Dr Sachin Tapasvi: Problems with the rotator cuff

The third most common issue faced with the shoulder is that of the rotator cuff. These problems are most common in the third, fourth and fifth decade of life. What is this rotator cuff exactly? We have heard a lot about it with elite sportsman having rotator cuff injuries as well as people in our neighbourhood in their late middle age having such issues as well.  Well, the rotator cuff is actually a group four of muscles. These arise from the scapula or the shoulder blade and they travel from the scapula and will go and insert inside of your arm bone or the humerus. In doing so, they crisscross the shoulder joint and they tightly hug the shoulder joint from all around thereby providing a thick muscular envelope. These muscles are primarily responsible for moving our shoulder in almost all directions. So any problem that affects these muscles would in turn affect the mobility of the shoulder and produce weakness as well as pain.

Rotator cuff problems may be of many types. In the simplest of forms, there is tendinosis or simple swelling of the rotator cuff; there could be deposition of calcium deposits within the substance of the tendon called Calcific Tendonitis or one would have either a partial or full thickness tear of these tendons. Rotator cuff is more vulnerable just at the site of insertion on to the arm bone or humerus. This is because the blood supply to the muscle is the least as it comes closer to its insertion site. Naturally, any form of increased strain at this site will cause this tendon to snap or to be affected. Thus we would find that the maximum problems to the rotator cuff occur in the area around the outside of the shoulder. One of the most common issues with the rotator cuff is that of impingement. As the name refers, impingement means to pinch. This tendon will pass between the undersurface of the clavicle or the collar-bone and the top surface of the humeral head or the ball of the shoulder joint. The space in this area is roughly between 12 to 15 mm.

Whenever we develop a spur or bony outgrowth from the undersurface of the clavicle or of there is an injury to the tendon during gym workout or during throwing which leads to swelling of the tendon, or if there is a deposit of calcium within the tendon substance causing the thickening of the tendon, there will be decreased mobility of the muscle in this narrow space. As a result, the swollen tendon cannot pass through the 15 mm space thus causing impingement or pinching of the tendon. Once the tendon gets pinched, the swelling increases and the problems worsen.

The other issue is that of a tear. Very frequently these are usually in elderly people above the age of 60 and a simple fall on an outstretched hand may cause this tendon to tear. These tears may also be associated with a shoulder dislocation. Once there is a tear, the shoulder becomes extremely painful and the patient is unable to rise the hand-the so-called pseudo paralysis sign.

Treatment of these rotator cuff problems is fairly straightforward and yields consistent results.  Early and quick diagnosis is the key. Hence, I would like to reiterate the fact that all pain around the shoulder is not frozen shoulder. Most often than not, I find that patients come to me with long standing shoulder pain and describe “My frozen shoulder is not getting better over the last 6 to 8 months”. But in reality, they do not have a true frozen shoulder. They are basically having cuff pathology. X rays help reveal bony out growths or spurs as well as calcific deposits. The use of ultrasounds and MRI is useful to allow further incite into diagnosis as well as grading or staging of the pathology. Tendinosis responds well to a stretching program in a phased manner followed by strengthening and the use of medication. In resistant cases, the use of injection may be administered to the space underneath the clavicle or the collarbone. This could either be locally acting steroid injection or what is more commonly what I use now is the Platelet Rich Plasma (PRP) injection. The PRP injection helps in regeneration of tissue rather then destroying the tissue, which is more common with a steroid injection. Tears of the rotator cuff will usually not heal non-surgically unless they are very tiny in size. These tears are usually fixed by doing keyhole arthroscopic surgery and the results are very rewarding.

Prevention is the key to rotator cuff problems. A lot of us are doing regular exercise programmes and the main reason that this muscle group gets involved is the lack of proper stretching and conditioning programme. It is a myth that people are engaged in regular exercises will have rotator cuff issues. Housewives and sedentary workers are more likely to have these problems due to lack of activity or inactivity. For this it would be essential that a good stretching and strengthening program with the help of elasticated resistance bands be instituted which will help in the prevention of this disabling pathology.


Dr Sachin Tapasvi

Dr Sachin Tapasvi

Dr Sachin Tapasvi is one of India’s leading joint replacement surgeons. He practises in Pune and has been awarded several fellowships with experience garnered internationally as well as in India. Dr Tapasvi writes every Wednesday on Pune365.
Dr Sachin Tapasvi