Q: I continue to have pain and weakness in my shoulder several months after falling on the ice. What could be going on?
You may have a rotator cuff tendon tear. The rotator cuff is made up of four muscle-tendon units: the subscapularis, supraspinatus, infraspinatus and teres minor. Muscle fibers turn into tendon fibers and these tendon fibers then insert onto bone, and this is how a muscle exerts its force on our skeleton. A rotator cuff tendon can either partially or fully tear off of its bony attachment. The incidence of rotator cuff tears increases with age.
Rotator cuff tendon tears are typically painful. My patients with rotator cuff tendon tears report the pain to be most severe at night, and it can wake them from sleep. Pain is also worse with overhead activities. Patients also complain of the pain being worse when their arm is in certain positions, such as reaching behind them to put on a coat or grabbing for the seatbelt. Depending on the size of the tear, the shoulder may be weak especially with lifting anything overhead.
Unfortunately, there is very limited ability for rotator cuff tendon tears to heal. Instead, once torn, these tendon tears tend to become larger tears. However, partial rotator cuff tendon tears are usually more painful than full thickness rotator cuff tendon tears. So, even though tears tend to get larger over time, they may actually become less symptomatic for a time.
When I see a patient in the office with a rotator cuff tendon tear, they typically have shoulder pain localized primarily over the side of their shoulder. Furthermore, the pain tends to radiate down the side of their arm toward their elbow. There is usually weakness in the rotator cuff musculature when I compare their strength to that of the other shoulder. Bringing their arm overhead or across their body may increase the pain.
As for diagnostic tests, an MRI of the shoulder is very helpful. MRIs show all the soft tissues around the shoulder such as tendons, muscle and cartilage as well as showing the bony structures. Moreover, there is no radiation to the patient with an MRI, unlike with a CT scan. Rotator cuff tendon tears can also be diagnosed with the use of an ultrasound. Although ultrasound is less costly, the accuracy of an ultrasound is very dependent on the operator and it also does not allow one to visualize other “deeper” parts of the shoulder for possible problems which may also be causing pain.
As for the treatment of rotator cuff tears, I typically recommend non-surgical management of partial thickness tears. I prescribe physical therapy in order to reverse any stiffness that may have developed in the shoulder as well as strengthening all the muscles around the shoulder and scapula. I also prescribe short courses of an anti-inflammatory medication or perform a single subacromial steroid injection, which is helpful in calming down the inflammation and pain so that patients can better participate in physical therapy and sleep better at night.
If a patient is active and otherwise healthy and has a full thickness tear of one or more of their rotator cuff tendons that is not excessively retracted, I recommend surgery. Without surgery, the tendon tear typically gets larger and more retracted over time, and the patient’s shoulder gets weaker and usually more painful. If one waits too long, the tendon tear eventually gets so large and retracted that the tendon tear is no longer repairable and then treatment options are limited.
Dr. Rick Cunningham is a Knee and Shoulder Sports Medicine Specialist with Vail-Summit Orthopaedics. He is a Physician for the US Ski Team and Chief of Surgery at Vail Valley Medical Center. Do you have a sports medicine question you’d like him to answer in this column? Visit his website at www.vailknee.com to submit your topic idea. For more information about Vail-Summit Orthopaedics, visit www.vsortho.com.