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Rotator Cuff : Symptoms and Causes, Common Problems and Injuries

What is the rotator cuff?

The rotator cuff is made up of a group of muscles and tendons that work together to keep the head of the upper arm bone (humerus) in place within the shoulder joint. They are the deepest group of muscles that surround the shoulder joint and allow for stability. In total there are 4 muscles that make up the rotator cuff. The four muscles that make up the rotator cuff are supraspinatus, infraspinatus, teres minor, and subscapularis. Together they form a protective sheath around the humerus, keeping it securely in place within the shoulder joint.

Rotator Cuff Muscles

What does the rotator cuff do?

The rotator cuff has two main roles. The first one is to maintain stability of the glenohumeral joint from the muscles and tendons that hold it in place. The second is to allow for shoulder movement, primarily internal and external rotation. These two functions are where it get’s its name- rotator for the function of rotation and cuff as the 4 muscles make a continuous tendon in a cuff like fashion, thus – Rotator Cuff.

Collectively, the rotator cuff muscles are responsible for controlling the movement of the shoulder joint, allowing it to rotate and move in multiple directions. They also provide stability and strength to the shoulder joint, helping to prevent dislocation or injury.

How does the rotator cuff work?

These muscles have similar but different functions. Separately, they maintain the arm and shoulder in the socket at various shoulder heights and allow for rotation as mentioned before. Together they play a larger role, primarily against the stronger, more prominent deltoid muscle.

The deltoid is the outermost and strongest shoulder muscle.

deltoid muscle
Deltoid Muscle

| As a general rule of thumb, superficial muscles are stronger and more powerful, while deeper muscles tend to focus more on endurance

The deltoid’s main function is to elevate/ flex/ or abduct the arm. This elevation moment arm needs to be countered by another force to maintain the arm in the socket. This is where the rotator cuff comes in. As the deltoid raises the arm, the rotator cuff keeps the arm in the socket via an equal and opposite downward pressure to counterbalance the deltoid. When this is imbalanced, the rotator cuff may get pinched, as these injuries are common.

deltoid RTC force coupel dysfunction anatomy view

Why is the rotator cuff important?

Without it, we would not be able to lift our arms above our heads or rotate them outward. The rotator cuff also helps to keep the head of the humerus in place within the shoulder joint, preventing it from slipping out of place or becoming dislocated. This is especially important during activities such as throwing, where forces can cause pinching or damage if not properly supported by the rotator cuff. Additionally, it helps to absorb shock when we move our arms, protecting other structures in the shoulder from injury. In summary, the rotator cuff is essential for proper shoulder function and protection from injury.

Why does a rotator cuff get injured?

It is commonly injured due to overuse, such as when playing sports or performing repetitive overhead arm movements. Other causes of rotator cuff injuries include direct trauma, like a fall on an outstretched arm known as a FOOSH, or degeneration caused by age-related wear and tear.

Chances of this type of injury increases with age due to repetitive use and poor posture for an extended period of time that puts extra strain on the muscles and tendons in the area. Additionally, people who have jobs that require them to lift heavy objects are more likely to experience rotator cuff injuries due to the increased stress placed on the shoulder joint.

What are common injuries to the rotator cuff?

As mentioned above, the rotator cuff’s main role when acting collectively is to slide the arm down into the socket when raising your arm overhead. Failure for the rotator cuff to pull the arm down will result in a painful condition known as impingement. This simply means the tendon is getting pinched when raising upwards.

When these muscles are overworked, the symptoms tend to develop over time known as wear and tear. This is just like how your favorite pair of jeans begin to fray. It doesn’t happen immediately, but happens slowly over time. This is exactly what happens with your rotator cuff as well. This is known as tendinopathy. You may be familiar with tendinitis or even tendinosis, but the more accurate and preferred term today is tendinopathy as it described the health of a tendon along a spectrum.

If a tendinopathy goes untreated it may lead to a tear. Rotator cuff tears can generally be split into 2 types, partial thickness (partial tear) and full thickness (complete rotator cuff tear).

Another classification is by types of rotator cuff tears by Harryman et al based on size and number of tendons:

Stage 0 = intact RTC

Stage 1A = partial thickness tear of supraspinatus tendon

Stage 1B = full thickness tear of only supraspinatus tendon

Stage II = portion of supraspinatus and infraspinatus 

Stage III = supraspinatus, infraspinatus, and subscapularis mm

Stage IV = RTC Arthropathy 

Arthropathy = Rotator cuff arthropathy is a specific pattern of shoulder degenerative joint disease that results from a rotator cuff tear leading to abnormal glenohumeral wear and subsequent superior migration of the humeral head.

Recap of Rotator Cuff injuries:

What are common rotator cuff injuries?

Rotator cuff injuries are common, especially in athletes and people who do a lot of repetitive overhead motions or heavy lifting. The rotator cuff is a group of four muscles and tendons that connect the shoulder blade to the upper arm bone. When these muscles and tendons become irritated or torn, it can cause pain and limit movement in the shoulder. Common rotator cuff injuries include tendonitis, bursitis, impingement syndrome, and tears. Tendonitis is an inflammation of the tendon due to overuse or strain. Bursitis is an inflammation of the bursa sacs which cushion the bones in the shoulder joint. Impingement syndrome occurs when there is too much pressure on the rotator cuff from nearby structures such as ligaments or bones. Tears occur when one of the tendons tears either partially or completely. Treatment for rotator cuff injuries depends on severity but may include rest, physical therapy, medications, or surgery.

What are the symptoms of a rotator cuff tear?

The symptoms of a rotator cuff tear can vary depending on the severity of the injury.

Common symptoms may include:

  • shoulder pain when you move your arm
  • weakness in the shoulder
  • difficulty sleeping due to discomfort

You may also experience a popping, clicking, or grinding sensation when you move your arm or shoulder. A rotator cuff tear may also cause a decrease in range of motion, as well as swelling and tenderness around the shoulder joint. If you suspect that you have a rotator cuff tear, it is important to seek medical attention from a healthcare provider right away. Your healthcare provider will be able to diagnose the injury and provide treatment options that are tailored to your individual needs. With proper care and rehabilitation, it is possible to reduce pain and improve mobility associated with a rotator cuff tear.

Where is rotator cuff pain located?

Rotator cuff pain can present in any of the cuff muscles or insertion sites. Below you can see the commonly mapped referral patterns of the Rotator Cuff. The X represents where the trigger point is noted and the red indicates the referral pattern with the darker red representing higher irritability sites.

(ADD REFERRAL PATTERN PAIN IMAGE HERE)

Rotator Cuff Pain Referral Pattern

How is a rotator cuff injury diagnosed?

A rotator cuff problem is typically diagnosed through a physical exam conducted by an orthopaedic physical therapist, an orthopedic physician or sports medicine physician in which they will need to perform a physical exam. During the exam, the healthcare provider will assess the shoulder for any signs of pain or tenderness, as well as any reduced range of motion. The healthcare provider may also ask you questions about the your complete medical history and any other relevant information related to their shoulder. In some cases, an imaging test such as an X-ray or MRI may be used to help diagnose a rotator cuff injury. This type of imaging can provide detailed images of the bones and soft tissues in the shoulder area, including any tears or damage to the tendon that make up the rotator cuff. Depending on the severity of the injury, further diagnosis and tests may be recommended to confirm a diagnosis of rotator cuff injury or tear in which your doctor may recommend surgery.

How long does it take to recover from a rotator cuff injury?

Rotator cuff injuries vary from lack of control that causes impingement to full-thickness tears; therefore, the time in which it takes to recover varies. Impingement like symptoms can resolve in as little as a couple weeks and a full-thickness tear recovery can last up to 6 months. The good news is if you are dealing with an injury now, worst-case scenario is 6-months from now it should all be a bad memory.

How long does it take for a torn rotator cuff to heal without surgery?

  • General rule of thumb is approx. 12-16 weeks
  • May take longer depending on severity of issue

Can a physical therapist tell if you have a torn rotator cuff?

Yes, a physical therapist can tell if you have a torn rotator cuff. They will assess the shoulder joint to check for any visible signs such as swelling, tenderness, and instability. Then they will ask you questions about your symptoms such as pain level and when it started. Lastly, they may do imaging tests such as musculoskeletal ultrasound or diagnostic ultrasound to look for any damage to the bone or tendons in the area.

Who should you see for a diagnosis: A physical therapist or orthopedist?

Overall it is best to see a physical therapist or orthopedic surgeon for a proper diagnosis.  There are plenty of active shoulder tests that can indicate if a rotator cuff is injury as well as both professions have solutions that can help. As far as which one, it really comes down to what is the treatment option you want. Do you want to get surgery or do you want to get better without it? It may sound crazy, but the data really shows that not only do both achieve relatively the same results, but more importantly, people tend to have better outcomes when they have the treatment they prefer.

Does rotator cuff tears show up on x-ray?

Generally speaking, X-rays cannot tell if a tear is present; however, if the humeral head migrates upwards it is often a good indication that Stage IV Rotator cuff arthropathy exists. It is also generally recommended to get further testing to confirm the suspected diagnosis. This could be an MRI or point of care ultrasound. Both of these will show structural integrity to the muscles and tendons. Many providers currently prefer an MRI as ultrasound heavily relies on the education of the practitioner for an accurate assessment.

Can a rotator cuff tear heal on its own?

Yes, a rotator cuff tear can heal on its own with proper rest and loaded rehabilitation. The shoulder must be rested from any activities that require repetitive motion or weight bearing to give the rotator cuff time to heal. Ice, anti-inflammatory medications used to be used; however, we now follow PEACE & LOVE principles for management of soft tissue injuries such as a rotator cuff. Without proper load and rest, the rotator cuff is at risk of a larger rotator cuff tear.

How is a rotator cuff injury treated?

Treatment for a rotator cuff injury depends on the severity of the injury. In most cases, nonsurgical treatment such as pain relievers or physical therapy that will focus on the weakness of the shoulder, which is generally enough to help the shoulder heal for both partial or complete rotator cuff tears. This may include exercises to strengthen the muscles around the shoulder joint and improve flexibility. If these treatments are not successful, surgery may be necessary to repair any tears in the rotator cuff. A rotator cuff repair surgery typically involves reattaching or repairing the tendons in the shoulder joint, as well as removing any bone spurs that have formed due to wear and tear on the joint. After surgery, you will need to wear a sling for four to six weeks before starting physical therapy. During physical therapy, your therapist will move your shoulder to speed up recovery time in order for the tendons in your shoulder to heal as well as prevent tendinitis and bursitis in the tendons that surround the shoulder. This also prevents frozen shoulder.

What happens if a torn rotator cuff goes untreated?

If a torn rotator cuff goes untreated, the condition can stay exactly the same or worsen over time and cause more serious issues. The shoulder joint may become unstable with decreased range of motion, as well as pain and weakness in the shoulder that can limit your ability to do everyday activities. If left untreated, the tear can get larger, leading to further damage and pain. In some cases, surgery may be necessary to repair the tear or to stabilize the shoulder joint. Additionally, without treatment, there is an increased risk of developing shoulder arthritis due to wear and tear on the joint from instability caused by the tear. It is important to seek medical attention for a torn rotator cuff as soon as possible in order to prevent further damage and begin treatment for relief.

Can you live with rotator cuff tear without surgery?

  • YES! Many people have too! In fact, we’ve seen this first hand in our practice, many many times, and so have others, including surgeons. 

Can you live with a fully torn rotator cuff?

  • Yes you can and many do. The real question is, what is your state of life look like? Are you doing all the things that you want to do? Are you limited in things that you wish you could do?

How long can you go without surgery for a torn rotator cuff?

  • You can go indefinitely, it’s not required.

How do I get my rotator cuff to stop hurting?

—> depends on treatment you want (as many show similar results):

  • Physical therapy
  • Meds/ Injections
  • Surgery
  • CBD/ ETC

What is the best home remedy for rotator cuff injury?

What can I do at home for treating my rotator cuff injury?

Some of the best things you can do at home include light movements, Range of Motion (ROM) exercises and strengthening exercises. This may sound simple and it can be, but there is still work involved.

What are some physical therapy exercises for strengthening my rotator cuff?

Below are BEST exercises that ours clients go through when overcoming rotator cuff pain. They may seem simple, but they work.

Pro tip: Don’t Skip the beginner ones just because nobody wants to be considered a beginner. It’s not about your experience level, its about where your shoulder is along the healing continuum.

Beginner

Advanced

Best Treatment for Rotator Cuff Disease?

The best treatment for rotator cuff disease depends on the severity of the injury. Physical therapy is often recommended as the first line of treatment to help alleviate pain and improve range of motion in the shoulder, especially in the presence of mild rotator cuff injuries as surgical repair is generally not needed. The physical therapist may also prescribe exercises and stretches designed to strengthen the muscles that support the upper arm bone firmly in the socket. Without treatment or proper management of rotator cuff injuries, you may need surgery to repair a torn rotator cuff. In more severe cases, surgery may be an option; this can include repairing or replacing damaged tissue, such as tendons or ligaments. Surgery is needed if there is significant damage to the rotator cuff making your arm difficult to use. After surgery to repair the torn tenon(s), physical therapy is usually recommended to help improve strength and give your shoulder mobility in the affected area. With proper rest, rehabilitation and maintenance, recovery from rotator cuff disease can be successful.

What other conditions mimic a rotator cuff injury?

  • Frozen Shoulder
  • Shoulder stiffness
  • Arthritis 
  • Bursitis
  • Pinched nerve
  • Shoulder ligament tears

Joseph Rosi, DPT

Dr. Rosi is a performance orthopedic and men’s pelvic health physical therapist. He has a passion for helping people get out of pain, recover from an injury, and increase performance. He believes everyone should take the time to learn how to move optimally before injuries ever occur. Outside of working with clients, he spends time with his wife and loves to travel the world.

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