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Injury Handbook
(rotator cuff tendonitis/tear)
Every 2 weeks I will release a new article that is involved with injury, injury treatment/prevention, exercise, fitness, nutrition, S & C or coaching. This article is for everyone but has an aim at PTs, Coaches and Therapists that want to learn more about the rotator cuff and associated injuries.
The Rotator Cuff
T
he rotator cuff is located within the shoulder joint and is one of the most common
causes of shoulder pain and weakness. There are three main conditions that affect the rotator cuff these being tendonitis, impingement and full rupture. This PDF will look into tendonitis, with upcoming ones looking at impingement and rupture. Before we talk about the rotator cuff we will have a look at the shoulder itself, the shoulder joint is technically named the glenohumeral joint, and this is where the head of the humerus sits with the glenoid making a ball and socket. The glenohumeral (GH) joint:
As you can also see the other bones that surround this joint are the scapula and clavicle, the glenohumeral joint is the joint that most people think of when they say “shoulder joint� however there are others that are in the area which may also be involved in injury. The acromioclavicualr joint joins the acromion of the scapula to the clavicle, technically a gliding joint it is stabilised by three ligaments and helps with scapula movement. The sternoclavicular joint joins the clavicle with the manubrium, allowing mobility of the pectoral girdle. Finally the scapulothoracic joint, which is not a true synovial joint but
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merely an articulation of the convex surface of the thoracic cage and concave surface of the anterior scapula. The main injuries that occur to the rotator cuff will affect the GH joint solely but other joint disruption can occur, particularly in odd mechanisms of injury. Now we have seen the bones that make the shoulder we will look at the rotator cuff itself, the muscles of the rotator cuff are: Supraspinatus Infraspinatus Subscapularis Teres minor
The rotator cuff muscles combine together to help maintain stability within the shoulder joint itself, but they are also very important in joint movement. Each muscle of the rotator cuff has a different origin yet they all act upon the humerus bone, many speak of the rotator cuff tendon, this is just what many call the combination of all 4 muscles. The origins of each of the rotator cuff muscles: Supraspinatus – supraspinious fossa of the scapula. Infraspinatus - infraspinatous fossa of the scapula. Subscapularis - subscapular fossa of the scapula. Teres minor – lateral border of scapula. Now we know a bit about the shoulder joint and what makes up the rotator cuff tendon, let us get on with the injuries. We will start with probably the most common ailment that effects the rotator cuff which is tendonitis.
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Tendonitis of the rotator cuff Tendonitis is caused by inflammation of all, some or one of the muscles of the rotator cuff. Tendonitis commonly comes on suddenly and can cause acute weakness at the shoulder joint. Tendonitis is prevalent in those who perform a lot of actions with the shoulder joint or those who place great stress on the major shoulder muscles. Tendonitis is an overuse injury and therefore can be avoided in the most part, it is possible that repeated injuries to the rotator cuff through long standing untreated tendonitis may lead to calcification of the muscle in question. Calcified supraspinatus:
Main symptoms of tendonitis of the rotator cuff are commonly acute onset of pain especially in movement. Many who perform shoulder press actions will get this worse and the pain will usually make these persons drop the weight they are carrying (not great for the head). Tendonitis and tears go hand in hand with rotator cuff injury and if pain is accompanied with rapid weakness especially in specific aspect of shoulder movement you can be pretty sure you have a tear. People most at risk of the injury occurring are: Bodybuilders, weightlifters, tennis players, squash players, hockey players, shot put, javelin throwers, power lifters, basketball players………………..the list goes on.
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Anyone can get tendonitis but those who have to use their hands above their head for sport or training will struggle the most with the injury. Now as a PT how often have you been asked by a client or possible client or asked yourself “how can I sort this shoulder problem out?” or “I have a dodgy shoulder, what can I do?” We wouldn’t recommend messing with anything you don’t think your capable of, but the majority of shoulder pain is caused by tendonitis of the rotator cuff or by osteoarthritis (OA), if the client has OA they will have probably already been to the docs and got the diagnosis. But what of the rotator cuff, how can you first tell your client that this is tendonitis or a tear? Drop arm test: Hold your arm straight out (abduction) to your side at 90 degrees with thumbs down. Always do both arms at same time, bring arms down slowly if one arm suddenly drops due to weakness you can say there is some form of rotator cuff tear going on. Empty can test: Hold your arm straight out (abduction) to your side at 90 degrees with thumbs up, now have someone press upon the wrists in a downward motion, repeat this with a thumbs down position. If there is a drop in one of the arms, or shaking within one of the arms then the test is positive for a rotator cuff tear. Empty Can Thumbs Down
These two tests are great for instilling confidence in a client as it shows that you know what you are talking about and that you are showing them attention!
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These tests are commonly used and whilst they measure a tear they will also give a sign of tendonitis. However to really impress and get to the bottom of if it’s the whole rotator cuff tendon or just one specifically you will need to know each of their actions. a.) Supraspinatus – Main agonist in abduction of the arm at the GH joint, mainly the first 10-15 degrees of the arc.
Test – Place pressure upon the client’s wrist as the try to abduct the arm in the first 10-15 degrees of movement, if there is severe pain in this part and less pain when repeated at 6090 degrees who can positively say that the supraspinatus is most likely inflamed. b.) Subscapularis – internal rotation of the GH joint.
Test – Place pressure upon a full range of internal rotation starting from the hand laterally going more medially, apply light force throughout the range. If there is pain throughout or in specific spots you can positively say that there is subscapularis injury involvement. c.) Teres minor/infraspinatus – lateral rotation of the GH joint.
Test – See subscapularis test and mimic but in the opposing fashion, from medial to lateral with force being applied throughout. Any pain would indicate injury involvement of the subscapularis muscle. The deltoid muscle is also involved with the above movements, and so are other major muscles. However deltoid tears and tendonitis would go hand in hand with a rotator cuff injury. How are you going to treat your newly diagnosed condition? Well this is tough because there are many variables, such as how longstanding is the injury and the injury severity. If the injury has occurred within 24 hours: Rest, I am afraid the best option is to rest the shoulder joint, using ice to help with pain. Painkillers are fine, with NSAIDS being the first choice for muscular injuries. So ibuprofen would be preferable to paracetemol or asprin. How much rest? Rest depends on the severity and person, I would recommend at least 4 days rest after any major onset of shoulder pain. When returning after this period, repeat the test, there should be some improvement. Depending on this improvement you can then start rehabilitation. Short overview of muscles required in rehabilitation exercises for the rotator cuff:
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The muscle groups targeted in a conditioning program include: • Deltoids (front, back and over the shoulder) • Trapezius muscles (upper back) • Rhomboid muscles (upper back) • Teres muscles (supporting the shoulder joint) • Supraspinatus (supporting the shoulder joint) • Infraspinatus (supporting the shoulder joint) • Subscapularis (front of shoulder) • Biceps (front of upper arm) • Triceps (back of upper arm) Coaches and PTs you will know what exercises to use to strengthen all the muscles listed, now you know what each of the rotator cuff muscles actions are you can use that to your advantage. We would recommend in the first 7 days of rehab concentrating on muscles that surround the effected muscle, for example if the pain occurs in abduction thanks to a bad supraspinatus we would not recommend any resistance work in abduction instead concentrating on movements that work other muscles around the area such as biceps and triceps which should not require a great deal of abduction. Now in reality the only way you know that your client is getting better is by repeating the tests outlined, when the client has no pain or weakness and the tests are negative you can safely restart your original programme remembering that there will be post injury weakness, unless the programme was not resistance based. If you are ever unsure always ask an appropriate person, physio, GP etc. Now we have looked at the rotator cuff tendonitis and tears, we will have a short look at prevention. Supplementing a training programme with light resistance shoulder rotational exercise is a great way to help strengthen certain rotator cuff muscles, these should be done on a day where you are not training upper body muscles. Why not add in three sets of 20reps cable or dumbbell internal and external rotation after your cardio or legs sessions, it will not take much time but may save weeks of missed training later down the line. Many believe that when they perform lat raises there supraspinatus will also improve, whilst this is very true, many train lat raises with a force or swing at the beginning of the rep, this is the part of the rep where the supraspinatus is working its most. The largest reason for rotator cuff injuries is imbalances where the major muscles such as the deltoid, pectorals and triceps have increased to an extent where the rotator cuff muscles struggle and become worn.
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It is important to work these small muscles as they will help down the line in your chosen sport and training. Coaches and PTs you may want to chuck some of these into your client’s workout to help prevent injuries down the line. And remember if you start feeling any twitches or weaknesses in your shoulder when lifting you may want to rest, struggling through could lead to injury, you know your bodies don’t let them down. If you require any more info just send me a message on my Facebook page: The Collins Online Sports Injury Clinic.