Whether you’re cleaning gutters, swimming laps or lifting weights and you begin to experience shoulder pain, don’t ignore it.

You can get it throwing a key pitch in the World Series, lifting weights at the local gym or, as one woman sheepishly admitted, reaching for a burger and fries at the drive-in window.

Rotator cuff tears, made famous by a number of high-profile pitchers, are actually very unromantic, painful injuries that tend to become more common with aging.

In the young, a torn rotator cuff is usually the result of a sports injury or accident; in older adults it’s more likely to occur reaching to a high cupboard or painting the ceiling.

The rotator cuff is a cluster of four small tendons at the end of larger muscles that keep the shoulder joint in place. The tendons hold the upper arm to the shoulder blade. Unlike other joints, the shoulder joint is able to move through a complete 360 degree circle as well as extend at a 90 degree angle from the body. A joint designed for such a high degree of rotation is necessarily less stable.

A common source of shoulder pain, rotator cuff tears account for more than half of all shoulder injuries. The risk is highest in those over age 40 and is often related to occupation, sports interests or hobbies.

Repetitive motions that place heavy demands on the shoulder muscles eventually take a toll. After years of rubbing against bone in the shoulders, the tendons that make up the rotator cuff begin to wear down and become vulnerable to tears. Swimming, serving a tennis ball, throwing, painting a ceiling or shooting a rifle all can trigger an injury. Plumbers, carpenters, painters and others whose jobs require overhead work are at risk.

Be Alert for Warning Signs
The first symptom of a rotator cuff problem is normally felt as a twinge when serving a tennis ball or changing a light bulb. Then the pain is felt at night when the shoulder is at rest. This early stage of rotator cuff injury is called impingement. Early action at this stage can head off a more serious injury.

The best action for shoulder pain is inaction. Resting the shoulder, using ice packs three times a day for 15 minutes each time and taking aspirin or nonsteroidal antiinflammatory drugs (NSAIDS) if you can’t take aspirin should improve the pain and inflammation after a couple of days. Gentle stretching exercises should be done to prevent stiffness and to maintain range of motion in the shoulder when the pain has subsided.

Slowly warming up the shoulder area before activity will help prevent re-injury. Resume activities at a lower level than before and, if pain persists, stop the activity and make an appointment with your doctor who will check for a tear or other shoulder problems.

More serious levels of pain and disability usually involve a tear. These range from small tears that can be treated conservatively to full thickness tears that require surgery.

A rotator cuff tear might interfere with a persons’s ability to put on a coat, do up a bra in the back, comb hair, sleep on the painful side, reach a high shelf, throw a ball overhand or lift a 10-pound weight above shoulder-level.

Magnetic resonance imaging (MRI) can be used to diagnose a rotator cuff tear, but researchers caution against using MRI as the only diagnostic tool. Studies show that 34 percent of persons aged between 19 and 88 years had evidence of rotator cuff tears on MRI, despite the fact that they had no symptoms of rotator cuff injury. MRI can be used to pinpoint the extent and location of a tear when symptoms are present.

Arthroscopic diagnosis consists of inserting a viewing instrument through a small incision. This form of diagnosis, although invasive, provides an accurate assessment of the extent of tears and allows a more comprehensive examination of the entire joint.

A patient history, physical examination and evaluation of symptoms during physical tests can also help diagnose a rotator cuff tear.

When Surgery Is Required
When conservative treatment has failed, or when there is severe pain and disability, a number of surgical options are available. Most physicians recommend rest, aspirin and physical therapy for three months before deciding to move on to more aggressive treatment. Surgical options include arthroscopy, arthroscopically-assisted mini-open rotator cuff repair and fully open rotator cuff repair.

The decision on what type of procedure to use depends on the extent and nature of the tear, the age of the patient and other individual considerations.

Arthroscopy involves repairing the tear with instruments and a viewing scope inserted through small incisions. Healing is more rapid because incisions are small and the procedure can be performed on an outpatient basis. Arthroscopy is usually used to repair smaller tears.

Arthroscopically-assisted mini-open rotator cuff repair is used when the tear involves more than 50 percent of the rotator cuff. This procedure involves making a small incision precisely located over the tear site. Arthroscopy can facilitate the repair with excellent results.

Arthroscopic techniques are often associated with less post-operative pain, and a faster rehabilitation period. They also lend themselves more readily to outpatient surgery.

Open rotator cuff repair involves more conventional surgery and is more likely to be used when the patient has large, full-thickness tears. Open surgery usually requires an overnight hospital stay and the patient uses a sling for approximately four weeks after surgery.

Physical therapy is usually begun within a few days of most types of surgery.

A number of studies have been conducted to compare the results of arthroscopically assisted mini-open surgery and open rotator cuff repair. Both techniques resulted in a good to excellent functional outcome for 80 to 95 percent of patients. The mini-open repair group had a more rapid return to full activity than the fully open group.

Surgical repairs of large tears of the rotator cuff generally have satisfactory long-term outcomes with patients reporting improved function, better range of motion, greater strength and less pain. Complete recovery from surgery for a full tear can take more than a year, however, and the operated shoulder will probably never be as strong as the opposing shoulder.

So whether you’re cleaning gutters, swimming laps or lifting weights and you begin to experience shoulder pain, don’t ignore it. Rest your shoulder for a few days and follow the conservative therapy outlined above. You may need to scale back your workouts, change your technique or spend more time stretching and warming up your shoulder muscles before taxing them. The shoulders bear a heavy load. By taking a few precautions you can help shoulder the burden.

REFERENCES:
Suzanne Arcuni, “Rotator Cuff Pathology and Subacromial Impingement,”The Nurse Practitioner, May 2000.
Jennifer Haigh, “A Joint Resolution,” Men’s Health, May 1997.
Jonathan Hersch and Nicholas Sgaglione, “Arthroscopically-Assisted Mini-Open Rotator Cuff Repairs,” The American Journal of Sports Medicine, May 2000.
“Large Rotator Cuff Tears Respond Well to Surgery,” The Journal of Musculoskeletal Medicine, December 1999.
Brian Leggin, “Arthroscopic Surgery Versus Supervised Exercises in Patients with Rotator Cuff Disease,” Physical Therapy, July 2000.
George Murrell and Judie Walton, Diagnosis of Rotator Cuff Tears,” The Lancet, March 10, 2001.
Jin Young Park et al, “Portal-Extension Approach for the Repair of Small and Medium Rotator Cuff Tears,” The American Journal of Sports Medicine, May 2000.
Michael Segell, “Shooter’s Shoulder,” Sports Afield, August 1997.
“Should I Get Rotator Cuff Surgery?” Harvard Health Letter, September 2000.