I see a number of rotator cuff injuries in my office. There are four different cuff muscles, and each muscle can have a few different types of injury severity and/or pattern. You can imagine that there are a myriad of recommendations for treatment options with such complexity around the shoulder joint. I will therefore focus on the most commonly injured cuff muscle, the supraspinatus. That particular muscle/tendon complex is involved in around 90% of shoulder muscle injuries I see in the office. Sometimes, there is no tear of the tendon, but rather severe inflammation, often called bursitis.
The supraspinatus controls a great deal of overhead strength, especially for lifting items above the head while the arm is in front of you. This obviously affects a great deal of daily activities and can therefore be quite debilitating when not functioning properly. Many times, the injury can be attributed to an imbalance of the muscle forces around the joint that chronically stress the shoulder muscles. This imbalance eventually will lead to failure of tissues at some point.
Diagnosis of severe bursitis or a partial tear can often be done in the office by the shoulder surgeon. If there is a question about the diagnosis, then I can look at the tendon in the office using the ultrasound machine. Ultrasound can reveal larger tears, but can be less accurate in older patients (due to degeneration of the tissue overall). MRI scan will give more information with greater clarity overall. Both ultrasound and MRI can often show an abnormal increase the amount of fluid that overlies the tendon in the setting of bursitis.
In the setting of a partial tear of the tendon (remember that the tendon is how the muscle attaches to bone), a guided formal physical therapy program is often the best initial treatment. I often hear patents tell me that they know how to workout in the gym, and therefore don’t need a therapist. The physical therapist teaches people how to activate the specific cuff muscles and other shoulder stabilizers in a way that many people don’t appreciate. These guided treatments are quite important for proper rehab. The majority of patients that end up seeing the therapist are surprised at how effective it can be. They also learn a lot about how to avoid future injuries! One of the most difficult things for a patient to do is so-called ‘activity modification’. This means avoiding the activities that cause worsening of the symptoms. It sounds simple, but people will sometimes scoff at having to stop a hobby during the rehab period. It doesn’t have to be forever, but it may take a few months of avoiding certain things to get the shoulder working right.
A standard program with a physical therapist will last about 6 weeks, usually attending two to three times per week. In the setting of a partial tear or severe bursitis, this can often take care of the problem and help to avoid surgery. If therapy is too difficult to tolerate because of pain, then I will offer a steroid injection in the office to facilitate the exercise program. Many times the therapist will give a home program to work on in between sessions. There are tools such as exercise bands and home pulleys that can help keep the sessions moving forward.
I would not consider any sort of surgical intervention unless a minimum of 6-8 weeks of supervised therapy fails to improve the pain/weakness.