Shoulder Injury: Rotator Cuff Tears

By Jeannette Franks, PhD, a passionate gerontologist who teaches at University of Washington and Bastyr University; she is the author of a book on assisted living and numerous articles.

Sometimes I wish I could take my body in for repairs just like I take my car to a mechanic to get new parts. “New battery or headlights-no problem!” But while wecanreplace more and more parts of the human body, some areas are less amenable to repairs and yet more subject to breakdown, particularly the knees and shoulders. Rotator cuff tears are one of the most common injuries in older people.

My own shoulder injury happened while hiking uphill on a rugged trail, fully-loaded with a heavy backpack. I grabbed a tree to keep from falling when I slipped, and although I broke my fall, my shoulder has not worked well since. It can happen to older people of all levels of fitness.

How The Shoulder Works

The shoulder is the most flexible joint in the body. While this allows us great range of motion, this same flexibility makes us more vulnerable to instability and injury. The shoulder is a ball-and-socket joint made up of three bones: the humerus (upper arm bone), the scapula (shoulder blade), and the clavicle (collarbone).

The joint capsule surrounding the shoulder joint is a thin sheet of fibers. The rotator cuff consists of four muscles (the supraspinatus, the infraspinatus, the subscapularis, and the teres minor) and their tendons covering the shoulder joint and joint capsule. Tendons are the stretchy cords that connect muscles to bones.

These tendons and muscles enable you to lift your arm, reach overhead, participate in sports, and perform normal activities of daily living.

How The Rotator Cuff Can Become Injured

A rotator cuff tear is most common in people over 40. However, it can occur at any age, either as a result of trauma, such as a fall or sharp tug on the arm, or a repetitive injury such as in sports, weight lifting, or overhead activities. Often tennis players, swimmers, pitchers, and basketball players will tear a rotator cuff. Workers in jobs such as construction, painting, or stocking overhead shelves are also at risk of shoulder injury.

A tear may also occur as a result of an accident causing a dislocation or fracture.

Symptoms

Most people with an acute tear immediately know something is wrong. The primary symptom is pain, especially on raising the arm or reaching behind. In an injury such as a collision, there may be a snapping sensation and weakness of the arm, as well as pain.

Of course, one should never continue to use the shoulder or participate in a sport if one suspects a shoulder injury has occurred. Use the “RICE” protocol as soon as possible:

• Rest
• Ice
• Compression
• Elevation (for a leg, foot, or ankle)

In the case of wear and tear over time, the repetitive activity becomes more and more difficult. As the tendon degenerates, one may feel pain radiating down the side of the arm or a burning sensation. It may be mild at first and easily alleviated with over-the-counter analgesics, ice, and rest. But the range of motion may be steadily decreasing, while the damage worsens.

Other symptoms include weakness in the arm, or a clicking or crackling sound or sensation when the arm is moved.

Diagnosis and Treatment

The physician will subject the patient to a variety of positions and stresses to elicit the major sign of a rotator cuff tear-pain. In addition to the physical examination, x-rays and an MRI (magnetic resonance imaging) may be required. Some cases may call for an arthrogram, where dye is injected into the joint in order to see the tear clearly.

Since there may be some ambiguity, the first line of treatment is generally ice, rest, and physical therapy. Non-surgical treatment options may also include the use of a sling, anti-inflammatory medication, and a steroid injection. If these do not restore the joint to normal function, the patient should revisit the doctor promptly for further examination and testing.

If the tendon or muscle has truly separated or become detached from the bone, surgery may be required. Tendons do not regenerate or reattach to the bone, no matter how excellent the physical therapy. Since there is no blood circulation in tendons, there is no re-creation of tissue. In some instances, delaying the surgical repair can increase the possibility that it will be more difficult to treat later.

Three types of surgery are available. Inarthroscopicrepair, a fiber optic scope and tiny instruments are inserted through small punctures. This minimally invasive surgery may result in a more rapid recovery.

Newer techniques and instruments permit surgeons to repair the rotator cuff through a very small incision-a “mini-open repair” using fiber optic instruments.

Anopen surgical repairis indicated if the tear is large or complex or further reconstruction is required. In some cases, shoulder replacement may be an option, especially with severe arthritis.

The choice of surgical technique is, of course, up to the surgeon.

Be sure to notify your physician immediately if you have any of these symptoms following surgery:

• Fever after the 2nd day following surgery
• Increasing pain or swelling
• Redness, warmth, or tenderness
• Unusual bleeding
• Numbness or tingling of the arm or hand

Rehabilitation

The duration of immobilization depends on the type of tear and type of surgery. Physical therapy tends to begin quite soon after the operation, often the same week. It is absolutely crucial to follow the regimen faithfully. Human nature being what it is, we tend to be dutifully compliant at first and then slack off once the arm starts working again. However, hard, painful work for at least several months is required for full recovery.

Prevention

An important prevention to shoulder injury is to increase upper body strength. This must be done very slowly and with proper technique and form. Usually a class or trainer is required, but make sure that he or she is an excellent certified professional. Many injuries occur at the gym under the supervision of someone who should have known better.

Arms should not be raised above the shoulder when standing and working out with weights in exercises such as the upright row. Many overhead lifts are performed in the safer prone position. I’ve witnessed many injuries in process when a group weight instructor demonstrates poor technique or fails to correct participants with incorrect form.

After mastering good form with an instructor, it’s easy for the patient to work out with weights at home; there are also many excellent DVDs to guide the patient. Or it may be more motivating to work out while watching a favorite TV show or listening to music.

It’s also important to do daily stretches, especially during and after working out.

It’s extremely important to “listen to your body.” Athletes no longer say, “No pain, no gain.” Pain is the body’s way of indicating that something is wrong. A bit of muscle tenderness or soreness is fine the day after. But pain during or immediately after a sport or working out indicates a problem. People need to learn to differentiate between the mild, tight feeling a muscle gets the day after being challenged, and the pain (even slight) during or immediately after doing damage to a joint, muscle, or tendon.

Regular exercise is the absolutely most important thing one can do to avoid a shoulder injury. Tendon injuries often occur in poorly conditioned muscles or “weekend athletes.” Older people are especially at risk and even simple activities such as getting out of a car can cause a serious injury in a sedentary person with poor upper body strength. Poor mobility leads to an even more restricted life and a downward spiral to frailty.