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Rotator cuff tendonitis

The rotator cuff is a large tendon. It’s really a confluence of three tendons and it is important in elevating - you know, abducting and raising up the shoulder. You can see these subacromial bursa right over the top of it. From a clinical standpoint, it’s almost impossible to differentiate subacromial bursitis from rotator cuff tendonitis. I just use the term rotator cuff tendonitis. I think even from a pathologic standpoint, we talk to orthopedic surgeons who go in and repair these things arthroscopically, they are often inflamed together rotator cuff tendonitis. But this is the most common tendonopathy that I seen in the office. Again, I think that in a primary care setting probably you are going to see a lot more of this than I do. That’s not the main reason that patients are referred to me. I see patients with rheumatoid arthritis, lupus, osteoarthritis, gout, occasionally these patients also have other problems and occasionally they are referred primarily to me for these problems. Many communities don’t even have a rheumatologist, so a lot of times orthopedic surgeons or maybe physiatrists, or maybe a pain management.

Many times when you see a patient, particularly someone in their middle age, 50, 60 or whatever, that this tendon has been irritated for a long time but it took awhile before it became clinically significant so the patient seeks medical attention. If it is relatively new onset, generally when you examine it … oh, the other thing is historically the patient may complain that when they are sleeping if they roll onto that shoulder that it’s very very uncomfortable.

On examination generally you will find focal tenderness over the rotator cuff, which is basically over the greater tubercula of the humerus, and that’s point tenderness. Obviously, if someone is very heavy or very muscular it is harder to feel that, but in the average person it should be fairly prominent. It’s about one or two finger breadths below the acromion. I can see everybody feeling their shoulder, and that’s sort of what I do too just to see where everything is. The longer this pain has been there, the more likely it is to be diffuse in nature and it may be hard…. If a patient comes in and says it has been hurting for six, eight months, they may have a lot of tenderness in other areas because of the natural way that pain spreads in the shoulder joint. They recruit other muscles to try and support. You may get secondary arthritic changes which can also add to the confusion, but if you see it early on, the pain and tenderness should be fairly localized and also examination, passive motion should be normal. It means you should raise the arm up, completely full range of motion, normal abduction, normal internal and external rotation. In someone that has had rotator cuff tendonitis for a long time they may lose some abduction, and obviously with active abduction. They may not be able to do the full 150 degrees because of the pain. If it goes for a very long time you can get secondary osteoarthritis with limitation in rotation. The supraspinatus is really about 80% and a lot of physicians will just call it supraspinatus tendonitis. On our billing form and in the coding book there is a code for rotator cuff tendonitis.

If the symptoms have been going on for a long time the patient develops either secondary osteoarthritis or sometimes adhesive capsulitis. You will get much more significant limitation of motion on even passive range of motion, but pure unadulterated rotator cuff tendonitis the range of motion should be completely normal, rotation and abduction. Generally I don’t get x-rays if the range of motion is normal. If I have a patient that has limited range of motion I will check x-rays. But early on in this disease it may be normal. The early changes on x-rays include migration of the radial head superiorally. So you lose the space between the humeral head and the acromion. And sometimes in a very severe case they will just be touching and you can see that’s not very good for the rotator cuff. It makes it even worse because there’s no room for that cuff and it just gets ground. It’s like taking rope and rubbing it over a rock. It’s just going to wear out. Sometimes you can get calcium deposits.

The treatment: a little injection of corticosteroids, lidocaine is usually very helpful. I will give a talk later on in the week about the use and techniques of injection, so I’m not going to go into it a lot today. My own personal bias - and I don’t know why, because all the doctors that I ever trained with loved to do injections. I mean, if someone came into the office they had needles lined up and they started injecting away. It’s not that I don’t like to do the procedures, I enjoy doing them because I know many times it will bring relief, but if I don’t have to I don’t do it. I think some patients like that. Some patients would rather just get the injection and be done with it. But this is one syndrome where I think injection really works. If a patient is agreeable to it then I think a local injection with corticosteroids and some lidocaine should bring relief within a few days. The one thing you want to be concerned about is repeat injections.

Occasionally surgery is helpful. You have to talk to an orthopedic surgeon, but there are at least three configurations of the acromion and some of them are such that they really impinge on the rotator cuff and an orthopedic surgeon can go in with an arthroscope. They have all these grinding tools and - you would think they were digging for gold, but I guess in a sense they are - but they can actually shave down the acromion to make more space and to almost dull the edge. Sometimes it’s a very sharp edge and it literally cuts into the rotator cuff. With these tools they can sort of grind it down and make it more comfortable for the patient.

Adhesive capsulitis, or frozen shoulder, which is more common in people who have underlying arthritis but particularly chronic rotator cuff disease, diabetes. That’s a big one. Diabetics are more prone to frozen shoulder and I think that is the most common reason that I’ve seen it. Occasionally after myocardial infarction patients will get a frozen shoulder. This is different because the patient will complain of pain in their shoulder but it is true shoulder pain. They will localize the pain over the glenohumeral joint, which is basically medial to the head of the humerus. If you examine, that’s where it will be tender.

It’s important to relieve the pain, which can be with antiinflammatory drugs. Sometimes oral corticosteroids, a short course, or intraarticular corticosteroids and get them into physical therapy to get that arm moving, the shoulder moving again. Otherwise, if it’s untreated, you could end up with a very poor functioning joint. If you do all these things, unless the patient is really delayed coming to the doctor, you usually have a pretty good outcome, although it can occur. Reflex sympathetic dystrophy is basically frozen shoulder with distal edema and pain in the hands. Some people think they are essentially the same things, just to different degrees. Again, the shoulder needs to be addressed and physical therapy is really the mainstay of a therapy for either frozen shoulder.