Rotator Cuff Lesions

The rotator cuff comprises a group of four muscle-tendon units that wrap around the front, top, and back of the shoulder joint. The muscles, which are connected to bones by tendons, move the shoulder in many directions and hold the humeral head (ball) and the glenoid (socket) together. A bursa, which lies over the tendons, reduces tension between the tendons and bone and protects the tendons from excessive pressure (Figs. 1 and 2).


If you overuse or injure your rotator cuff, you can develop lesions (changes in the tissue). There are many degrees of rotator cuff lesions. You may have a minor lesion, such as inflammation or tendinitis (inflammation of the tendons), or you may have a more severe injury, such as a partial tear of the muscle and tendon fibers or a complete tear of the tendon that causes the muscle to pull away from the bone (Figs. 3 and 4).

Symptoms
Symptoms associated with a rotator cuff tear are often mild at first and worsen overtime. Common symptoms include pain at night and pain that worsens with activities, particularly when using your arm over your head (e.g., lifting a box off a shelf. These symptoms are similar to those of tendinitis or bursitis (inflammation of the bursa). However, unlike bursitis or tendinitis, which gets better when you rest, modify your activities, and take anti-inflammatory medications (such as aspirin or ibuprofen), the symptoms of rotator cuff tears may not get better with the usual treatment.

In addition to pain, your arm and shoulder may feel weak when you use your arm over your head or when you raise your arm out to the side of your body. Occasionally, a trivial activity, Such as lifting a suitcase from the trunk of a car, may cause acute pain in the shoulder. This pain may indicate that your partially torn rotator cuff is now completely torn or your degenerative rotator cuff tendon is torn.

Causes
There are many things that can cause the rotator cuff to tear. Constant stress and wear from doing the same activity over and over can cause the tendons to fray from the bone. The rotator Cuff tendons often tear in people who are about 40 years of age or older because their tendons have been worn down slowly over time from the stresses of everyday work and activities, especially when the work or activities were done with their arms over their head. The rotator Cuff tendons of a person with an abnormally loose or unstable shoulder can get sandwiched between the humeral head and acromion (roof of bone above the tendons) and eventually can tear (Fig. 5). And sometimes, natural variations in the way the shoulder joint is built causes abnormal wear on the tendons that can cause a tear.

Treatment
The first treatment your doctor will ask you to try to relieve the inflammation and irritation of the rotator cuff tendons and the bursa over the tendons is resting and icing your shoulder and taking anti-inflammatory medications. occasionally, the doctor may inject cortisone (a strong anti-inflammatory medication) in the bursa to decrease inflammation and pain. When the inflammation is under control or has decreased significantly, You can do exercises that strengthen the muscles around the shoulder joint.

If you have had tendinitis of the rotator Cuff for a long time, you may develop irreversible changes that lead to partial or complete tearing of the rotator cuff tendons. If your rotator cuff is inflamed and partially torn, your doctor may remove bone spurs (ligament that has turned to bone where it attached to the bone) and inflamed tissue to create a more suitable environment for the tear to heal. Some people who have partial rotator cuff tears have little discomfort and function very well without Surgery. Exercises and an occasional injection of cortisone may hell) them control symptoms so they do not have to have surgery.

If the rotator cuff has completely torn and the muscle has pulled away from the bone, the doctor will usually operate on your shoulder to repair the tendons and remove bony prominences. The operation helps relieve the pain you have at night, during rest, and from daily activities.

To repair the torn rotator cuff, the doctor makes an incision in your shoulder. After removing the overlying bursa and any degenerative, frayed, or fragmented pieces from the edges of the torn tendon, the doctor decide how to repair the rotator cuff tendon. If the tear is small, the ends of the tendon may be sewn together. However, if the tear is large, the doctor will attach the tendon to the bone on the other side. First, the doctor creates a small trough in the humeral head and drills several small holes in the bone. Next, three or four sutures (stitches) are placed through the tendon and tied (Link to Fig. 6).

After surgery, your shoulder will be immobilized to help the rotator cuff heal. Before the brace is removed, you will begin an exercise program to regain full range of motion in the shoulder and to strengthen shoulder muscles. Rotator cuff lesions can cause mild to severe shoulder pain and can cause you to limit your activities. Nonoperative treatment, such as strengthening exercises, having injections of cortisone, taking anti-inflammatory medications, and modifying your activities, may promote healing of a partial rotator cuff tear and help decrease the inflammation that causes pain. But you will probably need to have an operation if you have a complete tear.

George M. McCluskey III, M.D.
Columbus, Georgia