Written by Alison Johnson
Photo by Brian Freer
Rotator cuff injuries are far more common than most people realize, but recognizing symptoms of trouble can lead to the most effective treatment.
Cindy Duncan had just turned 50 when she noticed her right shoulder felt stiff and achy when she raised her arm, did yard work or went swimming. Maybe arthritis, she figured, and tried to ignore the symptoms. But they only got worse, and eight months later, the Chesapeake resident was in so much pain that she could barely lift a coffee cup. When Duncan finally saw a doctor, tests showed she had torn her rotator cuff, the group of tendons that helps move and stabilize the shoulder.
Duncan’s injury was past the point where non-surgical options—cortisone injections or physical therapy—could help. So last June, she underwent surgery to repair the tear and began 12 weeks of intensive rehabilitation, including six weeks when therapists had to move her shoulder for her. All the hard work has given her great results, but Duncan has a message for others who experience persistent shoulder pain: don’t wait so long to get medical attention.
“In my case, the damage had already been done,” she says. “At that point, there was no way I could avoid surgery if I wanted to get better. I think if I had gone sooner, I probably would have avoided it.” The possibility of a rotator cuff tear never occurred to her all those months, she adds: “I thought that was something that only happened to serious athletes.”
That’s a widespread misconception, doctors say. In fact, tears are more often the result of wear from everyday motions such as throwing out the garbage or starting a lawnmower, says Dr. Kevin F. Bonner, an orthopaedic surgeon with the Jordan-Young Institute in Virginia Beach and practitioner at Sentara Leigh Hospital in Norfolk. The injury is also very common, says Bonner, a specialist in sports medicine and shoulder and knee repair: by age 70, one in five Americans likely will suffer a full or partial tear.
Some people wait years or even decades to see a doctor, at which point the tissue may be beyond repair because it has grown too weak, or atrophied. “I have people who don’t come in until they’re at the point where the pain is unbearable and they can barely lift their arm at all,” Bonner says. “We have a lot of tricks to fix tears now, but we often can’t fix tissue that is severely degenerated or atrophied.”
Not everyone with a rotator cuff injury needs surgery, doctors emphasize. The decision depends on a variety of factors, including a patient’s age and activity level, the size of a tear and how much pain it is causing. Very generally, younger patients with full tears are more likely to respond well to surgery, although older adults who are still active also may be good candidates. For people who don’t have surgery, cortisone injections can reduce inflammation and physical therapy may strengthen muscles around the rotator cuff enough to compensate for the injury. About 75 percent of patients with only tendon weakness or partial tears, for example, can improve with non-surgical treatments.
Either way, earlier evaluation of symptoms is always better, says Dr. Nicholas K. Sablan, an orthopaedic sports medicine surgeon with Tidewater Orthopaedic Associates, which has offices in Hampton and Williamsburg. “My fear as a doctor is that if the rotator cuff is untreated for too long, you can reach a point where there are no longer any good treatment options,” Sablan says. “Small tears that haven’t had time to retract or atrophy have much greater success, upwards of 90 percent.” People who don’t have an operation also benefit from close follow-up with a physician to make sure their symptoms aren’t worsening, he adds.
Signs of trouble
Rotator cuff injuries come in two basic forms. First is an acute, traumatic injury: feeling an obvious “pop” and sudden pain, often while lifting something heavy, in association with a shoulder-centered motion such as hurling a baseball or after a fall. Second is damage that occurs over time as tendons become irritated or frayed. The classic symptom is pain and weakness with overhead or shoulder-stretching activities, from putting dishes away in cabinets to reaching around to put on a seat belt. Pain may extend down to the elbow, and discomfort—for mysterious reasons—also tends to be worse at night.
Anyone can hurt their rotator cuff, although some people are more at risk. Athletes who move their arms repetitively, particularly baseball and tennis players, swimmers and weight-lifters are one vulnerable population, but so are people who regularly have their arms overhead or in the same position: carpenters, painters and hairdressers, to name a few, and even people who sleep on the same side every night. Some people also have a shoulder anatomy that leaves a narrower space for the rotator cuff, which can pinch the tendon and cause increasing weakness over time.
People who suffer an obvious acute injury should see a doctor as quickly as possible, says Dr. Kenneth R. Zaslav, an orthopaedic surgeon with Advanced Orthopaedics in Richmond who specializes in shoulder injuries and sports medicine. Those who notice continued discomfort likely need medical attention if they don’t improve after one or two weeks of anti-inflammatory pain medication and rest, Zaslav says.
Doctors use magnetic resonance imagery, or MRI, to diagnose full or partial tears and pinpoint their exact size and location along with overall tissue quality—all clues on how well a patient might respond to physical therapy or surgery. Timing is important, because the operation is most effective if done before the tissue begins to atrophy. After about three months, a tendon that has fully detached from the bone also will begin to change; specifically, it morphs into fatty tissue that may never be able to function like a tendon again. And after a year or so, the tendon likely will retract, or shrink, to the point that doctors can’t restore it to its former length. “You may be able to improve pain levels and some range of motion after a longer period of time, but earlier repair likely is going to give you much better functional results,” Zaslav says.
Luckily for patients, rotator cuff surgery has changed dramatically over the past two decades. Doctors now can perform about 90 percent of operations arthroscopically—using a scope and several tiny incisions rather than one large incision—and many surgeons do open surgery even more rarely. That means no overnight hospital stay and less post-operative pain for patients. In addition, new techniques of reattaching tendons to bone seem to improve shoulder function, according to early data.
Still, the healing process remains the same after open or arthroscopic surgery, Bonner says. Patients generally need three to five months of rehabilitation time before shoulder function begins to return to normal. For the first four to six weeks, patients wear a sling and can’t move their arm on their own; physical therapists do that for them to prevent muscle stiffness and weakening. “Physical therapy is so important,” Bonner says. “It’s a long rehabilitation process, and to get good results you’ve got to follow all the steps and respect the biology of healing.”
The payoff, though, is worth the effort, Cindy Duncan says. Six months after her surgery, she felt “95 percent better” and was back to gardening and all the other activities she enjoys. Even so, she continues to do 30 to 40 minutes of shoulder-strengthening exercises twice a day at home. “I would definitely recommend the surgery if you need it,” she says. “Then keep up with the therapy, because it will make it or break it. I have recovered more quickly than I thought I would.”
Doctors are hoping to find new treatments to speed repair, although that is proving tricky. One idea is platelet-rich plasma therapy, in which doctors take a small vial of a patient’s blood, separate out platelets— specialized cells involved in clotting and healing— in a laboratory and inject them at the site of the injury. Natural growth hormones secreted by platelets, the theory goes, might speed healing. Yet despite promising early data, recent studies showed no significant benefit, and only time will tell, Bonner says. The therapy remains experimental and generally isn’t covered by insurance.
Unfortunately, no one can fully guard against a rotator cuff tear, doctors say. There is some evidence that smoking increases the risk, and cigarettes certainly interfere with the healing process after surgery, Bonner says. Staying in good shape overall and lifting lighter weights as an older adult—especially when it comes to overhead weights—also may help, he says. So could certain shoulder and biceps exercises and stretches a physical trainer can teach, including work with bands and push-ups, Zaslav adds.
Patients who experience pain prior to an actual tear also may benefit from surgery to increase space for the rotator cuff inside their shoulder joint. In Duncan’s case, for example, a bone spur – a tiny, pointed outgrowth of bone – had caused the tear in her right shoulder by rubbing against her tendons. After imaging tests showed a similar problem developing in her left shoulder, doctors opted to shave down a spur with minor surgery through two tiny incisions. “We caught that one in time,” Duncan says.
The best strategy for everyone, though, is to pay attention to persistent pain—and to realize that
rotator cuff injuries have more to do with aging than sports. “These injuries are much more common in the middle age and elderly population than in young athletes,” Sablan says. “Hopefully just being aware of that should make a difference in how people respond to problems.”