What is the Rotator Cuff?
The Rotator Cuff is comprised of four muscles that attach to the ball of the shoulder (humeral head). These muscles attach to the ball of the shoulder as tendons, which can be seen in the pictures as the white extension of the muscle. When the rotator cuff tears, it occurs where the tendon attaches to the bone.
The four rotator cuff muscles are called the:
- Teres Minor
The rotator cuff muscles help raise the arm in the air, rotate the arm in and out and reach up the back. More specifically the Supraspinatus and Infraspinatus help raise the arm in the air while the Teres Minor and part of the Infraspinatus help to rotate the arm out or “externally rotate” the shoulder like a pitcher cocking back to throw a baseball. The Subscapularis is the only one of the four rotator cuff muscles to rotate the arm in or “internally rotate” the shoulder.
What is Rotator Cuff Tendonitis/Bursitis?
Rotator cuff tendonitis and bursitis are fairly synonyms with one another. This means that as the rotator cuff tendons pass below the AC joint (the acromio-clavicular joint; this space is called the sub-acromial space) they become inflamed in this area. This occurs from repetitive work overhead, a trauma, heavy lifting away from the body or simple things like sleeping on your side more than the other. This can become very painful with overhead work, sports and everyday activities like reaching into a cabinet.
At the same time the bursa that helps decrease friction on the tendons and separate the top of the rotator cuff tendons and the under surface of the AC joint, becomes inflamed and enlarged. Normally the bursa is small and can’t be seen on an MRI or during a surgical scope of the shoulder. However, when this inflammation happens it further adds to a narrowing of the subacromial space between the the rotator cuff tendons and the under surface of the AC joint. This leads to further pain and irritation of the shoulder with work overhead, sports and activities of daily living. Most of the time this pathology will resolve on its own…other times it will persist for months if no treatment is performed.
What is Rotator Cuff Impingement?
This occurs when the acromion, as pictured on the right, pushes into the rotator cuff tendons from above. When the acromion is curved or hooked this can increase the likelihood that someone could develop subacromial impingement of the rotator cuff. Pain will be experienced with raising the arm in the air as this also decreases the amount of joint space in the subacromial space. A curved or hooked acromion can cause bursitis and tendonitis due to the increase in pressure and friction on the bursa and rotator cuff tendons. Most commonly these types of an acromion are congenital but can also be developed over time from repetitive heavy lifting over head with blue collar type work as well as weightlifters.
A: Illustration represents a normal shoulder without rotator cuff impingement; Notice the acromion is not pushing onto the rotator cuff from above. B: This Illustration represents a shoulder with impingement and burial inflammation due to the acromion pushing down onto those structures. Please visit this link for more information on subacromial impingement: http://www.orthobullets.com/sports/3041/outlet-subacromial-impingement
This illustration depicts how an altered acromion can impinge on the rotator cuff. Type 1 being a normal acromion; Type 2 being a curved acomion; Type 3 being a hooked acromion. A hooked acromion leads to the highest likelihood someone will have rotator cuff impingement.
What is Calcific Tendonitis?
Calcific tendonitis is a particular sub-condition of rotator cuff tendonitis. Over time, rotator cuff tendonitis could lead to calcific tendonitis. This occurs when chronic inflammation in the subacromial space and the rotator cuff tendons can lead to development of calcium deposits with the rotator cuff tendon. Calcium is a fundamental building block of bone so that being said, on an x-ray, this calcium deposit will show up almost as a floating piece of bone within the subacromial space. As you can imagine, this can cause intense pain to most any movement where the rotator cuff is being utilized especially with overhead activity. Over time this will continue to bother and could develop more and more bone/calcium if left untreated.
What are treatment options for Rotator Cuff Calcific Tendonitis/Bursitis/Impingement?
Typically, patients will do well with conservative treatment. This will consist of anti-inflammatory medication, rest, ice, physical therapy and a cortisone injection. A cortisone injection will help decrease the inflammation of the tendons and the bursa as a steroid is an anti-inflammatory. This will also help decrease the pain. In patients with calcific tendonitis, an injection can help dissolve the calcium deposit within the rotator cuff. Physical therapy will help increase muscular strength of the rotator cuff as well as the bigger muscles in the shoulder like the deltoid, pec, and trap. This will help with posture and open the subacromial space as it is narrowed due to inflammation and poor posture.
If rotator cuff bursitis/tendonitis/impingement or calcific tendonitis persists for months and months without improvement, surgery could be considered. Surgery would consist of an arthroscopic shoulder procedure where a camera and shaver are placed into the shoulder joint. The subacromial space is then debrided, any subacromial bone spurs are removed, the acromion is reshaped to a normal acromion and the bursa is released. This will help increase the subacromial space, in turn decreasing the pain and irritation onto the rotator cuff tendons. This is an outpatient procedure. Patients will begin moving their shoulder immediately after surgery as nothing was repaired or reconstructed. A sling will be used for comfort and can be discontinued when the patient is comfortable without it. The goal is to restore passive and active range of motion as quickly as possible after surgery.
Please watch the video below as this is one of my patients who had a large deposit of calcium within the rotator cuff tendon. It will help in understanding how I remove calcific tendonitis with an arthroscopic procedure.