Rotator Cuff Tear and Tendinopathy
A rotator cuff tear can occur as a result of trauma or chronic overload. Often this may present in combination with other conditions such as a subacromial shoulder bursitis.
Rotator cuff tendinopathy is usually the result of repetitive strain to a rotator cuff tendon which exceeds the force absorbing capacity of the tissue which then leads to tendon degradation.
Symptoms of a Rotator Cuff Tear and Tendinopathy
The most common symptoms of a rotator cuff injury are:
- Pain as you raise your arm to the side or reaching behind you
- Pain reaching overhead eg. taking objects of high shelves
- Weakness and Pain when pushing your hand away from your body when the elbow is bent to 90 degrees
- Pain lying on the side in bed which can wake you overnight
Shoulder Joint Anatomy
The main stabilising structures of the shoulder joint are the rotator cuff muscles.
This is a group of 4 muscles that provide stability to keep the humerus (upper arm bone) in contact with the socket of the scapula (Shoulder blade). When there is an imbalance of these muscles, the delicate balance of keeping the humerus in the centre of the socket of the shoulder joint can become disturbed. This may lead to strain on tendons or compression of structures and tendons. Over time with repeated micro trauma like this, it may cause a rotator cuff tendon to start to fail and become “tendinopathic”. This is where the force absorbing capacity of the tendon is exceeded and it starts to break down and not heal. Prolonged trauma like this may lead to degenerative tears in the tendon.
An Ultrasound scan is an excellent way to dynamically visualise the rotator cuff and establish if you have a tear or if it is tendinopathy. Often the two conditions will occur simultaneously especially in cases where the injury has progressively come on over time. Traumatic injuries to the rotator cuff following a fall for example are also well visualised on diagnostic ultrasound scan but in some cases we may need to refer you for an X-ray or MRI.
The most commonly affected rotator cuff muscle is the supraspinatus. Its location on top of the shoulder puts it in the most likely place to get injured.
It is essential we get your diagnosis right so that we can manage your shoulder pain effectively.
How to diagnose
During your Physiotherapy assessment we will carry out a range of resisted and range of motion tests which may help identify the likely injured structure. Unfortunately this alone can not give us the complete picture so we will also carry out a diagnostic ultrasound scan. This will allow us to dynamically assess the rotator cuff and provide you with a more accurate diagnosis. If required we may also request and MRI scan.
A rotator cuff tear that is traumatic and left you with some weakness after the accident may require a surgical opinion. We will assess the tear using an ultrasound scanner and let you know if it is a partial tear or full rupture and what the best next steps are. Not all tears will require surgery as it is common as we age to develop partial tears in the rotator cuff tendons if we are particularly active. The location of the tear and whether it is chronic or acute will dictate whether you will need to have an assessment with a consultant.
In general, rotator cuff tendinopathy and most small rotator cuff tears can be well managed with conservative Physiotherapy treatment and not require surgical intervention.
Rotator Cuff Tear and Ultrasound guided corticosteroid injection
If symptoms have not improved after 6 weeks of physiotherapy, or if the pain is affecting your sleep, stopping you from performing everyday activities such as getting dressed or is limiting you from performing your physiotherapy exercises you may want to consider an ultrasound guided steroid injection.
Steroid injections use a small dose of corticosteroid (a strong anti-inflammatory drug) and are injected under ultrasound-guidance into the subacromial subdeltoid bursa. Current evidence found that injections performed under ultrasound guidance are more accurate and more effective at reducing pain and improving function than landmark guided injections (Daniels et al, 2018).
Daniels, E.W., Cole, D., Jacobs, B. and Phillips, S.F., 2018. Existing Evidence on Ultrasound-Guided Injections in Sports Medicine. Los Angeles, CA: SAGE Publications.
Mall, N.A., Foley, E., Chalmers, P.N., Cole, B.J., Romeo, A.A. and Bach Jr, B.R., 2013. Degenerative joint disease of the acromioclavicular joint: a review. The American journal of sports medicine, 41(11), pp.2684-2692.