Ask the Physical Therapist: Rotator Cuff Injuries

Michael S. comes to the physical therapist after seeing his orthopaedic physician. He has a script for physical therapy and has a diagnosis of Rotator Cuff Impingement.

Michael S: What is my Rotator Cuff and what does it do?

Physical Therapist (P.T.): The rotator cuff is a group of 4 small muscles in the shoulder. They are often referred to as the "SITS" muscles: Supraspinatus, Infraspinatus, Teres Minor, and Subscapularis Muscles (see Figures 1-4). The rotator cuff stabilizes the shoulder joint (refer to figure 1 and 4 and note where the humerus (arm bone), meets the scapula (shoulder blade.) In addition, the muscles assist in moving the arm in abduction (moving the arm sideways away from the body, and in external rotation (with elbow bent, at your side, forearm straight forward, and moving the hand outwards.

Michael S: How could I have injured my rotator cuff?

Physical Therapist (P.T.): First of all let’s take a look at the shoulder joint. It is a ball and socket joint, much like the hip. However, it moves much more freely than the hip. Because it has greater mobility than the hip, it is not as stable as the hip. The previous predisposes the shoulder for injury.

Injury to the rotator cuff can occur from the following:

1. Trauma: Most likely occurs from either a forceful and sudden contraction of the rotator cuff, or from falling on an outstretched arm. Throwing has been shown to be one of the movements that most consistently produces rotator cuff tears.
2. Overuse or Impingement: Occurs when the rotator cuff and one of the shoulder bursa are pinched underneath the front aspect of the scapula. This area is referred to as the coracoacromial arch (Fig.5.) There are different stages of impingement. They are based on the age of the patient and the severity of symptoms. Stage I usually occurs in individuals under age 25, and swelling is the most common symptom. Stage II usually occurs in patients 25 - 40 years old. The condition is now chronic, and thickening of the bursa, and fibrosis of the rotator cuff occur. In Stage III, there is degeneration, and often tears in the rotator cuff.
3. Aging and Attrition (Wear and Tear): Aging causes progressive degeneration of the entire rotator cuff, decreasing its ability to adapt to stresses, and to heal after injuries.

Michael S: How does one determine that my rotator cuff is injured?

Physical Therapist (P.T.): First of all, most patients complain of pain in their shoulder area. An orthopaedic physician and physical therapist will notice abnormal shoulder movements and weakness. An MRI is an effective means to evaluate the shoulder.

Michael S: How do I treat my condition?

Physical Therapist (P.T.): Depending on what stage your impingement is, will determine the treatment. For all stages, some sort of rest is required. This means the patient needs to avoid any movements that aggravate their symptoms. Ice, heat, ultrasound, electrical stimulation, and specific exercises may be recommended by a physical therapist. A physician may prescribe anti-inflammatories, and/ or local steroid injections. Surgery is indicated when all forms of conservative treatment fail (e.g. physical therapy.)

References:

Donnatelli,Robert and Wooden, Michael. Orthopaedic Physical Therapy. Churchill Livingstone, Philadelphia, PA, 2001.

Hoppenfeld, Stanley. Physical Examination of the Spine and the Extremities. Appleton Century Crofts, East Norfolk, VA, 1976.

Netter, Frank. Atlas of Human Anatomy. Ciba-Geigy Corporation, Summit, NJ, 1989.

Sieg, Kay and Adams, Sandra. Illustrated Essentials of Musculoskeletal Anatomy. Megabooks, Gainesville, FL 1985.