Shoulder pain. Yes correct, the Rotator Cuff muscles are the four most important muscles required for the shoulder joint to function. No wonder then, that a Rotator Cuff muscle strain will also be one of the main reasons for shoulder pain. Not only do the Rotator Cuff muscles provide movement of the shoulder and arm but they also stabilize the whole shoulder joint. Pain when sleeping or lying on the shoulder and any movement that happens over-head (like combing your hair) are the first signs of an injury of one of these Rotator Cuff muscles.
What is the Rotator Cuff made up of?
The rotator cuff muscles are four muscle that keep the upper arm bone in position with the shoulder blade. A shallow ball-and-socket formation is what the shoulder is made up of. Because it is shallow it is quite unstable. The stability is enhanced from the labrum (a cartilage like structure inside the joint) and from the shoulder capsule (ligaments around the joint). Following are the four Rotator Cuff muscles are:
Infraspinatus (biggest muscle on the back of the shoulder blade)
Supraspinatus (above the small bony bridge of the shoulder blade)
Subscapularis (on the inside of the shoulder blade)
Teres minor (smaller muscle on the outside of the Infraspinatus muscle)
All four muscles originate from the shoulder blade and attach to the upper arm bone. They go through a small opening of the roof bone of the shoulder blade with tendinous attachments.
The Rotator Cuff muscles have two different functions. To stabilize the joint is their primary function. Seeing that the joint has little stability from the bony structure, the main stability comes from these four muscles. The second function is specific to the different muscles.
Infraspinatus: the open the door movement; it rotates the shoulder to the outside
Supraspinatus: it lifts your arm up to the side, as when you are nudging a friend
Subscapularis: the downward action when throwing a ball; it rotates the shoulder to the inside
Teres minor: it assists the Infraspinatus muscle and also holds the upper arm bone down when the arm moves to the side
The Rotator Cuff muscles are used a lot in over-head sports such as tennis, cricket and swimming. They also play a big role in every day activities such as brushing your hair and closing your bra behind your back. Simple things as reaching out of your car to get a parking ticket or reaching up to a cupboard to get a coffee mug, may become painful actions when you have a Rotator Cuff muscle tear.
Substantial injuries, like a fall, progressive degeneration or continuous wear and tear may lead to a Rotator Cuff muscle strains.
As mentioned above these come from accidents or falls. Falling onto an outstretched arm or breaking your collar bone can both leave you with a torn rotator cuff muscle. Quadbikers, mountain bikers or elderly people are the most common individuals that will experience this sort of injury.
An audible snap can be heard at the time of injury, but this is quite uncommon because there is mostly another injury that is noticed before the muscle tear. The swelling of the tendons and muscles will make movement of the affected shoulder very painful.
Continuous loading of the shoulder, as with certain sport activities or occupations cause these sort of Rotator Cuff muscle strains. A constant wearing down of the tendon will eventually cause a muscle tear. The dominant shoulder is at highest risk to have a muscle tear because the most load will be going through that shoulder joint.
In elderly people, a lack of blood supply may also be a leading cause of Rotator Cuff muscle tears, as the tendons do not receive enough blood for their healing process that is needed.
Poor movement patterns
They are often the reason for an adjusted position of the joint. The movement pattern can be adjusted because of a poor technique or because of muscle fatigue that sets in when a long tennis match is played or the load becomes to heavy at those last reps that need to be done to finish the WOD. Pressure is increased from the roof like bone of the shoulder blade onto the tendons of the Rotator Cuff muscles because of the adjusted position of the shoulder. Once the pressure increases on the tendons, they start to fry. This causes inflammation which always comes hand in hand with swelling. The swelling in turn increases the pressure even more inside the joint causing you more pain and grief. Tennis players, swimmers, cross-fitters and even painters that work a lot over-head are susceptible to this type of injury.
Another reason for a poor movement pattern is an imbalance of these four muscle strengths. An imbalance emerges from repetitive same direction actions such as in a serve of a tennis players. If the used muscles are not stretched after an intense session or exercises that strengthen the reverse action are done, you will have developed very strong muscles that pull the shoulder forward and rotate it inwards. The muscles that pull the shoulder back and down will have lengthened and will be weaker.
There is a genetic predisposition to this specific condition. The one finger like bone at the front top of the shoulder blade can be a bit longer in some individuals. Therefore the bone will rub onto the Rotator cuff tendons when lifting the arm up and cause a muscle tear. Even without having that “bone spur” you can have shoulder Impingement by a sustained poor posture. If you have long working hours and a poor office chair, your shoulders will always seem to be more to the front. This poor position puts a lot of pressure on the tendons that only have a very little space they have to fit through to attach to the upper arm bone. You narrow that space with the poor positioning of the upper arm bone. Therefore you will start to have inflamed tendons with increased pressure that eventually leads to a Rotator Cuff muscle strain.
repetitive movements at sport (Volleyball or tennis serve, cricket bowling or swimming)
over-head occupation such as a painter, gardener or hairdresser
pain after sports that makes it difficult to lift the arm up
trying to brush the hair in the mornings provides pain
lifting the arm up in a different way to avoid pain eg pushing the arm down lifting it more to the front than the side to get it overhead)
Understanding the development of your shoulder pain
A muscle imbalance will have established around your shoulder joint from repeating a tennis serve a million times. The movement only goes to the front, strengthening the muscle that give you power to get a hard serve. No action is done the same amount of times to strengthen the muscles at the back of the shoulder to pull the shoulder into its natural position. Now the arm bone has a different position within the ball and socket joint, lying more to the front of the T. This will cause that there is more pressure on the muscles that still have to fit through a (now even smaller!) opening. That extra pressure will translate into the bone rubbing against the muscle every time you want to lift the shoulder. More and more fibres will tear because of this friction.
In the early stage this presents as a tendinopathy. Typically moving the arm at the beginning of a practice is painful, but as the muscle gets warm, the pain subsides.
How does a tendinopathy turn into a muscle strain?
The small amount of torn fibres, will follow the natural healing process to recover. Inflammation is going to be present in form of swelling around the Rotator Cuff muscles. The swelling narrows the space even more, which you will feel as not wanting to lift the arm at all anymore. Everyday activities like blow waving your hair and picking up the kettle to make a coffee will be painful at this stage. Your other arm is going to try to make your life easier, yet he cannot reach over all the way to get to the parking ticket at the other side of the car at the mall or shift the gears at the other side of the seat when you are driving.
SO… the rubbing of the bone against the Rotator Cuff muscles continues. This time even bigger scale. A Rotator Cuff muscle strain or tear is going to be the consequence.
pain after participating at your sport
discomfort when someone presses on the upper neck area or shoulder blade
discomfort when carrying the heavy rubbish bag out keeping it far away from the body (with a straight elbow)
pain when lying on the shoulder
throwing out a heavy jug of water with the painful side only
weaker and painful when arm wrestling, swimming, bowling etc
severe pain trying to make your bed in the morning
carrying a bag that is on your shoulder is painful
opening and closing a door is very painful
If you experience any of the symptoms listed above you may need referral to a specialist for the necessary imaging.
Full can test: take a full 2 litre bottle and try picking it up with a straight elbow
right in front of you
at a 45 degree angle in front of you
right next to you
If any of these give you pain, you most probably have a Rotator Cuff muscle strain.
Empty can test: keep the bottle in your hand, keep the elbow straight and try to through out the content of the bottle, like trhowing the water into the sink. If you feel weak, as in dropping the arm down or a pain deep inside the shoulder joint it is an indication of impingement with or without a Rotator Cuff muscle strain.
Lift-off test: try to place your hand behind your back that the palm of the hand is facing away from you. Now try to lift off the hand from the lower back. If you are struggling to do so, your Subscapularis (one of the Rotator Cuff muscles) has an injury.
Certain movements will be painful but every day things can still be performed without a problem. The pain resolves as soon as your position is adjusted. A small muscle tear is around 1 cm. The Rotator Cuff muscle will take 4-5 days to recover, if it is not aggrevated a lot during that healing process. No pins and needles should be felt down the arm, neither should the arm feel heavy or very fatigued.
2nd degree Rotator Cuff tear:
2nd degree muscle strains often come with compensatory patterns of the neck and surrounding muscles of the shoulder. One of the self-tests will be painful when enough weight is applied (according to your own strength level). Combing your hair or movements above your head are going to be painful. Stretches of the shoulder will also be painful, like the sleepers stretch or when trying to throw a ball with vigor. Pressing or rubbing over the shoulder area will have a tight feeling with a couple of very tender or painful spots.
Medium to large tears range from 3-5cm. The healing process of the affected muscle alone takes around 2 weeks. Yet it is very hard not to use the arm in certain positions and to restrain yourself on certain pain provoking movements. Throwing or blocking someone at a netball game will aggravate the Rotator Cuff muscles and increase the healing time.
3rd degree tear
Lifting the arm to the side or rotating the arm bone in the shoulder joint (open and close door movement) are going to be very painful. You avoid any movements that are above 90 degrees because of pain. Pins and needles or a dead, numb feeling can be felt down the arm into the finger tips. In severe cases you can loose feeling of the upper part of the outside shoulder. Most shoulder movements are going to be painful. Massive tears are above 5 cm up to full tears. The Rotator Cuff muscle strain alone will take 4 weeks to recover but depending on associated injuries the whole process will take longer.
The degree of the Rotator Cuff muscle strains are defined differently. Sometimes it is the size of the tear in one of the four muscles that will grade the injury. Other times it is the amount of muscles that tore that determine the severity.
In the event of a traumatic injury, X-rays can be helpful to rule out a fracture of the arm or shoulder blade. They only show bony elements, therefore they will not be able to assist with the diagnosis of a torn muscle. None of the Rotator Cuff muscles will display on an X-ray. The clinical tests are very accurate and will be able to give a diagnosis without having to get X-rays done.
Once the clinical testing is done, an ultrasound can be helpful to measure the extent of a muscle tear. It also confirms the clinical findings.
An MRI (Magnetic Resonance Imaging) uses very strong magnet and radio frequencies to create and image of the body. It is mostly referred for if another associated injury is suspected, especially for labral tears. It is very expensive and therefore only referred for when it is really deemed helpful in further management. For labral tears a contrast solution might be injected into the shoulder joint to better visualize the injury.
How we test
strength of the 4 Rotator Cuff muscles with specific individual tests you are going to be asked to press against the therapist who will place your arm in a specific position and then push against you
your range of motion of the shoulder, weather you can move it into all the directions into the full movement that you need Often there will be a restriction that you will have picked up already that makes it difficult to move the arm further in a certain position. You also do not notice that you start compensation (using other muscles) to do a certain movement. Other times the whole shoulder will start moving in stead of the arm alone. These tests will show us not only if you can move the whole arm but will also show us how you move the arm and if that is the correct movement pattern.
the stability of your shoulder with special tests that will show us weather your ligaments are still strong and efficient We will be pulling and pushing the arm bone within the socket to see if there is too much movement which will mean that your ligaments are lax. It will also tel us about the position of your arm bone inside the socket. This is often associated with your specific sport, previous injuries and with your daily posture.
possible associated injuries; special test for the labrum (cartilage), elbow and AC joint as well as other structures
The initial injury will have causes tissue trauma. This means that there will be pain and inflammation. When there is pain and inflammation one has to try and get rid of it. It is very hard not to use the arm though in every day actions. Therefore muscle spasm in the surrounding area will appear. This causes you to use the arm differently, altering your movement pattern and using other muscles. The result is: muscles imbalance- which very likely was the cause of the injury in the first place.
Active rest is the best solution, which entails doing certain exercises that do not go into extreme pain as to not restart the vicious cycle. Unfortunately it is hard to not use the arm in every day actions: Through the day you just quickly need to pick up the school or laptop bag and…ouch, there is pain. You switch it to the other side but unfortunately the pain is already there again. In the evening you just want to relax in the bath, as you get out you pull yourself up and again….ouch-pain! The pain will be an irritation for the muscle and increase or start the inflammatory process again. This will again be the reason to stop moving all together, which weakens the muscles. To get out of the vicious cycle is the trick.
What makes it worse?
sleeping on the shoulder
brushing your hair
carrying your bag on the shoulder
lifting something heavy above your head
continue throwing/serving/swimming etc
Physiotherapy treatment for a Rotator Cuff injury
A thorough evaluation will be the key to a good treatment.
Firstly we will address the pain because no one can function well whilst being in pain. Secondly we will correct your muscle imbalances with exercises as well as get the correct movement patterns back. This can entail positioning of your shoulder blade or posture related issues that will be worked on. The middle and upper back play a very important role in this aspect. Neural mobility is of utmost importance as well. This is worked on with specific neural mobilization techniques and dynamic nerve gliding or sliding stretches. The actual cause of the injury will be treated to also prevent re-injury.
Massage, Soft tissue mobilization and muscle Stretches to lengthen the shortened muscles.
Myofascial release of the Rotator Cuff muscles to guide the scar tissue formation.
Dynamic, static and ballistic stretches together with eccentric loading exercises to condition the muscle fibers
We will gradually progress your rehabilitation exercises to regain full function of the shoulder again
Phases of Rehab
Phase 1: Decrease pain and rest
The shoulder needs to be rested and severe pain and inflammation needs to be controlled before any rehabilitation can start. There are different means and ways. Some prefer medication and a sling others manage it with hot packs/ ice and using the arm below 90 degrees only.
Phase 2: Activate correct muscles for shoulder stability and improve dissociation
Pain decreases the neural activity to the muscles that normally provide the shoulder joint with stability. These muscles have to be activated again that no imbalance will start to happen when we start to move and use the shoulder. Seeing that the stability muscles are not working the shoulder will often have a compensatory pattern already. The movements of this pattern will have to be broken down and your normal movement, that your arm moves without the shoulder blade being part of the movement, has to be re-established.
Phase 3: Strengthen and provide endurance
At this stage most of the pain of the shoulder should have resolved. A lot of patients stop the rehab process at this point because there is no pain anymore. This applies specifically to the younger sports people and the older “kan nie dood nie’s”. The whole shoulder complex has to be strengthened again as well as the endurance of the stability muscles has to improve. Then you will not be susceptible for future injuries. If it is not addressed re-injuries or niggles will stay and the return to sport is with quite a big aspect of fear of full-out engagement and movement of the shoulder.
Phase 4: Return to sport
Sport specific strengthening and movement patterns will have to be retrained. If there is no pain and you are confident to use your shoulder this phase will be very short and effective. Still scared and not confident in the strength of your shoulder? Unfortunately this can then cause you to struggle up to a life-time with this. The movements will easily come back to you, just as one does not loose the skill of driving a bicycle. Compensatory patterns will only be present if the previous phases were not concluded and worked trough step by step. A Rotator Cuff strain or tear will most probably reoccur without a confident and successful return to your sport.
In severe or chronic Rotator Cuff tears surgery may be an option. It will have to be discussed with your Physiotherapist whether the risk, expenses and long recovery time out-way the conservative treatment. Before any surgery is done an MRI should be taken to confirm the diagnosis.