THE SHOULDER ROTATOR CUFF – WHAT IS IT AND CAN IT BE FIXED?
I have now embarked on a new feature of writing some more in depth articles on conditions that affect the body, where I hope to provoke some interest.
So this is the first one and I’ll trial it and if you like it, do let me know and similarly if they require some tweaking do let me know as I’m deliberately making them a little more technical
The reason for this is that all too often when you google something on which you want so information it can be either over technical or so simplistic that neither is helpful or gives information that is not altogether accurate!
I am attempting a half-way house between over simplification and not being too technical so only you can let me know, if I have struck the right balance. I have also put in a Video in which I talk through the topic and for those who have nothing better to do an audio file.
I have recently had quite a few patients complaining of shoulder disability a preponderance of them having been diagnosed as a Rotator Cuff Injury. The problem with this diagnosis is that most shoulders I usually see are diagnosed as either a “rotator cuff tear” or a frozen shoulder. The truth is as always a bit more complicated
To help you understand the issues surrounding the shoulder it may I hope be a lot clearer as to what your problem might be and more importantly what can be done about it.
leno – Humeral Joint
The gleno – humeral joint sits at the end of the shoulder bone (humerus fitting into the hollow glenoid fossa at the end of the shoulder blade). The joint has the most movement of all the joints in the body facilitated by the shallowness of this joint. You can picture it like a golf ball balancing on a tee. So it doesn’t take an awful lot for the golf ball or in our case our humerus to just fall off, giving its inherent instability. This is where the rotator cuff group of muscles come in as it is these which give it stability.
So what are the rotator cuff group of muscles?
To give an understanding I will go through which muscle constitute them
The top one, is called the supraspinatus, whose main function is to lift the arm up (abduct it), so when this tendon goes wrong there is great difficulty in lifting the arm up.
Below Supraspinatus is Infraspinatus which insert on the inner side of the humerus.
The last one is subscapularis which comes from underneath the shoulder blade, which inserts to the front of the humeral head on the lesser tuberosity.
All three muscle, have the function of rotating, lifting, internally rotating the arm.
They are called dynamic stabilisers. They work continuously to keep the gleno humeral joint stable and in its socket.
They work as a dynamic couple for example subscapularis which comes from underneath the shoulder blade rotates the arm internally which work in dynamic equilibrium with teres minor. One muscle opposing the others action in a way to prevent the humerus being pivoted off its socket the glenoid fossa. This is in part how they add to the stability of the gleno humeral joint.
Just below this cuff of muscles lies what is called the rotator interval which has no muscle enveloping it this is where ligaments help stabilise the joint. In addition there is also the biceps tendon which travels over the humerus and is again a stabiliser which prevents the humeral head popping out of its socket.
There is also the labrum which is fibrocartilage which extends over the glenoid fossa to help deepen it and also adds another layer of stability.
Lastly the whole joint is enclosed with a joint capsule which has a negative pressure which draws the joint upwards adding a final layer of stability.
What Happens When the Rotator Cuff Muscles go Wrong?
The main pathology affecting these tendons are tears:
- <25% is a small tear
- 25-50% is a medium sized tear
- >50% are large tears
- Up to complete tears is where there is severe disruption to arm movement.
In a complete tear you are not able to lift the arm at all and it is important to be assessed as surgery is the only answer and if not done fairly quickly surgery becomes less effective.
As a general rule tendons as they age become weaker and are more prone to tears. If exercise is done throughout life working on the shoulders as well there is much less likelihood of tears as strength and tendon integrity is maintained.
In fact I see many patients who often tell me that all they did was to turn their arm outward which was enough to cause a tear.
Does Treatment Help?
If the rotator cuff goes wrong Osteopathy, Acupuncture is effective in getting at least 70% of patients back to normal and fairly quickly over a number of weeks. However at the same time it has to be said shoulders take longer than any other part of the body to recover partly because of its stability issues.
Osteopathy helps stretch and activitate tenocytes the tendon building cells in tendon repair broken tissue and Acupuncture can be used for pain relief and also stimulating healing.
Of course when pain permits building up the musculature is very important both in terms of repair and promoting shoulder stability.
It is always possible to tell how well a shoulder can progress as on a scan fatty infiltration can be seen which means the muscle has degreaded making repair difficult. If there is a huge amount of muscle wasting then again it is difficult to repair either by conservative treatment or surgical.
If there is a lot of pain and nothing helps the inflammatory reaction may be too great and this is when a steroid injection might help in dampening down the reaction and during this time the shoulder can be worked on to help build it up and bring back stability. It should though be borne in mind that steroid injections only subdue the inflammation and don’t solve the problem in fact long term studies show they have no further beneficial effect than conservative treatment although they may well help for a short period in reducing pain.
Rotator Cuff Arthropathy
If the rotator cuff looses complete functioning then what happens is the humeral head can migrate upwards. The only option here is shoulder replacement as the cuff muscles will never have enough integrity to stabilize the shoulder joint again.
This is where the shoulder hurts increasingly as you bring it up and is often caused by a small bony spur called an osteophyte which slams into the Supraspinatus tendon as you bring your arm up. Though conservative treatment can help if the spicule of bone is too large then surgery may be required to shave off this extra bone to prevent it continually injuring the tendon and this can be very successfully treated.
I hope having watched my video and reading this has given some insight into what the rotator cuff group of tendons are , what they do, what goes wrong and how treatment can help.
Do email me or contact me if you have any questions or indeed have any comments.