Rotator Cuff Disorders

Topic Overview

What are rotator cuff disorders?

The rotator cuff is a group of strong, ropelike fibers (tendons) and muscles in the shoulder . Rotator cuff disorders occur when tissues in the shoulder get irritated or damaged. Rotator cuff disorders include:

• Inflammation of the tendons (tendinitis) or of a bursa (bursitis). In the shoulder, a bursa is a small, fluid-filled sac that serves as a cushion between the tendons and the bones.
• Impingement, in which a tendon is squeezed and rubs against bone.
• Calcium buildup in the tendons, which causes a painful condition called calcific tendinitis.
• Partial or complete tears of the rotator cuff tendons. See a picture of a torn rotator cuff tendon .

How does the shoulder work, and what does the rotator cuff do?

The shoulder is a joint with three main bones: the upper arm bone (humerus), the collarbone (clavicle), and the shoulder blade (scapula). The bones are held together by muscles, tendons, and ligaments. The rotator cuff keeps the upper arm bone in the shoulder socket and lets you raise and twist your arm.

The shoulder is a ball-and-socket joint. The ball at the top of the upper arm bone fits into the socket of the shoulder blade. This socket is shallow, which lets you move your arm in a wide range of motion. But it also means that the muscles and tendons of the rotator cuff have to work hard to hold the bones in place. As a result, they are easy to injure and are prone to wear and tear.

What causes rotator cuff disorders?

Most rotator cuff disorders are caused by a combination of:

• Normal wear and tear. Using your shoulder for many years slowly damages the rotator cuff. As you age, everyday activities can lead to changes in the rotator cuff, such as thinning and fraying of the tendons and reduced blood supply.
• Overuse. Activities in which you use your arms above your head a lot-such as tennis, swimming, or house painting-can lead to rotator cuff problems. Even normal motions made often over a long period can stress or injure the rotator cuff.

Both normal wear and tear and overuse can lead to impingement, when a tendon rubs against bone. This damages and irritates the tendon, which causes bleeding and inflammation. Over time, scar tissue replaces healthy tissue, and the tendons become stiff, stringy, and more easily injured.

It takes great force to tear a healthy rotator cuff tendon. This can happen during sports, an accident, or a severe fall. But even a simple movement like lifting a suitcase can cause a rotator cuff tear in an older adult or someone whose shoulder is already damaged.

What are the symptoms?

Symptoms of a rotator cuff disorder include pain and weakness in the shoulder. Most often, the pain is on the side and front of the upper arm and shoulder. It may hurt or be impossible to do everyday things, such as comb your hair, tuck in your shirt, or reach for something. You may have pain during the night and trouble sleeping.

How are rotator cuff disorders diagnosed?

To diagnose a rotator cuff disorder, doctors ask about any shoulder injuries or past shoulder pain. They also do a physical exam to see how well the shoulder works and to find painful areas or activities. Moving your arm in certain ways can help a doctor learn about the condition of the rotator cuff.

You may have an X-ray to check the bones of the shoulder. If the diagnosis is still unclear, the doctor may order an imaging test, such as an MRI or an ultrasound.

How are they treated?

It is important to treat a rotator cuff problem. Without treatment, your shoulder may get weaker and you may not be able to lift up your arm.

For most rotator cuff disorders, doctors recommend these steps first:

• Rest the shoulder. Use the arm, but do so carefully. Don't keep the shoulder still with a sling or brace. This can cause the joint to become stiff (frozen shoulder).
• Use ice or heat on the shoulder, whichever feels better.
• Take anti-inflammatory drugs (NSAIDs) to relieve pain and reduce swelling and inflammation. Examples include aspirin, ibuprofen (such as Advil), and naproxen (such as Aleve).
• Avoid positions and activities that are uncomfortable, such as lifting or reaching overhead. Stop any activity that hurts the shoulder.

The doctor may also suggest physical therapy. Physical therapy can reduce pain and help your shoulder be stronger and more flexible. In physical therapy, you learn exercises to stretch and strengthen your shoulder. After you learn the exercises, you can do them at home.

It is important to give treatment time to work. It may take from a couple of weeks to several months to get good results.

If other treatments don't help, your doctor may give you shots of steroid medicine in the shoulder. The shots probably don't cure rotator cuff disorders, but they can help relieve pain and inflammation so you are able to do exercises to strengthen the shoulder. The shots may also help your doctor find out if your shoulder pain is from your rotator cuff. If a steroid shot near the rotator cuff relieves your pain, even if the pain comes back later, it means the rotator cuff-not some other shoulder problem-is causing the pain.

Most rotator cuff disorders are not treated with surgery, but doctors may do surgery if a rotator cuff tendon is torn or if several months of other treatments have not helped.

• Surgery may be a good choice if you are young and your rotator cuff has been in good shape. Surgery may not work as well if your tendons are weak and frayed.
• Surgery is not a substitute for physical therapy. Even after surgery, you may need months of physical therapy to have a full recovery.

Frequently Asked Questions

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	Rotator cuff problems: Exercises you can do at home

Cause

Rotator cuff disorders are caused by a combination of factors. The rotator cuff moves within a confined space called the subacromial space. Also within that space is a small sac of fluid (subacromial bursa), which serves as a cushion between the tendons and bone. When the subacromial space becomes smaller due to inflammation, bone spurs, or fluid buildup, the rotator cuff tendons may be squeezed and rub against bone (impingement). As a result, the tendons may become damaged and irritated, causing bleeding and inflammation of the bursa or tendons. With continuing damage, the tendons develop scarring and become stringy (fibrous), which makes them weaker and less flexible. Eventually, this may lead to partial or even complete tears.

A rotator cuff is more easily damaged or torn as age-related degeneration develops. The factors below often occur together or overlap.

• Bones that are irregularly shaped can affect how the rotator cuff moves in the subacromial space. You may be born with these irregularities, or they may occur after some type of injury, such as a broken bone or dislocation of the shoulder joint. If the acromion is hooked or curved, impingement or degeneration of rotator cuff tendons may be more likely.
• As you age, everyday activities and normal wear and tear lead to some changes in the rotator cuff, such as:
  • General degeneration of the tendon, which includes thinning, fraying, and tearing.
  • Reduced blood supply to the tendons.
  • Arthritis of the acromioclavicular (AC) joint, which can cause bony growths that can damage the rotator cuff.
• Joint looseness and muscle imbalance in the shoulder can cause damage, including the formation of scar tissue and changes in the tissue itself.
• Repetitive activities, especially forceful overhead motions, can damage the rotator cuff. These motions are common in certain sports or occupations, including throwing a baseball, the overhead swing in tennis, swimming, lifting, or painting.
  • Repetitive activity can cause tendons to rub or scrape against the acromion, which can irritate the rotator cuff.
  • Repeated overhead motions can damage stabilizing ligaments and result in an imbalance of opposing shoulder muscles, which may cause tendons to rub against the bones (impingement).
• Overuse may occur with or be closely related to repetitive activities. Normal motions made frequently over a long period can stress or injure rotator cuff tissues. Athletes, including young people, may develop tendinitis from overuse in throwing, swimming, and racquet sports.
  • Overuse can cause the shoulder joint to become unstable and allow the ball of your upper arm bone (humeral head) to move upward, narrowing the subacromial space where the rotator cuff moves. In this narrowed space, the rotator cuff is squeezed, forcing the tendon to rub against bone (impingement).

Symptoms

Symptoms of a rotator cuff disorder include pain and weakness in your shoulder. It may be uncomfortable or impossible to do everyday activities, such as combing your hair, tucking in your shirt, or reaching above your head. Most often, you will feel the pain on the side and front of your upper arm and shoulder. You may have pain during the night and experience trouble sleeping on the affected side.¹

The amount of pain varies, although it often increases when you raise your arm above the shoulder. The pain usually is closely related to the degree of damage. It is almost always worse when making overhead movements.

• Minor damage: Pain most often occurs only when you are active, and is usually relieved with rest.
• Moderate damage: You will likely notice pain both during and after activity. Pain may also occur at night, especially when you lie on your shoulder.
• Severe damage: You may have continuous pain.

Pain may result in limited use, which can cause more weakness and stiffness in the shoulder. Pain that affects function is not always directly related to the amount of damage to the rotator cuff. For example, your rotator cuff may have minor damage, but strength and the loss of range of motion may be severe because it is too painful to move in certain ways. This is especially true if you normally make a lot of overhead movements.

Symptoms of rotator cuff tendinitis

Pain is the main symptom of inflammation in the tendon (tendinitis). The pain usually starts gradually, over the side of the shoulder and the upper arm. The shoulder and arm will not be particularly weak but are painful when they are being used. The pain may radiate down the outside of the upper arm, even to the elbow. The pain may be worse at night and may interfere with sleep, especially if you lie on the injured shoulder. Lifting the arm to the side (abduction), especially when combined with a forward movement (forward flexion), makes the pain worse.

Eventually, you may have continuous pain. In some cases, this "tendinitis" may actually be one or more small tendon tears.

Rotator cuff tendinitis may be linked to inflammation in adjacent structures, which can result in conditions such as tendinitis in the biceps tendons or inflammation of the subacromial bursa (bursitis). Some people have neck pain from using other muscles to help move the shoulder.

Symptoms of rotator cuff tears

The most common symptoms of a partial tear are:

• Pain when moving your arm, especially against resistance.
• Weakness in your shoulder, although some people don't notice any weakness.

Symptoms of a sudden, severe (acute) tear include:

• A popping sound or tearing sensation in your shoulder.
• Immediate pain in your shoulder.
• Weakness when lifting or rotating your arm.
• Limited range of motion and inability to raise your arm because of pain or weakness.
• A crackling sound in the shoulder when it is moved.
• Possibly, bruising in your shoulder or upper arm.

A complete tear can be present without obvious symptoms, especially in an older adult who is not very active.

In some cases, shoulder pain may be a sign of a more serious problem, such as a heart attack. If you have other symptoms such as chest pain, sweating, shortness of breath, or nausea, call 911 or other emergency services. For additional information, see the topic Chest Pain.

What Happens

Most often, rotator cuff disorders develop gradually, from aging, continued overuse, repetitive activity, or a combination of these things.

The rotator cuff is a group of four tendons. These tendons connect the main muscles of the shoulder-the supraspinatus, infraspinatus, subscapularis, and teres minor-to the upper arm. The rotator cuff tendons and muscles stabilize the shoulder joint and allow you to raise and rotate your arm. Every time you raise your arm above your head, the upper tendon in the rotator cuff (supraspinatus tendon) and the subacromial bursa, which lies on top, glide on the underside of the upper end of your shoulder blade (acromion). The undersurface of the acromion may be rough or abnormally shaped and rub or scrape (abrade) the bursa and tendon. Activities that require repeated overhead arm movements can result in painful inflammation of the bursa (bursitis) and/or the tendon (tendinitis).

Over time, the tendon may rub against the undersurface of the acromion, causing tiny tears and bleeding. As those tears heal, the original healthy tissue is replaced by scar tissue that is weak, less flexible, and stringy. The gradual scarring of the tendon causes the entire rotator cuff to weaken. Finally, the tendons in the rotator cuff can no longer balance the upward pull of the muscle in your shoulder called the deltoid. This can lead to further damage to the tendon, renewing the cycle of tearing and scar formation. The weaker the tendon becomes, the more susceptible it is to partial or complete tears.

Without treatment, a cycle of inflammation, tearing of tendons, and scar formation may develop, resulting in pain and loss of function. This cycle of inflammation, wear and tear, and limited use can lead to other shoulder problems, such as stiffness or frozen shoulder (adhesive capsulitis).

Rotator cuff tears generally occur when the related tendons become weak from inflammation, scarring, or fraying. Tears often result from slow, progressive damage over time, often without a known injury. In older, less active adults, even simple movements such as lifting a suitcase can cause a tear.

It takes tremendous force to tear a healthy rotator cuff tendon. This may happen while you are playing sports or during an accident or a severe fall.

What Increases Your Risk

Things that may increase the risk of rotator cuff disorders include:

• Aging.
• Having long-standing rotator cuff tendinitis.
• Holding or moving your arm overhead frequently, such as when you regularly paint, wait tables, or play tennis, baseball, and other throwing sports.
• Previous shoulder injuries, such as dislocations and broken bones.
• Having a rotator cuff tear in the other shoulder.
• Irregularities of the muscles, tendons, and bones in the shoulder that increase wear on the rotator cuff tendons.
• Having received multiple corticosteroid injections in the shoulder, which may weaken tendons and increase your risk.
• Smoking, which decreases the blood supply and slows the healing process.
• Shoulder instability.

As the rotator cuff and the shoulder weaken, the risk of developing a partial or complete tear increases. Complete tears are present in 25% of people older than 60.¹

When To Call a Doctor

Emergencies. Shoulder pain and weakness may be part of a group of symptoms that indicate a much more serious problem, such as a heart attack. If shoulder pain or weakness occurs with chest pain, shortness of breath, sweating, or nausea, call 911 or other emergency services immediately. For more information, see the topic Chest Pain.

Call your health professional immediately if you have an injury to your shoulder and:

• Your shoulder is very painful.
• Your shoulder appears to be deformed.
• You cannot move your shoulder normally.
• You have signs of damage to the nerves or blood vessels, such as numbness, tingling, a "pins-and-needles" sensation below the injury, or pale, cold, or bluish skin.

If you have had a shoulder problem in the past and you have shoulder pain, call your health professional to find out what you need to do. For more information, see the topic Shoulder Problems and Injuries.

Watchful Waiting

Watchful waiting is a period of time during which you and your health professional observe your symptoms or condition without using medical treatment. A watchful waiting period may vary from a few days to weeks or possibly months. Watchful waiting is not appropriate if:

• Pain in your shoulder is unbearable.
• Your shoulder is deformed.
• You suspect there is nerve damage (loss of feeling) from an injury or vascular damage (pale, cold, or bluish skin).

Most shoulder pain that is not caused by a severe (acute) injury will get better with rest and by avoiding painful movements and positions. Apply ice or heat to your shoulder and take nonsteroidal anti-inflammatory drugs, which can reduce pain and inflammation. If this relieves the pain in your shoulder, gradually resume your regular activities.

If your shoulder is still painful after 7 to 10 days of home treatment, call your health professional.

Who To See

Health professionals who can diagnose and manage rotator cuff disorders include:

• Primary care health professionals who are familiar with shoulder injuries. These include:
  • Family medicine physicians.
  • Internists.
  • General practitioners.
• Orthopedic surgeons.
• Emergency medicine specialists (for severe symptoms or injury).

For treatment, you may be referred to a specialist, such as:

• A sports medicine specialist.
• An orthopedic surgeon.
• A physical medicine specialist (physiatrist).
• A rheumatologist.
• A physical therapist.

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Exams and Tests

To diagnose a rotator cuff disorder, your health professional will ask about your injury or shoulder pain history and will do a physical exam to see how your shoulder is working. Your exam may include tests of your shoulder movement and strength. If your shoulder is painful and you cannot move it much, your doctor may give you a shot of an anesthetic such as lidocaine to reduce your pain. After the shot, your doctor will test your shoulder movement and strength again. Or you may have a steroid shot to help your doctor find out if your shoulder pain is from your rotator cuff. If a steroid shot near the rotator cuff relieves your pain, even if the pain comes back later, it means the rotator cuff-and not some other shoulder problem-is causing the pain. Your doctor may also order an X-ray. An X-ray is a picture of the bones in your shoulder.

Your age, job, and activity level are considered when your doctor is deciding about further testing to diagnose a rotator cuff disorder. For example, if you are a competitive athlete or have a job that requires frequent overhead activity, you may need further testing earlier than a relatively inactive older adult. A more complete diagnosis is important if you are likely to continue activities that may further damage your shoulder.

Imaging tests that may help your health professional diagnose a rotator cuff disorder include magnetic resonance imaging (MRI) and an ultrasound. In rare cases, you may have a type of X-ray called an arthrogram. If your symptoms, exam, and X-ray show that you may have a complete rotator cuff tear, you may have one or more of these tests to confirm the diagnosis. Otherwise, these tests are not usually done until you have first tried several weeks of rest, ice or heat, other home treatment measures, and rehabilitation exercises to restore shoulder strength and movement.

Treatment Overview

Treatment for rotator cuff disorders focuses on relieving pain and inflammation and restoring shoulder strength, flexibility, and function. Treatment may help to prevent further complications, such as loss of strength and movement in the shoulder or additional degeneration or tearing. Treatment considerations include your symptoms, age, activity level, and whether your symptoms appear to be related to a rotator cuff injury. You and your health professional will decide together which treatment is best for you.

Nonsurgical treatment

Most rotator cuff disorders are treated without surgery. Your treatment may include:

• Resting, although gentle movement of the shoulder is recommended. Prolonged immobilization (holding the shoulder still), such as with slings or braces, may cause the shoulder joint to become stiff or even lead to frozen shoulder.
• Applying cold or heat, whichever helps more.
• Taking nonsteroidal anti-inflammatory drugs (NSAIDs).
• Avoiding positions and activities that hurt your shoulder. Usually, these are overhead positions and activities.
• Strengthening your other shoulder muscles.
• Physical therapy, usually involving exercises to stretch and gradually strengthen the shoulder. Physical therapy can reduce pain in the soft tissues (muscles, ligaments, and tendons), improve function, and build muscle strength. A physical therapist may provide these treatments and will also provide education, instruction, and support for recovery.

Most people with tendinitis or bursitis recover without surgery. If symptoms do not improve after a few months of nonsurgical treatment, you and your health professional may consider testing (such as X-rays or magnetic resonance imaging) to find out if you have a rotator cuff tear. Your health professional may consider a corticosteroid injection if a severely inflamed tendon or bursa does not respond to other nonsurgical treatment.

Surgery

Surgery is most useful in relieving pain and weakness in the shoulder or if the tendons are being squeezed as they move through their normal ranges of motion. The two types of surgery for rotator cuff disorders are subacromial smoothing and rotator cuff repair.

Surgery typically is used to repair a torn rotator cuff in a healthy young person, because good results are more likely if there is little or no evidence of degeneration or impingement. People with advanced rotator cuff disorders and tendons that are tough, stringy (fibrous), and stiff usually respond less well to surgery. Surgery may successfully repair the tear, but it cannot repair all the damage caused by age or degeneration. But surgery may be considered for people who have:¹

• A rotator cuff tear caused by a sudden injury. In these cases, it's best to do surgery within a few months of the injury.
• Symptoms that do not respond well to 3 to 6 months of nonsurgical treatment. These symptoms might include:
  • Severe pain.
  • Loss of shoulder strength and movement.

Should I have rotator cuff surgery?

What To Think About

Treatment of rotator cuff disorders should begin soon after an injury or symptoms develop, to give you the best chance of restoring flexibility and strength to your shoulder. Without treatment, a cycle of inflammation, tearing of tendons, and scar formation may develop, resulting in pain, decreased tendon strength, and loss of function.

Recovery from a rotator cuff disorder varies with each individual. Your physical therapy and home exercise program should continue until your shoulder is as strong and flexible as possible. Some treatments for rotator cuff disorders can last up to a year. Most people can return to their previous activities after several weeks of rehabilitation.

Health professionals have differing opinions about treating rotator cuff tears. Nonsurgical treatment is preferred by some health professionals to treat people older than 60. But other health professionals believe the sooner a rotator cuff tear is surgically repaired, the better the chance of a successful outcome, regardless of age.

Prevention

The long-term changes that occur in and around the shoulder joint as a result of everyday wear and tear cannot be totally prevented. But you may be able to prevent some rotator cuff disorders by:

• Keeping the muscles in your shoulders flexible and strong. Daily exercises to maintain strength and flexibility may be the best defense against rotator cuff disorders.
• Keeping good posture at all times. Stand straight and relaxed, without slumping.
• Not lifting objects that are too heavy for you.
• Not catching falling objects.
• Avoiding sports or other activities where forceful contact or falls are likely or common.
• Not keeping your arms out to the side or raised over your head for long periods of time, such as when painting a ceiling. If you must do these activities, take frequent breaks, ice your shoulder several times a day and at night, and take a nonsteroidal anti-inflammatory drug to relieve any swelling and pain in the tissues that are being pinched. Ask your health professional if it would be helpful to take an anti-inflammatory medication before activities that may stress your shoulder.

For more exercises you can do at home (with your health professional's approval), see:

Rotator cuff problems: Exercises you can do at home.

Home Treatment

You can relieve the discomfort of rotator cuff disorders and keep them from getting worse in a number of ways. These methods are often the first course of treatment for rotator cuff disorders.

• Rest your injured shoulder. Limit repetitive movement, and avoid strenuous activity and activities where your arms move above your head. Be sure to follow your health professional's advice on how long to limit movement. Most people do not rest long enough. The rest period for a rotator cuff disorder may be a couple of days to several weeks. During rest:
  • Avoid putting your arm in a sling. It is important that you do not keep your shoulder completely still (immobilized), because it can cause the joint to stiffen.
  • Move your arm carefully through its full range of motion several times a day. Progress slowly to avoid injury.
• Avoid activities or positions that cause discomfort, such as playing golf or tennis or carrying heavy bags of groceries. Stop any activity that hurts your shoulder.
• Take nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen, or naproxen sodium to relieve pain.

Ice and heat are used to help with treating rotator cuff disorders. People respond to heat and ice differently. Apply whichever one makes you feel better. In some cases, heat feels good for a while but may intensify pain and stiffness after 1 to 2 hours. For a sudden (acute) injury, do not use heat for the first 48 hours.

• At first, ice helps relieve pain and reduce swelling. Try applying ice to your shoulder for the first 48 hours after discomfort begins.
  • To avoid harming your skin, place a thin towel between the ice pack and your body, or put a pillowcase over the ice pack.
  • Apply ice 2 to 3 times a day, up to 20 minutes at a time.
  • Apply an ice pack after exercising your shoulder, to help prevent swelling.
• After 2 to 3 days, start moving your shoulder with the aid of moist heat.
  • Soak a towel in hot water and wring it out. Fold the towel to about 8 in. (20 cm) square.
  • While holding the towel on your shoulder, relax your shoulder, lean forward so your arm hangs freely, and gently swing your arm back and forth like a pendulum.
  • You also can do this exercise standing under a warm shower. Heat relaxes your muscles and tendons by increasing blood flow to them. When combined with gentle motion, heat can ease inflammation.
  • Repeat these steps 2 to 3 times a day to reduce the risk of permanent stiffness in the joint.

For more exercises you can do at home (with your health professional's approval), see:

Rotator cuff problems: Exercises you can do at home.

Medications

Medication and physical rehabilitation are often used with or without surgery to treat rotator cuff disorders. Medication relieves or reduces inflammation and pain.

Medication Choices

Your health professional may recommend medications for pain (analgesics). These are available with or without a prescription.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are the most common medications used to help manage rotator cuff disorders. NSAIDs are available with or without a prescription.

Corticosteroid injections are sometimes given with an anesthetic, such as lidocaine, to help diagnose the source of your shoulder pain. They also may be used if tendinitis or bursitis is suspected. Corticosteroids are strong anti-inflammatory medications that are usually given only after 3 to 4 weeks of other treatment (such as rest, ice or heat, NSAIDs, and physical therapy) has not improved the shoulder. Corticosteroids can be effective treatment for rotator cuff disorders. But if used excessively, corticosteroids may have side effects that impair the healing of injured tissues or make tendons more likely to rupture or tear. If the first corticosteroid shot does not provide significant relief, a second shot may be given to ensure the first shot was given in the correct place. But there is rarely a need for more than a few corticosteroid shots. In addition, multiple injections may be linked to less successful rotator cuff surgery.² Corticosteroids are important medications for the treatment of rotator cuff disorders, but caution is needed to avoid overuse.

What To Think About

Nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroid injections do not heal rotator cuff disorders. These medications reduce pain and inflammation to help you move your shoulder comfortably. This allows you to start exercises to stretch and gradually strengthen the shoulder, which reduces the risk of stiffness or a frozen shoulder.

Aspirin and other NSAIDs usually are not taken for at least 5 days before surgery, because they interfere with blood clotting.

Before taking NSAIDs, let your health professional know about any other medications you use. Combining NSAIDs with certain other medications can be harmful.

After a corticosteroid injection, your health professional may recommend a 6-week home treatment program to improve tendinitis.

Surgery

Most rotator cuff disorders are treated without surgery. But surgery may be considered if the injury is very severe. Surgery also may be recommended if the shoulder does not respond well after 3 to 6 months of nonsurgical treatment (rest, ice or heat, use of nonsteroidal anti-inflammatory drugs, and physical therapy).¹

Should I have rotator cuff surgery?

Surgery for rotator cuff disorders is done to:

• Repair tendon tears and smooth the underside of the upper point of the shoulder blade (acromion ) to make more room for the tendon and bursa.
• Restore strength and use of the shoulder.

Surgery may be a good first choice for shoulder weakness caused by complete tears, especially when the rotator cuff is otherwise healthy (little or no degeneration). Surgery may be considered if you have severe pain and loss of shoulder function that has not responded to appropriate nonsurgical treatment.¹ This lack of improvement may indicate that you have partial rotator cuff tears, complete tears, or subacromial roughness. Surgery for these problems focuses on creating a smooth passage for the tendon and bursa beneath the acromion.

You may regain more of your shoulder strength and movement after an acute tear if it is repaired soon after the injury. If surgery is delayed, repair of a large tear may not be as successful, but damaged tissues can still be removed and pressure on the tendon and bursa reduced. This usually relieves pain and restores enough strength for you to do routine, nonstrenuous activities.

Rehabilitation after surgery (home treatment and physical therapy) is important to the success of surgery. People who are not willing or able to commit themselves to the rigors of physical rehab may not do as well after surgery.

Surgery Choices

Shoulder surgery for rotator cuff disorders usually involves one or more of the following procedures:

Subacromial smoothing

Rotator cuff repair

These procedures may be done arthroscopically, by traditional open surgery, or by a combination of the two approaches.

What To Think About

Both arthroscopic surgery and open surgery can be effective. Your surgeon may be more comfortable with one of the methods.

• Open surgery is the traditional type of surgery for rotator cuff disorders.
• Arthroscopic debridement and smoothing to repair the rotator cuff is becoming more common.
• A combination of open surgery and arthroscopy may allow your doctor to split rather than cut the shoulder muscle (deltoid) during open surgery, so you may have a less difficult recovery.

The success of surgery for rotator cuff tears depends on many things, such as:

• The amount of degeneration present.
• Your age.
• Other medical conditions. Some medical conditions may cause you to heal slower.
• Your recovery goals and commitment to and compliance with a physical rehabilitation program.
• Whether you smoke, because smoking decreases the blood supply throughout the body and slows the healing process.

Other Treatment

Physical therapy and rehabilitation for rotator cuff disorders focus on improving range of motion and gradually building muscle strength. Physical therapy may be used alone to manage rotator cuff disorders or as part of recovery after surgery.

Experts are studying a new treatment for chronic calcifying tendinitis of the rotator cuff. The treatment uses ultrasound to create shock waves that destroy calcium deposits in the rotator cuff tendons. Good results were reported, with pain relief and increased range of motion, but further studies are needed to see whether these results can be duplicated and to measure long-term results.³

Other Treatment Choices

Physical therapy can reduce pain in the soft tissues (such as the muscles, ligaments, and tendons), improve function, and build muscle strength. A physical rehabilitation program should be developed by a health professional, a physical therapist, or an athletic trainer. Exercises for rotator cuff disorders include:

• Gentle stretching exercises. These are often the most important part of physical therapy for rotator cuff disorders, especially when stiffness is a major symptom. Stretching includes range-of-motion exercises.
• Strengthening exercises. Generally, you will not start these exercises until your rotator cuff has healed and is able to perform the stretching and range-of-motion exercises comfortably. Strengthening exercises can help build and maintain shoulder function and stability.

Rotator cuff problems: Exercises you can do at home (with your health professional's approval)

Some physical therapists may use other techniques to relieve pain and reduce muscle spasms, such as massage or ultrasound therapy.

What To Think About

Although completing a rehab program may be difficult, a successful outcome after surgery depends on your commitment to treatment. If you follow your physical therapy plan closely and get help when you need it, you are more likely to restore shoulder strength and movement.

Common difficulties with rehab programs include:

• Impatience during the long periods of rest needed to let your shoulder heal. Athletes and people whose jobs depend upon the use of their arms may find it hard to be patient with this aspect of treatment.
• Not performing exercises as often as prescribed.
• Using incorrect technique when doing exercises.

Other Places To Get Help

Online Resource

Organizations

Related Information

• Bursitis
• Shoulder Problems and Injuries

References

Citations

1. Andrews JR, ed. (2005). Impingement syndrome, Procedure-subacromial bursa injection, Overhead throwing shoulder, and Rotator cuff tears sections of Shoulder. In LY Griffin, ed., Essentials of Musculoskeletal Care, 3rd ed., pp. 188-193. Rosemont, IL: American Academy of Orthopaedic Surgeons and American Academy of Pediatrics.

2. Mantone JK, et al. (2000). Nonoperative treatment of rotator cuff tears. Orthopedic Clinics of North America, 31(2): 295-311.

3. Gerdesmeyer L, et al. (2003). Extracorporeal shock wave therapy for the treatment of chronic calcifying tendonitis of the rotator cuff. JAMA, 290(19): 2573-2580.

Other Works Consulted

• Devinney DS, et al. (2005). Surgery of shoulder arthritis. In WJ Koopman, LW Moreland, eds., Arthritis and Allied Conditions, 15th ed., vol. 1, pp. 995-1015. Philadelphia: Lippincott Williams and Wilkins.

• Husni EM, Donohue JP (2005). Painful shoulder and reflex sympathetic dystrophy syndrome. In WJ Koopman, LW Moreland, eds., Arthritis and Allied Conditions, 15th ed., vol. 2, pp. 2133-2151. Philadelphia: Lippincott Williams and Wilkins.

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