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Shoulder & Elbow Injuries

Rotator Cuff Injuries

How does the rotator cuff get injured?

Your shoulder is made up of three bones: the upper arm bone (humerus), the shoulder blade (scapula), and the collarbone (clavicle). The shoulder is a ball-and-socket joint: The ball, or head, of the upper arm bone fits into a shallow socket in the shoulder blade.

When one or more of the rotator cuff tendons is torn, the tendon becomes partially or completely detached from the humerus.

Illustration of a rotator cuff tendon torn away from bone

In most rotator cuff tears, the tendon is torn away from the bone. Most tears occur in the supraspinatus tendon, but other parts of the rotator cuff may also be involved. In many cases, torn tendons begin by fraying. As the damage progresses, the tendon can completely tear, sometimes with lifting a heavy object.

There are different types of tears.

Partial tear. This type of tear does not completely detach the tendon from the bone. It is called partial because the tear goes only partially through the thickness of the tendon. The tendon is still attached to the bone, but it is thinned.
Full-thickness tear. With this type of tear, there is detachment of part of the tendon from the bone.
- When only a small part of the tendon is detached from the bone, it is referred to as a full-thickness incomplete tear.
- When a tendon is completely detached from the bone, it is referred to as a full-thickness complete tear. With a full-thickness complete tear, there is basically a hole in the tendon.

Rotator cuff tendons and a full-thickness tear in the supraspinatus tendon

(Left) Overhead view of the four tendons that form the rotator cuff.
(Right) A full-thickness tear in the supraspinatus tendon.

Front view of rotator cuff and full-thickness tear in supraspinatus tendon

(Left) The front view of a normal rotator cuff. (Right) A full-thickness tear in the supraspinatus tendon.

Courtesy of AAOS

Do I need imaging?

X-rays. The first imaging tests performed are usually X-rays. Because X-rays do not show the soft tissues of your shoulder like the rotator cuff, plain X-rays of a shoulder with rotator cuff pain are usually normal and may show a small bone spur, which is a normal finding. The reason X-rays are done is to make sure you don't have other reasons for your shoulder pain, such as arthritis.
Magnetic resonance imaging (MRI) or ultrasound. An MRI can better show soft tissues, like the rotator cuff tendons, than an X-ray. It can show the rotator cuff tear, as well as where the tear is located within the tendon and the size of the tear. An MRI can also give your doctor a better idea of how old or new a tear is because it can show the quality of the rotator cuff muscles.

The goal of any treatment is to reduce pain and restore function. There are several treatment options for a rotator cuff tear, and the best option is different for every person. In determining the best treatment, multiple factors will be considered, including: tear type and severity, age, activity level, and your overall health

Nonsurgical treatment options may include:

Activity modification
Anti-inflammatory medications or topicals
Physical therapy
Steroid injection

Surgical treatment

Other signs that surgery may be a good option for you include:

Your symptoms have lasted 6 to 12 months
You have a large tear and the quality of the surrounding tissue is good (limited or no atrophy)
You have significant weakness and loss of function in your shoulder
Your tear was caused by a recent, acute injury

Shoulder Instability

What is a dislocated shoulder (or shoulder instability)?

The shoulder joint is the body's most mobile joint. It can turn in many directions, but this advantage also makes the shoulder an easy joint to dislocate.

A partial dislocation (subluxation) means the head of the upper arm bone (humerus) is partially out of the socket (glenoid). A complete dislocation means it is all the way out of the socket. Both partial and complete dislocations cause pain and unsteadiness in the shoulder.

Shoulder instability

What are the symptoms of a dislocated shoulder?

These symptoms include:

Deformity
Swelling
Numbness
Weakness
Bruising

Sometimes a dislocation may tear ligaments or tendons in the shoulder or damage nerves.

The shoulder joint can dislocate forward, backward, or downward. A common type of shoulder dislocation is when the shoulder slips forward (anterior instability). This means the upper arm bone moved forward and out of its socket. It may happen when the arm is put in a throwing position.

The muscles may have spasms from the dislocation, and this can make it hurt more. When the shoulder dislocates time and again, there is recurrent shoulder instability.

Do I need surgery?

Initial management includes reducing the shoulder joint, otherwise known as putting it "back in place." Sometimes this can be done in the Emergency Department, but on occasion requires reduction in the operating room. A post-reduction X-ray and MRI will be ordered to understand the extent of soft tissue or bony damage to the shoulder joint. You may need to immobilize the shoulder in a sling for a few to several weeks depending on the imaging findings.

Non operative vs surgical care is determined by: imaging findings, age, activity level, overall health, frequency/history of dislocations, among other factors.

Non surgical management focuses on physical therapy to strengthen the muscles around the shoulder girdle after a period of immobilization. If shoulder dislocation becomes a recurrent problem or if therapy fails to improve symptoms, surgery may be needed to repair or tighten the torn or stretched ligaments that help hold the joint in place, particularly in young athletes.

At times, the recurrently dislocating shoulder can result in some bone damage to the humerus or shoulder socket. If your surgeon identifies some bone damage, bone grafting may be necessary.

Shoulder & Elbow Injuries

Rotator Cuff Injuries

Shoulder Instability

Biceps Injuries

Shoulder Impingement

Tennis Elbow

Golfer's Elbow

AC Joint Injuries

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