Doctors disagree on rotator cuff injuries

You tore your rotator cuff? How can that be?! You don’t have any pain. Or maybe you do.

It might have started with an old tennis injury or other repetitive overhead activity. An incorrect weight training technique. Perhaps a fall on the ice. Even poor posture. Imagine wincing from pain as you simply raise your arm to comb your hair or get dressed.

Your rotator cuff includes shoulder muscles and tendons that connect your upper arm bone to your shoulder blade. The chances of tearing your rotator cuff increases as you get older. When you repeatedly develop tears, it’s usually because of degeneration and injuries. However, one serious injury can cause an acute rotator cuff tear.

Most often, they begin with partial tears. If a patient does not rest, ice and rehab with exercises under a doctor’s care, a partial tear can lead to a full thickness tear requiring surgery.

Doctors disagree.

Rotator cuff injuries remain the biggest reason why patients end up in waiting rooms with shoulder pain. This adds up to about 4.5 million physician visits and 40,000 surgeries a year in the U.S.

Despite this, controversy continues as physicians disagree on several points:
1.    What causes rotator cuff injuries?
2.    What role do tears play in generating pain?
3.    Can commonly accepted tests diagnose them?

Understanding the relationship between rotator cuff tears and shoulder pain continues to evolve. So clinicians can’t put too much weight on the presence or absence of pain when making a diagnosis.

Causes:

  • Degeneration with aging, which may be inevitable after 50
  • Injury
  • Overdoing it

Symptoms:

  • Pain, especially with overhead or reaching movement and at night, possibly while lying on the injured shoulder
  • No pain
  • Weakness

Risks:

  • 50 or older
  • Sports and occupations with lots of overhead activity
  • Smoking
  • Obesity
  • Trauma

Diagnosis:

Physical examination:

  • Can you raise and lower your arms without pain? Are you weaker when moving your arms out to your sides? If you’re older than 60, these are all that’s needed for diagnosis.

X-ray:

  • Usually normal. But anterior-posterior, lateral and outlet views can help when assessing large, chronic rotator cuff tears.

Ultrasound:

  • Can accurately diagnose a rotator cuff tear.

MRI:

  • Can accurately diagnose a rotator cuff tear; in addition, it can show the degree of the tear, tendon retraction and muscle atrophy, all critical in preoperative planning.

Treatment

It’s hard to detect partial thickness rotator cuff tears. Patients may have pain with little or no loss of function. Or no pain. But if you know you only have a partial tear, delay surgery.

Nonsurgical management:

  • Nonoperative management may be best for elderly and/or unhealthy patients.
    • Rest
    • Ice
    • Consider Ibuprofen
    • Stretch the shoulder capsule to restore flexibility and range of motion, as well as strengthen the periscapular, rotator cuff and deltoid muscles
    • If you have severe pain, one or two subacromial glucocorticoid injections may provide short-term relief. But they can also hurt healthy tendons.

Surgery:

  • Healthy individuals with acute, full thickness rotator cuff tears should see an orthopedic surgeon immediately.
    • Schedule surgery within six weeks of the injury or face significant muscle atrophy with tendon degeneration and retraction that may become irreversible, as well as poorer surgical results.

 

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