SHOULDER PAIN? IT MAY BE YOUR ROTATOR CUFF by Dr. Gregory Sarkisian

The rotator cuff consists of a group of four muscles located deep in the shoulder that are very important for everyday use of the shoulder. The shoulder joint is classified as a ball and socket joint of which the rotator cuff attaches to the ball component. Many people experience shoulder pain due to injury or damage to the rotator cuff muscles. The pain from rotator cuff pathology is usually felt on the top and outside of the shoulder. This pain occurs after use of the shoulder and is often quite significant at night when trying to sleep. The pain that keeps you from sleeping usually occurs on the outside of the shoulder. Rotator cuff pain is not limited to the top and outside of the shoulder but can occur anywhere between the shoulder and elbow. If you are experiencing pain at the base of the neck, behind the shoulder or below the elbow, your problem most likely is not from the rotator cuff. There are various ways a rotator cuff can be injured. A fall onto the shoulder or an outstretched arm certainly can produce a rotator cuff injury. However, the rotator cuff is usually injured over the course of time. People can develop some arthritic change in the joint located above the shoulder and at the far or distal end of the collar bone or clavicle. When this joint becomes arthritic, spurs form which can protrude down into the rotator cuff. Over time, with just normal use of the shoulder, the spur can eventually wear a hole into the rotator cuff itself. This is the most common type of rotator cuff problem. It is most common in people over the age of 45. Other ways to injure the rotator cuff are with overuse or abuse of the shoulder in athletic activities such as throwing, swimming and weightlifting.

Besides the pain described above, weakness in the arm is another sign that could indicate a rotator cuff problem. Specifically, weakness in the arm while doing an activity that requires your arm to be held away from your body is an indicator. A simple test for a rotator cuff injury would be to hold your arm straight down against the side of your body with the elbow straight. Then try to raise your arm to shoulder height while holding an object that weighs roughly 5-10 pounds. If this causes significant pain in the shoulder or you are unable to do it because of weakness in the shoulder you may have a rotator cuff problem.

When medical attention is sought usually x-rays of the shoulder are obtained. Often, the x-rays will reveal arthritic changes at the distal end of the clavicle with spur formation as previously mentioned. Sometimes arthritic changes are also noted in the ball and socket components in the shoulder joint. This can mimic rotator cuff pathology. Cortisone can be injected into the bursa of the shoulder which can offer significant relief of pain and improve function if there is not yet a rotator cuff tear. When injections do not offer relief it may indicate that the rotator cuff is torn. A simple, non-invasive test to diagnose a rotator cuff tear is an MRI (magnetic resonance imaging). An MRI is an imaging study which does not involve radiation and takes approximately 40 minutes. It clearly shows the rotator cuff muscle and tendon along with the bony structures of the shoulder. If there is a rotator cuff tear it can be seen on an MRI about 90% of the time. The good news is that over the past several years arthroscopy has been used to repair many rotator cuffs. This is a much less invasive way to repair a rotator cuff tear. Arthroscopic surgery involves two to four small 1/4” incisions into the shoulder. A camera and surgical instruments are inserted into the shoulder joint through the small incisions and the rotator cuff is repaired. With this technique there is much less damage to the surrounding tissues, recovery is much quicker and there is much less pain for the patient. This surgery is done without leaving large unsightly scars. With the advent of arthroscopy, rotator cuff repair has become an outpatient surgery.

One of the problems when dealing with the rotator cuff is when the pain has been neglected for a very long time. If the rotator cuff has been torn for several months or years, the tear can become so large that the tissues become difficult to repair arthroscopically. In this case, an open procedure may be used to do the repair. An open procedure requires an incision approximately 3-4 inches long on the top of the shoulder. Also, if a rotator cuff tear is neglected for a very long time, it can become irreparable. This leaves the patient with persistent pain and weakness in the shoulder. If the rotator cuff is not able to be repaired, progressive arthritis can settle in the shoulder joint.

So if you are experiencing discomfort in your shoulder, certainly try conservative measures at home. Try decreasing the amount of overhead lifting and other aggravating activities for a period of two weeks. You can also try using cold compresses for 20-30 minutes, 3-4 times a day as well as over the counter anti-inflammatory agents such as Advil or Aleve. Make sure you understand the side effects of these medications. If the pain still persists or returns upon resuming normal activities, medical attention should be sought.

With the newer techniques in rotator cuff surgery, a pain free shoulder could be a stones throw away.

Dr. Gregory Sarkisian is a partner at Precision Orthopaedic Specialties, Inc. and he is Chief of Orthopaedic Surgery at University Hospitals Geauga Medical Center

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