Rotator Cuff: Injuries, symptoms, causes and treatment
The rotator cuff is a part of the shoulder, and is a common area of injury for many individuals. Rotator cuff injuries can happen suddenly, or over time, and can be caused by many different factors.
The rotator cuff consists of 4 muscles that attach to the scapula (aka shoulder blade) and then surround the head of the humerus. These are:
- Teres Minor
These muscles surround the humerus from all directions and can be seen clearly in the picture below from a lateral view. Notice how the rotator cuff muscles hug the humeral head, this positioning allows them not only to perform their own specific arm movements but also to stabilize the humerus into the shoulder joint. Collectively, they allow the arm to remain in the joint socket during movement, thus these muscles are very important to prevent dislocations!
The four rotator cuff muscles originate from different areas of the shoulder blade, but they all have a common insertion point on the humerus. Due to this, the orientation of each of the muscles is slightly different and therefore allows them to perform different actions.
Origin: Subscapular fossa of the scapula
Insertion: greater tubercle of the humerus
Action: Internal rotation of the arm
Origin: Supraspinous fossa of the scapula
Insertion: Greater tubercle of the humerus
Action: Abduction of the arm
Origin: infraspinous fossa of the scapula
Insertion: Greater tubercle of the humerus
Action: External rotation of the arm
Origin: Lateral border of the scapula
Insertion: Greater tubercle of the humerus
Action: External rotation and adduction of the arm
The four rotator cuff muscles sit outside of the joint capsule, which is a thick connective tissue that surrounds the joint itself. Also located in this area is a bursa. A bursa is a fluid-filled sac that usually sits between 2 structures and acts to decrease friction. The bursa in the shoulder is located below the Acromion Process and on top of the supraspinatus muscle. It’s called the subacromial bursa, and this bursa is prone to inflammation and impingement in shoulder injuries and dysfunction.
What can happen to the rotator cuff?
This is where structures that run through the subacromial space get pinched. The subacromial space is located near the front and top of the shoulder, the most common structures to get pinched here are the tendons of the supraspinatus and long head biceps, as well as the subacromial bursa.
Posterior impingement is similar to subacromial impingement where structures are getting pinched in a small space. However, impingement occurs on the infraspinatus tendon.
Wear and tear
Repetitive strain, sports, age, overuse, instability can all contribute to insidious degeneration of the rotator cuff tendons. This eventually leads to weakness and more instability.
Strains, partial thickness tears, full-thickness tears
Both acute and chronic mechanisms can lead to rotator cuff strains and tears. This type of injury occurs when the muscle becomes overly stretched under load, or from repetitive strain and degeneration. Strains mainly affect only a portion of the muscle, partial thickness tears are ruptures in part of the muscle, and full-thickness tears are a rupture of the full muscle tendon.
Tendinitis is when a tendon gets inflamed or irritated, this can happen to any one of the tendons of the rotator cuff
Bursitis is the inflammation of a bursa, most commonly in the rotator cuff area the subacromial bursa is affected
Signs and Symptoms
Apart from them, there are a few symptoms that can suggest rotator cuff injuries.
Rotator Cuff Pathology Diagnosis
Depending on what might be going on in your rotator cuff, your physiotherapist may use a variety of techniques in order to figure out what the issue or injury may be.
Regardless of what your symptoms may be or whether your injury is acute or chronic, your physiotherapist will always begin your assessment with a subjective history.
This is where you and your physiotherapist will have a conversation about what is bothering you, what your pain or discomfort is like, how long you have been experiencing it, whether you remember how you hurt it, your history of shoulder and arm injuries, your medical history, previous treatments or imaging you have received, and lots of other questions alike. This may feel like a casual interview because your physiotherapist will ask you many questions in order to collect the most details that they can.
A thorough subjective history is very important for your physiotherapist to start forming ideas, suspicions, and gain an idea of in what direction they will continue with your assessment. Your physio may ask to see any imaging such as ultrasounds, CTs, MRIs, or X-Rays you may have brought with you.
Part of the physical assessment is simply visually observing what your
shoulder looks like, deformities, swelling, redness, bruising, your posture, your
willingness to move, and how you may be holding your arm
Your physiotherapist may use their hands to touch different parts of your
shoulder. They may feel around for muscles, tendons, ligaments, and they can
use what they feel through their touch to guide their hypothesis
Active Range Of Motion
During this part, your physio will ask you to move your shoulder in a variety of directions and they will observe how far it moves, the quality of movement, and your posture while moving it. Assessing your ability to actively move your arm will give your physio information mostly about the strength of your rotator cuff muscles. Strained, weak, or torn muscles may result in your inability to lift your arm past a certain point, or at all. Your physio will ask you to move your arm in the rolling directions, and then compare them to your uninjured side:
- Internal rotation
- External rotation
Passive Range of Motion
Your passive range of motion will be investigated by the physiotherapist followed by the assessment of your active ability to move the shoulder.
After assessing your active ability to move your shoulder, your physio will likely proceed to investigate your passive range of motion. This means that the physiotherapist will tell you to fully relax your arm and allow them to move it in a few different directions. This allows the physio to assess how your shoulder can move without the activation of any of your rotator cuff muscles. They will take note of how far they can move your arm, and what it feels like when they reach the end of your range. This gives physios more information about possible muscle strains and tears, and bursa, ligament, and capsule involvement.
Manual Muscle Testing
The next most common piece to the assessment is to isolate and test the strength of each of your rotator cuff muscles. Your physio will tell you to put your arm in a few different positions, and then they will press on it and tell you to resist their force. Through this, your physiotherapist will be able to gauge the level of strength in each of the 4 cuff muscles. This will give your physiotherapist information about the injury to the muscle belly of the tendon of the muscles, which may lead them to suspect strains, partial tears, or full tears of one or more of the rotator cuff muscles.
After all of the above, your physio will likely have a pretty good idea of what may be going on in your shoulder and rotator cuff. They may choose to continue with the assessment to confirm their suspicions, and that is where “special tests” come into play.
Special tests are physical tests that are specifically designed to stress or stretch a certain structure, such as a muscle, tendon, or nerve. Some tests can detect more than one injury, but many of them are very specific to one. Thus, after performing a test, your physio will be able to tell whether the test was positive or negative. Positive tests most likely confirm that there is an injury to the structure that was tested, and negative tests most likely allow the physio to rule out that injury.
Below are just a few common tests used to diagnose rotator cuff pathologies:
After collective as much info as possible, your physiotherapist will have a general idea of where to begin the physical assessment.
Detects rotator cuff tears
Empty Can test
Detects supraspinatus pathologies and impingement
Internal Rotation Lag Sign
Detects subscapularis tears
Detects supraspinatus impingement
If your doctor has ordered imaging for your shoulder, your physiotherapist will likely want to see the results of the imaging. X-rays or MRIs allow both your physio and your physician to rule out fractures, as well as diagnose visible tears.
The Importance of Early Intervention
Intervening in the early stages of any rotator cuff pathology is extremely important, for a few reasons.
Firstly your physiotherapist understands and empathizes with you that living with shoulder pain and discomfort is very difficult. It can make the smallest daily tasks feel like a chore. The goal of rotator cuff physiotherapy is to reduce your pain and discomfort, strengthen your shoulder, and regain your range of motion. Achieving this as early as possible is not only important for regaining your shoulder function, but also to prevent progression of your shoulder stiffness and reduced range.
One of the most common progressions of rotator cuff pathologies is frozen shoulder. Frozen shoulder occurs when individuals with shoulder pain and discomfort avoid moving their shoulder, thus keeping it stiff and in place. The reduced movement causes the capsule surrounding the shoulder to tighten and stiffen, further restricting the range of motion. Beginning rotator cuff physiotherapy before the frozen shoulder starts to set in will ensure efficient recovery of your rotator cuff.
Rotator Cuff Physiotherapy Treatment:
How your physiotherapist will approach your unique injury will vary greatly between therapists and between patients. However, the goal is always the same: to return you to pain-free and full movement as fast as possible. Your therapist may choose to use a combination of:
- Manual therapy
- Massage/soft tissue release
The timeline of your physical therapy will begin with pain management and increasing range of motion. This acute phase after your injury usually looks like:
- Interferential current or TENS for pain management
- Heat or ice
- Manual therapy shoulder mobilizations
- Passive range of motion exercises
If you have had surgery for your injury, the rehabilitation process is similar but you may have to wait out an immobilization phase as instructed by your surgeon. After the immobilization phase, the proceeding is similar. Your physiotherapist will begin by performing a passive range of movement on you where you are relaxed, this will help to gradually increase the range of motion at your shoulder
After regaining a fair amount of your range back, and having a reduction in your inflammation/swelling/bruising, your physiotherapist may start you on active-assisted range of motion (AAROM) exercises. These are meant to start recruiting your rotator cuff muscles to help move your shoulder, but with some help. Below are some diagrams of AAROM exercises.
The progression after incorporating AAROM exercises into the treatment plan would be to proceed to closed chain isometric contraction exercises to begin to rebuild the strength of the rotator cuff muscles. After rotator cuff surgery, this may be implemented around the 6 week mark, but on less serious injuries not requiring surgery, isometric exercise may be implemented even earlier as the physiotherapist sees the client progress.
To reiterate, early intervention is extremely important with shoulder rehabilitation, thus, the sooner the client can safely begin retraining the rotator cuff muscle strength, the better they will progress through treatment. Below are diagrams of classic isometric exercises for the shoulder that can be done against a wall. These should be performed for 3 sets of 15-30s holds, almost every day.
Once you have regained some strength and more range of motion, you will be able to progress from isometric exercises to concentric exercises. This progression is usually made after the patient has been performing regular isometric exercise for 2-4 weeks with improvement, and the physiotherapists deems them ready to progress. Progression to concentric exercise too quickly without proper foundational shoulder strength and stability may result in recurrence of poor shoulder mechanics, overload of the muscles and tendons, and potential re-injury.
Below are some diagrams of concentric rotator cuff exercises. These should be performed for 3 sets of 10-12, at a controlled tempo, almost every day.
As you progress through these different exercises, your physiotherapist will re-check and make sure that you have regained full range of motion. You will continue to perform stretches and shoulder mobilization exercises every day on top of your strengthening exercises in order to ensure pain-free and full movement.
Frequently Asked Questions
Q. How to Prevent Rotator Cuff Injuries
A. One of the best things you can do to prevent rotator cuff injuries is to build and maintain strength and range of motion. This can be accomplished with regular exercise and stretching! The exercises to do this do not need to be complex or difficult, but they do need to be specific! Below are diagrams of shoulder strengthening exercises and stretches to maintain and increase range of motion.
Author - Denish Tamakuwala
Denish Tamakuwala is a Physiotherapist and Clinic Director at Innova Physio. He is a Registered Physiotherapist with a Bachelor's degree in Physical Therapy from the Rajiv Gandhi University of Health Science. He obtained a Diploma degree (honours) in Fitness & Health Promotion from Humber College. He possesses extensive knowledge and practical experience in therapy and rehabilitation treatment. Apart from assisting his patients through physiotherapy, he loves to compose informational articles to educate the mass.