As I came up with the title of this article I actually laughed out loud. With the amount of information on and diversity of options about rotator cuff injuries, “surviving” the information tsunami is quite appropriate. Rotator cuff symptoms can vary based on the degree and location of the injury. Meanwhile, I was secretly hoping my professional colleagues would read this article to share my humor before the title made them think that I was truly insane.
The rotator cuff is a group of four muscles, which function to dynamically stabilize the glenohumeral (shoulder) joint. The four independent muscles bind to a cuff-like covering of the humerus (upper arm) bone to provide control and strength to the shoulder joint for both rotational and directional movements.
The four (4) rotator cuff muscles and their main function at the shoulder joint:
- Supraspinatus Muscle – Lifting the arm out to the side (abduction) and slightly forward.
- Infrspinatus Muscle – External rotation of the shoulder.
- Subscapularis Muscle – Internal rotation of the shoulder.
- Teres Minor Muscle – External rotation of the shoulder.
The most commonly rotator cuff injury is a strain or tear to the supraspinatus. Due to the large amount overhead throwing and lifting activities for active individuals, excess strain and trauma is placed on the rotator cuff tissue. In addition, the weakest motion of the shoulder is external rotation which contributes to the prevalence of an impingement mechanism upon the rotator cuff.
A rotator cuff injury can be grouped into two categories:
- Tendinopathy – Inflammation or degeneration of a tendon.
- Tear or Strain – Disruption of a tendon and/or muscle.
Signs and Symptoms of a Rotator Cuff Injury
- Discomfort that can range from an ache to a sharp localized pain.
- Common location of point tenderness is in the front of the shoulder that is more accessible when reaching behind the back along with lateral deltoid pain that is more general in nature with no associated point tenderness in that area of the shoulder.
- Increased symptoms with raising and lowering of the arm especially in the horizontal or shoulder-level range of motion.
- Noticeable weakness for most shoulder arm movements especially when lifting the arm overhead and with resisted external rotation.
Acute Rotator Cuff Tear Symptoms
- Common mechanism of injury is a sudden fall on an outstretched arm or a rapid loading of the shoulder muscles such as from the ground or an opposing player.
- Tearing sensation within the shoulder immediately followed by significant pain through shoulder girdle.
- A degree of limitations with active shoulder movement secondary to pain and weakness.
- Severe pain in a specific location followed by spasms and general shoulder joint stiffness.
- Depending upon the degree of tendon/muscle disruption, the resulting weakness can range from minimal to severe enough to impair any active abduction (move the arm away from the side of the body) of the arm.
Chronic Rotator Cuff Tear Symptoms
Chronic rotator cuff injuries develop over a period of time. Due to the excess impingement-type friction related to a more chronic pathology, the rotator cuff tear usually takes place at or near the tendon. Usually found on the dominant side
- Ongoing symptoms with a gradual increase in both pain and weakness, both of which can get severe.
- Increased symptoms with rest and while sleeping on the involved side.
- Athletes with symptoms tend to be 35+ in age.
- Depending upon the location and the severity of the rotator cuff injury, the limitations in range of motion and weakness will vary.
Treating a Rotator Cuff Injury
- Getting a clean history of the trauma to the shoulder, neck, chest and upper arm will help address the treatment to the proper body part and type of tissue.
- Thorough bilateral assessment will demonstrate the major limiting factors: weakness, range of motion, and/or pain.
- Progressively regaining shoulder range of motion early is necessary.
- Ice shoulder when an increase in shoulder joint warmth and soreness is demonstrated. A contrast of warm/cold treatments will help increase blood flow for a chronic rotator cuff injury.
- Increasing the strength of the rotator cuff without increasing the rotator cuff symptoms is probably the top priority when treating any type of a rotator cuff injury. With strengthening program, special attention is addressed towards increasing the strength of the external rotators and caution is applied to all overhead exercises.
- Soft tissue massage and manual therapy to the shoulder, upper back and neck will help normalize mechanics of the entire shoulder girdle.
- Scapula (shoulder blade) stabilizing exercises are implemented early in the rehab plan. The strength and endurance of the shoulder stabilizers are enhanced with activities such as planks, isometric arm holds and upper extremity weight bearing medicine ball rolls.
- Distal extremity strength work such as hand-gripping, wrist curls and tricep extensions can help improve proximal shoulder strength.
- Sports-specific activities can be included in treatment plan when shoulder strength has returned to at least 75% with extra caution given to all throwing and overhead activities.
Asking the Right Questions
A smart professional athlete with a rotator cuff injury who wants to safely return to his/her sport should ask his sports medicine specialist the following questions:
- Are my rotator cuff symptoms coming from an actual tear of my rotator cuff or is it related to a tendinopathy?
- Do I need to get an MRI or MRI Arthrogram to properly diagnose my injury?
- How would you grade my shoulder strength compared to the other side?
- Do you think that I will need surgery on my rotator cuff now or in the future?
- Who do you recommend as a physical therapist to coordinate my rotator cuff injury?
Sports Medicine Tips for Living With a Rotator Cuff Injury
Nerve Related? – Nerves can be funny things so make sure your sports medicine specialist evaluates your neck, nerves, muscles and shoulders to avoid missing some other reason for your weakness.
Hx Matters – That concussion last month or the pins & needles feeling you get when you sleep on that arm…those things do matter. Tell your doctor all that you know and let him/her figure out what’s not important.
Living With It For Now – Don’t let the fact that you have a rotator cuff tear make you believe that you need surgery. Weight the lifestyle factors with the limitations that you presently have along with the medical opinions of trusted resources before you “go under the knife”.
Long-Term Treatment – Surgery or not, if you have a rotator cuff injury you need to have a long-term treatment plan. That plan will give you a clear roadmap of stretches and strengthening exercises that you WILL DO and vulnerable activities/exercises that you WILL NOT DO. Knowing both is important for an active future.