Questions about shoulder pain due to rotator cuff disease, answered by an orthopaedic surgeon

Rotator Cuff Tear-feature-2

Questions about shoulder pain due to rotator cuff disease, answered by an orthopaedic surgeon

Rotator cuff injuries are a common cause of shoulder pain and these injuries can significantly limit activities of daily living. The symptoms often start without an obvious injury and isolating the exact cause can be complex. Below are some of the common questions asked by patients regarding these injuries and their associated treatments.

What is the rotator cuff?

The rotator cuff is a group of 4 muscles and tendons that surround the shoulder joint, keeping the head of the humerus firmly within the shallow socket of the shoulder.

Each rotator cuff muscle and tendon is responsible for a different movement of the shoulder.

Rotator Cuff

How do I know I have damaged my rotator cuff?

Shoulder pain is the most common complaint. Pain is often first noticed when sleeping on the affected shoulder or when trying to do things with your hand above shoulder level. This could be simple activities like putting on a cap or brushing your hair but it can progress to a point where most movements are painful.

Shoulder stiffness is the second most common complaint and usually accompanies pain. Sudden severe weakness or inability to lift the arm after a seemingly insignificant injury, is a less frequent but possible first complaint.

What is rotator cuff disease?

Rotator cuff disease often starts as an inflammation of the tendons (tendonitis) and of the overlying bursa (bursitis). Impingement (which is where one or more of the tendons rub against the overlying bone – the acromion), and causes further inflammation and pain and possibly tears.

Calcium deposits can form in the injured tendons, which causes a painful condition called calcific tendonitis. The rotator cuff tendons can tear, causing pain and even severe weakness to the point where it is difficult to use the arm.

What other conditions are associated with rotator cuff disease?

Biceps tendonitis is inflammation and chronic pain of the long biceps tendon. Pain in the front of the shoulder is often due to biceps tendonitis as the tendon enters the shoulder between the first two rotator cuff tendons, and is virtually always involved when there is rotator cuff disease.

Acromioclavicular joint arthritis is arthritis of the joint that connects the collar bone or clavicle to the acromion of the shoulder. Pain due to arthritis can contribute to shoulder pain and should be addressed at the same time as the rotator cuff, if present.

What is the first-line treatment for rotator cuff disorders?

Oral analgesia and anti-inflammatory medication, steroid injections of the shoulder and physical therapy is the mainstay of early treatment. The goals are decreasing pain, relieving stiffness and recovering strength. Ultrasound-guided needling (barbotage) can also be helpful if calcific tendonitis is present.

What kind of surgery can be done to repair rotator cuff disorders?

When surgical treatment is required, most rotator cuff conditions can be addressed with arthroscopic or keyhole surgical techniques. It is important to remember that there are often multiple causes of shoulder pain as listed above, and that each cause needs to be addressed on its own merit.

  • Bursectomy: Excision and debridement of the inflamed subacromial bursa that overlies the rotator cuff.
  • Acromioplasty: Removal of a thin layer of bone above the rotator cuff to increase the space available for movement and to increase space and visibility to perform the rotator cuff debridement and repair.
  • Rotator cuff debridement and repair: The tendon ends are freshened up and the bone is debrided and prepared. The tendon ends are then repaired down to the bone, usually with a double row of specialized anchors and sutures.
  • Biceps tenodesis: The top part of the tendon that enters the shoulder joint is often very inflamed and painful. Debriding and shortening the tendon back to normal tissue and then anchoring it into healthy bone further down the arm, relieves the pain while also maintaining the correct length and strength of the muscle.
  • Synovectomy: Debridement of inflamed synovium.
  • Debridement of calcific tendonitis
  • Lateral clavicle excision: Excision of a few millimetres of the lateral or outside edge of the collarbone as it forms the acromioclavicular joint of the shoulder. This is necessary if there is painful osteoarthritis of the acromioclavicular joint. It creates a bit of space which prevents further contact and scratching of the bone ends, and thereby decreases pain.
Biceps Tenodesis
Biceps tenodesis

Rotator cuff repair

What are the risks or complications of rotator cuff surgery?

Adverse events following shoulder surgery such as infection and blood clots are extremely rare, but they cannot be completely eliminated. Complications are minimised by using a specific treatment plan that includes careful monitoring, specialized surgical and anaesthetic techniques and medications during and after surgery. Should you require surgery, your surgeon will discuss the possible complications with you in more detail. 

How long does it take to heal and rehabilitate after surgical repair of rotator cuff tears?

A specific rehabilitation program and access to a knowledgeable and experienced physiotherapist is extremely important to allow for the best recovery. 

Usually, the first 6 weeks involve permanent sling wear except during physiotherapy sessions, showering and specific home exercises prescribed by your physiotherapist.

Week 7 to 12 involve less sling wear, especially around the house, and more progressive physiotherapy work.

At Week 13 sling wear is stopped and normal daily activities are usually possible. Further rehabilitation that includes more specific sporting or leisure activities is started.

Progressive improvements in function and decrease in discomfort can be expected post-surgery up to at least 6 months but even up to 1 year. Rehabilitation for rotator cuff surgery is slow and careful but the benefits are worth the wait and the effort.

What happens if rotator cuff disorders are left untreated?

If all non-surgical treatment methods have been exhausted, no further improvement can really be expected. The symptoms could actually get worse over time and in the worst-case scenario, progress to a painful frozen shoulder.

In the long term, large tendon tears result in something called fatty degeneration in the rotator cuff muscles because they aren’t used anymore. After this has happened the outcomes of the rotator cuff repairs become much less successful as the muscle itself has become dysfunctional. 

If you have any further questions regarding your rotator cuff injury, please contact us.