How the cuff works and why it breaks
Four muscles—the supraspinatus, infraspinatus, teres minor, and subscapularis—use their tendons to form a cuff around the head of the humerus. The space between the cuff and the bony arch of the scapula is narrow, and each time the arm is raised, the tendon passes through it. Over the years, the edge of the arch thickens, the blood supply to the tendon deteriorates, and microdamages occur. Gradually, in the tendon, most often the supraspinatus muscle, first a partial and then a complete rupture is formed. In young people, the cause is usually a single injury - a fall on an outstretched arm or a sharp jerk.
- Degenerative rupture due to tendon wear
- Traumatic rupture from a fall or jerk
- Partial and complete rupture
- Massive rupture of multiple tendons
- Concomitant impingement syndrome and bursitis
Symptoms
The pain is usually felt along the outer surface of the shoulder and extends down to the middle of the arm, but not below the elbow. It intensifies when you raise your arm, place it behind your back, and especially at night, when a person lies down on the sore side. The second important sign is weakness: it becomes difficult to hold objects at arm's length, get things from the top shelf, or comb your hair. With a massive rupture, the arm almost does not rise actively, although the doctor lifts it passively without difficulty. Sometimes you hear clicks and a feeling of friction when moving.
- Pain on the outer surface of the shoulder
- Night pain, inability to lie on the affected side
- Weakness when raising and abducting the arm
- Difficulty getting dressed and combing one's hair
- Clicking and crunching noises when moving
- Gradual limitation of range of motion
Diagnostics
The examination includes special tests in which the doctor evaluates the strength of individual cuff muscles and the presence of pain in certain positions of the arm. An X-ray does not show the tendon, but reveals arthrosis, calcifications and the consequences of injuries, and in case of an old massive rupture, a characteristic upward displacement of the humeral head. Ultrasound is an accessible and informative method that allows you to see the gap in movement and compare it with the healthy side. MRI gives the most complete picture: the size of the tear, the condition of the muscles and associated damage; it is usually performed when planning an operation.
- Clinical tests for cuff muscle strength
- X-ray of the shoulder joint in two projections
- Ultrasound of the shoulder joint with dynamic tests
- MRI when planning surgery and questionable ultrasound
- Comparison with the opposite shoulder
- Rule out cervical radiculopathy for arm pain
Treatment without surgery
For partial and small tears, as well as in older patients with moderate demands on the shoulder, conservative treatment is started. The key role is played not by rest, but by properly structured physical therapy: first, the range of motion is restored, then the remaining muscles of the cuff and the muscles of the scapula, which stabilize the shoulder, are strengthened. Pain medications and physical therapy can help reduce pain and allow you to begin exercising. Hormone injections into the joint have limited use: they relieve pain, but with repeated use they deteriorate the quality of the tendon. The result is usually assessed after 3 months of regular exercise.
- Temporary restriction of overhead movements
- Short course painkillers
- Therapeutic exercise with gradual complication
- Strengthening the scapula muscles and correcting posture
- Physiotherapy as an adjunct to exercise
- Limited use of glucocorticoid injections
When is surgery needed?
Surgical repair is considered for an acute complete tear in an active person, when exercise has been ineffective for several months, or when there is significant weakness and impairment of daily activities. The operation is often performed arthroscopically: the tendon is sutured to the bone with anchor clamps, if necessary, expanding the space under the arch of the scapula. After the intervention, the arm is fixed on an abductor pad for several weeks, then passive and later active movements begin. Full recovery takes 4–6 months or more. The earlier the intervention is performed in case of an acute rupture, the better the result: over time, the muscle is replaced by fatty tissue and it becomes more difficult to suture the tendon.
- Arthroscopic suture of the rotator cuff
- Expansion of the subacromial space when indicated
- Fixation on abductor pad 4–6 weeks
- Staged rehabilitation: passive, then active movements
- Return to exercise in 4–6 months
- For a massive old rupture - other intervention options