What are the symptoms and treatment options for a rotator cuff injury?

Symptoms and Treatment of Rotator Cuff Injury

Rotator cuff injuries typically present with shoulder pain, weakness, and limited range of motion, with pain often radiating down the upper arm and worsening at night. 1, 2 These symptoms significantly impact quality of life and can lead to substantial disability if not properly managed.

Common Symptoms

• Pain characteristics:

  • Pain with overhead activities
  • Night pain, especially when lying on the affected shoulder
  • Pain radiating down the upper arm (not typically beyond the elbow)
  • Pain with specific movements (abduction and external rotation)

• Functional limitations:

  • Weakness in shoulder movements, particularly with lifting and rotating
  • Limited range of motion
  • Difficulty with daily activities requiring overhead reaching
  • Crepitus or catching sensation during movement

• Physical examination findings:

  • Tenderness over the affected tendon(s)
  • Deltoid and rotator cuff muscle atrophy in chronic cases
  • Weakness on abduction and external rotation
  • Positive impingement signs

Risk Factors

• Age: Prevalence increases significantly with age (13% in fifth decade, 20% in sixth decade, 31% in seventh decade) 1
• Occupational: Repetitive overhead activities (painters, carpenters)
• Athletic: Throwing athletes, tennis players, baseball pitchers
• Dominant arm: More common in the dominant arm 1
• Trauma: Falls or shoulder dislocations (especially in younger patients)

Treatment Algorithm

1. Initial Conservative Management (First 6 Weeks)

• Pain control:

  • NSAIDs as first-line medication 3
  • Cryotherapy in the first week 3
  • Activity modification to avoid painful movements

• Early rehabilitation:

  • Gentle range of motion exercises within pain-free range 3
  • Isometric exercises for muscle reactivation if no pain is present 3
  • Proper positioning education

2. Intermediate Management (6 Weeks - 3 Months)

• Reassess at 6 weeks to evaluate progress 3

• Advance rehabilitation:

  • Progressive ROM exercises
  • Light strengthening exercises for rotator cuff and periscapular muscles
  • Scapular stabilization exercises

• Consider injection therapy:

  • Corticosteroid injections for significant pain (limited to 3-4 per year) 3

3. Advanced Management (Beyond 3 Months)

• Rehabilitation progress evaluation at 3 months 3

• For improving cases:

  • Progressive resistance training
  • Advanced scapular stabilization
  • Sport or activity-specific training
  • Focus on functional activities that mimic daily tasks

• For non-improving cases:

  • Consider repeat imaging (MRI preferred) 3
  • Surgical consultation if no improvement after 3 months of appropriate rehabilitation 3

Imaging Considerations

• Initial imaging: Plain radiographs (anteroposterior, Grashey projection, and axillary lateral or scapular Y view) 3
• Advanced imaging if needed:
  • MRI without contrast is highly effective for evaluating rotator cuff pathology
  • MR arthrography is the gold standard for patients under 35 years 3
  • Ultrasound can evaluate rotator cuff and biceps tendon pathology but has limitations for labral tears 3

Surgical Considerations

• Indications for surgical referral:

  • Failure of conservative treatment after 3 months
  • Young patients (under 30 years)
  • High-demand or contact sport participants
  • Acute traumatic tears with significant functional deficit

• Important considerations:

  • Non-surgical treatment should be the primary approach for most rotator cuff tears 3
  • Return to work and sports is typically faster with non-operative treatment 3
  • Surgery creates an increase in quality-adjusted life-years for all patients, regardless of age 1

Common Pitfalls and Caveats

• Not all tears are symptomatic: Many rotator cuff tears (especially in older adults) are asymptomatic and do not require surgical intervention 1
• Avoid overtreatment: Surgery is not recommended for asymptomatic full-thickness tears 1
• Recognize age-related differences: Tears in younger patients are more likely traumatic, while degenerative tears are more common in older patients 1
• Monitor injection frequency: Limit corticosteroid injections to avoid potential tendon weakening 3
• Supervised therapy benefits: Supervised physical therapy shows better outcomes than unsupervised home exercise programs 3

Remember that the goal of treatment is functional improvement and pain reduction rather than necessarily achieving anatomical healing of the tear 3. Most patients with rotator cuff injuries can be successfully managed with a well-structured conservative approach.