Physical Therapist’s Guide to Rotator Cuff Tear

Take care of your shoulders, and learn more about rotator cuff tears in this article from the American Physical Therapy Association, written by by Charles Thigpen, PhD, PT, ATC and Lane Bailey, PT, DPT, CSCS. For more questions, call our studio at 619-756-7500!

 

The “rotator cuff” is a group of 4 muscles that are responsible for keeping the shoulder joint stable. Unfortunately, injuries to the rotator cuff are very common, either from injury or with repeated overuse of the shoulder. Injuries to the rotator cuff can vary as a person ages. Rotator cuff tears are more common later in life, but they also can occur in younger people. Athletes and heavy laborers are commonly affected; older adults also can injure the rotator cuff when they fall or strain the shoulder, such as when walking a dog that pulls on the leash. When left untreated, this injury can cause severe pain and a decrease in the ability to use the arm.


What is a Rotator Cuff Tear?

The “rotator cuff” is a group of 4 muscles and their tendons (which attach them to the bone). These muscles connect the upper-arm bone, or humerus, to the shoulder blade. The important job of the rotator cuff is to keep the shoulder joint stable. Sometimes, the rotator cuff becomes inflamed or irritated due to heavy lifting, repetitive arm movements, or a fall. A rotator cuff tear occurs when injuries to the muscles or tendons cause tissue damage or disruption.

Rotator cuff tears are called either “full-thickness” or partial-thickness,” depending on how severe they are. Full-thickness tears extend from the top to the bottom of a rotator cuff muscle/tendon. Partial-thickness tears affect at least some portion of a rotator cuff muscle/tendon, but do not extend all the way through.

Tears often develop as a result of either a traumatic event or long-term overuse of the shoulder. These conditions are commonly called acute or chronic:

  • An acute rotator cuff tear is one that just recently occurred, often due to a trauma such as a fall or lifting a heavy object.
  • Chronic rotator cuff tears are much slower to develop. These tears are often the result of repeated actions with the arms working above shoulder level—such as with ball-throwing sports or certain work activities.

People with chronic rotator cuff injuries often have a history of rotator cuff tendon irritation that causes shoulder pain with movement. This condition is known as shoulder impingement syndrome (SIS).

Rotator cuff tears also may occur in combination with injuries or irritation of the biceps tendon at the shoulder, or with labral tears (to the ring of cartilage at the shoulder joint).

Rotator Cuff Tear-SmallRotator Cuff Tear: See More Detail

How Does it Feel?

Rotator cuff tears can cause:

  • Pain over the top of the shoulder or down the outside of the arm
  • Shoulder weakness
  • Loss of shoulder motion

The injured arm often feels heavy, weak, and painful. In severe cases, tears may keep you from doing your daily activities or even raising your arm. People with rotator cuff tears often are unable to lift the arm to reach high shelves or reach behind their backs to tuck in a shirt or blouse, pull out a wallet, or fasten a bra.

 

How Is It Diagnosed?

Your physical therapist will review your health history, perform a thorough examination, and conduct a series of tests designed specifically to help pinpoint the cause of your shoulder pain.

Physical therapists perform specialized tests–such as the Hawkins-Kennedy impingement test, Neer’s impingement sign, and the external rotation lag sign– to diagnose an impingement or a tear. For instance, your therapist may raise your arm, move your arm out to the side, or raise your arm and ask you to resist a force, all at specific angles of elevation. These tests may cause you to feel some temporary discomfort, but don’t worry—that’s normal and part of what helps the therapist identify the exact source of your problem.

In some cases, the results of these tests might indicate the need for a referral to an orthopedist or for imaging tests, such as ultrasound imaging, magnetic resonance imaging (MRI), or computed tomography (CT).

 

How Can a Physical Therapist Help?

Once a rotator cuff injury has been diagnosed, you will work with your orthopedist and physical therapist to decide if you should have surgery or if you can try to manage your recovery without surgery. If you don’t have surgery, your therapist will work with you to restore your range of motion, muscle strength, and coordination, so that you can return to your regular activities. In some cases, your therapist may help you learn to modify your physical activity so that you put less stress on your shoulder. If you decide to have surgery, your therapist can help you both before and after the procedure.

Regardless of which treatment you have—physical therapy only, or surgery and physical therapy—early treatment can help speed up healing and avoid permanent damage.

 

If You Have an Acute Injury

If a rotator cuff tear is suspected following a trauma, seek the attention of a physical therapist or other health care provider to rule out the possibility of serious life- or limb-threatening conditions. Once serious injury is ruled out, your physical therapist will help you manage your pain and will prepare you for the best course of treatment.

 

If You Have a Chronic Injury

A physical therapist can help manage the symptoms of chronic rotator cuff tears as well as improve how your shoulder works. For large rotator cuff tears that can’t be fully repaired, physical therapists can teach special strategies to improve shoulder movement.

 

If You Have Surgery

Once a full-thickness rotator cuff tear develops, you may need surgery to restore use of the shoulder or decrease painful symptoms. Physical therapy is an important part of the recovery process. The repaired rotator cuff is vulnerable to reinjury following shoulder surgery, so it’s important to work with a physical therapist to safely regain full use of the injured arm. After the surgical repair, you will need to wear a sling to keep your shoulder and arm protected as the repair heals. Once you are able to remove the sling for exercise, the physical therapist will begin your exercise program.

Your physical therapist will design a treatment program based on both the findings of the evaluation and your personal goals. He or she will guide you through your postsurgical rehabilitation, which will progress from gentle range-of-motion and strengthening exercises and ultimately to activity- or sport-specific exercises. Your treatment program most likely will include a combination of exercises to strengthen the rotator cuff and other muscles that support the shoulder joint. Your therapist will instruct you in how to use therapeutic resistance bands. The timeline for your recovery will vary depending on the surgical procedure and your general state of health, but full return to sports, heavy lifting, and other strenuous activities might not begin until 4 months after surgery. Your shoulder will be very susceptible to reinjury, so it is extremely important to follow the postoperative instructions provided by your surgeon and physical therapist.

Physical therapy after your shoulder surgery is essential to restore your shoulder’s function. Your rehabilitation will typically be divided into 4 phases:

  • Phase I (maximal protection). This phase lasts for the first few weeks after your surgery, when your shoulder is at the greatest risk of reinjury. During this phase, your arm will be in a sling. You will likely need assistance or need strategies to accomplish everyday tasks such as bathing and dressing. Your physical therapist will teach you gentle range-of-motion and isometric strengthening exercises, will provide hands-on techniques such as gentle massage, will offer advice on reducing your pain, and may use cold compression and electrical stimulation to relieve pain.
  • Phase II (moderate protection). This next phase has the goal of restoring mobility to the shoulder. You will reduce the use of your sling, and your range-of-motion and strengthening exercises will become more challenging. Exercises will be added to strengthen the “core” muscles of your trunk and shoulder blade (scapula) and “rotator cuff” muscles that provide additional support and stability to your shoulder. You will be able to begin using your arm for daily activities, but will still avoid any heavy lifting with your arm. Your physical therapist may use special hands-on mobilization techniques during this phase to help restore your shoulder’s range of motion.
  • Phase III (return to activity). This phase has the goal of restoring your strength and joint awareness to equal that of your other shoulder. At this point, you should have full use of your arm for daily activities, but you will still be unable to participate in activities such as sports, yard work, or physically strenuous work-related tasks. Your physical therapist will advance the difficulty of your exercises by adding more weight or by having you use more challenging movement patterns. A modified weight-lifting/gym-based program may also be started during this phase.
  • Phase IV (return to occupation/sport). This phase will help you return to sports, work, and other higher-level activities. During this phase, your physical therapist will instruct you in activity-specific exercises to meet your needs. For certain athletes, this may include throwing and catching drills. For others, it may include practice in lifting heavier items onto shelves, or instruction in raking, shoveling, or housework.

 

Can this Injury or Condition be Prevented?

A physical therapist can help you decrease your risk of developing or worsening a rotator cuff tear, especially if you seek assistance at the first sign of shoulder pain or discomfort. To avoid developing or progressing to a rotator cuff tear from an existing shoulder impingement, it is imperative to avoid future exacerbations. Your physical therapist can help you strengthen your rotator cuff muscles, train you to avoid potentially harmful positions, and determine when it is appropriate for you to return to your normal activities.

General Tips:

  • Avoid repeated overhead arm positions that may cause shoulder pain. If your job requires such movements, seek out the advice of a physical therapist to learn arm positions that may be used with less risk.
  • Apply rotator cuff muscle and scapular strengthening exercises into your normal exercise routine. The strength of the rotator cuff is just as important as the strength of any other muscle group. To avoid potential detriment to the rotator cuff, general strengthening and fitness programs may improve shoulder health.
  • Practice good posture. A forward position of the head and shoulders has been shown to alter shoulder blade position and create shoulder impingement syndrome.
  • Avoid sleeping on your side with your arm stretched overhead, or lying on your shoulder. These positions can begin the process that causes rotator cuff damage.
  • Avoid carrying heavy objects at your side; this can strain the rotator cuff.
  • Avoid smoking; it can decrease the blood flow to your rotator cuff.
  • Consult a physical therapist at the first sign of symptoms.

 

Real Life Experiences

Over the past 3 weeks, Jonathan has felt pain in his shoulder while repainting his house. Now, every time he raises his arm overhead, it hurts. He notices that the pain has been steadily getting worse.

What should he do?

  • Rest. Avoid activities that require reaching overhead and rest his elbow on an armrest when sitting. This may allow the irritated muscles and tendons to heal.
  • Ice. Apply ice to the shoulder to help decrease any irritation and swelling.

Jonathan has stopped reaching overhead to paint and puts ice on his shoulder in the evening. But he still feels pain and stiffness in the area, and he can’t move his arm without pain or weakness. He contacts his physical therapist, who prescribes exercises to strengthen his rotator cuff muscles and improve postural habits, and provides education to avoid exacerbating activities.

This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case.

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and experience to treat patients who have a rotator cuff tear, but you may want to consider:

  • A physical therapist who is experienced in treating people with musculoskeletal problems. Some physical therapists have a practice with an orthopedic focus.
  • A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in orthopedics physical therapy has advanced knowledge, experience, and skills that may apply to your condition.

You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you’re looking for a physical therapist (or any other health care provider):

  • Get recommendations from family and friends or from other health care providers.
  • When you contact a physical therapy clinic for an appointment, ask about the physical therapists’ experience in helping people with labral tears.
  • During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.

Skip the Running: Alternatives to High-Impact Exercises

When it’s time to get back into the gym, running always appears to be one of the best forms of cardio. However, it get be very stressful on your joints. Adrienne Santos-Longhurst gives us some great cardio alternatives in this article posted on Livestrong.com. For additional questions, give us a call at 619-756-7500!

Give your joints a rest and test your meddle with these high-intensity/low-impact alternatives—not for beginners.
Written by Adrienne Santos-Longhurst
Medically Reviewed on June 5, 2013 by George Krucik, MD, MBA

Those who have felt the proverbial “runner’s high” will tell you that there’s no other activity that even compares to running. As intoxicating as a hard run can be, running can take a toll on your joints even if you’re in tip-top shape. Finding alternatives to running will help keep you active while giving your joints a much-needed break. According to a 1994 study conducted by the Exercise Science Unit at the University of Tennessee at Knoxville, cross-training is highly beneficial to your overall health and an effective alternative for athletes who are taking a break because of physical injury, overtraining, or fatigue.
Whether you’re in need of some recovery time from an injury or just looking for high-impact alternatives to mix things up and give your joints a break from the pavement pounding, these alternatives to running fit the bill.

Cycling
Cycling offers runners the perfect alternative to running. Just like running, cycling can be enjoyed indoors or out thanks to stationary bikes and bike trainers. Cycling allows you to maintain and improve your fitness but without the same stress on your joints and shins. Hop onto a road bike, a stationary bike at home or at the gym, or try an advanced Spin class for a high-intensity workout that just might offer runners a new kind of high.

The Elliptical Trainer
Love it or hate it, the elliptical trainer offers an excellent training alternative for runners who are injured or looking to rest their joints. Elliptical machines allow you to mimic the motion of running, and though a weight-bearing activity, it is low-impact for your joints so that you can get a workout comparable to jogging with less impact on your joints and no knee pain, according to Mayo Clinic physical medicine and rehabilitation specialist Edward R. Laskowski, MD. Focusing on motions that are as similar as possible to your usual running form and sticking to a similar training schedule will help you make the most of this activity and maintain your fitness level.

Water Running
Runners who need a change but are reluctant to try anything other than running are likely to find water running, which is also referred to as pool running, to be a good compromise. Just as the name suggests, water running is performed by running in water, often the deep end of a swimming pool. This great alternative to running lets you enjoy the benefits that come from the motion of running without any impact on your joints. To get the most out of pool running, focus on your form, staying consistent with your regular running motion. Following a training schedule similar to your running one will also help you get the most from this unique alternative while still allowing your joints a break.

Walking
Contrary to popular belief that walking isn’t nearly as good a workout as running; walking is in fact an effective alternative for runners who want the same health benefits but without the impact on their joints. A study published by the American Heart Association in their journal, Arteriosclerosis, Thrombosis, and Vascular Biology, found that walking was just as effective as running in lowering the risk of hypertension, diabetes, and high cholesterol. The key is to walk for twice as long as you would run in order to get the same benefits as you would from running. Along with the health benefits, you also get to enjoy the fresh air and scenery that makes running so appealing.

Step Aerobics
Taking a step aerobics class or working out to a step video offers a high-intensity and low-impact workout that is easier on the joints than running but still effective in improving muscular strength and cardiovascular endurance. A 2006 study published in the British Journal of Sports Medicine found that step exercise offers a workout with a biomechanical load that falls between what you would get from walking and running. The key is to perform the moves properly and safely to avoid injury.

Read more: http://www.healthline.com/health/osteoarthritis/knee/alternatives-to-high-impact-exercises#ixzz37Alz0m00

Shoulder Injury Prevention – Causes and Solutions

Do your shoulders give you problems? Read this article by Joe Heiler PT, CSCS for some background on how to prevent shoulder injuries!

Joe Heiler is a physical therapist specializing in sports medicine and orthopedics in Traverse City, Michigan. Joe is also a highly sought after strength and conditioning coach working with athletes at all levels in football, baseball, hockey, track, and power lifting.

Chronic shoulder pain is nothing new to lifters or overhead athletes. It can range from something you just live with and work around to debilitating and career ending. It is not something you mess with. If you currently have shoulder pain, go have it looked at. If you haven’t experienced it to this point then pay close attention to the following.

Shoulder pain that is chronic in nature is often the result of an “impingement syndrome”. In a nutshell, the soft tissues between the head of the humerus and the acromion and coracoid are literally pinched during throwing, striking, pressing, and other high speed or weighted activities. Those soft tissues include the rotator cuff tendons, the subacromial bursa, glenoid labrum, and even the biceps tendon. Ask an orthopedic surgeon and they will tell you the rotator cuff will look like someone took sandpaper to it and just wore a hole into it. These chronic type symptoms can also lead to acute tears of the cuff, labrum, and biceps tendon which in many cases means surgery and a long, painful rehab process.

So how does one get to that point? There can be any number of causes, the most common of which I will touch on here because they are preventable.

Poor posture – Sitting is a necessary evil for many of us. From sitting in front of a computer all day, to driving for a living, and for students who must sit in class all day. God forbid they’re given a physical education class to run around in and undo what institutional learning has done to them physically. Over time prolonged sitting leads to muscle adaptations. Some muscles become short and tight while other become lengthened and weak. Anyone familiar with Janda’s upper crossed syndrome will recognize this: the tight pecs and levator along with weak rhomboids, serratus anterior, and deep cervical flexors.

What these muscle adaptations do is alter scapular mechanics and gleno-humeral rhythm. The humeral head then rides up into the acromion and/or forward into the corocoacromial ligament causing impingement.

Volume of pressing is greater than pulling – What this does is reinforce the anterior dominance of the pecs in relation to the scapular stabilizers of the upper back. Again, posture and shoulder girdle mechanics suffer.

A lack of stability through the trunk and hips – We have known for some time that poor trunk and hip stability is a prominent cause of shoulder and elbow injury amongst pitchers. This is well documented. More and more research is coming forth looking at these factors with other athletic populations and finding the same results. A study is underway right now looking at swimmers with and without shoulder pain. To this point the leading indicator of shoulder pain is single leg balance (side opposite the painful shoulder). The shoulder will only be as stable as the rest of the body.

Exercise selection – There are just certain exercises that should be avoided by overhead athletes, powerlifters, and Olympic lifters. In particularly bodybuilding type exercises. Heavy shrugs and upright rows, flyes and pec dec for the chest, and front and lateral deltoid raises really should be excluded. It’s rare to see someone performing them correctly and they all increase the risk of impingement through various mechanisms. Little reward for such high risk. If you are a bodybuilder then I understand you must do them but please use a weight that allows you to maintain perfect posture and form.

GIRD (Glenohumeral Internal Rotation Deficit) – This involves the overhead athlete more so than lifters but they too should test themselves (see picture). A difference of 25 degrees dominant shoulder to non-dominant indicates a positive test. GIRD develops because throwing or striking from an overhead position requires a great deal of shoulder joint external rotation. Over time, the athlete develops excessive external rotation at the expense of internal rotation. Physiologically what happens is the posterior shoulder capsule tightens and thickens resulting in superior/posterior translation during the cocking phase, and superior/anterior translation during the follow through. In both instances, impingement can occur as well as significant shear on the labrum.

Sleeper Stretch

So now that we have discussed the causes, what should you be doing about it? The following list consists of seven strategies aimed at maintaining shoulder health while maximizing performance. Note: The order of the solutions does not correlate exactly with the order of causes above. The first three solutions are aimed toward improving posture and gleno-humeral rhythm.

Increase thoracic spine extension and rotation – The faulty posture we see so much of is due in part to the rounding of the thoracic spine. The scapulae must be seated properly for normal gleno-humeral rhythm to occur, and this cannot happen with a kyphotic t-spine.

Thoracic spine extension mobilizations can be performed lying over a foam roller. Start at the top of the shoulder blades and work down to just below the inferior angles about an inch at a time. Take 2-3 deep breaths as you relax back over the roll at each level.

Thoracic spine rotation begins sidelying with the top hip at 90 degrees pressing the knee into a ball or the ground, depending on how mobile you are. Roll the shoulders back toward the floor, reach with the down arm, and give a pull on the ribs with the top arm to take the t-spine as far as possible. The goal is to get the shoulders flat on the floor. You will probably see a difference side to side especially if you are a thrower. Work the limited side twice as many sets as the other.

These are great preventative exercises to use as part of the warm-up.

Thoracic Mobility

Decrease tone and lengthen overactive muscle groups – A foam roller and/or the massage stick are great for decreasing muscle tone. The main targets in this case are the pecs, upper traps, and levator. Follow up with flexibility work to lengthen the muscles. To get the levator, retract and depress the shoulder blades, tilt your head toward your shoulder, then rotate in that same direction. You will feel the opposite side stretching. Optimal length is chin touching the clavicle. If you know a good manual therapist, take advantage. There are many techniques they can use that you really can’t do well to yourself.

Activate under-active and lengthened muscle groups – Targets in this case would be the lower traps, rhomboids, and serratus anterior. T’s, Y’s, L’s, and W’s are great for strengthening the scapular stabilizers and rotator cuff musculature simultaneously. Be sure to lock the scapulae into retraction and depression before lifting, and go light. It is easy for the upper traps to start taking over especially once fatigued.

W’s

Y’s

Push-ups with a plus are great for activating the serratus. Turkish Get-Ups with a kettlebell is just a great way to put it all together. This is a fairly technical lift and unfortunately a single picture will not do it justice. Those of you who have tried these know how difficult they can be, but are the ultimate shoulder stability exercise.

Adjust training volume front to back – At a minimum, training volume should be 1:1, meaning for every set of bench press, you perform a set of rows. Shoulder press – chins. Flies – reverse flies (posterior delt raise). And so on. Superset the exercises or do them on separate days. It doesn’t matter as long as it evens out in the end.

I know Mike Boyle and others are now advocating kicking it up to a 1:2 ratio as they have seen fewer shoulder injuries using this strategy.

Improve trunk stability – Perform prone and lateral pillar bridges to engage the trunk and scapular muscles simultaneously. Do these in place of crunches during your core work. Yes, I said replace crunches. The only things crunches are good for are increasing thoracic kyphosis, pulling the scapulae into a more protracted and elevated position, and putting undo stress on the cervical spine. All things we are trying to prevent.

Improve hip stability – Single leg squats and deadlifts will force greater hip stabilization versus the traditional squat and deadlift. I’m not saying to replace these, but use the single leg versions of these exercises instead of hitting the leg press and hamstring curl machine. Y can’t go wrong with exercises that challenge everything from the ground up.

Use the sleeper stretch – The test is the cure in the case of GIRD. This can be done before or after training. Just do it daily.

So there you have it. The causes and the solutions. While prevention takes some time and effort, it is always easier and less painful than the rehab. Don’t let your shoulders get in the way of your gains in the gym or your performance on the field.