Although there are many reasons for shoulder pain, a common problem for people over 40 years of age is a rotator cuff tear. The rotator cuff is comprised of the muscles and tendons that surround the top of the upper arm bone (humerus) and hold it in the shoulder joint. A tear may result suddenly from a single traumatic event or develop gradually because of repetitive overhead activities.

Signs and symptoms

• Recurrent, constant pain, particularly with overhead activities.

• Pain at night that prevents you from sleeping on the affected side.

• Muscle weakness, especially when attempting to lift the arm.

• Catching and grating or cracking sounds when the arm is moved.

• Limited motion.

• Usually occurs in the dominant arm (right shoulder for right-handed people; left shoulder for left-handed people).

• May be triggered by a specific incident.

Risk factors

• Repetitive overhead motion, such as pitching or painting a ceiling.

• Heavy lifting.

• Excessive force, such as a fall.

• Degeneration due to aging, including a reduction in the blood supply to the tendon.

• Narrowing of the space (acromioclavicular arch) between the collarbone (clavicle) and the top portion (acromion) of the shoulder bone (scapula).

• Abrasion (rubbing) of the cuff surface by the top portion of the shoulder bone.

Diagnosing a tear

When your consult your physician, he or she will ask you about your symptoms and any recent trauma or injuries. Your doctor will carefully examine the top and back of your shoulder to see if the muscles have begun to shrink (atrophy). You may be asked to move your arm in several directions, or to hold it in various positions. X-rays can help the doctor see any problems with the bones, although other imaging tests may be required to confirm a rotator cuff tear. One such test is an arthrogram, in which a dye is injected into the joint before the X-ray is taken. Other imaging tests include magnetic resonance imaging (MRI) and ultrasound.

Rotator cuff tears may be partial- or full-thickness. Partial-thickness tears do not completely sever the tendon and may respond well to nonoperative treatments. Full-thickness tears require surgery to correct. Surgery may also be used to treat partial-thickness tears that do not respond to nonoperative treatment.

Treatment options

Your doctor will prescribe a treatment regimen based on your injury and your need for pain relief, movement and function. In most cases, the initial treatment is nonsurgical and involves several modalities.

• Rest. If the tear is due in part to overuse, resting the shoulder may help.

• Nonsteroidal anti-inflammatory medications will help control pain.

• Strengthening and stretching exercises, as part of a physical therapy program, are recommended.

• Corticosteroid injections can help reduce pain but cannot be repeated frequently because they can also weaken the tendon.

• Ultrasound can enhance the delivery of topically applied drugs and has thermal effects that may also help in the healing process.

There are several surgical options to treat rotator cuff tears, depending on the size, depth, and location of the tear. If other problems with the shoulder are discovered during the surgery, they will be corrected as well.

• Arthroscopy, in which miniature instruments are inserted into small incisions, can be used to remove bone spurs or inflammatory portions of muscle and to repair lesser tears.

• A mini-open repair that combines arthroscopy and a small incision can be used to treat full-thickness tears.

• In more severe cases, open surgery is required to repair the injured tendon. Sometimes a tissue transfer or a tendon graft is used. Joint replacement is also an option.

Rehabilitation

It takes some time to recover from shoulder surgery. Full functioning may not return for six months or more. Your orthopaedic surgeon will recommend a program of exercises to strengthen and restore motion. Your commitment to following the program outlined will make a difference in the ultimate results. Although every case is unique, surgery can relieve pain for most people and rehabilitation can restore functional range of motion.

December 2000