The shoulder has the greatest range of motion of any joint in the body. It allows the arm to move away from the body’s midline, towards the body’s midline, forward, and backwards. It can also move the arm in a full circle, as well as rotate it towards or away from the midline. The articulation of the shoulder is so unique, in fact, that the hip is the only other joint in the human body that is also classified as a spheroidal joint, which is commonly known as a “ball and socket” joint.
While the rotator cuff is highly complex, it is also relatively weak. Similar to other structures of the body, it can be damaged by traumatic injuries, and is also extremely susceptible to wear and tear. Athletes who excessively use their shoulder—such as baseball and tennis players—are at the greatest risk of a rotator cuff injury. But, as any of these athletes would tell you, repetitive use of the shoulder is an unavoidable part of the game.
So what can athletes do to prevent rotator cuff injuries? Like all other sports-related injuries, prevention entails education, physical conditioning, and practice.
The Anatomy of the Rotator Cuff
The shoulder consists of the humerus (upper arm bone), the scapula (the shoulder blade), and the clavicle (the collar bone). The joint is formed from the spherical head of the humerus, which acts as a “ball”, and the glenoid cavity, which forms the “socket”.
The rotator cuff is a group of four muscles that come together at the head of the humerus. These muscles not only help stabilize the shoulder but they also keep the arm in its socket. In addition, each muscle also serves a specific, unique function related to movement.
- Infraspinatus: Rotates the arm laterally (away from the midline) at the shoulder joint.
- Supraspinatus: Helps the deltoid muscle abduct (raise) the arm at the shoulder joint.
- Subscapularis: Rotates the arm medially (towards the midline) at the shoulder joint.
- Teres minor: Rotates the arm laterally and weakly adducts (lowers) the arm at the shoulder joint.
Common Rotator Cuff Injuries
Rotator Cuff Tears
Rotator cuff tears are a common orthopaedic condition. When a rotator cuff muscle tears, it partially or completely detaches from the head of the humerus, causing shoulder pain and instability. Tears are most likely to occur in the supraspinatus muscle and tendon. Because these injuries result from a variety of causes and range in severity, they can be categorized in a number of ways.
An acute tear results from a sudden injury, such as blunt force to the shoulder or a fall on an outstretched arm; however, a rotator cuff with pre-existing degeneration can also be torn by simple, everyday activities such as gardening or putting away the dishes.
A chronic tear, also called a degenerative tear, results from repetitive use of the shoulder cuff muscles over time. Athletes are at especially high risk for this type of overuse injury. Degradation, like the kind that is associated with chronic tears, occurs naturally with age as well. As such, people over 40 are at increased risk for this type of injury. Some common causes include:
- Reduced blood flow – Blood oxygen levels naturally decrease as people become older. Since oxygen is essential to all parts of the body, reduced oxygen both increases the risk of a rotator cuff tear and makes healing more difficult.
- Bone spurs – Bone spurs are little growths that occur on the bone as a result of too much calcium. These spurs rub on the rotator cuff, causing pain and degradation. Bone spurs can also lead to shoulder impingement, a condition where the arms cannot go above shoulder level without severe pain.
Signs of a rotator cuff tear include:
- A sudden tearing sensation
- Immediate weakness in your arm
- A cracking sensation when moving your arm
- Pain during certain movements
Symptoms of a rotator cuff tear include:
- Shoulder pain that gradually worsens over time and persists throughout the night
- Shoulder weakness that gradually worsens over time
- Difficulty performing overhead movements
A rotator cuff tear is described as either a partial or full thickness tear based on its severity.
Partial Rotator Cuff Tears
This form of injury is also referred to as partial thickness rotator cuff tear because the tear only extends part way through the tendon and often only involves one of the four rotator cuff muscles. It is more common than a complete tear and more common in younger individuals. And while seemingly less severe than a complete tear, there is no correlation between the size of a tear and the amount of pain it causes. In fact, in some instances, a partial tear can be more painful than a full-thickness tear.
Full-Thickness Rotator Cuff Tears
A full-thickness rotator cuff tear occurs when one or more muscles and tendons completely separate from the humerus. Large tears can cause significant shoulder weakness. For example, an individual may have to support their injured arm with their other arm when lifting or moving an object. Large tears can also cause a loss of shoulder mobility; however, this is not always the case.
Tendinitis and Bursitis
Tendinitis causes tendons to become swollen and painful, often due to over use and inflammation. Similarly, bursitis occurs when bursae—small fluid-filled sacs between bones, tendons, and muscles—become inflamed. These conditions can occur alone or simultaneously and are more likely to occur in people age 40 or older.
Tendonitis, in particular, is often a precursor to a tear. When tendons become inflamed, they scrape against the bones in the shoulder joint. This frays the tendons and consequently makes them more susceptible to tears.
Treatments for Rotator Cuff Injuries
RICE (Rest, Ice, Compression, and Elevation) should be applied as soon as possible after an injury occurs. Rest provides time for the injury to heal while ice and compression reduce the amount the amount of swelling. In the case of rotator cuffs, however, individuals may forgo elevating the arm if it is difficult or uncomfortable.
The majority of rotator cuff injuries can be treated with a combination of rest and physical therapy. Physical therapy helps restore shoulder flexibility and strength as well as reduce pain.
If a patient does not achieve relief with conservative treatments, a physician may recommend regenerative medicine, which is centered on the body’s own ability to itself. Regenerative medicine aids the body in creating new, functional tissue to replace old and damaged tissue. Forms of regenerative medicine that have been shown to be effective for rotator cuff injuries include:
- PRP (platelet rich plasma) therapy
- Stem cell therapy
Surgery is also an effective option; however, it is often a method of last resort. Candidates for surgery have symptoms that limit normal, everyday function and do not improve with conservative treatments. A talk with an orthopaedic specialist can determine if surgery is the right option for you.
How to Prevent Rotator Cuff Injuries
In general, the best way to prevent rotator cuff injuries is to strengthen the rotator cuff. Keep in mind that even simple, daily exercise can go far in strengthening muscles and tendons. The “doorway stretch” is one such exercise that can be performed at home. To perform the exercise:
- Stand in an open doorway and spread your arms out to your side.
- Grip the sides of the doorway at shoulder height.
- While maintaining your grip and keeping a straight back, lean forward until you feel a light stretch in the front of your shoulder.
- Slowly return to the original position. Repeat 10 times.
As always, speak with a physical therapist before starting an exercise program.
In addition to exercise, athletes should focus on proper form. Improper form puts increased stress on the rotator cuff and increases an athlete’s risk of an injury. Frequent breaks can help an athlete avoid fatigue that consequently leads to improper form.
When to See an Orthopaedic Specialist
While the majority of rotator cuff injuries heal with rest, it’s a slow process. Moreover, because many everyday activities require the use of the shoulder, patients can potentially worsen their condition by not seeking early treatment. For all of these reasons, it’s important to talk with an orthopaedic specialist at the first sign of an injury. An orthopaedist will ensure that you’re on the best path to recovery.
Dr. Robert Rolf is a board certified orthopaedic surgeon at Beacon Orthopaedics and Sports Medicine who provides extensive expertise in rotator cuff tears as well as other conditions related to the shoulder or elbow. Patients can meet with Dr. Rolf at Beacon’s Batesville, Lawrenceburg, or Northern Kentucky location as well as Beacon West in Harrison, Ohio. Dr. Rolf also offers informational Shoulder Talks at Beacon West. For a list of upcoming talks, visit Dr. Rolf’s page.