Rotator Cuff - Injuries & Prevention
I did this research as part of my coursework but find it very relevant among the clients I work with so I figured why not include this as part of my blog. Rotator cuff tear is a common injury which starts to become more prevalent after 40 as the body goes through more wear and tear.
What is the Rotator cuff exactly:
The rotator cuff is a group of four muscles (supraspinatus, infraspinatus, teres minor, and subscapularis) that join together as tendons in our shoulder, keeping the head of our upper arm bone firmly within the shallow socket of the shoulder. The rotator cuff is responsible for various motions such as stabilization of the glenohumeral joint, abduction, as well as internal and external rotation of the humerus. When shoulder trauma occurs, these functions can get compromised. A rotator cuff tear is a tear of one or more of the tendons of the four rotator cuff muscles of the shoulder. A rotator cuff 'injury' can include any type of irritation or overuse of those muscles or tendons and is amongst the most common conditions affecting the shoulder.
Since individuals are highly dependent on the shoulder for many activities, overuse of the muscles can lead to tears, the vast majority occurring in the supraspinatus tendon as it passes below the acromion which is like a roof above it. The supraspinatus passes underneath it to insert onto greater tuberosity of the humerus. When you elevate your arm this space narrows, meaning it can get pinched, inflamed and consequently tear. Such a tear usually occurs at its point of insertion onto the humeral head at the greater tubercle.
Rotator cuff muscle tear is common in young athletes in sports which require repetitive overhead movements like bowling in cricket or pitching in baseball and in certain occupations like painting and decorating where there's a lot of overhead arm use. Rotator cuff tears are also rampantly prevalent in people over 40 and tend to happen more as you get older. Other associated factors include a history of trauma, limb dominance, contralateral shoulder, smoking-status, hypercholesterolemia, posture and occupational dispositions.
Rotator cuff tears can be partial, complete, acute or degenerative (chronic) and can be further subdivided as follows:
Grade 1: Swelling and inflammation
Grade 2: Tendinopathy, or weakened tendons in the shoulder
Grade 3: Tears in the rotator cuff or changes in the shoulder bone, such as the growth of bony spurs called osteophytes
Some of the signs of having a rotator cuff tear are pain and reduced power with abduction of the shoulder, painful arc where maximum pain is felt between 60 and 120 degrees of abduction as this is where the subacromial space is most narrow. Pain is usually felt at the side of the shoulder and can often radiate toward the elbow. Injured shoulders can also be troublesome at night when lying down as it allows the inflamed joint to stretch or when sleeping on your side. Occasionally, night-time pain can get so bad that sleep is possible only in a reclining chair -- and some patients can’t sleep at all.
Rotator Cuff Injury Treatment:
If rotator cuff injury does happen, depending on the nature of the injury, treatments range from resting the affected arm to surgery. Tendinitis (small tear) can progress to a rotator cuff tear, and that injury can get worse with time therefore seeking treatment as quickly as possible helps to keep the injury from progressing. Nonsurgical treatments improve symptoms in about 50 percent of people with a rotator cuff injury. These kinds of treatments include:
● Applying hot or cold packs to the affected shoulder to reduce swelling
● Exercises to restore strength and range of motion
● Physical therapy
● Injecting the affected area with cortisone, a steroid that helps to reduce inflammation
● Resting the affected arm and wearing a sling to isolate arm motions
● Over-the-counter anti-inflammatory medications, like ibuprofen and naproxen
Majority of times, rotator cuff tendinitis without a cuff tear normally does not require surgery, and treatment as described above is usually enough to cure the inflammation. However, if pain continues after several months of these treatments and steroid injections have provided only temporary relief, surgery becomes an option. Early surgery should be considered in younger, healthier, active and symptomatic patients. Lower grades of tears do well with debridement alone while more severe lesions warrant a repair. “The most common procedure for rotator cuff tendinitis is called acromioplasty. Using an arthroscope (a small camera inserted into the shoulder joint through an incision about the size of a buttonhole), the surgeon can view the affected area and shave the underside of the acromion to increase the space between it and the cuff tendon that is injured. This space helps prevent pinching of the tendon and irritation during shoulder movements. Also, damaged tissue can be removed and minor tears can be repaired”. (Source: https://www.hopkinsmedicine.org/health/conditions-and-diseases/rotator-cuff-tendinitis). Arthroscopic double-row repairs are superior in patients with massive tears. Satisfactory results are obtained with timely diagnosis and execution of the appropriate treatment modality.
Rotator Cuff Injury Recovery:
When it comes to recovery from the rotator cuff tear, rehabilitation usually begins the first week after arthroscopic surgery. It is very important to follow the program that the doctor recommends. The physical therapist should demonstrate how to do the exercises to increase range of motion and to build muscle strength. A typical program might start with stretching and some minor strengthening exercises with rubber bands and light weights. Strengthening the cuff means the humeral head will be better compressed and depressed against the glenoid so you can get more clearance between the humerus and acromion during movement of your arm. It might take up to several months before strength is back to normal, but with hard work and adherence to the recommended program, in most cases a full recovery is likely. Once you have completely recovered, working with a personal trainer to develop a customized program around the injury can we helpful so the pain doesn’t get aggravated again.
Rotator Cuff Injury Rehab Stages:
The timing of rehab will vary based on the extent of the tear but below are the rehab stages and some of the rehab exercises that can be done to help with rotator cuff tear recovery. They should be performed in the following order so we don’t end up aggravating the injury:
1. Safe Cardio Exercise : Recumbent bike (to get heart rate up, provide shoulder stability and gain strength by grabbing and squeezing the handle similar to a stress ball)
2. Range of Motion Exercise: Pendulum (to improve flexibility, increase range of motion, and reduce pain)
3. Early Rehab/ Gentle Strengthening Exercise (Inflammatory Response Phase): Seated resistance band row (to improve flexibility, ROM and strengthen the back and shoulder muscles that help stabilize the rotator cuff overall)
4. Mid-Rehab Strengthening Exercise (Fibroblastic repair phase): Shoulder external and internal rotations (to build strength and a foundation for more specific exercises)
5. Late stage rehab Exercise (Maturation Remodelling Phase): Wall Ball Toss (to improve proprioception, build power and endurance)
Usually a rotator cuff tear might not require wearing a brace but in some instances where extra support is needed, compression should be the key in finding the appropriate brace. When selecting your shoulder brace, you should consider how active you need to be with this injury as well as how severely you are hurt. If you are experiencing a minor injury, then a simpler stretch fabric support will provide gentle pressure reminding you not to overexert yourself so that you do not worsen the injury. If you have a slightly more severe injury, using a more intense level of support, like a neoprene shoulder brace or professional stretch fabric shoulder support is better to keep your injury stabilized. For severe injuries, your doctor or physical therapist will likely advise immobilizing the shoulder for lengthy periods to prevent further injury. Some additional activity modification such as avoiding heavy and long-lever lifting, avoiding repetitive or other painful movements/positions and avoiding sleeping on injured side might be needed in order to completely heal from the injury and avoid similar issues in future.
Rotator Cuff Injury Prevention:
Since a lot of these tears occur due to overuse, it is important to practice certain habits which can help prevent these injuries from happening. Some of these prevention techniques include:
● Practicing Regular Shoulder Conditioning by working out regularly and not just on weekends.
● Working out properly and knowing your correct form.
● Using equipment safely and properly and making sure all your gear is in good shape. Tennis rackets, for example, need to be properly strung to maintain adequate tension.
● Training early (and often) and not just showing up cold on the first day of your sports season as that could be a certain recipe for injury.
● Warm up, cool down, and stretch and not skip these critical parts of your workout. Warming up gets the blood flowing to your muscles and tendons, making them more flexible and resilient. Cooling down and stretching prevents tightness (tight muscles and tendons can be more prone to tearing and rupture). Both these activities maintain and improve your range of motion, which is crucial when relying on a rotating joint like the shoulder -especially if you’re involved in a throwing sport such as baseball or cricket.
● Seeing a professional on a regular basis especially if you are an elite athlete as working with a physical therapist or orthopaedist can help you condition and prepare better for the season ahead. A professional can design a preventative care program for you that will help to keep your rotator cuff and your entire shoulder joint as healthy as possible throughout your season.
References
1. Sambandam SN, Khanna V, Gul A, Mounasamy V. Rotator cuff tears: An evidence based approach. World J Orthop. 2015 Dec 18;6(11):902-18. [PMC free article] [PubMed] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4686437/
