Rotator cuff injuries

Findings

a)      Though a fall onto the hand or elbow can cause acute impingement, an acute episode of pain during activity that is followed by weakness suggests a rupture.

b)      Gradual onset of pain reffered to the deltoid area, although there may be referral to the elbow or the forearm, and the lesion may be misdiagnosed as a tennis elbow.

c)      Pain, particularly with the elbow elevated above the shoulder, such as when drying hair or reaching forwards or backwards.

d)      Reaching behind the back, towards the dorsal spine.

e)      Acute shoulder pain, getting worse over 4-5 days, suggests the possibility of calcific tendonitis.

f)       The athlete indicates the top of arm and deltoid as being where the pain is localized.

g)      There is a painful arc on active movements, and especially on eccentric movement, although passive movement is pain-free.

h)     Pain on resisted internal rotation suggests the subscapularis is involved, whereas pain with resisted external rotation suggests the infraspinatus and, with abduction, the supraspinatus. These may be either weak and/or painful. However, note that the eccentric stabilizing effects of the other rotator cuff muscles(which are technically not involved in the test) may produce pain so that the infraspinatus, acting to stabilize the shoulder, may produce some discomfort on resisted internal rotation.

i)        Localized tenderness. Subscapularis anteriorly, supraspinatus over the greater tuberosity; the palpation being made easier with the arm in internal rotation. Infraspinatus – lying prone and leaning on the elbows, as in reading a book, when the posterior humeral head is more tender to palpation than the unaffected shoulder.

j)        The impingement signs are invariably positive.

Cause

Damage to subscapularis, supraspinatus or infraspinatus. Clinically, teres major and minor, which are part of the rotator cuff complex, have not had the signs and symptoms of their injuries well defined. The rotator cuff stabilizes the shoulder and decelerates the shoulder movements to prevent the arm following the ball in a throw. The injury may be a tear, often during eccentric movements, or tendon degeneration from compression of the rotator cuff between the humeral head and acromion causing localized avascularization. The lesion is thus more common in the older person. The other actions of the rotator cuff are to depress and stabilize the humeral head away from the acromion. Rotator cuff damage, therefore, will allow elevation of the humerus, which impinges on the acromion, which inflames the rotator cuff, setting up the vicious cycle.

Treatment

a)      Treatment is designed to break the vicious cycle, where an injection of the subacromial space calms the inflammation, decreases the pain and allows the rotator cuff to work, even if in a weakened state. A functioning rotator cuff can prevent humeral elevation and the subsequent impingement, which, once again, would irritiate and inflame the rotator cuff.

b)      Electrotherapeutic modalities to settle inflammation, such as ultrasound, laser and interferential.

c)      Massage techniques to control and organize scar tissue.

d)      Local injection of cortisone, under ultrasound guidance, into the area of calcific tendonitis. This can be performed successfully without ultrasound guidance by injecting the area that is acutely tender to palpation.

e)      Proprioceptive strapping, to encourage scapular rotation and prevent shoulder elevation during circumduction, i.e. improving scapulohumeral dissociation. The strapping pulls on the skin and this sensation informs the patient of any aberrant movement, such as shrugging.

f)       Isometrics for the rotator cuff.

g)      Isometrics or isokinetics for the rotator cuff.

h)     Throwing rehabilitation ladder

i)        Operation to repair any rotator cuff tear. This may be accompanied by debridement of adhesions and debridement of the inferior surface of the acromion, the coracoacromial ligament of the acromioclavicular joint to create more space for the rotator cuff, especially if a mal-shaped acromion is present.

Sports

a)      Golf – an arm take away with no shoulder rotation injuries the left shoulder, particularly the infraspinatus and supraspinatus. The right arm taken flat, but with a flying elbow, compresses the infraspinatus at the posterior aspect of the shoulder

b)      Tennis – hitting too soon on the serve before the scapulothoracic “set” position is obtained. This problem is often accompanied by inflammation of the subacromial space

c)      All throwing events – if too much power is used, too soon, then the muscles of the rotator cuff may be torn or strained. Many people train their legs to run or kick, but few train their shoulders with graduated exercises, in the off season, to build sufficient strength in the decelerators and stabilizers of the shoulder – the rotator cuff. In soccer this is typical goalkeeper’s injury; once throwing long balls, if having irregular technique and using too much power too soon, an injury may occur

Failure to progress through rehabilitation, or recurrent inflammation of the subacromial space in spite of rest, requires arthroscopic surgery to the space of the rotator cuff, depending upon the findings. Proprioceptive strapping that informs the athlete when they are shrugging is very helpful for rehabilitation.

"Concise guide to sports injuries, 2^nd edition",Churchill Livingstone, Malcolm T.F. Read,  foreword by Bryan English