A rotator cuff is a functionally important group of muscles of the shoulder joint that originates from the shoulder blade (scapula) and that wraps around the upper arm head like a cuff and is jointly responsible for the rotation (rotation) and lifting of the arm.
A distinction is made with the rotator cuff
The subscapularis muscle (Latin “sub”: under, “scapula”: shoulder blade) arises from the front of the shoulder blade in the subscapular fossa and attaches to the front of the humerus on the tubercle minus. Functionally, it serves to rotate the arm inwards (inner rotation), and is even the strongest inner rotator on the upper arm. It also supports the movement of the arm forwards (anteversion) and backwards (retroversion). Like all muscles of the rotator cuff, it also contributes to the tension of the joint capsule. It is innervated by the subscapular nerve.
The supraspinatus muscle (lat. "Supra": above, "spina": spine) arises from the upper part of the back surface of the shoulder blade in the supraspinous fossa and extends under the shoulder roof to the majestic tubercle on the humerus. Its function is that of the side arm lift (abduction), especially in the start phase of the movement up to approx. 15 ° abduction, it is the "abduction starter". He shares this function with the deltoid muscle. He also contributes less to the external rotation of the arm and also tensions the joint capsule. It is innervated by the suprascapular nerve.
He has the most common injury of all rotator cuff muscles, especially since his tendon often shows calcifications as he ages. These limescale deposits can lead to a so-called impingement syndrome: This clinical picture involves pinching or pinching the tendon of the supraspinatus muscle under the shoulder roof. This results in pain when the arm is lifted to the side or when under stress, such as when lying on the affected arm.
Another clinical picture is the Suprascapularis syndrome: In this case, the suprascapular nerve, which supplies both the supraspinatus and the infraspinatus, is pinched in a notch in the shoulder blade and there is pain in the shoulder and a weakening external rotation and abduction.
The infraspinatus muscle (lat. "Infra": below, "spina": spine) arises from the lower part of the rear surface of the shoulder blade, the so-called infraspinate fossa, and also extends to the tubercle majus of the humerus, somewhat behind the supraspinatus muscle. If you look at the course of the muscle - from the shoulder blade to the lateral head of the upper arm - you can understand its function well: If the infraspinatus muscle contracts, it causes the arm to turn outward (external rotation), it is even the strongest external rotator of the upper arm. In addition to external rotation, he is also involved in pulling the upper arm towards the middle of the body (adduction). When the arm is raised, however, it causes the arm to move away from the center of the body. Together with the other muscles of the rotator cuff, he stretches the capsule around the shoulder joint. The innervation occurs over the suprascapular nerve.
The teres minor muscle (lat "minor": smaller, "teres": round) has its origin at the side edge of the shoulder blade below the infraspinatus muscle. He also pulls to the tubercle majus on the humerus. Functionally, it is a weak external twist (external rotation) of the upper arm. He also participates in pulling the upper arm towards the body (adduction). The M. teres minor and the M. infraspinatus thus form not only an anatomical but also a functional unit. However, both muscles differ in their innervation: the teres minor muscle is innervated by the axillary nerve.
The function for arm movement of each muscle involved in the rotator cuff has already been described.
In summary, the rotator cuff has a significant part in the rotation of the arm, that is, in the external and internal rotation of the upper arm.
The rotator cuff is therefore extremely important for the mobility of the whole arm. Together with other muscles, the rotator cuff gives the shoulder joint the greatest freedom of movement of all joints in humans.
In addition, each muscle of the rotator cuff tightens the joint capsule of the shoulder joint and thus gives the shoulder joint stability.
Because of the poor bony guidance of the shoulder joint and the weak ligamentous apparatus, the shoulder joint is mainly secured by the rotator cuff and the deltoid muscle (deltoid muscle). Together they cause the humerus head to be held (centered) in the socket.
However, this also explains to the same extent the high loads that act on the rotator cuff and the consequences of injuries that result from it.
In contrast to other large joints in the body, the shoulder joint is mainly guided and stabilized by its soft parts (muscles, ligaments, joint capsule).
The contact of the large humerus to the shoulder socket (glenoid) is only slight. Due to these enormous loads, diseases of the shoulder joint are frequently found in the area of the rotator cuff.
The supraspinatus muscle, which travels under the roof of the shoulder to the humerus, is particularly often affected. When the arm is moved across the horizontal, there is a shoulder roof for this muscle because the upper arm head rises up under the shoulder roof when the arm is raised. An impingement syndrome caused by the condition of the shoulder or wear caused by wear and tear can lead to the clinical picture of impingement syndrome. This means the repeated pinching of the supraspinatus tendon under the shoulder roof, which causes inflammation of the tendon and the bursitis located there (subacromial bursitis). If the load capacity of the supraspinatus tendon is exceeded, it can tear without adequate injury (supraspinatus tendon rupture / rotator cuff tear).
Impingement syndrome is also called bottleneck syndrome, which is also synonymously referred to as shoulder bottleneck syndrome.
Due to chronic damage, lime can also accumulate in the supraspinatus tendon, but also in other tendons of the rotator cuff.
One then speaks of the clinical picture of tendinitis calcarea or calcareous shoulder.
Often the cause of shoulder pain is in the area of the rotator cuff. Most discomfort occurs when you exercise, such as spreading your arm and trying to lift your arm completely. Symptoms include pain when exercising or lying on the arm, e.g. at night, which even radiate to the hand. Muscle weakness in the shoulder area and functional restrictions can also be symptoms.
Typically, tendon changes are the cause of these complaints. Changes in the bone structure, degenerative changes in the tendons, e.g. calcifications that increase with age, or trauma can lead to the tendon of the supraspinatus muscle being pinched. This pinching is called impingement syndrome and causes pain that occurs when the arm is raised above 60° and disappears when the arm is raised above 120°. This area is also called "Painful Arc".
This phenomenon is due to the fact that when the arm is raised, the space under the shoulder roof is reduced and the previously damaged, damaged tendon of the supraspinatus muscle is pinched. This phenomenon often occurs in athletes, especially swimmers, tennis, golf and handball players. Imaging (X-ray, MRI) is often performed to confirm the diagnosis. Therapy can be carried out conservatively, i.e. with the help of physiotherapy and various medications, or surgically using arthroscopy.
Inflammation is often a reaction of the body to injuries and occurs particularly when muscles or tendons are irritated. Inflammation in the shoulder area is often observed when calcifications are present.
If the rotator cuff is inflamed, classic symptoms can be observed: the shoulder area is reddened in the side comparison, often overheated and swollen, the movement is often restricted and painful. If the symptoms persist for several days or worsen, a visit to the doctor should be considered.
With repeated inflammations, calcifications, especially in the area of the tendons, can form and lead to functional restrictions and pain, see Impingement Syndrome. A detailed medical history and physical examination, a blood sample to measure inflammation parameters, and an imaging procedure (e.g. MRI) can help to confirm the diagnosis. In any case, the shoulder should be protected and if possible a shoulder orthosis or bandage should be worn. It is best to consider non-steroidal anti-inflammatory drugs for pain management. Physiotherapy and physiotherapy can help minimize pain and loss of function.
Depending on the underlying cause, the symptoms of a rotator cuff rupture differ.
A rotator cuff tear most often occurs due to wear, i.e. that over the years the tendon mirror is thinned out by loads and abrasion and the natural tendon quality and tear resistance decrease.
Minor injuries or even without an accident can ultimately tear the tendon. In such cases, the patient initially feels a lack of strength in the arm during certain movements. For example, the arm can no longer be held at shoulder height or only with great effort. The pain occurs with various movements (see functional shoulder joint examination), which is why the patient usually begins to avoid painful movements. One speaks of taking a protective posture.
If the rotator cuff breaks as a result of an accident, sudden pain occurs. In the event of a total rupture, external rotation or spreading (see functional shoulder joint examination) is not possible or is difficult.
Pressure pains in the attachment area of the supraspinatus tendon are typical in both cases (major tubercle).
The pain caused by a rotator cuff rupture can radiate over the upper arm into the hand, but mostly the pain is concentrated on the shoulder and the lateral upper arm.
An impingement syndrome is often found at the same time.
Loss of strength is a typical symptom of a rotator cuff tear. In an acute case, this loss of force occurs immediately depending on the severity of the rotator cuff tear. In addition, there is immediate pain. If the rotator cuff tears are only slightly pronounced, those affected sometimes only feel weak. Otherwise, a strong rotator cuff tear can be assumed in the event of a complete loss of power.
The loss of strength manifests itself when the arm moves. It is difficult for those affected to raise their arms to shoulder level. In addition, external rotation or spreading of the arm are difficult or not possible at all.
With a rotator cuff tear, severe pain in the shoulder often occurs in the acute accident, which can also drag into the environment. Movement in the shoulder is associated with uncomfortable pulling pain that sometimes makes it impossible to move. The patient holds the arm in a gentle position in front of the body in order not to strain. This causes sharp pain at night and when lying on the shoulder. Above all, raising the arm causes problems. If there is a rotator cuff tear due to occlusion, it may not be actively perceived with pain and is only noticeable due to the restricted movement.
With regard to the diagnosis of a rotator cuff rupture, different examination options are available.
A functional shoulder joint examination is usually started.
This examination includes, among other things, checking the force development of the rotator cuff by lifting the arm sideways (abduction) against resistance, by turning it outside (rotation) against resistance when the arm is hanging and the elbow flexed, and by turning the arm inside against resistance.
While the spreading reflects the functionality of the supraspinatus muscle, the functional test that checks the external rotation against resistance relates to the teres minor muscle and the infraspinatus muscle.
Checking the powerful internal rotation of the arm controls the functionality of the subscapularis muscle.
In addition to the functional shoulder joint examination, there are imaging methods, such as:
The x-ray image cannot directly detect a tear in the rotator cuff because tendons and muscles belong to the soft tissues of the body and these are radiolucent to x-rays, i.e. they are not imaged.
However, since the absence of the rotator cuff causes the upper arm head to rise under the shoulder roof, the observation of this phenomenon is an indirect indication of the presence of a severe rotator cuff rupture.
Smaller cracks do not cause this phenomenon. It is more important, however, that comorbidities (e.g. omarthrosis = arthrosis of the shoulder joint, tendinosis calcarea) can be uncovered by an X-ray and that it can provide information about the cause of the rotator cuff rupture.
Here, for example, a bony spur under the shoulder roof should be mentioned (subacromial spur = impingement syndrome), which may have torn a hole in the rotator cuff.
The great advantage of sonography lies in its easy availability and applicability, as well as the possibility of dynamic shoulder examination by moving the arm during the examination. So you can examine the rotator cuff "at work". Even a small hole in the rotator cuff can be discovered by an experienced examiner.
Shoulder MRI is increasingly being used if a rotator cuff tear is suspected. Cracks in the rotator cuff can be reliably recognized. In addition, the tendon quality and retraction (retraction of the tendon after the tear) can be assessed well by the MRI, which can have immediate consequences on the therapy recommendation of the doctor.
A suspected diagnosis can be confirmed by a shoulder joint mirroring (arthroscopy). The extent of the rotator cuff lesion can also be assessed here (partial or total rupture) and, if necessary, therapy can also take place at the same time (rotator cuff seam = suture of the torn tendon).
Soft tissue structures, such as tendons and muscles, can be better visualized on MRI compared to CT and X-rays.
A rotator cuff tear can be seen on the MRI at the point where the continuous structure of the tendon ends abruptly ends. The radiologist can see edema (liquid) at the corresponding point and also along the other muscle, which is light or dark depending on the setting of the MRI.
The extent and position of the rotator cuff tear can be described in more detail on MRI and statements can already be made as to how surgery should be carried out - i.e. whether tendon plastic is used, for example. In addition, accompanying problems can also be recorded here, e.g. an impingement (shoulder tightness) or osteoarthritis.
Compared to other examinations, the MRI of the shoulder is significantly more expensive and also time-consuming.
In the event of a rotator cuff tear, the function of the affected muscle becomes painful or can only be carried out to a limited extent. The supraspinatus muscle is usually affected. This muscle is responsible for lifting (abduction) the shoulder. If this muscle breaks or tears, the shoulder can only be lifted in pain. Movements that are often difficult are overhead movements or putting on jackets. With complete and also fresh cracks, it may not be possible to lift the shoulder initially. If a rotator cuff tear persists, some patients complain that the entire shoulder becomes stiff over time.
There are two common causes of rotator cuff tear. On the one hand the tear caused by trauma and on the other hand the wear. Patients for whom wear is the cause of the rotator cuff tear tend to be older patients (55 years and older). If patients indicate that there has been no adequate trauma, such as a fall or violent stress, then it is very likely that the rotator cuff tear is due to wear. The condition of the tendon can be assessed well by an ultrasound or MRI examination, which is often done in the course of diagnostics. If the visible parts, the torn tendon, show signs of thinning and calcification, this indicates a wear process.
Furthermore, the patient's history is often conspicuous when the rotator cuff tear occurs due to wear. A tear from an injury is suggested by the fact that the patient is younger (50 and significantly younger). At this age, wear and tear can occur - but it is not so pronounced that it would crack. If patients report an accident that also affects the shoulder and after the corresponding discomfort occurred on the shoulder, then an injury is likely to be the cause of the rotator cuff tear. If arthroscopy, ultrasound and MRI make it clear that the tendon looks unobtrusive and healthy except for the tear, the cause of the wear can be ruled out. In older people who are wearing and suffering an accident, it is likely a combination of the two that causes the rotator cuff tear.
With regard to various diagnostic options, some functional tests to check the functionality of the shoulder joint have already been described. In addition, there are other examination options that should be consulted as part of a physical (clinical) examination. This examination usually includes the delimitation of two clinical pictures, the impingement syndrome and the rupture of the rotator cuff.
In the course of a rotator cuff rupture, both conservative and surgical therapy measures can be followed. As a rule, an incomplete rupture of the supraspinatus tendon speaks for conservative therapy. If there is a complete rupture, an individual decision is made. As a rule, patients who are older than 65 and who have tolerable pain are also treated conservatively.
Conservative therapy measures can include the following areas:
If such a result does not appear after about three months, you and your doctor should consider whether conservative therapy still promises success or whether surgical measures should be taken. These measures are described below.
Not every rotator cuff tear is automatically treated surgically. A good option is conservative treatment, in which physiotherapy and muscle strengthening play an important role. Performed exercises should be discussed with the attending physician or physiotherapist, as the rotator cuff tear can be made worse if the exercises are performed incorrectly. A first important group of rotator cuff tear exercises are stretching and loosening exercises. It is about loosening the surrounding joints and muscles and making them suitable for everyday use. Circling the arms is a good way to loosen the shoulder. This should be done carefully and evenly and jerky movements should be avoided. For stretching it is important to include the chest and back. For stretching the chest it is advisable to keep the arms horizontally stretched sideways while standing. Now both arms in an extended position try to move as far as possible towards the back and then hold for 30-60 seconds. A pull in the chest should be felt.
For the upper back and the back shoulder, the following is recommended: One arm is placed around the neck from the front and the hand is placed on the back shoulder. The other hand is pressed gently against the elbow so that the arm continues towards the back. A physiotherapist can show further stretching exercises. The next important step is to strengthen the muscles. Since the torn parts of the rotator cuff usually do not grow together again, other muscles have to compensate for their task as much as possible and this has to be learned.
Most of the exercises can be carried out in physiotherapy on a cable or simply at home with the Theraband. Thera tapes are available for less than € 20. It is important to train the internal and external rotation. The Theraband is placed around a door handle so that you can hold both ends in your hand. To train the external rotation, stand with the other shoulder to the side of the door handle. Now you hold both ends of the Theraband with your hand, the shoulder to be trained. The elbow is placed on the side of the body and bent by 90 ° so that the forearm points horizontally forward. With your hand you pull the Theraband outwards and backwards, the Theraband is stretched. It is important that the elbow remains on the body. This can be done in three runs with 15-20 repetitions. The same is done for the other arm, only that you have to turn around.
To train the internal rotation, you again stand to the side of the door handle. This time you stand with the shoulder to be trained towards the door and hold the Theraband with your hand, the shoulder to be trained. Here, too, the elbow is bent 90 ° and remains attached to the body. This time the forearm is rotated towards the abdomen as if one wanted to touch the abdomen. There are three runs with 15 - 20 repetitions each. To train the other shoulder you have to turn around again. An additional good exercise that trains the external rotation and shoulder lift is as follows. The Theraband is held on the opposite side with the arm stretched and applied. The stretched Theraband is held at the end with the side to be trained and evenly pulled upwards with the arm extended. The arm makes a slight curve. Then the arm is moved back slowly and evenly. This exercise can be done for each arm in three rounds of 10-15 repetitions. It is important that the pain is not continued, but that the doctor or physiotherapist is consulted first.
A fourth helpful exercise to strengthen the shoulder muscles is that the arms are held horizontally and stretched in front of the body about shoulder width. The Theraband is held tight with both hands. Now both arms are pulled evenly backwards so that you have the feeling that the shoulder blades are touching. This exercise can be done in three rounds of 10-15 repetitions. Another group of exercises that strengthen the muscles are the support exercises. You can lie down in the forearm support. You lie down on your stomach, then place your forearms lengthways under you on the floor and lift your stomach, buttocks and knees so that you only touch the ground with your forearms and the tips of your feet. One tries to hold this position as long as possible. The same can be done in the push-up position. You push your hands a little wider than shoulder width from the floor and try to hold it. In both exercises, the body tension must be maintained by tensing the abdomen, back and buttocks. For all exercises, it is essential that they are discussed with the doctor or physiotherapist who is treating them, as individually complicated factors can occur in each patient.
Taping the shoulder in the event of a rotator cuff tear can be helpful and relieve discomfort. The goal is to redistribute the load that the affected tendon would otherwise have to carry. Furthermore, the circulation should be improved and the pain should be reduced. The tapes can be glued in different ways. There are different methods and views behind this. The basic type and meadow is the same as that used for taping the shoulder impingement.
Indicative criteria with regard to operative therapy of a rotator cuff rupture are, for example:
Surgical therapy differentiates between incomplete and complete rupture with regard to the surgical intervention. Whether or not an arthroscopic or open surgery is possible depends on the size of the tear. The smaller the crack, the better it can be treated with arthroscopy of the shoulder joint. Larger cracks can usually only be cleaned arthroscopically and the pain relieved by endoscopic subacromial decompression (ESD). Different procedures are available, such as Neom acromion plastic surgery or excision of the tendon area. The seam of the supraspinatus tendon is also conceivable, for example in the event of a transverse tear in the rotator cuff. In this case one speaks of a so-called transosseous suture, i.e. of a seam that is to be sewn through the bone at the place where it originally tore off. There are different ways of anchoring for this procedure:
Restoration of tendon rupture of rotatory cuff is a pretty difficult operation. Reconstruction of rotatory cuff can be made either with an open approach (via cut on the shoulder), or by arthroscopy.
The main disadvantage of open surgery is the need to make huge traumatic cuts on shoulder to get access to damaged tendons, which poses high risk of side effects and requires long-term recovery after the operation.
In German clinics, surgical treatment of damage of rotatory cuff is performed with modern approaches without cut of joint. Operation are performed under arthroscopic control, so you can be sure in their safety and efficiency.
Instead of a cut, small incisions are made, and arthroscope with a camera is put in one of them, and instruments for performing manipulations are put through other incisions. The image from camera is enlarged and displayed on a monitor for the surgeon to perform the operation watching all structures of the joing and defining the location of damage.
When it comes to an arthroscopic operation, the cut is stitches, and if tendon has torn away from the place of fixation, a stitch with special „spud legs“ is made.
At the first stage of shoulder surgery, the joint is cleaned: all dead and degenerate tissues of the rotatory cuff are removed. After that, the area of shoulder bone where the rotatory cuff torn or damaged, is cleaned from the rest of soft tissues to that the tendon will grow together with it quickly. As a rule, 2-3 „spud legs“ are required for fixation of torn tendon. The fixator consists of an anchor and fibers. The anchor is fixed to bone, and fibers are used to underrun the tendon.
The choice of anchor fixator is made by the surgeon, but patient must be informed on which type of fixator is used in his case. We recommend using fixators of globally acknowledged brands that have proved to be reliable and safe. Consult with your doctor and ask about the options available: you will figure out a suitable fixator that fits your demands and budget.
The rotator cuff consists of a total of 4 muscles: infraspinatus muscle, supraspinatus muscle, subscapularis muscle and teres minor muscle. If the rotator cuff breaks, the tendon of the supraspinatus muscle is most often affected. The reason for this is the anatomical position of the sinewy part. The tendon runs directly between the shoulder roof and the head of the humerus. As soon as this space is narrowed a little, the tendon can be affected. Since this is very often the case with inflammation of the bursa, injuries or degenerative changes, the tendon of the supraspinatus muscle is considered to be very susceptible to irritation that results in a tear. Classically, a tear in the supraspinatus tendon can be recognized by an arm restraint. The function of this muscle, namely the abduction or spreading of the arm in the shoulder joint, is not retained in the event of a tear.
Self-healing of a rotator cuff tear is unlikely without taking conservative or surgical measures. In order to regain full functionality and resilience, torn parts are operationally brought together again. With purely conservative therapy, this goal of growing together can no longer be achieved, so that movement and stress restrictions can remain.
If you leave a tear in the rotator cuff to yourself, only symptoms such as pain can decrease. A restriction of movement or a loss of strength persist because the torn parts do not reassemble themselves. Pain can effectively reduce over time without therapeutic measures - but in terms of functionality and mobility, the arm and shoulder joint will have to lose.
The length of a sick leave or incapacity to work depends on the severity of the tear, the type of therapy and, to a large extent, the profession.
As a rule, the rotator cuff tear is surgically restored to completely restore functionality and load. This means that the arm has to be immobilized 4-6 weeks after the operation. In the meantime, physiotherapy is already started to avoid stiffening by immobilization. This is followed by a rehabilitation of several weeks.
The duration of the sick leave or incapacity to work varies depending on whether those affected only have to carry out an office job with a slight strain on the shoulder and arm or in physically active occupations such as construction workers or craftsmen. For pure office jobs, it amounts to 2-3 weeks. Since a complete repair of a torn tendon can take up to 4 months, a sick leave or inability to work is issued for physically demanding occupations for a period of 3-4 months.
A rotator cuff tear can occur very briefly due to trauma, but also due to long-term damage. At first there can only be a small crack, which continues to tear over several weeks until it becomes painful and causes problems. After a tear, one can assume that no matter whether surgery or conservative treatment, 6 weeks must be scheduled in which no active movement may be carried out at all. It is only allowed to move slowly again after 6 weeks. But even then no heavy work may be carried out or heavy weights lifted. Some patients are ready for use again after 3-4 months. Other sufferers have complaints and pain for years and are not fully operational. However, those affected have in common that sports and occupations that put a strain on the shoulder can only be fully loaded again after about six months. And even then, it is essential to consult with pain.
Training the shoulder muscles not only has an aesthetic and sporty meaning, but is also medically suitable to counteract future damage to the shoulder area. In order to be able to train the rotator cuff effectively, you should take a good look at its variety of functions: external rotation, internal rotation, abduction and adduction.
Attention: Before you start training, you should always stretch your muscles! An exercise band is also required for meaningful exercises. After you have fixed the exercise band at a fixed point at shoulder height, you can train the inner and outer rotation by stretching your arm sideways, holding your elbow at a 90 ° angle and slowly performing the throwing movement. In order to train the external rotation even more effectively, it is advisable to securely attach the exercise band to the floor and then, in the position as just described (upper arm extended sideways, elbow at a 90 ° angle), turn the upper arm upwards and thus the band to stretch upwards.
The abduction can be trained by holding both arms on the side of the body, holding the ligament with each hand, although it should be quite tense, and then slowly spreading the extended arms sideways. Sports, such as swimming or handball, can be good for training the rotator cuff.