As a sports medicine surgeon, the complaint of shoulder pain is prevalent throughout my clinic. The human shoulder is composed of many structures that can become injured and, thus, there are a multitude of reasons why your shoulder can hurt. The shoulder joint is an extremely complex joint that is composed of bones, ligaments, muscles, tendons, and the joint capsule. All of the shoulder’s bone and soft tissue components must coalesce to provide strength and stability to an inherently unstable joint. While each individual structure is crucial to overall shoulder health, none is more important than the rotator cuff tendons. The rotator cuff is composed of four tendons (supraspinatus, infraspinatus, teres minor, and subscapularis). These tendons surround the humeral head, which is the “ball” component of the shoulder’s ball and socket joint. The function of the rotator cuff is to help elevate the arm, provide rotational strength, and keep the humeral head stabilized within the glenoid, or the “socket”. Thus, their importance to the shoulder can not be understated.
Injury to one or more of these tendons is extremely common. The highest incidence of rotator cuff tears occurs in patients over 60 years of age and in the dominant arm. However, some rotator cuff tears are not painful and occur in normal functioning shoulders. Therefore, a thorough physical examination and careful patient history are crucial in determining the cause of shoulder discomfort and/or loss of function. Furthermore, all rotator cuff tears are not treated the same and many will not require surgery. Individuals who have failed specific nonoperative treatments will be those patients considered for surgical intervention.
Rotator cuff damage occurs in two general flavors. Tears of the rotator cuff receive more attention because this type of injury leads to surgery more commonly than the second type of injury known as tendinopathy. Rotator cuff tears can be acute or chronic. Chronic tears are commonly found with repetitive overhead use (e.g. tennis players or factory workers) or with impingement of the tendons on bones within the shoulder. Acute tears of the cuff occur with falls, shoulder dislocations, or a sudden force on an outstretched arm. The second general type of injury is tendinopathy. This is a generic term that applies to inflammation of the tendons, micro-tears, and degeneration of the tissue with age.
The first line treatment of most injuries to the rotator cuff is physical therapy, anti-inflammatory medicines (e.g. Ibuprofen or Naprosyn), and ice. A steroid injection in the shoulder may also be offered by your physician. This injection can decrease inflammation, as well as, provide valuable diagnostic information. Most evaluations of the shoulder also include baseline x-rays to rule out arthritis, fracture, dislocation, or malignancy. Many physicians also utilize magnetic resonance imaging (MRI) or ultrasound to further evaluate the specific structures within the shoulder.
If nonoperative treatments do not alleviate pain and/or weakness then surgery may be a viable option. Traditionally, rotator cuff surgery has been performed through a somewhat large incision on the shoulder, known better as “open” rotator cuff repair. This surgical approach requires more dissection and release of muscles than arthroscopic rotator cuff repair. Open cuff repair has very favorable outcomes and remains the standard to which arthroscopic repair is compared. However, many surgeons are turning to arthroscopy because the outcomes (success rates) are better than, or at least equal to, open repair. Rather than one large surgical incision, arthroscopy requires a couple of small incisions that are less than an inch long. This allows for a more pleasing cosmetic result and much less of a scar. Furthermore, arthroscopic surgery is outpatient, meaning you can go home the same day as your surgery. Several studies have also shown less pain after surgery with arthroscopy. With arthroscopy the entire shoulder and entire rotator cuff can be visualized. This is of a great benefit to the surgeon and patient because all torn or injured structures in the shoulder can be repaired. Some of these injuries would go unnoticed with open rotator cuff surgery.
After surgery, patients go into a sling to protect the repaired tendons until range of motion can be safely resumed. Physical therapy is a mainstay of the post-operative recovery period and patients should plan to attend several therapy sessions after surgery. Returning to work is highly variable and depends greatly on the demands of your job and whether light duty is available at your work place. Most patients can resume their pre-surgical activities around 4 months, but strength gains and decreases in pain continue for up to a year.
In summary, shoulder pain is common and is the result of several distinct causes. However, there is an extremely good chance the pain can be alleviated. Comprehensive and timely evaluation can dramatically improve your quality of life and return you to pre-injury status and activity levels.