Description Medical definition:
- Rotator cuff tendinosis, formally referred to as tendonitis.
- Subacromial impingement and associated subacromial bursitis.
Pain in the shoulder due to a rotator cuff problem is typically due to the so-called overuse syndrome, which implies that the damage to the rotator cuff occurs over time. The anatomical space where this is occurring is known as the subacromial space, and it is termed an impingement syndrome. Although historically this has been referred to as a rotator cuff tendonitis, a more accurate description is that of a rotator cuff tendinosis. The difference being a tendonitis implies inflammation, and a tendinosis implies a degeneration of the tendon.
The spectrum of tendinosis of the rotator cuff and the impingement that occurs can over time lead to a full-thickness tear or rupture of the rotator cuff. Therefore, the end-stage impingement syndrome or rotator cuff tendinosis is a full-thickness rotator cuff tear. The early stages of impingement syndrome would be the ideal opportunity to treat the impingement syndrome, therefore, preventing an end-stage rupture. A second form of shoulder impingement occurs anatomically in the shoulder joint itself as opposed to the subacromial space, and is referred to as internal impingement. Symptoms Typical symptoms include shoulder pain with associated clicking or catching as well as nocturnal or pain awaking from sleep.
Possible Causes/Risk Factors Subacromial and internal impingement are related to repetitive, overhead, recreational or work related activities. Subacromial impingement is especially common in baseball, tennis, or any throwing sport and occupation such as carpentry, or avocations such as painting that requires repetitive position of the shoulder with elevation and internal and external rotation in a repetitive manner. The tendon degeneration produces tendon swelling and secondary bursitis in the subacromial space where there is not enough room for the abnormal anatomy. Calcium deposits can occur in the tendon. The tendon progressively loses its integrity and becomes weakened leading to disruption, tearing and then loss of motion of the humerus.
On top of the shoulder is the acromioclavicular joint, which can also be involved in a co-existent manner with impingement, or it may occur isolated from the rotator cuff and subacromial space. Acromioclavicular (AC) joint problems are most commonly related to a history of a direct blow or force on the AC joint producing an acromioclavicular joint sprain. Diagnosis This requires an evaluation by an experienced clinician and usually will also include specific shoulder x-rays and an MRI with contrast or dye that is injected into the shoulder joint.
Treatment
Cortisone injections: treatment recommendations will occur as a result of the physical examination and the imaging studies. In the early stages, a nonoperative regime is most appropriate and may include a subacromial space injection for diagnosis, as well as, for treatment, and may also include a small dose of corticosteroid derivative. The use of cortisone can be helpful; however, at the same time, the cortisone theoretically can provide for weakness of tendons over several weeks by as much as 50% and can further compromise an already degenerative and weak rotator cuff tendon. Physical therapy: physical therapy can often be very beneficial, in addition to, the use of the anti-inflammatory modalities, ice and heat in contrast, neuromuscular stimulation, ultrasound and massage.
The rotator cuff tendons can be independently rehabilitated by an experienced physical therapist. Surgery: surgery most commonly would occur in the patients who are refractory to the nonoperative treatment. Among the goals of the surgical treatment include the so-called subacromioplasty, which diminishes the width of the bony acromion or roof to provide more space for the degenerative tendon complex. This also provides for removing the inflamed bursa. This is an outpatient procedure, which requires a sling for a period of time and then appropriate physical therapy to regain the range of motion and the strength. If the acromioclavicular joint is involved, then an additional operative procedure occurs to eliminate the degenerative component of the AC joint at the distal clavicle, and this is referred to as a Mumford procedure.
If the rotator cuff is torn and/or ruptured, then operative techniques using the arthroscope are also used to replace the tendon or repair the tendon at its normal anatomical location on the proximal humerus in the region of the greater tuberosity. Performance Issues All stages of impingement syndrome or rotator cuff tendinosis affect primarily overhead sports and overhead activities such as painting, wallpaper hanging, carpentry or sculpting. A secondary loss of motion and development of adhesions in the shoulder can develop, as well. Long-term effects of untreated rotator cuff rupture can ultimately lead to a non-repairable rotator cuff due to the retraction that occurs over time. This retraction normally occurs over many months.
Possible Outcomes Early treatment provides for the best opportunity to get an asymptomatic and completely functional shoulder. The outcomes are definitely a function of how degenerative the rotator cuff tendons are and for what period of time this was present. This also is a factor in a re-tear or re-rupture of the rotator cuff that can occur up to 20-30%, depending upon the basic integrity and health of the repaired tendons.
Prevention
Prevention is the key. It is important for the individual to understand his or her activity is one that is going to put them at increased risk. This knowledge would then provide the basis for a pre-injury conditioning-fitness-flexibility program that is comprehensive for the shoulder girdle. These program methods and techniques are available through the clinicians and physical therapists at SportExcel Health and Human Performance.
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