Rotator Cuff Problems

The rotator cuff is a structure consisting of four tendons that help you elevate your shoulder. The rotator cuff is the most common source of pain, weakness and dysfunction about the shoulder. While the rotator cuff can be injured in a fall, a motor vehicle accident or by other trauma, most of the time it gets damaged simply by normal wear and tear, especially if overuse is involved.

There are a lot of misconceptions about the rotator cuff. Many surgeons were taught that the rotator cuff gets injured because the bone above it, the acromion, has a hook or a spur that ‘impinges’ against it when the shoulder is raised. This has led to the term ‘impingement syndrome’ being commonly used to describe rotator cuff pain. Because of this, the most common shoulder surgery performed is the ‘subacromial decompression’ or ‘acromioplasty’, where bone from the acromion is removed to relieve this impingement.

However, essentially all of the recent research has shown that this is not true. This ‘hook’ or ‘spur’ is formed within a very important back-up structure, the CA (coracoacromial) ligament. Many MRI and cadaveric studies have shown that this ‘hook’ or ‘spur’ doesn’t cause problems in the vast majority of patients. In fact, surgically removing the CA ligament, that the hook is inside, can cause a significant number of problems including, in some cases, permanently losing the ability to elevate the shoulder.

The real reason that the rotator cuff has problems is because its blood supply is poor, and the rotator cuff has a critical, high-demand job opposing other bigger and stronger muscles to keep the shoulder stable. The rotator cuff develops tendinosis (tendon degeneration) because the stress placed on the shoulder is greater than the rotator cuff’s strength ability to handle this stress. The tendon degenerates and pain occurs. Most people use the term ‘tendinitis’, but that term implies inflammation, which does not actually occur; therefore the term ‘tendinitis’ is inaccurate, although commonly used. Older physicians may use the term ‘bursitis’, but this term is extremely inaccurate. Pain from the rotator cuff can occur over the front or outside of the shoulder, and can radiate to or past the elbow. It’s usually worse at night, when elevating the shoulder, when putting your hand behind your back (as when putting your hand in your back pocket, fastening your bra or reaching into the back seat of a car) and with sudden motion.

The cure for most cases of rotator cuff pain (ie. ‘impingement syndrome’) is specialized strengthening exercises for the rotator cuff and often the shoulder blade muscles. In most cases, this will solve the problem. The exercises are taught by a therapist and performed using elastic resistance (big rubber bands), which work better than dumbbell weights. A steroid injection may also be given. The injection is not a long-term cure, but it can decrease pain and keep the shoulder from hurting at night and allow the rotator cuff strengthening exercises to be performed better, without discomfort. The relief from injections lasts an average of three months, although they don’t help some people at all and others swear the injection cured them.

If three months of strengthening and an injection don’t lead to a decrease in pain, then the choice is to: 1) accept the problem and live with it, 2) continue strengthening, although if exercises haven’t helped after 2-3 months the odds are low that they will in the future, 3) have surgery.

While most surgeons are most familiar with the arthroscopic subacromial decompression, which removes the ‘bone spur’ or ‘hook’, this procedure simply does not work that well. Many times appropriate strengthening exercises are not tried before surgery, so that this surgery is often performed in cases where the strengthening would have cured the problem. After the surgery is done, strengthening is then taught to the patient, who then recovers. But was it the surgery or the therapy that helped?

Good question: Dr. Kirkley conducted an excellent research study where she made sure that all of her patients had appropriate strengthening performed before surgery and then operated only on those patients who didn’t get better from the strengthening. The results? Only 47% (less than half) got better from subacromial decompression (aka. acromioplasty).1 A more recent study by Dr. Ketola showed that patients that had the subacromial decompression surgery plus strengthening did no better than those patients who had strengthening alone without surgery.2

So if subacromial decompression doesn’t work any better than rotator cuff and shoulder blade strengthening alone, what surgery does? There is another arthroscopic procedure where the bad degenerated tendon (ie. the tendinosis) is removed. This is called arthoscopic rotator cuff debridement (ARCD) and is extremely effective. The acromion bone and any ‘hook’ or ‘spur’ is not addressed, unless it is obviously a problem. In two original research studies that I published3,4 ARCD led to excellent or good results in 79- 87% of patients that had already failed 3-6 months of rotator cuff and shoulder blade strengthening. The complication rate was extremely low, and no patient was made worse. This is in contrast to the subacromial decompression, where permanent pain, stiffness, and even permanent loss of shoulder elevation may occur. For a better description of the ARCD procedure, complete with photographs, please see the ‘Rotator Cuff’ section of my website.

In summary, most patients with pain from rotator cuff degeneration (also called ‘tendinitis’, ‘bursitis’ or ‘impingement syndrome’) can be cured with a simple exercise program. For those that don’t get better from exercises alone, ARCD is an extremely effective arthroscopic outpatient (no overnight stay) surgery, with a low complication rate. Following ARCD, the vast majority of patients obtain significant, if not total, pain relief and resume the work and play activities that they enjoy most.

References:
1) Kirkley A, Litchfield RB, Jackowski DM, Lo IK: The use of the impingement test as a predictor of outcome following subacromial decompression for rotator cuff tendinosis. Arthroscopy 18:8-15, 2002.
2) Ketola, S., J. Lehtinen, et al: Does arthroscopic acromioplasty provide any additional value in the treatment of shoulder impingement syndrome?: a two-year randomised controlled trial. J Bone Joint Surg Br 91: 1326-34, 2009.
3) Budoff JE, Nirschl RP, Guidi EJ: Debridement of Partial-Thickness Tears of the Rotator Cuff Without Acromioplasty: Long-Term Follow-up and Review of the Literature. J Bone Joint Surg 80A:733-748, 1998.
4) Arthroscopic Rotator Cuff Debridement (Without Decompression) for Tendinosis, Budoff JE, Rodin DM, Ochiai D, Nirschl RP, Arthroscopy, Vol 21; 1081-9, 2005

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