What is the Rotator Cuff and why is it important?:
Your shoulder is made up of three bones. The upper arm bone (humerus), the shoulder blade (scapula), and the collarbone (clavicle), collectively all form the shoulder joint. The shoulder is a ball-and-socket joint: The ball, or head, of your upper arm bone fits into a shallow socket in your shoulder blade.
Your arm is kept in your shoulder socket by A network of ligaments, the joint capsule and your rotator cuff. The rotator cuff is a network of four muscles that come together as tendons to form a covering around the head of the humerus. The rotator cuff attaches the humerus to the shoulder blade and helps to lift and rotate your arm.
This ability to lift the arm is made possible by the four muscles collectively working together to pull the humerus (long arm bone) into the glenoid fossa (socket). This is referred to as humeral head depression. This function allows the big muscles of the shoulder (deltoid) to move the arm in various directions. Without this function, abnormal wear and tear will occur and significant functional deficits will be noted such as the inability to raise your arm. Eventually a shoulder with poor cuff function will become arthritic and have significant pain.
What are the muscles that make up the Rotator Cuff?
The complex is made up of four muscles. They each have a little different function but all collectively depress the humeral head. Starting in the front of the shoulder is the subscapularis. This muscle is responsible for internal rotation of the shoulder and is usually injured with a traumatic event. On top, is the supraspinatus. This is the most commonly injured muscle of the rotator cuff. It aids the shoulder in lifting in a functional plain of motion known as scaption. In the back are two external rotators of the shoulder which can also become injured either through wear and tear or a traumatic event. These muscles are the infraspinatus and teres minor.
Why are rotator cuff injuries so common?
The following factors that may lead to rotator cuff dysfunction.
Normal wear and tear. Increasingly after age 40, normal wear and tear on your rotator cuff can cause a breakdown of fibrous protein (collagen) in the cuff’s tendons and muscles. This makes them more prone to degeneration and injury. With age, you may also develop calcium deposits within the cuff or arthritic bone spurs that can pinch or irritate your rotator cuff. This is known as impingement. The rotator cuff has a poor blood supply so when injuries occur they have difficulty healing.
Poor posture. We spend a lot of our waking lives in a seated position. When you slouch your neck and shoulders forward, the space where the rotator cuff muscles reside can become smaller. This can allow a muscle or tendon to become pinched under your shoulder bones (including your collarbone), especially during overhead activities, such as throwing. This pinching is known as impingement syndrome.
- Falling. Using your arm to break a fall or falling on your arm can bruise or tear a rotator cuff tendon or muscle.
- Lifting or pulling. Lifting an object that’s too heavy or doing so improperly — especially overhead — can strain or tear your tendons or muscles.
- Repetitive stress. Repetitive overhead movement of your arms can stress your rotator cuff muscles and tendons, causing inflammation and eventually tearing. This occurs often in athletes, especially baseball pitchers, swimmers and tennis players. It’s also common among people who routinely perform manual labor.
Conservative Care For Rotator Cuff Injuries:
It has been estimated that 75% of patients will respond positively to conservative therapy focusing on restoration of normal joint mobility, and strengthening to the scapular musculature as well as strengthening to the non-pathological rotator cuff musculature.
In a recent study in the Journal of Shoulder and Elbow Surgery, conservative treatment of full thickness rotator cuff tears was examinied. In the study they followed a group of 381 patients with traumatic full-thickness tears of the rotator cuff for a minimum of two tears.
The patients performed 6-12 weeks of nonoperative physical therapy focusing on basic rotator cuff strengthening, soft tissue mobilization, and joint mobilizations.
At the six-week mark, patients were assessed and 9% chose to have rotator cuff repair surgery. Patients were again assessed and the 12-week mark. At 12-weeks, an additional 6% chose to have surgery. In total, 26% of patients decided to have surgery by the 2-year follow-up mark. Statistical analysis revealed that if a patient does not choose to have surgery within the first 12-weeks of nonoperative rehabilitation, they are unlikely to need to surgery.
Nearly 75% of patients in this study avoided rotator cuff repair surgery by performing physical therapy despite having full thickness cuff tears.
More information on this study as well as conservative rotator cuff rehab is available at Mike Reinold’s Blog
Nonoperative Rotator Cuff Rehabilitation Principles
Restore Shoulder Mobility
It is imperative to restore symmetrical range of motion and joint mobility in the shoulder to improve pain and function. This is always the primary initial focus of rehab. Strength without motion is worthless.
Restore the Anterior and Posterior Rotator Cuff Couple
Restoring and strengthening strength to the non-involved musculature will aide in improving humeral head depression. Focusing strengthening on the anterior (subscapularis) and posterior (infraspinatus and teres minor) rotator cuff couple will re-establish humeral head depression in even shoulders with full thickness supraspinatus tears. This is known as the rotator cuff “suspension bridge” concept.
Address Other Mobility and Stability Issues throughout of the Kinetic Chain
Any dysfunctions of the scapulothoracic joint, cervical, thoracic and lumbar spine, should be addressed. These areas all have a significant impact on the alignment, mobility, and stability of the glenohumeral joint.