Paul B. Roache, MD - Orthopaedic Specialist
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Tennis Elbow

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What is the Rotator Cuff?

The rotator cuff is a group of four muscles and their tendons of insertion that attach circumferentially around the shoulder joint to the upper most portion of the upper arm bone called the humerus. The shoulder joint itself is not a ball and socket joint, but rather the union of a large "ball" on one side with a shallow "dish" or saucer like surface attached to the scapula (or shoulder blade). The rotator cuff couples these structures together, providing both stability and mobility. Just above the rotator cuff lies a bony "roof" made up of the upper tip of the shoulder girdle called the acromion and the joint it makes with the clavicle (collar bone). Irregularities of these structures or the ligaments that attach to them can contribute to irritation of the underlying rotator cuff.

Mechanical wear and tear through repetitive overuse, recurrent trauma or injury, and muscle forces can result in localized injury to the rotator cuff tendon, which may then become inflamed and painful. Frequently, the shape of the overlying acromion and acromioclavicular joint may be prominent in patients with problems of the rotator cuff. This may be due to the patient's natural anatomy or it may be due to "wear and tear changes" resulting in formation of "bone spurs" along the front edge of the undersurface of the acromion and acromioclavicular joint. The rotator cuff may become squeezed between the humeral head and these overlying bony prominences as the arm is brought into elevation, resulting in damage to the rotator cuff through a process known as "impingement syndrome".

Signs and Symptoms of Rotator Cuff Disorders

Early stages of rotator cuff irritation are associated with some inflammation of the tendon itself, known as tendinitis. If wear and tear persists and damage continues, an actual erosion or degeneration of a portion of the thickness of the rotator cuff may result (either on the outer surface, the inner surface, or within the substance of the rotator cuff itself). This has been referred to as a "partial thickness rotator cuff tear". If the degenerative process continues unchecked, a complete erosion of a portion of the full thickness of the rotator cuff may result in what has been termed a "full thickness rotator cuff tear". With time and persistent damage, this tear may enlarge. Additionally, the tendon of a portion of the biceps muscle, which enters the shoulder joint just below the attachment of the rotator cuff, may also be worn and may rupture as part of this degenerative process. In some cases after longstanding tears of the rotator cuff have gone untreated, derangement in shoulder joint mechanics may result in arthritic changes of the actual shoulder joint known as a "cuff tear arthropathy".

Pain in and around the shoulder region, sometimes with radiation down the upper arm or across the upper shoulder, especially related to movement of the shoulder, is the most consistent symptom. Pain with reaching overhead, reaching back to put an arm in a sleeve or reaching to the back seat of an automobile, pain with lifting a heavy object or when rolling onto the shoulder in bed are all common symptoms. Weakness is also a common complaint with difficulty externally rotating the arm, lifting objects, performing a sustained overhead activity or performing a throwing motion.

How are Rotator Cuff Disorders Diagnosed?

A careful history and physical examination by your physician combined with diagnostic tests such as x-rays and special imaging studies usually lead to a correct diagnosis.

Common Treatments for Rotator Cuff Disorders

Treatment is based on the degree of severity of the symptoms. The primary treatment is a combination of rest, anti-inflammatory medication and rehabilitation progressing from gentle mobility exercises through progressive endurance and strengthening exercises as tolerated. When this conservative management fails to relieve symptoms over a prolonged period of time, surgery may be indicated. The type of surgery depends on the severity of the symptoms and the extent of the pathology. Frequently in the earlier stages of rotator cuff disease, arthroscopy can be used to remove offending bone spurs and arthritic changes and removes some of the inflammatory tissue. Smaller tears of the rotator cuff may be repaired using arthroscopy or with a technique combining arthroscopy with minimally invasive open surgery. Larger rotator cuff tears usually require open reconstruction and in those cases with endstage arthritic changes of the shoulder, joint replacement may be indicated.


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