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Rotator Cuff Tear

What is it?

The rotator cuff is a series of four muscles that surround the ball of the shoulder (humeral head). The rotator cuff and tendons allows your shoulder to move in different ways (lifting, rotating) while keeping the shoulder secure in the socket, providing strength and stability. A rotator cuff tear is characterized by pain and weakness of the shoulder due to tearing of the rotator cuff tendons and can be either partial (not completely severed) or complete also known as a “full-thickness” tear.

What causes it?

Rotator cuff tears can be the result of a single, traumatic injury or event, or can result from prolonged over use. If you fall on an outstretched arm or lift a heavy item with a sudden motion, it is possible to tear the rotator cuff, while some tears are the result of a wearing down of the tendon that occurs slowly over time. This degeneration occurs naturally as we age. Bone spurs may develop and, over time, weaken the rotator cuff as they rub against the tendons. Many athletes who perform repetitive overhead movements, such as baseball players, tennis players, or rowers, develop this issue.

Risk factors include:

  • Contact sports (football, wrestling)
  • Throwing sports (baseball, tennis)
  • Weightlifting/bodybuilding
  • Heavy labor
  • Previous injury to rotator cuff
  • Poor physical conditioning
  • Increasing age
  • Spurring of the acromion (bone spur formation)

What are the symptoms?

People with rotator cuff tears often complain of pain and/or weakness when lifting, lowering, or rotating the arm. Sometimes people feel a crackling sensation when moving their shoulder. Pain is usually worse with increased use, and with sleeping on the affected side. You may experience a loss of strength and limited range of motion, especially when reaching behind or across your body. Many activities, such as combing your hair or getting dressed, may become difficult.

How is it diagnosed?

After discussion of your symptoms and medical history, examination of your shoulder will allow your doctor to see what areas are tender and check your range of motion and strength.Imaging tests will likely be recommended, including x-rays and MRI.

What are the treatment options?

Nonsurgical treatment including rest, activity modification, limited overhead activity, or using a sling may be effective. Anti-inflammatory medication or a cortisone injection may be recommended. Specific exercises may be prescribed, or you may benefit from physical therapy, to help restore movement and strengthen the shoulder.

Surgery is often recommended in acute tears to allow full muscular recovery, and occasionally in chronic tears which fail to recover from a full course of rehabilitation.

What is involved in surgery?

Surgery to repair a torn rotator cuff most often involves re-attaching the tendon to the head of the humerus (upper arm bone), but the type of surgery recommended depends on the size, shape, and location of the tear. Partial tears may require only a trimming or smoothing procedure, whereas complete tears in the thickest part of the tendon are often repaired by suturing the tendon back to its body attachment. Any of these tears can potentially be treated with arthroscopic techniques which allow a shorter duration of pain and rehabilitation.
 

Impingement Syndrome

What is it?

Impingement syndrome is characterized by pain motion of the shoulder due to inflammation of the rotator cuff tendons, bursitis, or a partial rotator cuff tear. The rotator cuff is a series of four muscles and tendons that surround the ball of the shoulder (humeral head), which work together to lift, rotate, and stabilize your shoulder. Impingement results from pressure on the rotator cuff from part of the shoulder blade (scapula) as the arm is lifted. Above the rotator cuff is a bony projection from the scapula called the acromion. Due to its position over and in front of the ball of your shoulder, it can rub (or “impinge”) on the surface of the rotator cuff.

Between the rotator cuff tendons and the acromion, there is a protective fluid-filled sac called a bursa. When you lift your arm, there is some contact between the rotator cuff, the bursa, and the acromion, but if inflammation of the bursa (bursitis) exists, the swollen bursa may become pinched between the humeral head and the acromion, causing impingement pain.

Impingement syndrome may represent a grade 1 or 2 strain of the tendon. A grade 1 is a mild strain, meaning a slight pull without obvious tearing and there is no loss of strength. A grade 2 strain is a moderate strain, characterized by the tearing of fibers within the tendon or where tendon meets bone or muscle, and there is decreased strength. A grade 3 strain is a complete rupture of the tendon.

What causes it?

Impingement syndrome can occur following strain from a sudden increase in the amount or intensity of activity, from a direct blow to the shoulder, from an acromial spur (bone spur), or just aging and degeneration of the tendon with normal use.

Risk factors include:

  • Contact sports (football, wrestling)
  • Throwing sports (baseball, tennis)
  • Weightlifting/bodybuilding
  • Heavy labor
  • Previous injury to rotator cuff
  • Poor physical conditioning
  • Increasing age
  • Spurring of the acromion (bone spur formation)

What are the symptoms?

People may experience mild symptoms to start. Common symptoms include pain that radiates from the front of the shoulder to the side of the arm that is often present during activity and with rest. There may be sudden pain when lifting or lowering the arm, or with performing reaching movements, including behind your back or across your body. When shoulder impingement progresses, it may become difficult to do

activities that require strength or motion. With acute bursitis, the shoulder may become severely tender and all movements may become limited or painful.

How is it diagnosed?

After discussion of your symptoms and medical history, examination of your shoulder will allow your doctor to see what areas are tender and check your range of motion and strength.

Imaging tests will likely be recommended, including x-rays and MRI. What are the treatment options?

Nonsurgical treatment of impingement syndrome is often recommended first. This may include rest, activity modification, limited overhead activity, and anti-inflammatory medication. Stretching and strengthening exercises may help and physical therapy may be recommended. Some patients have success with cortisone injections, which can relieve pain and allow patients to continue their stretching and strengthening exercises.

When nonsurgical treatment does not relieve pain, your doctor may recommend surgery to remove the impingement.

What is involved in surgery?

The goal of surgery is to eliminate the shoulder pain caused by impingement by creating more space for the rotator cuff. This can be done arthroscopically in an outpatient procedure. Your shoulder will be immobilized in a sling for a short period of time following surgery until you begin increasing shoulder flexibility and strength through stretching and strengthening exercises. Full recovery can take two or three months.

 

Biceps Tendon Tear at the Shoulder

What is it?

The biceps muscle is a two-headed muscle that lies in the front of the upper arm, between your shoulder and your elbow. Its primary actions are to bend the arm at the elbow (flexion) and turn the palm face up (forearm supination). If the biceps tendon is torn at the shoulder, there is a loss of strength in the arm, along with an inability to forcefully turn the arm from palm down to palm up. Your biceps tendon attaches the biceps muscle to bones in the shoulder and the elbow.

There are two attachments of the biceps tendon at the shoulder joint. The long head attaches to the top of the shoulder socket (glenoid) and the short head attached to a bump on the shoulder blade called the coracoid process. The long head of the biceps tendon is more likely to be injured due to its location; the short head of the biceps rarely tears. Because of this second attachment, many people can still use their biceps even after a complete tear of the long head.

What causes it?

The two main causes of biceps tendon tears are injury and overuse. An injury to the biceps tendon might involve a hard fall onto an outstretched arm or lifting something too heavy. Wearing down and fraying of the tendon occurs naturally as we age and can be worsened by overuse and repetitive motion.

Risk factors include:

  • Age
  • Heavy overhead activities
  • Shoulder overuse

What are the symptoms?

  • Sudden, sharp pain in the upper arm
  • Cramping of the biceps muscle
  • Bruising from the upper arm down to the elbow
  • Pain and tenderness at the shoulder and elbow
  • Difficulty turning your palm up or down
  • Weakness in the shoulder and elbow
  • At times an audible “pop” or snap may be heard at the time of injury
  • As the biceps muscle contracts, it may cause a bulge in the upper arm above the elbow.

How is it diagnosed?

After discussion of symptoms and medical history, examination of the shoulder will be performed. The diagnosis is often obvious for complete ruptures because of the deformity of the arm muscle. Partial ruptures are less obvious. Pain when using your biceps muscle may indicate a partial tear.

X-rays may be useful in ruling out other problems that can cause shoulder pain. Magnetic resonance imaging (MRI) can show both partial and complete tears.

What are the treatment options?

Nonsurgical treatment is successful for most patients and they are able to successfully resume all pre-injury activities. Initial treatment consists of medication and ice for pain relief, gentle active stretching and strengthening exercises, and activity modification to avoid those motions that cause pain. For many people, pain from a long head biceps tendon tear resolves over time.Surgical options are available when other options fail.

What is involved in surgery?

Surgery is occasionally recommended to reinsert the tendon into the humerus (upper arm bone). This is known as a biceps tenodesis. Surgery is most often recommended for younger, more active individuals, but may also be indicated for those undergoing surgical treatment for associated conditions, such as rotator cuff tears. Following a period of immobilization, you will undergo a gradual return to activities over several months as recommended by your surgeon. Rotator cuff repair adds to this recovery timetable.

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