Injuries to the Shoulder: When should you worry?
By Robert Dow Hoffman, M.D
Each year, more than four million people in the United States visit their doctor for diagnosis and treatment of shoulder problems. While there are many potential causes of shoulder pain, rotator cuff problems account for a large percentage of these visits. This is especially true for people over 40 years old. Rotator cuff problems become increasingly common as we get older, and for some people, the pain associated with them can be quite debilitating.
The term “rotator cuff” refers to the four muscles that originate on the shoulder blade (scapula) and insert on the top of the humerus, effectively covering the ball of the shoulder joint. These muscles work in a coordinated fashion to rotate and elevate the shoulder. Sitting directly above these muscles are a bony extension of the scapula called the acromion, and the end of the collarbone or clavicle. These bones can be easily felt just under the skin on the top of the shoulder. Normally, as you move your shoulder, these rotator cuff muscles glide smoothly under this bony roof with the help of a thin fluid filled sac called a bursa found between the rotator cuff and the acromion.
As a result of advancing age, overuse, or a traumatic event, this smooth motion can be lost and rotating and elevating the shoulder can become painful. The fluid filled sac or bursa can become inflamed, a condition known as “bursitis.” As the problem progresses, the tendons of the rotator cuff can wear and become thickened, a condition known as “tendonitis.” Later, as the injury to the rotator cuff progresses, the tendons of the rotator cuff can fail and detach from the humerus resulting in a “rotator cuff tear.”
The main complaint of patients with rotator cuff problems is pain. Although some patients can recall a specific event or injury that caused their shoulder pain, most patients cannot. It often occurs with activities such as throwing and overhead lifting. Many patients note they are unable to sleep on the painful shoulder. They may also note weakness or decreased endurance when using the affected arm. Some patients feel a grinding sensation when they move their shoulder.
When patients present these symptoms to their doctor, a careful history, physical exam, and regular x-rays are often used to differentiate rotator cuff problems from other causes of shoulder pain. In some cases, magnetic resonance imaging (MRI) or ultrasound may also be used to assist in making the correct diagnosis. X-rays may also be taken after dye has been injected into the shoulder in a test called an arthrogram to diagnose a rotator cuff tear. This test, although common in the past, is used less often today with the advent of MRI.
Once the rotator cuff problem has been identified, a number of treatment options are available. The majority of patients can be treated successfully with a combination of rest, use of pain relieving medications, and physical therapy. Physical therapy usually involves stretching exercises to improve motion along with exercises aimed at strengthening the rotator cuff muscles. An injection of a corticosteroid, often referred to as a “cortisone injection,” can also be helpful in relieving pain. However, multiple injections of corticosteroids over a short period of time into the shoulder probably decrease the healing ability of the rotator cuff tendons and should be avoided.
Some patients continue to have pain despite several months of rest, physical therapy, and use of pain relieving medications. For those patients, surgical treatment may be considered. Surgical treatment of rotator cuff problems can be accomplished through an incision over the top of the shoulder, but over the past several years, arthroscopic treatment has become increasingly popular. Both methods are used to accomplish the same goals: repair the rotator cuff tendons to the humerus and remove all bone spurs that can abrade the rotator cuff. Arthroscopic surgery of the shoulder is performed using a small camera called an arthroscope placed into the shoulder through a small incision. This type of surgery offers similar long term outcomes to the standard open procedures but avoids large scars and damage to the deltoid muscle that can occur in an open procedure. The vast majority of patients can expect significant pain relief after rotator cuff surgery. However, the recommended treatment varies from patient to patient. Individual questions can be answered by your orthopaedic surgeon.
Dr. Hoffman can be contacted at Chatham Orthopedics, 4425 Paulsen Street, Savannah, GA 31405; 912-355-6615