Rotator Cuff Injury
The rotator cuff is a common structure of injury in the shoulder. The “cuff” itself is composed of four different muscles and a few connective tissues which make a continuous connection around your shoulder joint (Asghar, Ghosh, and Narayan 2020). The four muscles are:
Supraspinatus
Infraspinatus
Teres minor
Subscapularis
The most commonly injured of these is the supraspinatus. It is very active while lifting the arm and rotating the arm outwards, however it is important to note that all of these muscles are active during most motions of the shoulder, even motions that are opposite of their main actions (Reed, Halaki, and Ginn 2010). There are a few different things that can happen to the rotator cuff to make lifting the arm painful:
Tears of varying degrees
Overloading the tendons that attach the muscle to the bone
Pain referral from the neck
Tightness from muscle strain
Injury to the Rotator Cuff:
The muscles of the rotator cuff can tear, leading to painful inflammation, swelling, and weakness in the shoulder. Tears themselves can vary from small, minor tears to full or “massive” tears in which the muscle retracts and is no longer connected at its attachment points. The swelling and inflammation are hallmarks of an acute tear, or a tear that occurs as a result of lifting or a fall. We can also have a chronic degeneration of these muscles, which can lead to tearing and weakness over time. This process occurs far more frequently than one might expect; ironically we only began to understand how frequently this occurred after taking images and MRIs of people that had no pain in their shoulders at all. Researchers have found that up to 46% of individuals without any shoulder pain might have a rotator cuff tear, and that number goes up with age (Lawrence, Moutzouros, and Bey 2019). In fact, many of these studies have compare peoples shoulders that have pain, with the shoulder that does not have pain, only to find that there are similar amounts of “damage” to each of the shoulders (Barreto et al. 2019). These findings may fill you with uncertainty and dread, however these findings ought to be framed in the context of hope, especially considering the relevant new research regarding rotator cuff rehabilitation.
A rotator cuff injury can be managed under two basic categories; operative and non operative. Operative management is a surgical intervention in which the damaged portions of the muscle are reattached, while scar tissue is removed. Non-operative management would be anything not including surgery such as rehabilitation, injection, and “wait and see” approaches (typically used as a control group in studies). We are not surgeons so we will not comment on surgical technique’s or its benefits and risks here, but we are rehabilitation specialists, so we will focus on different aspects of rehabilitation such as ruling out the neck, progressive loading, and closed versus open chain exercises.
Ruling out the Neck:
An often overlooked culprit in shoulder pain is actually pain coming from the neck. In certain pathologies, pain can be present outside of the area of actual discomfort. The classic example is left side arm pain during a heart attack, or referral into the tip of the right side shoulder with gallbladder pathologies (yes if your shoulder hurts more after eating than after exercising it might be from your gallbladder). But usually in our active clients the neck is the usual suspect that we look at first. Indeed there have been many crossfit athletes that have come into our office thinking that they had a shoulder issue which was resolved by neck movements and exercises. Ruling out the neck comes down to performing both an orthopedic and mechanical evaluation with repeated movements to assess if the neck is contributing to your shoulder pain. Many research publications utilize both of these evaluations to rule out the neck before classifying patients with pain related to the shoulder (Such as the work done by (Littlewood et al. 2012)).
Rotator cuff tear:
Tears of the rotator cuff are common in both people with shoulder pain and people without shoulder pain. Tears can be both minor, or small, in size, as well as major or large in size. Typically minor rotator cuff tears can be managed with progressive rehabilitation exercises. In these cases rehabilitation has been shown to be equally as effective as surgical management about 93% of the time (Ranebo et al. 2020). While rehabilitating a torn rotator cuff can sometime be tricky, it more often than not follows a simple progression based on how you respond to different exercises and load types. Progression typically flows as follows:
Isometric loading with mild discomfort and no pain afterwards
Isotonic movements with resistance to tolerance
Resistance can be either with a resistance band or small weight
Again discomfort shoulder not linger after the exercise
Dynamic exercises or sport specific exercises
With rehab exercise, particularly loading exercise, pain does not always equal gain. However, it is somewhat beneficial to feel a small amount of discomfort (maybe an increase of 1 or 2 of the 10 point pain scale. This way we know that we are stimulating the connective tissues enough for them to adapt, but we are not overloading them to the point of causing further damage.
Overloaded Rotator Cuff Tendons:
In this case it is not the muscle itself, but the tendon that is causing pain and limitations. Tendons are dense pieces of connective tissue that connect the muscle to the bone. Sometimes terms like tendonitis, or tendinopathy are thrown around regarding the tendons. Either of these can potentially cause issues depending on what is going on in the tendon, and what stage of the pathology the tendon is in. “itis” refers to inflammation, so when then tendon is in an acute inflamed state after a recent overload it may warranted to call it tendonitis. With a chronic overload, it is less likely that inflammation is present so tendinopathy is a more apt diagnosis (Cook et al. 2016).
When in an inflammatory state it is important to modify activities and perform only low load rehabilitation until the reactive processes after overload have diminished. Once the reactivity and inflammation has gone down we can begin to progressively load the tendon with exercises in a similar manner to muscle tear rehabilitation. The only difference is that a greater emphasis is placed on time under tension when performing tendon rehabilitation. Thus reps are typically very slow in nature so that we can increase the time under tension. The same rules still apply regarding pain during and after the exercises in tendon rehabilitation as in muscle rehabilitation.
Muscle Strain:
Muscle strains are commonplace after a hard workout or new type of workout. In this case there may be microdamage in the muscle and also some inflammatory cytokines which cause pain and tenderness while trying to use the muscle. These kinds of issues typically resolve on their own with light movements and gradually building back up to normal activities over a period of 2-5 days. You can read more about muscle strains evil cousin delayed onset muscle soreness by clicking HERE
Tips For Rotator Cuff Rehab:
Don’t catastrophize or blow your symptoms out of proportion. Often times the context and framing of our symptoms can have a greater effect on symptoms than the amount of damage (Wylie et al. 2016)
In minor tears, conservative management should be considered first before surgery because the results are often similar (Ranebo et al. 2020)
Be sure to see a clinician that has the education and knowledge to rule out the neck before beginning shoulder rehabilitation (Rosedale et al. 2019)
Passive therapies such as soft tissue therapy can potentially help modulate pain and increase the effectiveness of rehabilitative exercises.
Clinical practice guidelines recommend 6-12 rehabilitation visits spaced over a period of 8-12 weeks (“DORA Shoulder Tx Guidelines,” n.d.)
Disclaimer: The content in this post is for educational use only and is not meant to substitute or overrule medical advice from a physician or medical practitioner. While the information in this article can help you understand shoulder rehabilitation, it is not meant to be a replacement for evaluation and management from a licensed healthcare professional. If you are struggling with a shoulder injury, visit our contact page by clicking HERE to schedule an appointment for a full evaluation and treatment to get you back to doing what you love.
References:
“DORA Shoulder Tx Guidelines.” n.d. https://www.colorado.gov/pacific/sites/default/files/Rule_17_Exhibit_4_Shoulder_Injury_2.pdf.
