News Letter, Vol. 2 (6), June, 2010, © Copyright
Jun Xu, M.D. Lic. Acup., Hong Su, C.M.D., Lic. Acup.
Rehabilitation Medicine and Acupuncture Center
1171 East Putnam Avenue, Building 1, 2nd Floor
Greenwich, CT 06878
Tel: (203) 637-7720
ROTATOR CUFF TEAR
Matthew P., a 45-year-old man, injured himself after pitching a few baseballs to his son. He felt a sudden onset of right shoulder pain, which was so severe that he could not raise his arm, and this considerably interfered with his daily activities.
When I questioned him, Matthew told me he had experienced this pain on and off for more than six months, but it was mild enough that he did not feel it was necessary to see a doctor. This pain was present both during daily activities and at night, radiating from the front of the shoulder to the side of the arm. It had been steadily worsening, and the injury was exacerbated by the fact that his son had just returned from boarding school two weeks before and they began playing baseball together again. Within those couple of weeks, Matthew’s condition had worsened and he was no longer able to raise his arm to a 90-degree angle.
When I performed the physical examination, I found that his right shoulder was moderately swollen and very tender to the touch at the front and back of the deltoid area. He also had a painful arc of movement between 60 and 120 degrees. I had to help him raise his arm from 60 to 90 degrees, which caused him pain, but once he got it past the 120 degree mark he could do it himself and the pain subsided. I also tried a drop arm test—I lifted his right arm passively up to 90 degrees, then let go—and he had difficulty maintaining the arm at this position on his own.
Based on the above observations, I concluded that Matthew had most likely torn his rotator cuff. This condition has different names: rotator cuff tendonitis, rotator cuff inflammation, shoulder impingement syndrome, rotator cuff bursitis, etc. The most common symptom is that patients experience gradual onset of shoulder pain with difficulty in raising the arms up to 120 degrees. The impingement of the rotator cuff tendons is the most common cause of shoulder pain.
The rotator cuff is a group of tendons composed of four muscles: the supraspinatus, infrapinatus, subscapularis and teres minor. These muscles cover the head of the humerus, and combined with the deltoid muscle, they form the bow of the shoulder. The muscles’ function is to rotate and lift the shoulder.
The acromion is the front edge of the shoulder. It normally sits over and in front of the humeral head when the arm is lifted and in most cases will not rub the tendons of the rotator cuff. However, in some cases, the acromion might wrap or impinge on the surface of the rotator cuff, which causes pain and limits the shoulder movement; this is called impingement syndrome. There are three stages of rotator cuff impingement syndrome:
- Stage one: edema or hemorrhage stage. This usually occurs when a patient is under 25 years old. The shoulder shows acute pain, edema or hemorrhage with signs of inflammation. This stage is reversible and surgery is rarely used to treat the condition.
- Stage two: fibrosis and tendonitis stage. The inflamed rotator cuff tendons continue to get worse, and develop to fibrosis and tendonitis. This most often occurs between age 25 and 40. Conservative treatment and surgery should both be considered, depending on the severity of the patient’s condition.
- Stage three: arcomioclavicular spur and rotator cuff tear. This stage occurs because of continuous mechanical disruption of the rotator cuff tendon between the arcomioclavicular and humoral head. Surgical anterior acromioplasty and rotator cuff repair is usually required.
Matthew appeared to have stage two (rotator cuff tear). In order to make a clear diagnosis of the disease, I ordered X-rays. They showed a anterior spur, which caused the impingement of the rotator cuff and the pain.
When Matthew played ball with his son, he had traumatized his shoulder, causing the rotator cuff to partially tear.
Western medicine is usually administered in four stages:
- Nonsurgical treatment: the patient takes a course of oral prednosone or some form of non-steroid, anti-inflammatory medication.
- The patient avoids strenuous activity and puts an ice pack on the injured shoulder.
- Injection of a local steroid into the affected area.
- Physical therapy: this can take from several weeks to a number of months. Many patients experience gradual improvement and a return to normal function.
Surgical treatment is usually indicated for full thickness or partial tears that failed to improve with conservative treatment. There are two kinds of surgical techniques.
- Arthrosopic technique: two or three small puncture wounds are made and a small instrument is inserted to remove the surface of the arcomion and clean out the injured tissue of the rotator cuff.
- Open technique: open surgery that cuts into the shoulder and allows direct visualization into the acromion and rotator cuff.
Matthew was offered all these options, but because of his work, he could not afford to take off time, and thus opted for a conservative treatment.
I first combined physical therapy with acupuncture, and advised him to put an ice pack on his shoulder immediately, and rest his arm as much as possible, strictly avoiding any activities that might aggravate the symptoms.
I then introduced acupuncture to decrease the pain. I used “the three famous shoulder needles” technique: Jian Qian, Jian Yu, and Jian Zhen. All of these must be inserted 2-3 inches deep into the respective anatomic points: the rotator cuff including bicepital, supraspinator tendons, and acromial bursa etc. Then, a strong electrical stimulation should be used to bring a large amount of blood flow to the shoulder and wash away the inflammation to gradually diminish the sensation of pain and improve the range of shoulder motion.
The ancillary points include LI 14 Bi Nao, SJ 5 Wai Guan, LI 4 He Gu and LI 11 Qu Chi. The patient was treated for about three months and, after passing through the acute stage, I gradually strengthened his rotator cuff muscle and after six months his shoulder had returned to normal. His range of motion also returned to normal, and there was no need for surgery.
|1||Jian Qian||Extra 23||Midway between the end of the anterior axillary fold and LI 15, Jian Yu||Pain in the shoulder and arm, paralysis of the upper extremities|
|2||Jian Yu||LI 15||Antero-inferior to the acromion, on the upper portion of m. deltoideus. When the arm is in full abduction, the point is in the depression appearing at the anterior border of the acromioclavicular joint||Pain in the shoulder and arm, motor impairment of the upper extremities, rubella, scrofula|
|3||Jian Zhen||SI 9||Posterior and inferior to the shoulder joint. When the arm is adducted, the point is 1 inch above the posterior end of the axillary fold||Pain in the scapular region, motor impairment of the hand and arm|
|4||Bi Nao||LI 14||On the line joining Qu Chi (LI 11) and Jian Yu (LI 15), 7 inches above Qu Chi (LI 11), on the radial side of the humerus, superior to the lower end of the m. deltoideus||Pain in the shoulder and arm, rigidity of the neck, scrofula.|
|5||Wai Guan||SJ 5||See table 5-1/Pic 5-3||See table 5-1|
|6||He Gu||LI 4||See table 3-1/Pic 3-4||See table 3-1|
|7||Qu Chi||LI11||See table 4-1/Pic 4-2||See table 4-1|
Tips for both acupuncturists and patients:
1. If the patient has rotator cuff tendonitis or impingement, and is less than 25 years old and in the acute stage, an ice pack on the shoulder to decrease both the edema and inflammation, followed by acupuncture, is usually a sufficient cure.
2. If the patient has stage two fibrosis and tendonitis, and is between the ages of 25 and 40, acupuncture should start as soon as possible, as described above. This is usually sufficient treatment at this stage.
3. If the patient has stage three acromioclavicular spur and rotator cuff tear, and is over the age of 40, doctors should cautiously examine treatment options. The patient should have an X-ray and MRI without contrast to discover if the patient has a partial or complete tear, and he should consult an orthopedic surgeon to see if surgery is necessary. If the patient is young and the injury is related to sports, the torn rotator cuff should be sutured as soon as possible in order to accelerate a complete recovery.