Condition of the Month: Rotator Cuff Syndrome

Overview

The shoulder is a relatively unstable ball and socket joint. It is stabilized by the rotator cuff, a group of four small muscles that wrap around the shoulder and serve to hold the arm bone (humerus) against the shoulder blade (scapula) during shoulder movements. However, many of the rotator cuff tendons are hidden under the bony point of the shoulder (acromion) and are therefore, quite prone to injury. Rotator cuff syndrome is a vague term used to describe the collection of injuries that can occur to the rotator cuff. These include, but are not limited, to the following:  rotator cuff tear (full or partial), rotator cuff tendinitis, rotator cuff tendinopathy, calcific tendinitis, bursitis, and shoulder impingement syndrome. Since all of these conditions present very similarly, I'll talk about them as one. They're all separate diagnoses but often overlap with one another.

Causes

Rotator cuff tendinitis/tendinopathy/tear
These are terms that describe inflammation or degeneration of the rotator cuff tendons. Typically, this injury occurs over time due to repetitive overuse and general wear and tear of the shoulder. Usually, it is caused by repeated overhead activity or participating in sports such as baseball or swimming. Rotator cuff tears can occur due to repeated microtrauma or after a significant traumatic event, such as a fall or a motor vehicle accident.

Bursitis
In between the rotator cuff tendons and the bony prominence of the shoulder is a bursa (a fluid-filled lubricating sac). The bursa provides a smooth surface for the tendons to glide over and protects the tendons from rubbing over the bone during movement. Bursitis occurs when this bursa becomes inflamed and irritated. This could be caused by various reasons such as repeated minor trauma due to overuse (i.e. work, sports, etc.) or a single more significant trauma (i.e. hit, fall, etc.).

Shoulder impingement
All of the above conditions could cause or be caused by shoulder impingement syndrome. This occurs when either the rotator cuff tendons or the bursa becomes intermittently trapped and compressed under the bony acromion during shoulder movements. Impingement does not occur during normal shoulder function. However, if it does, the rotator cuff tendons can become swollen and inflamed (tendinitis). Likewise, the bursa could become inflamed (bursitis). These conditions can co-exist or present independently. Many factors can cause shoulder impingement, and these are grouped into either primary or secondary impingement.

Primary shoulder impingement is caused by a structural problem of the shoulder. Some of us are born with acromions of different shapes and sizes, and this could result in a smaller subacromial space (the area under the bony acromion). Others may have narrowed spaces due to bone spurs and osteoarthritis. Because of this structural narrowing, soft tissues are more likely to be compressed and irritated.

Secondary shoulder impingement occurs when there is a dynamic instability of the shoulder. This could include a combination of muscular weakness around the shoulder, excessive joint mobility, and ligament laxity. It usually develops over time due to poor posture, repetitive overhead activity, trauma, or previous injury. In an unstable shoulder, the rotator cuff muscles must work even harder to control movement, leading to consistent inflammation and wear and tear. On the other hand, if the rotator cuff muscles do not function properly, the arm bone is not centered in the ball and socket joint, and this results in abnormal compression and irritation of the surrounding soft tissues.

Signs and symptoms

• Pain (and maybe swelling) in the front of the shoulder and side of the arm
• Pain that may radiate from the shoulder down to the elbow
• Pain when sleeping on the affected shoulder at night
• Pain or weakness that is especially worse when reaching or lifting overhead
• Pain when putting the hand behind the back or behind the head
• Clicking or snapping sensation in the shoulder
• A gradual loss of shoulder mobility and function
• Difficulty with activities such as putting on a coat, reaching for the seatbelt, driving, putting on a bra, brushing hair, reaching for the back pant pocket, etc.

Physiotherapy Treatment

• Rest:  Initial treatment of rotator cuff injuries includes resting and avoiding aggravating activities that cause pain. Because many of the conditions are caused by overuse and repetitive activities, resting the shoulder will help to reduce irritation and inflammation.
• Activity modification:  In addition to resting the shoulder, other techniques can be employed to prevent flareups. It includes modifying activities such as carrying things closer to the body, avoiding carrying bags on one shoulder, taking frequent breaks from repetitive activities, minimizing overhead lifting, avoiding sleeping on the same side every night, practicing good posture while sitting, and many more.
• Modalities:  Various modalities can be used to decrease swelling and inflammation such as ultrasound and cold laser therapy. Ice is sometimes recommended as well; however, I've noticed that tendons respond really well to heat. A major reason why tendons are prone to injury and are slow to recover is due to poor blood flow. Heat definitely helps to increase circulation and promote healing. 
• Acupuncture and dry needling:  Many people who have rotator cuff diseases tend to have a lot of trigger points in the surrounding muscles of the shoulder. Acupuncture and intramuscular stimulation are beneficial in releasing these tight soft tissues and muscle imbalances.
• Manual therapy:  In today's society, many of us present with forward rounded shoulders due to the many hours that we spend sitting hunched over in front of the computer. Joint mobilizations are typically performed to re-center the shoulder "ball" back into the "socket" joint. Repositioning the shoulder joint and increasing mobility will help the rotator cuff muscles function more optimally. Soft tissue techniques are also used to release tight muscles that may be contributing to the problem.
• Exercise:  Rotator cuff strengthening is important to stabilize the shoulder joint. They are the primary stabilizers of the shoulder but are often neglected or overlooked because these muscles are small, and they don't add any aesthetic value. Also, people who have shoulder issues tend to have dysfunctional scapular movement patterns; therefore, scapular stabilizers need to be trained as well. 
• Bracing and taping:  Bracing techniques can be used to help re-center the arm bone into the shoulder socket. This will temporarily alleviate symptoms of impingement and irritation of the surrounding tissues.

Other treatments

• Anti-inflammatory pain medications
• Cortisone injections
• Surgery