What is the rotator cuff? The rotator cuff is the name applied to a group of four muscles in your shoulder and arm. These are responsible for holding the upper arm in place with the shoulder forming the shoulder joint. Rotator cuff injury may be an injury to either or all of the muscles and tendons of the rotator cuff.

It goes without saying that the rotator cuff functions in all the movements of the arm and shoulder at the joint; extension, flexion, rotation, etc.

As one moves away from the arm out away from the body (extension), the muscles involved in keeping the rotator cuff of the shoulder joint prevent the dislocation of the bones involved.

The rotator cuff is a common injury in athletes, especially as age advances.

The anatomy of the rotator cuff?

The shoulder joint is a ball and socket joint. The head of the bone of the upper arm, the humerus, forms the ball of the joint. It fits into the socket, the glenoid socket, made by a hollow in the shoulder blade bone, the scapula.

There are four muscles involved in the shoulder joint. While each one performs its function and enables you to make different movements, they all work together to keep the upper arm in its place, that is within the socket.

All the four muscles originate from the shoulder bone, the scapula and get attached to different sites on the upper arm bone the humerus.

The four muscles involved in making the rotators cuff make the acronym SITS.  Their point of attachment is on the upper part of the humerus in the sequence same as the acronym SITS.

Their attachment details are;

• Supraspinatus

When you move your upper arm away from your body, the move is called abduction. The supraspinatus is the muscle responsible for the first 15-degree motion. The muscles is assisted by two other muscles to complete the motion; the deltoid and the trapezius.

• Infraspinatus

The infraspinatus is a thick muscle responsible primarily for the lateral rotation of your arm away from the centerline of your body. This muscle originates from the back of the shoulder blade, deep under the skin and close to the bone.  

• Teres minor

Originating from just below the infraspinatus, teres minor is a small-sized muscle that makes lateral rotation or extension of the arm possible.

• Subscapularis

A large triangular-shaped muscle lying below the other three muscles, subscapularis is the largest and strongest of all.  It is the most used muscle of all the four participating in all movements of the shoulder. This muscle is specifically important for medial rotation of the arm, which is the rotation of the arm toward the midline of the body.

While all the other three muscles attach to the back of the humerus bone, the subscapularis attaches to the front of the bone.

What are the common causes of rotator cuff injuries

Injury to the rotator cuff causes shoulder pain and it may appear following different situations like;

• Falling on outstretched arm which causes sudden pain in shoulder
• Repetitive motions which result in gradual symptoms

A sports injury may be sudden with obvious pain in the shoulder. More often the complaint is chronic in nature developing slowly over the years due to repetitive motion.

Rotator cuff injury may be mild or severe depending upon the injury encountered.

1. Tendinopathy

Pain in and around the tendons of the muscles involved in the shoulder joint is called tendinopathy. Tendinitis is the mildest form of rotator cuff injury, the other variation being tendinosis. Overuse and repetitive motion as in playing tennis, basketball, volleyball, badminton, etc. may cause injury to the tendons.

• Bursitis

Another common rotator cuff injury is bursitis, which is inflammation of the bursa (fluid-filled sacs present between the rotator cuff tendons and the underlying bone)

• Rotator cuff strains or tears

The overstretching of tendons can cause tears as may happen in overuse or acute injury. Strains and tears cause intense sudden pain. Strains are damage to the tendons while the tear causes complete separation of the tendon from the bone.

• Impingement

Subacromial impingement syndrome is the common cause of shoulder pain that happens when a rotator cuff muscle swells, restricting the space between the arm and shoulder bone. This causes pinching pain.

A strain, overuse, and bony spurs are some of the common causes of swelling and impingement. The top of the shoulder (the acromion) rubs against the tendon and the bursa in the rotators cuff.

What are the Symptoms of rotators cuff injury?

These vary according to the severity of the injury and include;

• pain in the shoulder area which is perceived as dull ache
• immobility or difficulty in moving the arm with limited movement
• overhead movements of the arm are difficult
• reaching behind the back may also become difficult in progressive cases
• cracking or popping sound upon movement of the shoulder
• stiffness affecting the shoulder muscles which may progress to weakness
• sleep disturbances when sleeping on the affected side due to pain in the shoulder

Treatment

Treatment follows the severity of the damage. Rotators cuff is often treated with conservative and non-invasive methods.

These include initial treatment within the first few hours to days of injury include;

1. RICER

In case of acute injury, following the RICE module helps manage the pain and cut back on swelling.

• Rest and complete abstinence of activity involving the shoulder joint
• Application of ice packs for 20 minutes a few times a day followed by heat therapy after 48-72 hours
• Compression if there is no open wound but visible swelling is present
• Keep the arm supported and elevated to reduce swelling, if any present
• If symptoms persist, then referral to a specialist is recommended

The daily activities should be modified and help should be acquired for the initial few days till symptoms get better.

• Over-the-counter analgesics

Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen should be given along with the RICE. Opioid analgesics, muscle relaxants, and corticosteroid injections should be reserved for severe cases.

• TENS

TENS helps to manage the pain associated with rotator's cuff.

For shoulder pain, the electrodes of the device should be placed around the painful area.  In the case of two electrodes, place one on the front of the shoulder and one behind it. If you have four electrodes, place the four electrodes one on the front, the back, on the side, and at the top of the shoulder blade.

The conservative treatment including RICE, medicine and TENS is effective for the severity of the shoulder injuries. It is 73 to 80% even in cases of full-thickness rotator cuff tears.

Usually, the full range of motion is achieved within four to six months. However, after the initial treatment, long-term management is required that prevents recurrence by strengthening the joint elements. This is achieved by;

• Massage

Massage therapy is useful for shoulder impingement syndrome as well as tendonitis of the rotator cuff.  It helps reduce inflammation, cut back on scar tissue build-up at the same time of aligning the torn fibers and alleviate pain. 

In low-grade strains (intact tendon) massaging the strain, muscles is very helpful.

Massage is usually taken after the conservative treatment. In the beginning, very light massage is used. As the swelling subsides and the pain is manageable, deep tissue therapy can also be employed in severe cases.

Light massage ensures minimal or no scar tissue formation. It helps in returning the shoulder to its full functioning as early as possible.

Light massage uses gentle rubbing motions on the inflamed tendon in case of tendonitis. Strokes with minimal pressure are applied perpendicular to the fibers of the tendon.

• Therapeutic ultrasound

Therapeutic ultrasound may have no obvious benefits as far as rotator cuff injury is concerned. But for some people, it may help to reduce pain.

Ultrasound therapy may also help to improve circulation and improve soft tissue healing including tendons ligaments and some parts of the muscles. It may also help to reduce inflammation if there is any sign of bursitis

• Active rehabilitative measures: Exercises for rotator cuff is a common injury

Some of the rehabilitative exercises for improving rotators cuff include;

Doorway stretch for Rotator cuff injury

• Stand in an open doorway.
• Warm up your muscles by standing in the doorway by spreading your arms out to the side.
• Staying at the shoulder level, grip the sides of the doorway with each hand.
• Keeping the grip lean forward through the doorway. Hold it to a point where you feel a stretch in your arms.  
• Keep your back straight back while leaning. Shift your weight onto your toes. Here you will feel a stretch in your shoulders.
• Do not overstretch.
• Repeat three sets of five repetitions each.

Side-lying external rotation for Rotator cuff injury

• Lie down on the healthy side, opposite to the injured side.
• Bend the elbow of the injured arm at 90 degrees. Rest the elbow on your side with the forearm resting across the abdomen.
• Hold a light-weight dumbbell in the hand of your injured side. Keep your elbow tucked against your side and slowly raise the dumbbell toward the ceiling away from the floor.
• Hold the dumbbell up for a few seconds.
• Return to the starting position and bring your arm down.
• Repeat 3 sets of 10 moves each.
• Increase the reps to more than ten when it becomes easy for you.  
• Do this exercise at least three times a day.

High-to-low rows for Rotator cuff injury

• Get a resistance band and attach it to a sturdy point. Keep the attachment at shoulder level or slightly above. Make sure the attachment of the band is secure and does not become lose while pulling.  
• Get down on one knee on the injured shoulder side.
• Keep your body and lowered knee aligned.
• Rest the other hand on your raised knee.
• Hold the band securely with your arm outstretched (the injured side).
• Pull your elbow of the painful shoulder toward your body.
• Keep your back straight at all times.
• Squeeze your shoulder blades together and down as you pull the band.
• There should be no movement or twist of your torso as you move the arm.
• Repeat three sets of 10 pulls each.

Reverse fly for Rotator cuff injury

• Stand with your feet shoulder-width apart.
• Keep your knees a bit bent.
• Keep your back straight.
• Bend forward at the waist making slight angle with the ground.
• Hold a light weight in each hand.
• Extend your arms away from your body.
• Take care not to lock your elbow.
• Squeeze your shoulder blades together as you extend your arms away.
• Take care not to raise your arms above your shoulders.
• Repeat 3 sets of ten moves each.

Lawn mower pull for Rotator cuff injury

• Stand and keep your feet shoulder-width apart.
• Take a resistance band and hold it securely under the foot opposite your injured side.
• Hold the other end of the band with the injured arm. The arm will direct diagonally across your body.
• Keep your healthy hand on your hip.
• Do not lock your knees and bend slightly at the waist. The hand holding the band comes parallel to the opposite knee.
• The movement is that of staring a lawn mower but in slow controlled motion.
• Keep the shoulder relaxed and pull at the band moving your elbows across your body to outside of your ribs.
• Squeeze the shoulder blades together as you pull the move.
• Repeat 3 sets of ten moves each.

Pendulum Exercise: for Rotator cuff injury

•       Lean ahead and place one hand on a counter or table for help. Let your other arm grasp freely at your side. As shown in fig

•       Gently swung your arm ahead and returned. Repeat the exercise shifting your arm aspect-to-side, and repeat once more in a circular motion.

•       Repeat the entire series with the other arm.

•       Days Per Week: five to 6

•       Repetitions: 2 sets of 10

Tip: Do no longer spherical your back or lock your knees.

Crossover Arm Stretch

Ease your shoulders and moderately pull one arm crossways your chest as away as viable, protecting your higher arm. As proven in fig 37b.

•       Hold the stretch for 30 seconds, after which loosen up for 30 seconds.

•       Repeat with the other arm.

•       Repetitions: 4 each side

•       Days Per Week: five to 6 Tip: Do not pull or place strain on your elbow.

Passive Internal Rotation

•       Hold a stick at the back of your return with one hand and gently grasp the alternative give up of the bar with your different hand. As shown in fig

•       Pull the stick horizontally as proven so that your shoulder is passively stretched to the factor of feeling a pull deprived of pain.

•       Now hold for 30 seconds and then ease for 30 seconds.

•       Repeat on the other facet.

•       Equipment needed: Light stick, which include a yardstick

•       Days Per Week: 5 to 6

•       Repetitions: 4 each aspect

Tip: Do now not lean over or twist to facet at the same time as pulling the stick.

Passive External Rotation

•       Grasp the band or stick with one hand and cup the alternative cease of the stay with the opposite hand. As shown in fig.

•       Keep the elbow of the shoulder you're stretching in opposition to the side of your body and push the stick horizontally as proven to the factor of feeling a pull without ache.

•       Hold for 30 seconds, after which relax for 30 seconds.

•       Repeat on the other aspect.

•       Equipment wished: Lightstick, along with a yardstick

•       Days Per Week: 5 to 6

•       Repetitions: four every facet

Tip: Keep your hips going through forward, and do now, not twist.

• Surgery for Rotator cuff injury

In case of worsening symptoms, surgery is recommended by doctors. Options for surgery include;

• Commonly arthroscopic surgery is done which is a minimalist procedure completed with the help of a camera. It requires small incisions
• Mini-open surgery requires miniature instruments and a small incision.
• For complex conditions, open surgery is undertaken.

Prevention of rotator cuff injury: how to prevent rotator cuff injury

Read on to know how to prevent rotator cuff, which is the most common of shoulder pain causes.

• Warm up before an exercise or physical activity requiring your arms to be raised above your head.
• Adopt proper form and posture for the activity or sport undertaken.
• Strengthen your muscles by doing exercises specific to the upper back.
• Avoid doing activities that require the arms above the shoulders for an extended period. For example; performing the military press.
• For players of multiple sports involving repetitive shoulder rotations, avoid back-to-back activity on the same day or regularly. Switch between different sports.