Rotator Cuff Tear

A rotator cuff strain is a tear to any of the four rotator cuff muscles in the shoulder and is common in throwing and racket sports. They are so called because their job is to rotate the arm at the shoulder and provide a supportive cuff around the joint. Rotator cuff tears can range from mild to severe.

Treatment consists of reducing pain and inflammation followed by a full rehabilitation program consisting of mobility, strengthening and sports specific exercises.

Symptoms

Torn rotator cuff symptoms will consist of sudden pain in the shoulder sometimes accompanied by a tearing feeling. Symptoms may radiate down into the arm. The patient will often be unable to sleep on the injured shoulder and there may be signs of shoulder impingement where the tendon pinches between the ball and socket of the shoulder joint when moving the arm out over head height.

Pain can gradually get worse over time and eventually weakness in the shoulder will occur to the point where the athlete is unable to lift their arm up to the side. Overhead movements such as in racket sports become very difficult.

Read more on rotator cuff tear symptoms including when to seek medical attention.

Causes

A rotator cuff tear is usually caused by over stretching or a rapid twisting of the joint. There are four rotator cuff muscles in the shoulder which work together to provide the joint with dynamic stability, helping to control it as it rotates. Because the shoulder joint has a large range of motion and often needs to move at very high speeds such as in throwing sports there is a higher risk of injury to the muscles or tendons (which join muscle to bone).

The rotator cuff muscles consist of the supraspinatus, infraspinatus, teres minor and subscapularis muscles. Supraspinatus and Infraspinatus are the most commonly injured rotator cuff muscles particularly in sports which involve a lot of shoulder rotation, for example bowling in cricket, pitching in baseball, swimming and kayaking. The injury is also more common in the older athlete, particularly where long term overuse or degeneration is present.

In throwing events it is often the case that injury is caused by the rapid deceleration or stopping of the arm once the throw has been released rather than the acceleration phase of the throw.

Treatment

Treatment for a rotator cuff tear consists of reducing the initial pain and inflammation, allowing the tissues to heel followed by a full rehabilitation program consisting of mobility, stretching, strengthening and functional shoulder exercises.

What can the athlete do?

Essential first aid for a torn rotator cuff muscle or tendon is rest and applying the PRICE principles of protection, rest, ice, compression and elevation. Apply ice or a cold therapy compression wrap to reduce pain and swelling. The sooner cold is applied the sooner you will stop swelling, inflammation and pain and the faster the healing process can begin. Cold therapy can be applied for 10 minutes every hour reducing to 3 or 4 times a days as pain reduces.

Rest the arm. A sling can sometimes be useful for more severe rotator cuff injuries if you still need to go to work school as it will immobilize the shoulder but can be removed at night. Once the acute stage is over mobility and strengthening exercises can begin as long as they are done pain free.

If the injury is more than a few days old and it has become chronic then alternating heat and ice may also be more beneficial and heat alone during the later stages of rehabilitation is often advised.

What can a Sports Injury professional do?

A doctor may prescribe pain relief and anti inflammatory medication for a rotator cuff injury. Imaging studies such as x-ray, MRI or CT Scan can confirm the diagnosis, and rule out a fracture. Sometimes you might be referred for a steroid injection directly into the site of the problem to help reduce any inflammation and allow you to proceed with rehabilitation. A full rehabilitation program consisting of stretching and strengthening exercises will be advised.

Shoulder massage including cross friction massage to the rotator cuff tendon can break the injury down to its acute stage to allow correct healing of the injury to take place.

Rehabilitation program

Rehabilitation of rotator cuff injuries consists of four elements; acute phase (immediately post injury), recovery phase, functional phase and finally returning to full training and competition.

1 - Acute phase

The acute phase of rotator cuff treatment occurs immediately after the injury occurs and will continue until pain free range of motion (below shoulder height) has been achieved and normal daily activites are relatively pain free.

Aims:  To allow tissue healing, reduce pain and inflammation, prevent muscles wasting, maintain normal movement in the shoulder blades (scapular control) and maintain fitness as much as possible.

Tissue healing: This involves resting the shoulder to allow tissues to heal. If you are constantly moving the shoulder and causing pain then this will slow down or prevent the healing process. Depending on how bad the injury is rest can be active rest where you simply avoid movements or activities which cause pain (specific weight training exercises or racket sports for example), but for more severe rotator cuff tears a sling to immobilize the shoulder joint may be required. A professional practitioner may use ultrasound therapy or other electrotherapy modalities to help stimulate the healing process.

Reduce the pain and inflammation: Apply cold therapy and compression wrap to the shoulder. This will help reduce pain and inflammation. Apply ice for up to 15 minutes every 2 hours, gradually reducing the frequency of applications as the shoulder improves. Specialist cold therapy wraps for shoulders apply compression to the area as well. Otherwise a simple ice pack applied with some pressure will be effective. Posture is important and sitting upright with the shoulders back, especially when sitting at a desk or using a computer can help relieve symptoms.

A doctor may prescribe NSAID's or anti-inflammatory medication (e.g. ibuprofen) may help in the early stages although it is argued they are not as effective later on or if the injury becomes chronic. Always check with your Doctor before taking medication if you are not sure. Again, electrotherapy such as ultrasound may be beneficial in reduce pain and inflammation.

Range of motion: Mobility exercises to regain range of movement in the shoulder joint should begin as soon as they can be done pain free. Pendulum exercises are the first priority, especially if it is a serious tear or following surgery. However, for mild torn rotator cuff injuries more advanced mobility and stretching exercises using a pole would be progressed onto.

Professional therapits may use sports massage techniques including cross friction massage to help the athlete regain full range of movement. Simply applying pressure to the tendon initially may be all that is needed. As pain reduces, a massage therapist may apply deeper cross friction techniques.

Read more on rotator cuff exercises.

Strengthening: Isometric or static exercises can begin as soon as they can be done pain free. However, for a rotator cuff strain it may not be until later in the rehabilitation process that strengthening exercises can begin. Scapular control exercises such as the scaular squeeze and elevation exercises are important to maintain the correct movement patterns in the shoulder joint as rehabilitation progresses.

Read more on rotator cuff exercises.

Maintaining fitness: Aerobic exercises such as running, cycling or stepping machines should be done to maintain fitness and also psychological well being. Use the opportunity to focus on other aspects of fitness such as agility, plyometric leg strength or flexibility.

2 - Recovery phase

The recovery phase begins when the initial pain and inflammation has gone and most normal daily activities are pain free and the injured arm has at least 75% range of movement compared to the uninjured one.

Aims: Regain full, pain free range of motion, normal upper body strength and normal shoulder joint movement patterns.

Range of motion:  This is achieved by wand or pole exercises which help with flexibility above shoulder height progressing onto stretching and mobility exercises without assistance from a pole. Scaular control is progressed with balance board exercises on your hands, press up type exercises and ball catch and return exercises.

Strengthening: Exercises to isolate the rotator cuff muscles can begin including strengthening exercises which concentrate more specifically on the external rotator muscles (the ones that rotate the arm out) and the scapular stabilisers (muscles that support the shoulder blade). It is also important to strengthen the whole joint and weight training exercises such as bench press, shoulder press (military press) and pull downs should be done but with very light wieghts. For example aiming for 12 to 20 reps of a light wieght concentrating on correct technique.

3 - Functional phase

During the functional phase exercises which are more sports specific are introduced in preparation for returning to full training and competition.

Aims: To increase power and endurence in the upper body muscles, improve strength of the shoulder joint in all directions and introduce sports specific shoulder exercises.

Increasing power: This is done through more plyometric or explosive type exercises and may depend on your particular sport. Diagonal and sports specific exercises using exercise bands can be done. Throwing and catching type exercises with mini medicine balls can be done. Racket sport players may begin to work more with rackets and balls, but with the emphasis on strengthening the weak muscles rather than full sports training. For example, throwers would start throwing a tennis ball against a wall in five sets of 20 throws, gradually increasing the number of sets and number of repetitions assuming no pain during, after or the next day.

4 - Return to competition

When functional exercises have progressed so the athlete feels back to full pain free fitness then a gradual return to competition can be done. It might be a good idea to only try half what you would normally do, for example a set of tennis rather than a full on 5 set match. Or trying three competitive Javelin throws and seeing how it feels the next day rather than giving 100% on all six followed by a discus throw.

It is important to identify possible causes of injury in order to prevent recurrance. The chance of the injury recurring are increased by any of the following:

  • If you have an unstable shoulder joint. An unstable shoulder joint means that there is a lot of movement and weakness in the joint. If you are not sure, see a sports injury professional. Failure to recognise this may mean the injury is likely to recur.
  • If you have poor technique or bad training habits. Overuse or training too hard is just as likely to cause injury as poor technique. If you are not sure, find a good coach.
  • If you have weakness in the rotator cuff muscles
  • If you have poor posture.

Rotator cuff surgery?

If the injury is quite severe and you are young and active then surgery may be indicated to repair the tear. People who are more likely to need surgery include:

  • Athletes under 60 years old.
  • Patients with complete tears of the rotator cuff tendon or muscle.
  • If conservative treatment of rest, ice, exercises and other treatments is not having the desired effect after 6 weeks
  • Professional sports people who want the short cut to making sure the injury heals in the shortest possible time.
  • If your job requires constant shoulder use then surgery for a severe injury may be preferable.

Recovery time for a torn rotator cuff will vary depending on several factors. Conservative treatment has a 40-90% success rate at fixing the problem. Surgery often has good results, with some studies citing a 94% satisfaction rate with the surgery, resulting in lasting pain relief and improved function. Very extensive tears often have a poor surgical outcome, however this injury is thankfully quite rare. If you are older, it will take you longer to heal.

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