All Posts tagged rotator cuff

Rotator cuff injuries

The rotator cuff  include the supraspinatus muscle/tendon, infraspinatus muscle/tendon, teres muscles/tendon, and the subscapularis muscle/tendon. The supraspinatus is most often the muscle that causes pain. Ths is because of wear and tear that causes degeneration due to its close anatomical relationship with the acromian process. The small space between the humeral head and the acromian process houses the supraspinatus tendon, subacromial bursa and biceps tendon. If anything reduces that subacromial space, then the chances of something being pinched and worn down increases greatly. 

I have seen an increase in patients with shoulder impingment syndrome. There are many causes of the impingement: 1) can be from an osteophyte (spurs or bone growth) growing down from the underside of the acromian; 2) previous shoulder trauma that either disrupts the stabilising mechanism of the shoulder joint (as in shoulder dislocation) or 3) from a past injury or poor posture that causes a change in the firing patterns of the stabilising rotator cuff muscles that allow the humeral head to bounce around or shear too much within the ‘socket’  and this increases the chance for impingement. By far the most common cause of rotator cuff problems is altered scapula position due to muscle tightness or poor muscle firing.  This can influence the position of the acromian as the arm is lifted above the head. The key muscle to influence a poor scapula position is the pec minor. This muscle causes the scapula to sit in a downwardly rotated position at rest, bringing the acromian process closer to the humeral head.

The way I treat this problem is by teaching clients the proper exercises to influence the firing patterns of the dynamic stabilisers of the shoulder – the rotator cuff. For example  the simplest way to activate a subscapularis muscle is grab a 1-2 kg dumbbell and lie on the floor on your back. Place the arm up into 90 degrees abduction so the elbow supports the arm on the floor and the hand holding the weight is directly over the elbow. Slowly lower the dumbbell towards the floor moving towards the head (this is eccentric external rotation – controlled by subscapularis). Only lower to about 45 degrees and then return to the start (concentric internal rotation – again subscapularis). As an activation drill this can be done with a light weight and non fatiguing repetitions.

The easiest way to loosen an infraspinatus is to self massage it. Stand against a wall, place the hand behind the head and with the other hand, reach around and place a tennis ball in the back of the shoulder (between the shoulder blade and the wall). If it hurts then press on it. Hold the trigger point for about 1 minute and then move on to a different spot.

Furthermore, the pec minor and levator scapulae need to be loosened and stretched. And the muscles which work to upwardly rotate the scapula need to be strengthened (the trapezius and the serratus anterior).

I always recommend the foam roll to improve poor thoracic spine mobilty and extension. Lack of motion in the thoracic spine influences the scapula. I have also used the warm laser on most of these cases with very good results.


Rotator cuff tears and shoulder pain

February 15, 2011 (San Diego, California) — A physical therapy program can effectively treat most patients who present with atraumatic full-thickness rotator cuff tears and shoulder pain, without the need for surgery, researchers announced at the American Academy of Orthopaedic Surgeons (AAOS) 2011 Annual Meeting.

“Our non-operative program is successful in over 90% of patients and the effect seems to last at least 2 years,” John E. Kuhn, MD, associate professor and chief of shoulder surgery at Vanderbilt University Medical Center in Nashville, Tennessee, and director of the Multicenter Orthopedic Outcomes Network (MOON) Shoulder Group, said.

In the United States, at least 10% of persons over age 60 years, or nearly 6 million people, will develop a rotator cuff tear.

Prospective Cohort Study

The study included 396 patients age 18 to 100 years who had atraumatic full-thickness tears documented by magnetic resonance imaging and no other abnormality. The primary symptom was pain in most patients.

Patients were assigned to a physical therapy program that included daily postural exercises, active-assisted motion, active training of scapula muscles, and active range of motion, along with anterior and posterior shoulder stretching. They also performed thrice-weekly rotator cuff and scapula exercises. The program has been shown to be effective in patients with impingement syndrome.

Study participants also did manual mobilization exercises with assistance from a therapist.

Patients returned at 6 and 12 weeks. At this point they could decide that 1) treatment was successful and they needed no formal follow-up, 2) they had improved but would like to continue therapy with scheduled reassessment in 6 weeks, or 3) nonoperative treatment had failed and they would undergo arthroscopic rotator cuff repair.

Patients were contacted by telephone at 1 and 2 years to determine whether they had undergone surgery since their last visit.

Improvements on Multiple Outcome Measures

Six-week data indicate that fewer than 10% of patients had decided to undergo surgery.

Of patients in whom follow-up data were available for at least 2 years, only 2% had opted for surgery.

The analysis also revealed that patients who decided to undergo surgery generally made their decision within 6 to 12 weeks of starting physical therapy. In addition, patients did most of their physical therapy at home and usually made only 1 weekly visit to the physical therapist.

Finally, Dr. Kuhn emphasized that the physical therapy program alleviated pain without “doing anything to the tear.” The finding suggests that pain may be a less suitable indication for rotator cuff repair than is weakness or loss of function.

American Academy of Orthopaedic Surgeons (AAOS) 2011 Annual Meeting; Abstract #319. Presented February 15, 2011.


These findings are typical of what I find in my rehab practice. Those clients that do the exercises improve.


What’s wrong with sitting?

I typically see:
tight hip flexors, hamstrings, calves
tightness through the external hip rotators, leading to restriction in hip joint range
limitation of lumbar spine extension
stiff thoracic spine
protracted and elevated scapulas with weak lower trapezius and serratus anterior
tight and weak posterior rotator cuff
poked chin posture with associated weak deep neck flexors and overactive upper trapezius, levator scapula and rhomboid muscles.

Prolonged sitting has also been linked to hamstring strains. The lumbar spine stiffness associated with sitting leads to altered neural input into the posterior thigh, the theory goes. This can manifest as increased muscle tone of the hamstrings, which will alter the length-tension relationship and increase the risk of strain.

Hunched postures cause thoracic spine stiffness, shoulder imbalance and winged scapulas.

Each of my clients is encouraged to correct their posture, perform a daily flexibility program and take a look at the ergonomics of their work-stations to help them regain the alignment and muscle balances that are essential for them to achieve their best health.


Shoulder Rehabilitation

12 O’clock Arm Raises

Lie face down with arms forward. Lower shoulder blades and raise both arms as high as possible. Be sure to keep arms in the “I” position.

Hold for 1-2 seconds.
Repeat 10 times per set.
Three sets per session.
Complete 2 sessions per day.

10 & 2 O’clock Arm Raises

With or without weights, arms are in a 10 and 2 o’clock position. Lift/raise both outstretched arms as far as possible. Be sure to lower the scapula when performing this exercise.

Hold for 1-2 seconds.
Repeat 10 times per set.
Three sets per session.
Complete 2 sessions per day.

3 & 9 O’clock Arm Raises

With or without weights, arms are in a 3 and 9 o’clock position. Raise both outstretched arms as far as possible. Keep the scapula down while performing this exercise.

Hold for 1-2 seconds.
Repeat 10 times per set.
Three sets per session.
Complete 2 sessions per day.

Wall Angels

Stand against wall, upper arms at shoulder level and elbows bent to 90°. Raise arms over head keeping arms, forearms and hands against wall.

Hold for 2 breaths.
Repeat 10 times per set.
Two sets per session.
Complete 2-3 sessions per day.