Rotator Cuff Injuries: Initial Treatment

There is a wide range of potential treatment options for most rotator cuff injuries. Partial and degenerative rotator cuff injuries often respond to rest and rehabilitation. If rest, rehabilitation, and other non-invasive treatments do not work, injections may be recommended.

Surgery is typically reserved for patients with complete or high-grade tears of the rotator cuff.

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Nonsurgical treatment

Typical management of rotator cuff muscle and tendon injuries requires patients to demonstrate patience and consistent effort. This approach has three phases:

1. Protection and pain-control phase
2. Restorative phase, which addresses range of motion and strength deficits
3. Integrative phase, which incorporates sports-specific activities

• Protection and Pain Control

  The initial treatment for rotator cuff injuries involves pain control and relative rest. Adequate pain management is typically achieved with anti-inflammatory medications or cortisone injections.

  The patient may need to wear a brace or sling to limit shoulder movement. Immobilization of the shoulder should be as brief as possible, even with complete tears. Immobilization for long periods can lead to further complications, such as the loss of range of motion and a painful condition called adhesive capsulitis (frozen shoulder).

  See Frozen Shoulder Symptoms

• Restorative phase

  Partial thickness tears and tendonitis may be treated with home therapy or formal physical therapy. Once pain and range of motion have been addressed, the therapy focuses on strengthening the rotator cuff; correcting strength and flexibility deficits or imbalances; and addressing stability and mobility issues surrounding the scapula, or shoulder blade, at the back of the shoulder (which can affect the rotator cuff).

• Integrative phase

  During this stage the patient returns to normal activities by incorporating appropriate biomechanics into complex and sports-specific skills. For example, small changes in throwing or lifting motions may help prevent future symptoms and injury.

In This Article:

• Rotator Cuff Injuries

• How Do Rotator Cuff Injuries Occur?

• Rotator Cuff Injuries: Symptoms

• Rotator Cuff Injuries: Causes and Risk Factors

• Rotator Cuff Injuries: Diagnosis

• Rotator Cuff Injuries: Initial Treatment

• Rotator Cuff Injections

• Rotator Cuff Repair Surgery

If these initial treatments do not work, doctors may recommend other non-invasive treatments or injections.

Other non-invasive treatments

Several non-invasive treatments for rotator cuff tendon injuries are described below. These treatments are not well researched, and there is no general consensus about whether they work. While the treatments are unproven, some doctors and physical therapists believe that they are worth a try before recommending injections or surgery.

Topical nitroglycerin. This medication comes in the form of a topical patch and may help with both pain and healing by encouraging better blood flow. Nitroglycerin, often used as a heart medication, relaxes and widens blood vessels.

Ultrasound. Efforts to heal the rotator cuff and reduce pain may get a small boost from ultrasound and electrical muscle stimulation.

¹
Orthoinfo. Rotator Cuff Tears: Surgical Treatment Options. American Association of Orthopaedic Surgeons. Last reviewed May 2011. Accessed November 3, 2014. http://www.orthoinfo. org/topic.cfm?topic=A00406

Iontophoresis. This treatment uses a mild electrical current to administer an anti-inflammatory medicine (e.g. dexamethasone) through healthy skin and into the sore area.8 Iontophoresis may be appropriate for people who can’t tolerate injections or want to avoid injections.

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These treatments are still being researched and are considered unproven; however, some insurance companies will still cover them. As with any elective treatment, patients concerned with cost should check with their insurance providers.

Dr. Michael Erickson is a sports medicine physician who provides care for adults and children. He also serves as the Sports Medicine Fellowship Director at Swedish Medical Center in Seattle, WA. Dr. Erickson’s interests are concussion management and musculoskeletal diagnostic procedures. He is the Head Team Physician for all of Seattle University’s varsity sport programs.

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Postoperative Care

1. Home
2. Patient Care
3. Services
4. Shoulder & Elbow
5. Overview
6. Rotator Cuff
7. Postoperative Care

Sling Instructions

After surgery, your shoulder will be placed in a sling as directed by your doctor. The sling is used to limit motion of your shoulder so that the rotator cuff tendon can incorporate and heal. In some cases where the repair must be carefully protected, your arm may be placed in a sling with a pillow that is attached around your waist. It is very important to wear your sling as directed by your doctor after surgery. 

• The sling is typically used for 4 to 6 weeks after surgery. 
• You should not do any reaching, lifting, pushing, or pulling with your shoulder during the first six weeks after surgery.
• You should not reach behind your back with the operative arm.
• You may remove your arm from the sling to bend and straighten your elbow and to move your fingers several times a day.
• You may remove the sling to bathe, dress, and perform elbow range of motion several times a day.

Watch the video below to see how you should properly wear your sling.

Your Diet

We recommend that you eat a light diet the evening of surgery and the next day. You may resume eating a regular diet as soon as you tolerate it.

Pain Management

When you are discharged from the hospital, you will be given a prescription for pain medicine. You may take this medicine as prescribed.

Ice Therapy

You will be given the option to purchase a cold pack machine. This machine has a sleeve which is attached to an ice cooler. You place ice and some water in the cooler and plug this in to a regular outlet. This circulates cold water through the shoulder sleeve providing relief of pain and swelling after surgery. If you do not purchase a cold pack, you may use ice bags or frozen vegetable bags to ice your shoulder.

• You should keep ice on the shoulder for the first 48-72 hours after surgery.
• Ice your shoulder two to three times per day for the first week, especially before sleep.
• We do recommend that you put a t-shirt or a thin towel between you and the sleeve so that it doesn’t injure your skin.

Caring for Your Surgical Incision

• You may remove your dressing and shower 48 hours after surgery if you do not have a pain catheter. If you had a biceps tenodesis surgery, you should leave your dressing on for five days after surgery. 
• If you have a pain catheter, this should be removed by a family member 72 hours after surgery along with the shoulder dressing before showering.
• You should not get in a tub or pool and immerse the incisions underwater for six weeks, but you may get in the shower and let the water run over them. Pat the incisions dry afterwards, and place Band Aid’s over the incisions. There is no need to place any ointment over the incisions.
• If you notice drainage, swelling or increased pain five days after surgery please call the office.
• Redness around the incision is very common and should not be a concern. However, please call our office if you have:
  • Redness and drainage five days after surgery
  • Redness spreading away from the incision
  • Redness and a fever

Sleeping

It is often very difficult to sleep in the week or two following rotator cuff surgery. The surgery itself may interfere with your sleep-wake cycle. In addition, many patients have increased shoulder pain lying flat on their back. We recommend that you try sleeping in a recliner or in a reclined position in bed. You may place a pillow between your body and your arm and also behind your elbow in order to move your arm away from your body slightly. You should wear your sling when you sleep.

Driving

Operating a motor vehicle may be difficult due to your inability to use your operative arm. If you should have an accident or get pulled over while wearing a sling, authorities may consider that driving while impaired. The decision to drive is based on your comfort level with driving essentially one-handed. If you need to drive, and a rotator cuff repair has been performed, you should wait at least until you have
seen your surgeon at the first postoperative visit. No one should operate a motor vehicle while taking narcotic medications.

Healing and Recovery
Tendon tissue heals much more slowly than other tissues in your body. For example, if you cut your skin, it will typically heal in seven to 10 days. Rotator cuff tendon tissue, however, heals over a three month period. After three months, it typically takes another two to three months to regain good
shoulder strength, depending on the size of the rotator cuff tear. While the goal of surgery is to restore a pain-free and functional shoulder, there may be some limitation based on the age and the size of the tear. In larger tears or tears in older patients, the tendon repair may not heal. In these cases, pain relief and function are usually good; however, some weakness usually remains in the shoulder. In general, about 90% of patients are satisfied with their shoulders after rotator cuff repair, and have significant improvements in pain and function after surgery.

Physical Therapy
The decision to prescribe physical therapy and when to start these activities is made on a case-by-case basis. This will be discussed with you on your first postoperative visit. You may be instructed by your surgeon or recovery room nurse to begin gentle range of motion exercises on the day of surgery. These will be self-directed exercises that you start on your own.

Surgical Risks and Complications

The list below includes some of the common possible side effects from this surgery. Fortunately complications are very rare. Please note that this list includes some, but not all, of the possible side effects or complications.

Complications may include: complications from anesthesia, infection (very rare with arthroscopic procedures), nerve injury (extremely rare), blood vessel injury (extremely rare), bleeding (extremely rare), shoulder stiffness, failure of repair (failure of the tendon to completely heal to bone), failure of the anchors or sutures, failure to improve your symptoms as much as you had hoped, a blood clot can form in your arms or legs and very rarely travel to your lungs, complex regional pain syndrome (a painful condition involving the arm).

>>Next topic: Medications to avoid before and after surgery

Calcific tendinitis of the shoulder – treatment, symptoms, causes, diagnosis

Calcific tendinitis of the shoulder occurs when calcium deposits form in the tendons of the shoulder. The tissues around the calcium deposits become inflamed, resulting in severe pain. This disease is quite common and most often occurs in people over the age of 40. Calcific tendinitis occurs in the tendons of the rotator cuff. The rotator cuff is made up of several tendons that connect the muscles around the shoulder to the humerus. Calcium deposits usually form on the tendon of the rotator cuff, which is called the supraspinatus tendon.

There are two different types of calcific tendonitis of the shoulder: degenerative calcification and reactive calcification. The wear and tear processes of aging are the main cause of degenerative calcification. As we age, the blood supply to the rotator cuff tendons decreases, resulting in weakening of the tendons. The wear process is accompanied by micro-tears of tendon fibers. And in damaged tendons, simultaneously with regeneration, processes of calcification deposition occur.

Reactive calcification is different from degenerative calcification. The mechanism of development of this type of calcification is not completely clear. This type of calcification is not associated with degenerative changes and is much more likely to cause shoulder pain than degenerative calcific tendinitis. It is believed that the development of reactive calcific tendonitis occurs in three stages. In the initial stage of calcification, changes occur in the tendons, in which conditions are formed for the formation of calcifications. In the calcification stage, calcium crystals are deposited in the tendons. But at this stage, calcifications are absorbed (reabsorbed) by the body. It is at this stage that pain is most likely to appear. In the post-calcification period, the body repairs the tendon and the damaged tissue is replaced with new tissue. The mechanism by which calcium absorption is triggered by the body has not been elucidated, but as soon as this happens and the tissue begins to regenerate, the pain usually decreases or disappears altogether.

Causes

No one knows exactly what causes calcific tendinitis. Physical aging or a combination of both leads to degenerative calcification. Some researchers suggest that calcium deposits are formed due to tissue hypoxia and insufficient oxygen supply to the tissues of the tendon. Others believe that pressure on the tendons can lead to damage, resulting in calcium deposits.

The mechanism of formation of reactive calcification is not completely understood. Typically, this type of calcific tendinitis occurs in younger patients and occurs without any apparent cause.

Symptoms

Mild to moderate pain may occur during calcium deposition, or the process may be painless. But when, with calcific tendinitis, the process of resorption of calcium deposits begins, a pronounced pain syndrome appears. Pain and stiffness in the shoulder can lead to a sharp decrease in the range of motion in the shoulder. Even raising the arm can become very painful. In severe cases, pain can interfere with sleep.

Diagnosis

To diagnose calcific tendinitis of the shoulder, the doctor will first take a medical history and do a physical examination. Shoulder pain can be associated not only with calcific tendonitis, but also with other diseases. Therefore, in order to make an accurate diagnosis, instrumental studies are necessary. X-ray allows you to visualize the presence of calcium deposits in the tendons. But the most informative for visualization of ligaments and tendons and the presence of pathological changes in them is MRI (magnetic resonance imaging). Visualization of calcifications using radiography or MRI in dynamics allows you to determine the tactics of treatment (conservative or surgical treatment). Laboratory studies are necessary in cases where it is necessary to differentiate this disease from inflammatory diseases of the connective tissue.

Treatment

Conservative treatment

The main objective of conservative treatment is to reduce inflammation and pain. Therefore, at the first stage, conservative treatment includes rest and taking NSAIDs (ibuprofen). Anti-inflammatory drugs can reduce the inflammatory process and reduce pain manifestations. If there is severe pain, corticosteroid injections may be given. The use of steroids allows for some time to effectively remove swelling and inflammation.

During the period when calcium deposits begin to be reabsorbed, the pain may be particularly severe. In such cases, it is possible to remove part of the calcium deposits using a saline wash. solution through two punctures in the area of ​​calcium deposits. This procedure is called lavage. Sometimes with this procedure it is possible to break the calcifications into pieces (they are removed with a needle). Removing deposits allows you to quickly reduce pain and achieve faster recovery of the tendon. Even when flushing does not remove calcium deposits, it can relieve pressure in the tendons, resulting in less pain.

Physiotherapy . Physiotherapy is one of the main components of the conservative treatment of calcific tendinitis. The use of a technique such as ultrasound helps to reduce pain and inflammation. But the effect of using ultrasound is achieved only with a course of treatment (up to 24 procedures within 6 weeks). Shock wave therapy is currently the most modern method of conservative treatment of such diseases. The shock wave breaks down large calcium deposits, allowing the body to absorb them faster.

Exercise therapy is indicated at the stage of completion of reabsorption and allows you to restore muscle tone and improve blood supply to the structures of the shoulder. As a rule, an individual selection of exercises is carried out and exercise therapy is carried out within 4-6 weeks. Exercise is very important for strengthening the rotator cuff muscles, as these muscles help control the stability of the shoulder joint. Strengthening these muscles can actually reduce the pressure on the calcium deposits in the tendon.

Surgical treatment

Surgical treatment is recommended in case of failure of conservative treatment and worsening of shoulder function or persistent pain. As a rule, surgical treatment is carried out using a minimally invasive arthroscopic method, which allows the patient not to stay overnight in the surgical department. During an arthroscopic operation, the surgeon visually determines the localization of calcium deposits in the tendons of the rotator cuff, removes them and rinses this area, free calcium crystals are also removed, which can irritate the surrounding tissues.

In rare cases, open surgery is necessary. With such an operation, access to calcium deposits goes through an incision in the muscles of the ligaments with the removal of part of the tendons. After the deposits are removed, the muscles and tendons are sutured.

Rehabilitation after shoulder surgery can take quite a long time. In the first 6-8 weeks after the operation, it is recommended to wear an orthosis and limit movements, then it is necessary to gradually begin to develop the joint and combine physiotherapy with exercise therapy. The volume of loads on the joint must be increased gradually and very carefully under the supervision of a physiotherapist. Beginning exercises, as a rule, no earlier than 6 weeks after surgery. The exercises are aimed at improving the muscle strength of the shoulder girdle and the muscles of the rotator cuff. Full recovery of shoulder function after surgery may take 3 to 4 months. After open surgery, recovery is much slower than with atroscopic resection.

Shoulder tendonitis | Symptoms

Biceps tendonitis of the shoulder joint is a common source of pain for tennis players, basketball players, weightlifters, in other words, athletes involved in sports with a constant load on the upper body. With age, the shoulder begins to wear out and wear away, leading to damage to the joint. Physiologically, the biceps muscle is located in the front of the upper arm. This muscle stretches from the front of the shoulder to the elbow and provides lifting of objects and rotation of the hand. At the end of this muscle are 2 tendons. One tendon inserts from the inside of the shoulder joint and belongs to the long head of the biceps. This tendon is the most commonly injured. The short head of the biceps is attached closer to the center line of the coracoid process of the scapula. Injuries to this tendon are rare.

When the long head of the biceps becomes inflamed and tender, the patient feels pain and weakness in the shoulder. Pain in the front of the shoulder and in some cases mechanical symptoms such as clicking or snapping are common in the condition we call shoulder tendonitis.

Shoulder tendonitis can also occur from overexertion of the biceps when turning or lifting something is done regularly and frequently. For example, professional swimmers or tennis players who make a lot of repetitive arm movements are at risk. The first symptom of tendinitis will be shoulder pain and constant weakness. The long head of the biceps tendon can also be damaged along with other shoulder problems, such as rotator cuff strain, shoulder arthritis, pinched shoulder, or shoulder instability. All of these conditions can cause situations in which the tendon of the long head of the biceps becomes damaged, inflamed, unstable, partially torn, or even torn completely.

Biceps tendinitis of the shoulder joint symptoms

Biceps tendinitis is manifested by constant or intermittent pain in the shoulder or front of the shoulder. Sometimes the pain radiates down to the muscles in the center of the arm. The symptoms of biceps tendinitis usually get worse when lifting something. Many patients may also occasionally hear popping and clicking sensations in the shoulder area. This occurs when the biceps tendon becomes unstable and flaps back and forth in relation to the biceps groove, a small gyrus or groove on the top of the humerus where the tendon joins. Biceps tendonitis is usually treated with rest and activity adjustments. If the condition worsens and the above methods do not help, the tendon of the long head of the biceps may remain painful, unstable, or in some cases sprained. When the biceps tendon stops sliding in the biceps groove, it can lead to a labrum tear or SLAP tear. In this case, surgery is sometimes required.

Biceps tendinitis of the shoulder joint treatment

If you develop chronic symptoms or rupture the long head of the biceps, you should consult a doctor.

Conservative

Treatment for tendinitis will depend on the severity of the symptoms and the results of investigations (such as an MRI). Sometimes even tears can be healed without surgery. The first stage will be a complete reduction in activities carried out with the help of hands, as well as rest. A sling (support bandage) may be required to keep the arm stable and at rest. Applying ice several times a day for 20 minutes helps reduce swelling and pain. Non-steroidal drugs (such as ibuprofen) can also help a lot. After a period of rest, the doctor may prescribe a course of physical therapy with stretching movements and stretching exercises in order to restore range of motion.

Surgical

In most cases, surgery is needed to relieve chronic pain caused by shoulder tendonitis. Quite often, biceps surgery accompanies procedures aimed at solving other problems of the shoulder, usually a rotator cuff injury. Usually, the operation is performed by arthroscopy, during which small incisions are made around the shoulder, into which a camera and thin instruments are inserted, allowing you to see the biceps muscle and perform manipulations aimed at restoring it. If during the operation it turns out that the damaged biceps tendon is too inflamed, we can remove this area and reconnect the remaining healthy tendon to the humerus. This procedure, known as tenodesis, is extremely effective in treating painful symptoms and restoring lost functions to the patient.