

• recurrent, constant pain, particularly with overhead activities
• pain at night that prevents you from sleeping
• muscle weakness, especially when lifting the arm
• popping or clicking sounds when the shoulder is moved
• limited range of motion in the shoulder joint

The doctor will ask about your symptoms and medical history, and perform a physical exam. The doctor will carefully examine your shoulder. You will be asked to move your shoulder in several directions. Tests may include:

• x-rays, to rule out fractures and bone spurs
• arthrogram

Dye is injected into the shoulder joint and then an x-ray is taken. The doctor will look for dye that leaks out of the joint, which indicates a tendon tear.

• magnetic resonance imaging (MRI) scan
  This is a test that uses magnetic waves to make pictures of the inside of the shoulder. This will show bones and tendons, and is an excellent way to determine either large or small tears of the cuff.
• arthroscopy
  A thin, lighted tube is inserted through a small incision in the shoulder to look at the structures inside the shoulder. Arthroscopy can also be used for treatment.
• ultrasound
  Although relatively uncommon in the United States, ultrasound can be useful in examining the rotator cuff for inflammation or tears.

Treatment Options

The treatment will depend on the extent of your injury, level of pain, and amount of immobility. The first step is usually a non-surgical approach.

Non-surgical Options

• rest to help the shoulder heal

The doctor may recommend that you wear an arm sling to help rest the shoulder area.

• nonsteroidal anti-inflammatory medications to help control the pain
• corticosteroid injections to help reduce swelling and pain
• ice to help reduce swelling and pain

Apply ice to shoulder area for 15 minutes, three to four times a day.

• physical therapy to help decrease inflammation and restore strength and motion to the shoulder area

Surgical Options

• arthroscopy
  A small instrument is inserted into the shoulder and used to remove bone spurs or degenerated portions of the rotator cuff tendons. Lesser tears can be repaired during arthroscopy as well.
• mini-open repair with arthroscopy
  This combines arthroscopy with an incision in the shoulder joint. Through the incision, the doctor can suture larger tears in the tendons.
• open surgery
  This is used to repair the injured tendon in more severe cases. A tissue transfer or a tendon graft can be done during surgery if the tear is too large to be closed together. In the most severe cases, a joint replacement may be necessary.

Prevention

To reduce your chances of getting a rotator cuff injury:

• Avoid overhead repetitive motion.
• Avoid heavy lifting.
• Exercise regularly to strengthen the muscles around the shoulder joint.

How do rotator cuff injuries develop?

Rotator cuff injuries can be caused by a direct blow to the shoulder or by excessive rubbing of the rotator cuff and the top part of your shoulder blade (called the acromion).

These types of injuries can cause the rotator cuff to tear or develop impingement syndrome. Participating in sports that require excessive overhead motion can cause impingement problems. If you do not seek medical care for the inflammation in your shoulder, it could eventually lead to a more serious injury.

Shoulder impingement involves one or a combination of problems, including inflammation of the lubricating sac (bursa) located just over the rotator cuff, a condition called bursitis; inflammation of the rotator cuff tendons, called tendonitis; and calcium deposits in tendons caused by wear and tear or injury. A torn rotator cuff is also a potential outcome of shoulder impingement.

Types of impingement include:

• Bursitis
  Frequent extension of the arm at high speed under high load, such as pitching a baseball or playing racquet sports, can cause bursitis. Medical research shows that the older you get, the more likely you are to develop bursitis.
• Tendinitis
  Tendinitis develops over time and is likely to occur when a person whose muscles are not in good condition starts an overly aggressive training program. In younger athletes, the causes of tendonitis are similar to those of bursitis.

How can I prevent a rotator cuff injury?

While some rotator cuff problems are associated with direct blows or falls, most are caused by overuse. One of the best ways to prevent these overuse injuries from recurring is to listen to your body and take rest when you need it, or seek medical care for your shoulder inflammation instead of trying to "work through the pain."

Furthermore, the rehabilitation exercises should be continued to ensure protective strength, range of motion, and stability of the injured area.

Other preventive techniques include:

• Don't play tennis or golf in an attempt to "loosen up" tightness. When a shoulder injury is ignored, it can become the source of chronic problems.
• If your shoulder is sore after you use it actively, especially at the limits of your reach, give it some rest. If pain persists or worsens, consult your doctor.
• Do exercises to strengthen arm, back, and chest muscles.
• Learn the proper technique for exercise and sporting activities. This will decrease stress on all your muscles, ligaments and tendons, including those around your shoulder.

Improving sports performance

The key to improving sports performance after recovering from a rotator cuff injury is a proper rehabilitation program, and adhering to some of those same principles after the injury is gone. Refer to the rehabilitation exercises regularly.

Also, the single most important aspect of improving performance is stretching before and after you step onto the field, court, ice, or golf course.

Benefits derived from stretching include:

• increased physical efficiency and performance
• decreased risk of injury
• increased blood supply and nutrients to joint structures
• increased coordination
• improved muscular balance and postural awareness
• reduced stress
• enhanced enjoyment

Rotator cuff rehabilitation

As an athlete, your number one concern is getting back to full strength as soon as possible so that you can return to training and competition. That is why appropriate rehabilitation is extremely important. Rehabilitation for a torn rotator cuff or impingement often includes the following:

• rest during the acute phase
• ice injury multiple times per day
• compression of the injured shoulder with an elastic compression bandage (ACE bandage) to limit swelling and pain
• use of anti-inflammatory medications such as ibuprofen to reduce inflammation and speed up recovery

Many rotator cuff injuries can be rehabilitated with a sling to immobilize your arm and shoulder. You also may be required to temporarily wear a shoulder brace when you return to your sport. These devices help hold the shoulder in place while the rotator cuff heals. Your doctor also may prescribe rehabilitation exercises once the sling is removed.

The major objectives of rehabilitation from a rotator cuff injury are to increase flexibility, obtain pain-free range of motion, and strengthen the muscles of the shoulders, upper back, front chest, and upper arms. In severe cases, you should avoid activity that causes shoulder pain altogether. In these cases, you can still maintain cardiovascular fitness by cycling, unless otherwise prescribed by your doctor.

Surgery is rarely needed to repair a shoulder impingement. However, it may be needed to repair very serious bursitis or torn rotator cuff.

Keep in mind that rehabilitation for bursitis may be much more involved. In these cases, your doctor may prescribe special physical therapy and recovery time will vary.

Rehabilitation exercises

Rehabilitation exercises often prescribed by your doctor may include stretching and strengthening exercises such as the following:

• Overhead stretch
  Lie on your back with your arms at your sides. Lift one arm straight up and over your head. Grab your elbow with your other arm and exert gentle pressure to stretch the arm as far as you can.
• Cross-body reach
  Stand and lift one arm straight out to the side. Keeping the arm at the same height, bring it to the front and across your body. As it passes the front of your body, grab the elbow with your other arm and exert gentle pressure to stretch the shoulder.
• Towel stretch
  Drape a towel over the opposite shoulder, and grab it with your hand behind your back. Gently pull the towel upward with your other hand. You should feel the stretch in your shoulder and upper arm.
• Shrugs
  Stand with hands at sides with no weight in either hand. Raise shoulders to the point of pain and hold for five seconds. Relax for five seconds. Perform this sequence 10 times, 3 times daily. As pain permits, hold dumbbells of equal weight in each hand while performing this exercise. Add weight by using hand-held dumbbells as pain permits.
• Bicep curls
  Stand with arms fully extended at sides while grasping 2- to 5-pound weights in each hand, held palm forward. Flex the arms at the elbow to approximately 100 degrees, or to the point of pain, whichever comes first. Hold this position for 5 to 10 seconds. Return to the start position. Rest for 5 seconds. Repeat this exercise 10 times. You can increase the weight as pain allows and strength develops.
• Triceps curls
  Stand with elbows directed upward over the shoulders and with arms relaxed. Extend arms at the elbow so that the hands proceed upward to the point of pain. Hold this position for five seconds. Return to the starting position and relax for five seconds. Perform this sequence 10 times, 3 times daily. As pain permits, add weight by using hand-held dumbbells.
• Chest raises
  Lie on belly with hands extended along sides of the body. Raise the upper chest from the floor to the point of pain and hold this position for 5 seconds. Return to the start position and relax for 10 seconds. Repeat this sequence 10 times, 3 times daily.
• Saws
  Reach out and place the unaffected side hand on a corner of a table. Bend at the waist. Flex the injured side arm at the elbow and pull the injured side arm backward and upward as if sawing wood. Slowly bring the shoulder blades as close together as pain will permit. Slowly bring the injured side arm down to its beginning position. Repeat this sequence 10 times, at least three times daily.
• Pendulum swings
  Stand with the hand of the unaffected arm resting on the corner of a table and supporting some of the body weight. Slightly bend the knee on the unaffected side and extend the other leg sideways. Allow the injured arm to hang loosely over the unaffected side foot. By shifting the body weight, cause the relaxed injured arm to swing in circles to the fullest extent possible as limited by pain. Perform 25 swings in a clockwise direction. Allow the injured arm to cease swinging. Perform 25 swings of the injured arm in a counterclockwise direction. Repeat this sequence at least three times daily.
• Shoulder rotation
  Stand in a doorway with affected side arm bent at the elbow and the palm of the hand against the doorframe. Turn the body away from the injured side hand until a stretching sensation is felt in the injured shoulder. Hold this position for 10 seconds. Return to the starting position. Relax for 10 seconds. Repeat this sequence 10 times at least three times a day.
• Shoulder flexion
  Stand erect close to a wall. With the palm of the injured side arm turned so as to face you, slowly slide the forearm and then the upper arm up the wall by moving closer to the wall. Slide the arm upward to the point of initial significant pain. Hold this position for 10 seconds. Return to the starting position and relax for 10 seconds. Repeat this sequence 10 times, at least three times daily.
• Flexed elbow pull
  Bend and raise the injured side elbow to shoulder height. Grasp the injured side elbow with the uninjured side hand. Gently pull the injured side elbow toward the opposite shoulder until limited by first significant pain. Hold this position for 10 seconds. Relax for 10 seconds. Repeat this sequence 10 times at least three times daily.

Alternative exercises

During the period when normal training should be avoided, alternative exercises may be used. These activities should not require any actions that create or intensify pain at the site of injury. They include:

• water running
• stationary bicycle (add resistance gradually from one session to the next, as pain allows)

Rehabilitation after surgery

Surgery may be needed to repair a shoulder impingement or severe rotator cuff tear. In these cases, you will need to wear a sling or figure-of-eight strap while your shoulder heals.

When your doctor decides you are ready, you may start range-of-motion and strengthening exercises. You may be referred to a physical therapist to assist you with these exercises and under no circumstance should you return to sports activity until your shoulder is fully healed.

A physical therapy program usually begins with range-of-motion and resistive exercises, then incorporates power, aerobic and muscular endurance, flexibility, and coordination drills.

How long will the effects of the injury last?

To some extent, the time to fully recover from a rotator cuff injury is influenced by your dedication to your rehabilitation program. Typically, athletes require anywhere from 2-12 weeks of healing time, depending on the severity, before returning to their sport.

When can I return to my sport or activity?

Return to full participation should be avoided until your rotator cuff injury has healed and you can perform all skills and other requirements of your sport without pain.

Remember: the goal of rehabilitation is to return you to your sport or activity as soon as is safely possible. If you return too soon you may worsen your injury, which could lead to permanent damage. Everyone recovers from injury at a different rate. Return to your activity is determined by how soon your rotator cuff recovers, not by how many days or weeks it has been since your injury occurred.