Rotator cuff problems

Four muscles start on the shoulder blade, and their tendons blend into a cuff over the top of the arm bone. Together they keep the ball of the shoulder centred in its socket while the bigger muscles move the arm, and they lift and turn the arm themselves. The tendons pass through a narrow space under the bony point of the shoulder, which is where they are most often irritated.

Most rotator cuff problems build up over time rather than from one injury:

• Age. The tendons become less strong with the years, and tears are very common after 50, many of them causing no pain at all
• Repeated overhead work or sport, and heavy or repetitive lifting
• A sudden injury, such as a fall or a heavy lift, which may tear a tendon
• Smoking, which may add to the wear of the tendons

The pain of an irritated tendon is often called shoulder impingement or subacromial pain, and a tendon can tear partly or right through. Finding a tear on a scan does not always mean the tear is the cause of all the pain.

The pain may show itself most when the arm is raised or you lie on that shoulder:

• Pain at the top and the outside of the shoulder, sometimes spreading down the upper arm
• Pain that is worse when you lift the arm, especially above your head, and on reaching behind your back
• Night pain, worst when you lie on that shoulder
• Weakness when you lift or turn the arm

The pain can start suddenly or come on gradually.

Testing which movements hurt, and which are weak, usually points to the rotator cuff and helps tell it apart from a frozen shoulder, arthritis of the joint or a problem in the neck. An X-ray does not show the tendons, though it can show changes around them, so an ultrasound scan or an MRI is used when the tendons need to be seen.

Ultrasound suits the rotator cuff well: it can show whether a tendon is inflamed or torn, and an MRI is the better test where the full extent of a tear matters. The scan is done by Dr Borukhson during your appointment, so the tendons can usually be seen there and then, and she arranges an MRI where it is needed. The ultrasound clinic page sets out how the scan is done.

Most rotator cuff problems get better without surgery, and the mainstay is exercise:

• Easing the load. Cutting down on the overhead movements and lifting that set off the pain, without stopping using the shoulder altogether, which slows recovery.
• Exercise and physiotherapy. A programme of exercises, often guided by a physiotherapist, to restore movement and then to strengthen the cuff and the muscles around the shoulder blade; starting early helps.
• Pain relief. Paracetamol, an anti-inflammatory gel, or a cold pack in a cloth on the shoulder for up to 20 minutes two or three times a day, so that you can keep moving and sleep. While using ibuprofen gel, do not smoke, and keep away from naked flames, since clothing it has touched burns more easily. A GP can prescribe a stronger painkiller if needed.
• A steroid injection, which can settle the pain for a time, enough to let the exercises work, if rest and exercises do not ease it on their own. An ultrasound-guided injection lets the needle be followed on the screen.
• Surgery for some tears: an operation can repair a torn tendon, often by keyhole surgery, with exercises afterwards to restore movement. It is offered mainly for a recent tear, or a tendon in good enough condition, whose pain and loss of use have not responded to the other treatments.

You and Dr Borukhson settle the plan together.

Keep the shoulder working while it settles, since complete rest tends to stiffen it:

• Adapt rather than abandon tasks: lower the things you reach for most, and break up overhead work
• Do your exercises regularly and keep going once the pain eases, since that is what restores lasting strength
• Sleep on the other side with a pillow supporting the sore arm
• Take pain relief when it helps you keep active and sleep

Recovery is usually measured in weeks to months. Most people end up with a shoulder that serves them well.

Rotator cuff problems are rarely urgent, and a GP, a physiotherapist or a booked assessment suits most of them. Some pictures need more, and the lists that follow, with the paragraph after them, give their routes; they include a dislocated or injured shoulder, sudden weakness or numbness in an arm with no injury to explain it, arm pain with its source in the heart, signs of infection, severe pain in both shoulders, a high temperature and feeling very ill, which could be sepsis, and tingling down the arm that comes with neck pain.

Treat any of these as a 999 or A&E emergency: call 999 and do not drive yourself to A&E.

• Severe illness with suspected sepsis: a high fever with shaking, confusion, rapid breathing, or feeling dramatically worse over hours
• With a fever or feeling unwell, a rash that does not fade when you press it, a stiff neck with eyes that cannot bear bright light, or skin, lips or tongue turning blue, grey, pale or blotchy, since these can be signs of meningitis or sepsis; on black or brown skin the rash and the change of colour may be easier to see on the palms of the hands or the soles of the feet
• A joint you cannot put weight on or move, or that has moved out of place, or, after a fall or injury, very bad pain or any tingling or numbness
• After an injury, a crack heard as it happened, or skin around it that has turned blue, grey or cold, since these can be signs of a broken bone
• Sudden weakness or numbness on one side, a drooping face or difficulty speaking, a sudden severe headache, sudden confusion or a seizure, or sudden loss of vision, any of which can be a stroke, even if it stops after a short time, and an arm that has suddenly gone weak or numb, with no fall, lift or injury behind it, is one of these signs
• An eye that suddenly and completely loses its sight
• Lips, mouth, throat or tongue that suddenly swell, a throat that feels tight, very fast breathing or a struggle to breathe or to swallow, skin, tongue or lips turning blue, grey or pale (on black or brown skin this may be easier to see on the palms of the hands or the soles of the feet), becoming suddenly very confused, drowsy or dizzy, or fainting and not being able to be woken, since this can be a severe allergic reaction, anaphylaxis, which can follow a dose of any medicine
• Chest pain that is crushing, tight or like a pressure, that spreads to an arm, the jaw, the neck, the stomach or the back, that comes with breathlessness, sweating, feeling sick or feeling light-headed, or that came on suddenly and does not go away
• Arm pain that comes on suddenly with pressure, heaviness or squeezing across the chest, which can mean a heart attack

Any of these needs an assessment that is urgent, on the same day, from your GP or NHS 111:

• A joint that is hot and swollen, with a fever or feeling unwell, since an infected joint has to be ruled out at once, at A&E or through NHS 111
• A joint that has become hot and very swollen suddenly, or is worsening quickly, even without a fever, since an infected joint does not always announce itself with one
• Joint pain with a fever, or feeling hot, cold or shivery, or generally unwell, since an infection in or around a joint has to be found the same day
• Arm pain that is brought on by exercise, stress, emotion or the cold, rather than by a particular movement of the arm, and stops within a few minutes of rest, which can mean angina, a sign of a heart problem; NHS 111 will tell you where to be seen
• Pins and needles, or numbness or weakness that has come on gradually, spreading down the arm or into the hand, with neck pain, since a nerve pressed at the neck can cause it, and the spinal cord itself has to be ruled out the same day
• Pins and needles in the arm or hand that do not go away, or an arm or shoulder that has slowly lost its feeling or its strength, with no injury and no neck pain, since a nerve that is being pressed, at the neck or along the arm, has to be found the same day
• Severe pain in both shoulders, which can be polymyalgia rheumatica rather than a rotator cuff problem; if both shoulders ache and stiffen without severe pain, see a GP when it has gone on for more than a week, but on the same day if a new headache, a sore scalp or pain in the jaw on chewing comes with it, and be seen at an eye casualty or urgent eye clinic that day if your sight changes in any way, since either can point to giant cell arteritis; a sudden severe headache, or sight that goes suddenly, even if it returns, is for the first list instead
• Sudden or very bad shoulder pain, or a shoulder that has become weak since a fall or a heavy lift, short of the signs in the first list, since a torn tendon or a break has to be found; a shoulder that is painful, bruised or swollen after it slipped out of place is a 999 or A&E emergency
• A shoulder or arm that has changed shape, become badly swollen or grown a lump, or that feels hot or cold to the touch, with no injury behind it, since something serious has to be ruled out the same day

See a GP if shoulder pain is getting worse or has not improved after two weeks, is stopping you doing your usual activities or keeps disturbing your sleep, or if six weeks of exercises have brought little improvement. Night pain that comes with unexplained weight loss, night sweats or weeks of feeling run down needs a GP within days, to rule out a cause other than the rotator cuff; with a fever or shivers, feeling unwell is a matter for the same-day list. Pins and needles that come and go, with no injury and no neck pain, are for a routine appointment with your GP; an arm that suddenly goes numb or weak without a fall, a lift or an injury to account for it, or numb after an injury, is for the first list. Weakness on lifting or turning the painful arm that has built up gradually, with no fall or heavy lift behind it, usually comes from the tendon itself and is for the GP as well; weakness since a fall or a heavy lift belongs to the second list, as does an arm losing strength beyond the painful movements or losing its feeling too. No referral is needed to be seen here; next-working-day appointments can almost always be arranged, and same-day appointments are sometimes possible. An injury that leaves the shoulder or arm out of shape, or a shoulder that is painful, bruised or swollen after it slipped out of place, is a 999 or A&E emergency; if a fall onto the shoulder brings none of these and none of the signs in the first list, ask NHS 111 where to be seen. If you cannot tell how urgent something is, asking is never a mistake.

Shoulder pain and weakness that are not improving deserve a careful look, to confirm whether the tendons are irritated or torn and to rule out the problems that mimic them. An ultrasound scan adds to the examination, and together they help shape the plan: exercises, an injection or a surgical opinion.

How is a rotator cuff problem confirmed?

Your account of the pain and an examination of which movements hurt, and which are weak, usually point to it. An ordinary X-ray cannot show the tendons, so a tear is confirmed with an ultrasound scan or an MRI, the MRI where the full extent of a tear matters. Here the ultrasound can usually be done in the consultation, and it can show whether a tendon is inflamed or torn.

Will I need an operation on the rotator cuff?

Usually not. Most people get better with exercises, often guided by a physiotherapist, to rebuild strength and movement, along with easing off the overhead activities that set off the pain. A steroid injection can help if the pain is holding back the exercises. Surgery is kept for some tears, particularly one caused by a fall in an active person, or a tear whose pain and weakness do not respond.

How long does recovery take?

Usually weeks to months rather than days, and it can take three to six months of steady exercise to get better, which is normal. Progress tends to be gradual, and it is steady practice over that time, even once the pain eases, that brings the strength back.

Is pain at night a worry?

Night pain is common with rotator cuff problems: lying on the sore shoulder can hurt enough to disturb sleep. Lying on the other side, with the sore arm propped on a pillow, usually helps. Night pain with weight loss you cannot explain, night sweats or weeks of feeling run down is different: see a GP within days. With a fever or shivers, feeling unwell is a same-day matter, for the second list under When to seek help.

Could it be a frozen shoulder instead?

In a rotator cuff problem the shoulder hurts and may be weak when you lift the arm, but someone else can usually still move it for you. In a frozen shoulder the joint itself stiffens, so it will not move fully in any direction even when it is moved for you. Examining the shoulder usually separates the two, with a scan where it helps, and they are treated differently.