Feeling persistent shoulder pain? It could be a rotator cuff injury
Shoulder pain is common and can wreak havoc on your day-to-day life. It can be caused by several conditions, so it’s important to be checked out by a professional.
Seeking prompt help, especially if your rotator cuff is injured, is important so the injury doesn’t become more severe.
The rotator cuff is a group of four relatively small muscles that come together as tendons to form a cuff over the head of the upper arm bone, or humerus. It helps to lift and rotate the arm and shoulder and stabilize the ball of the shoulder within the joint during normal daily activities.
Rotator cuff injuries tend to occur more frequently with age, with people over 40 being at greater risk. The older you are, the more likely you are to have an injury to the rotator cuff. Professions that require repeated overhead motion such as construction workers, painters, carpenters and athletes — especially baseball pitchers, swimmers and tennis players — are particularly susceptible to rotator cuff problems. Falling is another common way to injure your shoulder.
“One common thread among patients is that they had a fall six months ago, maybe on the ice in the winter,” said Dr. Douglass Stull, an orthopedic surgeon at OrthoKansas. “They injured their shoulder, but the pain wasn’t enough to see a doctor at the time.”
High cholesterol levels and being a smoker also increase your risk.
What are the types of rotator cuff injuries?
Stull said that problems related to the rotator cuff are the most common diagnosis for shoulder-related complaints, whether they are acute or chronic. Acute injuries occur suddenly or from a specific event, such as falling on an outstretched arm or lifting something that’s too heavy. A chronic injury is one that develops slowly over a period of time.
“I think of the diagnosis as occurring along a spectrum of disease, from impingement — meaning the tendons in the rotator cuff are pinched — moving to partial-thickness (and) then full-thickness tears; and finally (injuries) that are irreparable,” he said.
When to see the doctor
Unless you have an acute injury, you might not be sure when to seek medical attention. If you’ve got any of these symptoms, it’s time to talk with your doctor:
• Persistent shoulder pain that has lasted for a month and hasn’t gotten better
• Difficulty sleeping due to shoulder or upper arm pain
• Dramatic change in range of motion, such as having trouble reaching a seat belt or bra strap
“It’s common that I’ll have a patient who fell six months prior and they’re just now coming to see me,” Stull said. “They may have fallen on the ice and injured their shoulder, but the discomfort wasn’t bothering them enough to call.”
Patients can expect to undergo a thorough examination at their first appointment. The provider will take a thorough health history, discuss any prior injuries and ask about any treatment that’s already been performed. You may also need to have X-rays, unless you’ve had recent images taken.
If you need more advanced imaging, Professional Radiologic Services, a partner of LMH Health, provides radiologists trained in musculoskeletal, or MSK, imaging.
“The beauty of having MSK-trained radiologists is their connection with orthopedics,” Stull said. “Dr. Todd Oberzan and Dr. Thomas Grillot can look at an image, and we’re able to communicate about it and zero in on the problem. They have the benefit of reading the exam notes, and having access to all of the patient’s medical records.”
Am I going to need surgery?
Seeing an orthopedic surgeon for a diagnosis doesn’t necessarily mean that you will end up having surgery. Depending on your history and examination, your doctor may recommend conservative treatment options before discussing surgical options.
Nonsurgical treatments may include taking a course of anti-inflammatory medications, such as Advil or Aleve, and physical therapy. Injections aren’t recommended until the presence of a tear has been confirmed or ruled out, as the treatment may affect surgical outcomes down the road.
“Rotator cuff injuries are the most common reason I send anyone to physical therapy. Seventy percent of chronic rotator cuff tears get better with therapy,” Stull said. “If you’re not at risk of an irreparable problem, we can treat you conservatively for an extended period of time.”
Physical therapy is often the first treatment and can be very effective. Stull sends many patients to Becky McClure, a physical therapist at LMH Health Therapy Services. Patients undergo an initial evaluation, which includes:
• Reviewing medical history, diagnostic testing and any prior shoulder problems
• Discussing normal activities at home, school, work, sport and hobbies
• Completing a physical examination, including a posture check, observing range of motion and testing muscle strength
“Once the evaluation is complete, we’ll talk about the findings and work with the patient to develop a plan of care to help resolve the problems,” McClure said.
Subsequent therapy visits include education on how to avoid aggravating activities and pain control. Patients perform exercises in the clinic and at home to retain shoulder mobility and strength. For some patients, these exercises provide enough improvement in range of motion, neuromuscular control, strength and endurance to regain full shoulder function.
“There isn’t a one-size-fits-all exercise program that’s suitable for everyone with a rotator cuff injury,” McClure said. “The physical therapist will develop an individualized exercise program for you based on your injury, evaluation and examination.”
Your physical therapy progress will be monitored and modified throughout your treatment until you can safely and comfortably return to normal daily activities. People with rotator cuff weakness or a minor tear might be in rehab for two to four weeks, though some injuries can be stubborn and take as long as four to six months to heal.
If medication and therapy don’t relieve your pain and improve function, you may need surgery to repair the injury. If you haven’t seen improvement over a six- to eight-week period of consistent therapy, you may fall into the 30% of patients for whom surgery is a treatment option.
A surgical recommendation may also depend on the severity of the rotator cuff tear. Stull said most tears requiring surgery are full-thickness tears. This means that part of one of the four tendons that make up the rotator cuff is completely detached from the bone. It isn’t common for partial-thickness tears, or those that only go part of the way into the tendon, to require surgery.
“Each patient has a different story and the indications for surgery aren’t always so straightforward. If you have an acute tear and you’re an active person, I’ll recommend surgery almost 100% of the time,” he said. “If you’ve got a fair amount of life ahead of you, you’ll generally do better with surgery than without.”
Patients who do undergo surgery will follow up with physical therapy to regain shoulder strength and mobility, typically for about four to six months. McClure said there are critical elements that factor into the duration of your rehab.
“The size of the rotator cuff tear, the surgical repair itself and the patient’s commitment to rehab all play a part in how long it will last,” she said.
Stull said that recovery generally takes about a year.
— Autumn Bishop is the marketing communications manager at LMH Health, which is a major sponsor of the Journal-World’s Health section.