by Lisa Chang
Shoulder pain is a common injury and leading source of discomfort,
coming in only behind lower back and neck pain. Athletes participating in sports with extensive overhead movements, and workers who spend long periods of time on the keyboard or with shoulder-height work are at increased risk for shoulder and neck disorders. There are many possible causes of shoulder pain; one cause originating from the rotator cuff surrounding the shoulder. Common injuries related to the rotator cuff include rotator cuff tears to various degrees, rotator cuff tendinitis and impingement syndromes. Treatment of these issues vary with the seriousness of the condition and a variety of approaches may be combined for the most effective treatment.
The shoulder is a ball and socket joint surrounded by the deltoid, the bicep, the tricep, the trapezius, and a group of muscles known as the rotator cuff. The rotator cuff is composed of four muscles: the supraspinatous muscle, the infraspinatous muscle, the teres minor muscle, and the subscapularis muscle. These muscles work together to give the shoulder joint 360 degree of motion. In other joints, ligaments and capsules stabilize the joints; however the rotator cuff also serves this function in the shoulder. This wide range of motion however also places the tendons and muscles at risk for injury, especially with repetitive overhead motions.
Rotator Cuff Diagram
General Shoulder Diagram
Epidemiology and Etiology
Athletes in sports such as tennis, baseball, swimming, and badminton place considerable strain on their shoulder when they perform repetitive overhead movements. Younger athletes are at even greater risk for shoulder injury because their skeletons are still immature and their joints are more unstable. Specializing in one sport can also cause muscle imbalances that cause further instability.
Occupations which require shoulder-level movement and repetitive use of tools such as mill-workers and carpenters also show a higher risk for injury. Injuries due to overuse are also more frequent than traumatic injuries to the shoulder. Overused and fatigued muscles are at greater risk for injury. In addition, bad posture such as slumping and slouching places more strain on certain muscles and causes imbalance
Rotator cuff impingement syndrome is caused by a decrease in space between the shoulder joints. There may be multiple causes of a decrease in space such as anatomical and mechanical issues. Anatomical issues include misalignment and bone spurs. Mechanical issues include shoulder instability, fracture malunion, joint separation/enlargement, weakness of the scapular muscles, separation in the joint between the clavicle and the scapula due to trauma, and poor posture. Continuous strain on the shoulder also causes the shoulder to be hyperelastic and unstable, narrowing the joint capsule.
Rotator cuff tendonitis is inflammation of the tendons in the rotator cuff. This condition is caused by wear and tear of the tendon due to overuse. Incorrect biomechanics and injuries can also place additional stress on the tendon and hasten its degeneration. Impingement syndrome may also exacerbate rotator cuff tendonitis by increasing the repeated irritation and friction of underlying tendons against the bone.
If impingement syndrome and tendonitis continue to deteriorate, it may lead to degeneration and tearing. Rotator cuff tears, also known as strains, may also be caused by trauma to the shoulder and overuse.
Some symptoms of shoulder impingement may be pain and weakness associated with overhead movements. Scapulothoracic muscle weakness may also be an indicator. Collecting a thorough history of a patient and performing a physical examination is sufficient to determine instability in the shoulder.
An examination may include postural analysis, inspection for muscle atrophy, swelling, joint prominence, scapular winging and range of motion. Impingement may be detected with passive movement of the shoulder with firm pressure on the top of the shoulder.
Some tests include the apprehension and relocation tests. Imaging tests such as arthrography, MRI, ultrasound, and arthroscopy are also useful for diagnosing full thickness tears. An MRI, x-ray, or ultrasound may also be used to diagnose tendonitis and rule-out other conditions. A local anesthetic injected into the shoulder is another method of differentiating a tear from tendonitis. After injection, patients with rotator cuff tears will usually feel relief from pain but still have muscle weakness; whereas patients with rotator cuff tendonitis will feel relief from pain and normal muscle strength.
Stretching, Strengthening and Tissue Work
One treatment option is a rehabilitation program that focuses on strengthening and stretching the muscles of the rotator cuff, the deltoid, and the muscles surrounding the scapula. Simple strengthening exercises include horizontal arm raises with light weights, bicep curls and tricep extensions. Resistant rotation exercises with an elastic band such as the standing row, internal and external rotation of the shoulder, and external rotation with the arm abducted also focuses on different muscles in the rotator cuff. Stretching exercises can be done by walking the arm as high as possible against a wall and using a pole to assist in range of rotation. Some tissue work such as massage, myofascial release and active release techniques may also be done to loosen tight muscles.
Anti-inflammatory medicines such as aspirin or ibuprofen may also be taken to reduce swelling and inflammation. If oral medicines prove ineffective, cortisone injections may be given.
There is fair evidence that manual manipulative therapy of the shoulder, shoulder girdle, and or the full kinetic chain associated with the shoulder (such as the neck and back), combined with exercise therapy is useful for rotator cuff injuries.
Thoracic spine manipulation may also improve the range of motion in the shoulder joint and decrease pain in cases of rotator cuff impingement. Even though some research shows that thoracic spine manipulation has no long term effect, decreasing pain in the short term allows for more aggressive treatment that can hasten the rehabilitation process.
When more conservative options prove ineffective, rotator cuff tears may be treated with surgery. Depending on how much of the tendon is involved in the tear, surgery is required. Usually if fifty percent or more of the tendon is involved, surgery is recommended, however more studies are currently being conducted to determine if a higher percentage of tendon involvement should be required before surgery is necessary. In general, partial tears in the tendon heal favorably after surgery. Recovery outcomes for full tear surgery repair however, are usually poor. Surgery may also be recommended in more serious cases of impingement and tendonitis.
Preventive measures include decreasing the duration of the activity that places stress on the shoulder and, in the case of young athletes, raising injury awareness and playing a variety of sports. Taping and wearing a brace can support weak muscles and joints while preventing excessive movement, aiding the patients return to their normal range of activity. Improving bad postures can also alleviate some stress on the shoulder muscles.
Shoulder injury related to rotator cuff issues is a common, yet treatable condition. Simple adjustments in daily life such as improving work ergonomics and playing a variety of sports can resolve minor symptoms. Conditions such as impingement, tendonitis, and rotator cuff tears may require more time to heal, but with a combination of treatments recovery is only a step away.
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