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) all collectively 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 complex of ligaments, the joint capsule, and the 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 (Pull the bone into the socket). 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..
Principles of Rotator Cuff Repair Rehabilitation:
Rotator cuff repair rehabilitation is a slow process. Due to the poor blood supply to the rotator cuff tendons, its healing is very slow. A 12 to 18 month timetable should be expected for full return to pain-free and unrestricted function.
The rehabilitation program following a rotator cuff repair should not be a standardized protocol but should be customized according to multiple variables. The patient’s age, tear size, tissue quality and security of the repair as well as the patients goals should all be factored into the plan of care. Communication with the surgeon regarding tear size, tissue quality and length of desired immobilization should all be addressed before progressing therapy.
In general, rehabilitation following a rotator cuff repair can be divided into 3 phases.
- The first phase is known as the Maximum Protection Phase. This phase usually lasts between 4 and 6 weeks post-operatively. This time-frame will be set by the surgeon. During this phase the patient will remain in their immobilizer at all times except while performing their prescribed home exercise program. The focus during the maximum protection phase are minimizing the negative effects of immobilization through passive range of motion and joint mobilization performed by your therapist. During this phase all motion should be PASSIVE. The anchors used to hold the rotator cuff tendon act as a scaffold to hold the repaired tendon to the bone. Active contraction of the muscle/tendon can theoretically pull the anchors out of the tendon resulting in a failed surgery. During the maximum protection phase we also focus on pain modulation as this is the single most common factor limiting progression of passive range of motion. The following video is the home exercise program we prescribe to our patients at Physio Pro during the Maximum Protection Phase.
- The next phase starts usually between 4-6 weeks (set by your surgeon) and is know as the EEarly Motion Phase. During this phase your therapist will continue the joint mobilization and passive range of motion exercises but will progress your home program integrating active assistive and then active range of motion exercises in the later stages of this phase. Towards the end of this phase isometric strengthening to the scapular and rotator cuff musculature will begin. Video of the Early Motion Phase home exercise program coming soon.
- The last phase is known as Functional RRestoration/Total Arm Strengthening Phase This phase begins no sooner than 12 weeks post-operatively. By 12 weeks post-op the shoulder should be within 85% of full passive range of motion. If ROM deficits are still present then more aggressive capsular stretching will be initiated. In this last phase we gradually begin to shift focus to restoring functional strength in a calculated and incremental basis. Video of the Functional Restoration/Total Arm Strengthening Phase home exercise program coming soon…
It is very important for you to follow the specific plan of care set by your surgeon and treating physical therapist. The exercises presented are general guidelines. DO NOT TRY ANY OF THE FOLLOWING VIDEO EXERCISES WITHOUT THE CONSENT OF YOUR TREATING PHYSICAL THERAPIST/SURGEON