Wholistic Toolbox: The Rotator Cuff and injuries related to it

Jenns 6 InjuriesThe shoulder is made up of three bones: the upper arm bone (humerus), the shoulder blade (scapula), and the collarbone (clavicle). The shoulder is a ball-and-socket joint: The ball, or head, of the upper arm bone fits into a shallow socket in the shoulder blade. The arm is kept in the shoulder socket by 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 the arm.

There is a lubricating sac called a bursa between the rotator cuff and the bone on top of the shoulder (acromion). The bursa allows the rotator cuff tendons to glide freely when the move your arm. When the rotator cuff tendons are injured or damaged, this bursa can also become inflamed and painful.

When one or more of the rotator cuff tendons is torn, the tendon no longer fully attaches to the head of the humerus. Most tears occur in the supraspinatus muscle and tendon, but other parts of the rotator cuff may also be involved. In many cases, torn tendons begin by fraying. As the damage progresses, the tendon can completely tear, sometimes with lifting a heavy object. The fraying is caused by too much tension or an imbalance in the muscles which needs to be corrected.

Causes of a rotator cuff injury may include falling, lifting and repetitive arm activities — especially those done overhead, such as throwing a baseball or placing items on overhead shelves. Repetitive use and/or improper body mechanics can also lead to injury. As we age and become less active we tend to lose strength and tendons begin to breakdown. Rotator Cuff Injuires are most common in people over 40 years old. There is a very good chance that a rotator cuff injury provided it is not severely torn, can heal with self-care measures or exercise therapy

Rotator cuff injury signs and symptoms may include:

Pain and tenderness in the shoulder, especially when reaching overhead, reaching behind the back, lifting, pulling or sleeping on the affected side

Shoulder weakness

Loss of shoulder range of motion

Inclination to keep the shoulder inactive

The most common symptom is pain. It may occur when reaching up to comb hair, bending the arm back to put on a jacket or carry something heavy. Lying on the affected shoulder also can be painful. If a severe injury, such as a large tear, has occurred there can be continuous pain and muscle weakness.

So our primary goal is to release scar tissue that has formed following injury, restore ranges of motion and regain stability. Torn muscles, most commonly the supraspinatus (on the top of the shoulder blade), create general instability in the shoulder joint. Once range of motion has been restored, strength will be required to fully resolve the injury and prevent the problem from becoming chronic (i.e. frozen shoulder).

The manner in which the treatment is tailored depends on which muscle is torn. Make sure to determine the exact injury and tailor the treatment accordingly. If your client is very apprehensive about stretching the shoulder, begin with strength training (i.e, manual resistance and ROM movements) to establish confidence and stability. Once initial gains in stability have been attained you will have greater success doing the stretching protocols. This is especially true for dislocations.

Make sure to pay attention to the client’s reactions both emotional and physical. Work with the client and address their issues as you go.

So how would I work with A Rotator Cuff Injury:

I would use the following Stretching protocol

Shoulder Horizontal Abduction

Shoulder Extension

Shoulder Internal Rotation

Shoulder External Rotation

Shoulder Horizontal Adduction

Shoulder Abduction

Posterior Hand Clasp

I would then proceed to opening up the cervical area with another series of stretches. Once I have the client out of pain and confident that they can in fact use their shoulder I would introduce strengthening exercises. Starting with a light manual resistance and gradually moving up to weights. I am also massaging (in between stretches – gives the client a break and brings their awareness to the changes in the soft tissue) and treating trigger points as they arise. Finally I would review the client’s body mechanics and try to correct improper use that is contributing to the problem. The client would be given a protocol do follow at home with daily shoulder stretches and a shoulder-strengthening to help prevent a recurrence. Especially important is a program of strength exercise to promote balanced strength about the shoulder.

So now you know my approach I would love to hear yours! Please share how you view and treat the Rotator Cuff.

7 thoughts on “Wholistic Toolbox: The Rotator Cuff and injuries related to it

  1. Hi Marjorie,

    Nice synopsis. Physical therapy for the rotator cuff injury covers a lot of potential ground, form the hands-off therapist who prescribes exercises and then walks away, to the fully hands-on PT (me) who believes this sort of approach is more effective.

    There is a great research study out there titled “Dead men and radiologists don’t lie: a review of cadaveric and radiological studies of rotator cuff tear prevalence.” (I find the more interesting the title, the more relevance the results!). The conclusion states:

    “Rotator cuff tears are frequently asymptomatic. Tears demonstrated during radiological investigation of the shoulder may be asymptomatic. It is important to correlate radiological and clinical findings in the shoulder.”

    They found that a good number of rotator cuff tears caused no issue/pain. But, go to the doctor with shoulder pain, have an MRI where a tear is “discovered”, and you may end up with surgery. But how do they know that the tear was the issue or if it was just the background noise described in the study? Good clinical examination should be the response, though that does not always occur.

    As a physical therapist trained in manual therapy, I examine for both soft tissue tightness as well as nervous system distress (even though I now understand that the nervous system distress usually leads to the soft tissue tightness). My primary focus is to restore motion. Strength often follows without much effort. If specific strengthening is needed, waiting until the environment is clean and open make the process actually work like it should. Attempting to strengthen a shoulder that is completely bound down is fruitless and can lead to further injury.

    Regards,
    Walt Fritz, PT

    Reference: http://www.ncbi.nlm.nih.gov/pubmed?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16551396&ordinalpos=10&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

  2. Hello Marjorie,
    Wonderful blog, great information.
    As a structural integrator I try to look at the whole body.
    As you stated the rotator cuff muscles originate on the scapula and cross the glenohumeral joint, but I usually like to start with looking at the scapula to see if it’s hanging off the neck and its placement on the ribs.
    Most clients in general seem to do a lot of flexion so they’re very round shouldered with forward head posture. So one of the first things that I like to do is open up that front line. I’ll start with lifting up rectus abdominals,up into the pec tissue and out into subclavius( my focus is on the fascia,which will effect the muscles).
    Then I’ll open up pec minor and into coracobrachialis, and even the bicipital tendon.
    Then I might work the superficial fascia of the neck and then into SCM and scalenes, levator scapula,upper traps and then the suboccipital’s,all to address forward head posture. At this point I try to teach the client how to bring their head into proper position by having them engage their posterior muscle while the relax the anterior muscle thu reciprocal inhibition.
    As you’re aware if the client has forward head posture that Levator scapula and upper traps are going to be dragging that scapular superior and anterior.
    I might at this point take some time to address serratus anterior, rhomboids and possibly lats all to try to bring the scapular into a more functional position.
    Once I freed up all the fascia that holds the scapular onto the axial skeleton I will then address the rotator cuff muscles.
    As you know most clients do not know which of their rotator cuff muscles are damaged, so at this point it’s really a lot of palpation skills and feeling for the restrictions and adhesions and trying to work with the client and their comfort level.
    Sometimes I’ll just work the muscle with client movement will possibly pin and stretch techniques trying to open up all the muscles. At some point I might give them some exercises to do.

    This is a very abbreviated and condensed version of what I try to address with clients that have rotator cuff issues.
    And also depends on how much time a client has and the type of work that they really want.

    Your friend Gerald Basile LMT BCSI

  3. Thanks Marjorie for this helpful forum! We (and ultimately our clients) will benefit from this opportunity to learn from the perspectives of other professionals. A synergistic approach to a healthy, balanced shoulder (and body!) is just the kind of “team effort” that increases the odds of a successful outcome for athletes and other clients we treat.

    Achieving balance, “leveling the playing field”, equalizing the “tug of war” in the body is what we are aiming for – in addition to your Stretching Protocol (I’m a long-time fan!) and soft tissue work I do based on a “global” look at the client, i.e. focusing on cause instead of symptoms (like Gerald’s structural integrative “whole body” approach), I have found Kinesio Taping to be an effective adjunct therapy to the team effort.

    It can be just the right “homework” for the body and can relieve pain, facilitate weak muscles or inhibit overused muscles by providing a “low-load”, long-term (can be worn 3-5 days) proprioceptive stimulus that works towards restoration of muscle balance and increased ROM. There are simple applications and more advanced combination tapings depending on the client’s needs – chronic, repetitive use shoulder symptoms (rotator cuff impingement or tendonitis) or it may be part of a rehabilitative treatment plan, possibly post-surgery and during the PT process. I might need to do some postural tapings, e.g. for forward shoulder, to reduce tension in pectoralis minor or biceps brachii…there are many possibilities!

    Depending on the amount of tension on the tape, the direction of application (D to P or P to D) and the cut (web, button hole, tails) many effects on the tissue can be achieved – fascial correction, mechanical correction, functional correction, etc. and it is very helpful in treating edema and contusions. I’m really “stuck” on this stuff:)

    Best wishes,

    Lou Ann Botsford, LMT, CKTP

    Kase, K., Clinical Therapeutic Applications of the Kinesio Taping Method, 2nd edition, 2003

    Kase, K. Kinesio Taping for Lymphoedema and Chronic Swelling

    http://www.kinesiotaping.com/global/association.html

    • Awesome Lou-Ann! Keniso-taping is really on the rise and an excellent addition to the toolbox! One side note to massage therapists- make sure that this form of therapy is in your state scope of practice. Many states such as NY are not allowing LMT/CMP to apply it.

  4. This is where Marjorie’s information demonstrates the importance of an interdisciplinary model. From the perspective of a fitness professional, the shoulder is a mysterious, oft frustrating area for which to account. One of the more recent trends among fitness professionals, even very experienced and qualified ones, is to completely remove overhead pressing from their client’s/athlete’s training.

    While I work with an entirely different demographic (the ASD population), I have always been suspect of outright removing compound movements (deadlifts, squats, presses) from a program without absolute necessity. For trainers, when a client does mention pain or discomfort, it is important to consider not only their current programming (and any movement or lackthereof outside the gym), but that localized pain does not equal localized injury.

    The pain I’ve been experiencing in my anterior deltoids was due to bicep tendonitis. As an Exercise Physiologist, I did not know this. It is very, very difficult to self-diagnose. Marjorie figured this issue out during one of our stretching sessions. We were able to put together a stretching program that began to alleviate the symptoms and overhead pressing is now possible. For fitness and other health and wellness professionals, it is not an issue of “admitting that you don’t have all the answers,” rather finding professionals in related fields who can help to enhance your practitioner base and enable clients to get the most from your program.

    Live Inspired,

    -EC, Founder, Autism Fitness

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