What is it?
The shoulder is a ball-and-socket joint that has great mobility however, has poor structural stability. The rotator cuff is composed of 4 muscles: supraspinatus, infraspinatus, teres minor, and subscapularis. The primary function of the rotator cuff is to stabilize the shoulder whereas the larger muscles move the shoulder. The rotator cuff muscles compress the humeral head into the shoulder joint.
Rotator cuff injuries are the most common problems affecting the shoulder. Injuries range from a mild strain of a piece of the tendon to complete rupture of all the tendon. Strains of the rotator cuff can happen abruptly from trauma like falling, pushing, pulling, throwing, or lifting. Other factors that could contribute to rotator cuff pathology include repetitive injury and age-related erosion in the joint.
Some predisposing factors include obesity, hypercholesterolemia, genetics, diabetes, or a history of corticosteroid injections. Impingement and hypovascularity (having a large number of blood vessels) may produce recurring damage and impair the cuff’s ability to recover.
Repetitive overhead activity predisposes you to a rotator cuff type injury. Jobs such as carpentry, painting, cleaning windows, and washing cars can also cause rotator cuff issues.
Those with scapular dyskinesis (an issue with the movement of the shoulder blade) or upper cross syndrome are highly susceptible to rotator cuff damage.
Patients usually feel “snapping” or “tearing” accompanied by severe pain and weakness, mostly when abducting (movement of shoulder away from the body) the shoulder. Patients often report gradual onset of pain and weakness within the shoulder followed by crepitus (popping, grinding, or crunching when moving the joint). Pain is most commonly localized to the anterolateral (front of body and away from the midline of body) aspect of the shoulder but can radiate down the arm.
Symptoms traditionally are provoked by overhead activity and may progress to the point of not being able to raise their arm over their head.
Pain arises at night, especially when lying on the affected shoulder. This causes patients to report troubles with sleeping. The shoulder will demonstrate a lack in range of motion with passive (someone helping you with the movement) internal rotation and active elevation and abduction.
If patients are over the age of 60, have supraspinatus weakness (abduction weakness), and weakness in resisted external rotation are positive signs for rotator cuff pathology.
Mechanical defects can start to occur, especially with overhand athletes, which causes issues with hip mobility and core stability.
The diagnosis of tendinopathy is based upon clinical findings, and imaging should be reserved for special circumstances. Clinicians will determine if images are warranted based on clinical findings and if images will help with treatment. In atraumatic tendinopathy cases without significant loss of strength, MRI should not be performed prior to a trial of conservative care.
Research has shown that conservative care should be the first choice for most non-traumatic tears. Conservative management of partial-thickness tears and chronic full-thickness tears have very good outcomes.
Conservative management of the rotator cuff includes activity modification, stretching, strengthening, manual therapies, and restoration of scapular mechanics. Patients should avoid activities such as any painful overhead activity, carrying heavy objects, and avoiding sleeping on the affected side especially with the affected arm stretched overhead. The best way to sleep with a rotator cuff injury is to sleep on the unaffected side with a pillow between their affected arm and trunk.
During recovery, immobilization has been shown to promote adhesions and delay recovery. The evidence supports a slowly progressive loading program, rather than complete rest.
Early in recovery the patient and clinician should minimize stressful loading of the injured tissues. Rehab should begin with moderate effort and low repetitions. The best exercises include those that are progressive and that have resistance. Stretching exercise should focus on adduction (towards body), internal rotation, and external rotation. The progression of exercises goes from stabilization type exercises to isotonic (resisting of weight while going through range of motion) strengthening to sports/daily activities specific actions.
Some other techniques that help include stretching and myofascial release (manipulative treatment whose main goal is to release contracted muscles, improve blood flow to the area, and receive better lymphatic circulation). A good transverse friction massage or instrument-assisted soft tissue mobilization (Graston/scraping) may help with the remodeling of scar tissue. The use of elastic therapeutic tape (kinesiotape) may help to gain muscular function. Joint mobilization and manipulation are treatments that will help restrictions in the scapulothoracic (joint space where the shoulder blade meets the middle spine area), glenohumeral joint (shoulder joint), and the cervicothoracic (where the neck ends and meets the middle of the back) joint. There is evidence that suggests that manipulation of the cervicothoracic and thoracic spine may decrease shoulder pain while increasing mobility and function.
Patients who have diabetes, smoke, and have high BMIs tend to have worse treatment outcomes.
Clinicians should address any likely concurrent defects in the patient's scapular (shoulder blade) mechanics with rehab protocols. Clinicians will also look for defects in hip mobility and trunk stability in athletes with rotator cuff issues because of the mechanical compensation that occurs.
The use of NSAIDs (ibuprofen, advil, tylenol, etc.) should be limited because they inhibit collagen synthesis (the body’s natural process of adding “cells” to strengthen the affected area) and may interfere with natural healing.