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Rotator Cuff Problems

Impingement syndrome

The rotator cuff is a term given to three main tendons that wrap around the joint. These tendons come from the three muscles that come off the shoulder blade. One in front (the subscapularis muscle,) one on top, (the supraspinatus tendon) and one behind. (the infraspinatus muscle).

The cup part of the shoulder is very shallow (More mini-saucer like than cup like). This is the glenoid. It is shallow in order to allow the kind of movement that the shoulder is able to perform. The cup is “deepened” by the rotator cuff muscles that wrap around the head of the humerus and hold the ball centred on the cup/saucer. These tendons are essential to the normal function of the shoulder. These muscles stabilise the joint allowing the much bigger and stronger muscles like the deltoid and pectoralis muscle to move the joint.

The most common problem encountered in the shoulder is when the upper of the three tendons (The supraspinatus tendon) gets trapped between the humeral head and the acromion which is the hook of bone off the shoulder blade. (The piece of bone you put your hand on if you cup your shoulder with your opposite hand.)

This gives rise to a condition that is called impimgement syndrome. In this condition the tendon will rub on the underside of the acromion whenever the arm is moved into certain positions. Typically when the arm is at the patient’s side they tend to be pain free or relatively pain free. When the arm is lifted out to the side the tendon comes up against the underside of the acromion and induces pain. This gives rise to what is commonly called the “painful arc syndrome”. Other actions like reaching out, putting on a jacket, putting on a bra, changing gears (left shoulder) or closing the drivers door (right shoulder) are commonly described as aggravating factors by patients.

If a patient has impingement syndrome they get into a vicious cycle where the tendon is “swollen” and therefore rubs on the bone, which in turn makes the tendon swollen. This condition can usually be treated by injecting steroid into the bursa that sits on top of the tendon and beneath the acromion. (The subacromial bursa). Sometimes it is necessary to repeat the injection 2 or 3 times. Some people have an acromion that is shaped in such a way that the bone will continue to rub the tendon irrespective of the steroid injection.

The shape of the bone may simply be the individuals genetic make up or in some cases a hook of bone develops on the underside of the acromion. When the patient fails to respond to injections then a decompression of the tendon is performed. This involves inserting an arthroscope into the bursa and then a shaver which is used to shave the piece of bone off the acromion.

Unfortunately it is not possible to simply do an MRI scan and look at the shape of the acomion, as some people who have what look like normal acromions will get the condition while others with obvious hooks don’t seem to have any problems. As a result it is often by a process of elimination that candidates for surgery are selected.

Rotator cuff tears

If the tendon is allowed to rub on the acromion for long enough there is a risk that eventually a hole will form in the rotator cuff. If this occurs the continuous action of the muscles pulling on the tendon will typically enlarge the hole if it is not repaired. Usually the repair can be performed by means of key-hole surgery. If left long enough the hole will become so large that an open operation may be necessary. If totally neglected eventually the tendons retracts so far that the muscle becomes functionless and the tendon become irreparable.

Most rotator cuff tears occur gradually but many will be associated with an injury. In particular if an elderly patient dislocates their shoulder but continues to have pain in the shoulder there they may well have a tear of the cuff and should be attended to urgently.

(If you would like more information on rotator cuff repairs or subacromial decompression select Arthroscopic cuff repair or mini-open Rotator cuff repair.)

Rotator Cuff Arthropathy

In some patients who have an irreparable rotator cuff tear the lack of cuff means that the humerus is no longer held in place centred on the glenoid and starts to sublux or dislocate upwards. This will often interfere with function in the arm and can become very painful for some patients. In some cases the change in biomechanics will also cause arthritic changes in the joint. This condition tends to affect the elderly and depending upon the patient’s general health can be treated in a number of ways. If the patient is not well enough for any surgery sometimes repeated injections at regular intervals can keep the patient comfortable. If able to tolerate a short anaesthetic key hole surgery to decompress the bone sometimes relieves the symptoms. If all of this fails and the patient is able to tolerate a longer anaesthetic then a reverse shoulder replacement can be carried out which is very affective in treating the pain. This condition is one of the more difficult conditions to treat in shoulder surgery and is one that individual surgeons will approach differently. Not every surgeon will perform the reverse shoulder replacement.