Many clients arrive at our clinic with the common complaint of shoulder pain. They often describe intense pain that restricts their workouts, radiates down their arm, affects their ability to lift or reach away from their body, and even keeps them awake at night. A common theme for these clients is that, upon clinical examination they have signs that indicate involvement of their rotator cuff (RC) muscle group in their injury. Simply put, this means that either their rotator cuff is the structure creating pain, or it is a related weakness causing pain in other local tissues like the shoulder's bursa (a small fluidfilled sac that can get inflamed). In many of these situations, clients have a history of endured repetitive-strain activities (i.e. a baseball pitcher's throwing arm, or unliateral/bilateral shoulders in a rower) that have led to deterioration of their rotator cuff over time.
The rotator cuff group is made up of four muscles that work in-unison to provide shoulder joint stability during activity. This means that when a pitcher is throwing, all of these muscles are engaged throughout the action to protect the alignment and control at the shoulder joint. These rotator cuff muscles are infraspinatus and teres minor (back of the shoulder), supraspinatus (top of the shoulder), and subscapularis (front of the shoulder).
One common injury to these rotator cuff muscles is tendinopathy, defined as "pain and weakness most commonly experienced with movements of shoulder external rotation [arm away from body] and elevation, as a consequence of excessive loads" (1). This style of rotator cuff injury can eventually lead to degenerative partial and full-thickness tearing over time. The diagram below shows a tear to the supraspinatus muscle (2):
One historical difficulty the health-care community has with managing rotator cuff tendinopathy and tearing, is in explaining and managing clients' pain. Research demonstrates that "asymptomatic partial and full-thickness rotator cuff tears have been reported in 50% of people in their seventh decade and in 80% of people over 80 years of age" (1). In a study on MRI investigation (our best means of imaging the rotator cuff), 55% of people previously diagnosed with rotator cuff pathology had evidence of supraspinatus injury, compared with 52% in people without symptoms (1). It seems then, that part of the trouble we have had with understanding pain experienced by those living with rotator cuff tendinopathy is that multiple mechanisms exist by which pain is manifested. As noted above, there is a tissue called the sub-acromial bursa which has been shown to trigger pain when inflamed (1). Also, if rotator cuff tendinopathies are not managed with appropriate activity modification then inflammation can be a pain trigger (1). Finally, when the rotator cuff has been aggravated for a long period of time (approx. 3+ months) the nerve tissues around the area can become "hypersensitive" and trigger more significant and more regular impulses of pain (1). Thus, our literature suggests that deterioration of our rotator cuff muscles is a normal part of aging and not always a source of pain. Our pain experienced from rotator cuff injury is likely complex and takes particular assessment and treatment to modulate.
The focus of physiotherapy then, for someone living with rotator cuff tendinopathy or tearing, should be very particular to their needs. For our baseball pitcher, rotator cuff injury can occur because of poor shoulder blade control, an old shoulder ligament sprain, or spinal stiffness. For our rower, the issue could be shoulder blade muscle weakness or rotator cuff weakness itself. A skilled physiotherapist will tailor the client's rehabilitation to be appropriate for them; taking into account the client's specific limitation and pain generating tissues. A combination of postural muscle strengthening, rotator cuff strengthening, spinal mobility exercises along with stretching/manual therapy is common and has been validated as effective for recovery in the literature (1). For partial degenerative tears, in comparison to rotator cuff repair surgery, "a well-structured and graduated exerotator cuffise program" leads to less sick leave, a faster return-to-work, and similar outcomes as 1, 2, and 5 year follow-ups (1).
As this blog post highlights, rotator cuff injuries are incredibly complex. As noted above, it takes particular care to discern what tissues create and modulate pain in a rotator cuff injury. It also takes attention to detail to best sort-out how to help someone recover from these injuries. At Movement Solutions Physiotherapy, we take one-to-one time with each client and all of our physiotherapists are trained and have experience providing both manual therapies and specific exercises appropriate for clients living with rotator cuff injury. These injuries are difficult to live with yet our research shows they can be managed and someone from our team would be happy to connect with you about your specific injury related experience.
1) Ginn K, Lewis J, McCreesh K, and Roy JS. Rotator Cuff Tendinopathy: Navigating the Diagnosis-Management Conundrum. Journal of Orthopaedic Sports and Physiotherapy. 2015; 45 (11): 923-37.
2) Rotator Cuff Injuries. Mobile Physiotherapy Clinic. http://mobilephysiotherapyclinic.in/rotator-cuff-injuries/. Accessed 31 March, 2018.