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  Fitness > Sports Injuries >  << Previous|Next >>
 

Rotator Cuff Tendinitis
(also see 4 Exercises to Avoid and What Goes Wrong)

Definition & Background

     The central role the rotator cuff has in shoulder function almost precludes its involvement in most painful disorders of this joint.  Rotator cuff tendinitis (RCT) refers to micro-tearing or inflammation of one or more of the four rotator cuff tendons of the shoulder (Supraspinatus, Infraspinatus, Teres minor, and Subscapularis, or SITS).  Commonly referred to as impingement syndrome, RCT can be primary bursitis, impingement from mechanical abutment, or secondary from glenohumeral instability.  RCT is common in those who are 25 to 40 years, when tendinitis and fibrosis are found to be most frequent and chronic.  After 40 years, there is full-thickness rotator cuff tearing, requiring operative repair.  This age-related characterization of RCT is accelerated in athletes involved in sports with repetitive overhead motions, who not only increase the forces on the cuff tendons, but also the repetitions of aggravating motions.

Signs & Symptoms/Muscle Testing

     Patients usually present with pain of insidious onset exacerbated with overhead activities.  The pain is usually in the anterior deltoid, but it can be referred anywhere on the deltoid and down the mid-arm.  The pain is often felt at night and can awaken patients from sleep.  Later, pain may occur when the arm is moved forward to shake hands.  Usually, pain will be elicited by pushing things away, with little or no pain on pulling objects in.

     On palpation, the patient will complain of tenderness in relationship to the irritated structure.  Their will usually be tenderness at the superior aspect of the greater tubercle and over associated tendons, especially when the arm is raised above the shoulder, but less common when the arm is held by the side.  Palpation anterior and inferior to the acromioclavicular joint and coracoacromial ligament are usually tender.  Possible atrophy may also be evident in the supraspinatus and infraspinatus fossae.

     A painful arc may be evident between 50 and 120 degrees of abduction   Severe pain is caused by adduction of the arm across the chest.  Shoulder abduction will be weak, usually due to underuse atrophy of the deltoid.  Three specific muscle tests are performed to assess possible involvement of individual muscles.  To examine anterior, subscapularis involvement, pain may be reproduced by having the patient resist internal rotation, or by performing the “lift-off” test as described by Gerber (1990) which may be more reliable.  Posterior involvement is tested by determining strength with thumb-down abduction at 70 degrees in the scapular plane and by testing external rotation strength at side.  Weakness with thumb-down elevation is more specific for supraspinatus involvement, whereas loss of external rotation strength at side is more indicative of infraspinatus and teres minor. 


Causes & Involved Tissues

     Many factors have been implicated in RCT, including extrinsic and intrinsic factors.

Whether a primary factor or secondary effect, RCT is thought to be an ongoing cause of tendon injury.  The supraspinatus insertion on the greater tuberosity must repeatedly pass under the coracoacromial arch when the arm is used in overhead activity.  The rotator cuff (S.I.T.S muscles) passes between the coracoacromial arch above and humeral head below.  Comprised of the anterior acromion and coracoacromial ligament, any abnormality of the coracoacromial arch, such as an acromial spur, or ligament thickening, can encroach on the cuff below altering cuff function.

     The clash of the humerus head against the coracoacromial arch and the pressure on the surrounding soft tissues result in damage to the rotator cuff tendons; this also leads to an inflammatory reaction characteristic of RCT.  There is an area of relative avascularity on the supraspinatus muscle tendon near its insertion (tenoperiosteal junction) on the greater tubercle of the humerus.  This region is called the critical zone of the rotator cuff.  The anatomical position of the rotator cuff tendons plays an important role in the development of the critical zone because it exposes the tendons to constant pressure from the humeral head, squeezing blood out of the surrounding blood vessels even when the arm is stationary in a position of abduction or neutral rotation.

     RCT may also originate from the weak external rotators of the shoulder, infraspinatus and teres minor muscles.  An existing weakness of the external rotators and adaptively shortened internal rotators of the shoulder results in an inadequate fixation of the humeral head in the glenoid fossa in the superior direction.  This significantly increases the pressure of the humeral head on the tendon blood vessels of the shoulder joint’s rotator cuff.  This leads to an increasingly greater degeneration of the critical zone accompanied by the progressive development of RCT. 

     In summary, the two principal theories, one anatomic (decreased vascularization), the other dynamic (muscle weakness), may both play roles in the origin of RCT.  At the same time it is quite clear that some causative factors can synergistically combine to produce RCT.  These include os acromiale, acute trauma to the shoulder, calcific deposits and excessive strain placed on the upper extremity during vigorous activity.  The clash of the humeral head against the acromion causes injury to the surrounding soft tissue, the tendon of supraspinatus, the long head of biceps brachii, and the subacromial bursa, which results in RCT and scarred healing.  Consequently, various functions of the rotator cuff are affected.  The humeral head is not firmly fixed in the glenoid fossa during arm motions and has a tendency to translate in the superior direction.  Such an unstable humeral head causes pain, decreases the range of movement possible in the shoulder joint, causes instability of the shoulder joint, and disrupts normal flow of synovial liquid which nourishes the joint cartilage; all this leads to further progression of RCT, impingement and eventual rupture of the tendons involved.  

Flexibility, Strength & Aerobic Prescription

Dysfunctional shoulder biomechanics, brought about by repeated activity includes:

 
*
muscle imbalance between internal and external rotators

* adaptively shortened internal rotators

* inflamed rotator cuff muscles

To be effective, a rotator cuff program must address all the components that contribute to dysfunctional shoulder biomechanics, It must...

* strengthen the external rotators/abductors

* stretch the internal rotators/adductors

* stabilize the glenohumeral joint directly through training specific to the rotator cuff

* stabilize the glenohumeral joint indirectly through stabilization and freedom of movement of the scapulothoracic joint

* stretch the posterior capsule

* eliminate postural/causative factors or training errors that promoted inflammation and initiated dysfunctional shoulder biomechanics in the first place.

The following program sequence advocated by Curwin (1984) was found to be extremely effective in rehabilitating patients with RCT in the late sub-acute and chronic phases:

1. static stretching for 15 to 30 seconds repeated
    3-5 times
(1 cycle) 

2. concentric and eccentric exercise begun with
    gravity or light weight progressing from slow
    speed to moderate to high speeds

3. static stretching as in 1.

4. 5-10 minutes of icing


Stretches

     It is necessary to stretch the internal rotators of the shoulder so the external rotators can be properly strengthened and normal internal/external rotator strength ratio (3:2) may be obtained.  The following internal rotators are the most relevant muscles to be stretched: Pectoralis major, Latissimus Dorsi, Teres Major, Subscapularis and Anterior Deltoid.  Secondarily, the Biceps, Supraspinatus, Levator Scapulae, Trapezius, Rhomboids, Scaleni and Triceps should also be stretched due to their relationship with the shoulder girdle.  However, to maintain brevity, only the most significant muscles (internal rotators, biceps and supraspinatus) will be discussed below.  As mentioned above each stretch should be held statically for 15-30 seconds and repeated 3-5 times with 7-14 cycles per week.   The following are all passive stretches (performed statically).  If any sharp pain is felt, the muscle may become further traumatized.  For this reason, the patients reaction should be carefully monitored throughout each stretch from start to finish.  

     Most of the stretches are shown with the help of a therapist, however, for self-stretch (SS), they are equally effective by either holding a light weight (2-4lbs), pulling with the other arm, or holding onto another object (i.e. chair, pole, doorframe). 

Pectoralis Major

The position of stretch for the clavicular division is with the shoulder abducted 90 degrees with external rotation.  For SS, the patient would hold onto a door frame in the indicated position and move the thorax slightly forward and away from the affected arm.

The position of stretch for the sternal division is with the arm placed at about 90 degrees abduction, then externally rotated and pressed backward into maximum tolerated extension.   SS is similar to the clavicular division.

The position of stretch for the lowest costal division is with the patient seated or supine, the arm flexed at the shoulder while held in external rotation.  SS is supine in the position shown holding onto a fixed object.

Latissimus Dorsi

The position of stretch is with the patient supine or side-lying with examiner assisted attempts at accessing full abduction. 

Teres Major

The position of stretch is with the patient supine with the arm placed in full abduction at the shoulder with the elbow bent to permit controlled internal and external rotation.  The scapula is stabilized best in the supine position.  SS is similar to the passive stretch with the exception of the patient using his free  hand to maintain abduction and external rotation of the affected arm.

Subscapularis

The position of stretch is with the patient supine with the arm abducted to 90 degrees and external rotation.  For SS, the patient may do the same as above but with a light weight in the hand of the arm to be stretched.  This uses gravity as assistance in pushing the weight down against the resistance of subscapularis and the external rotators.

Anterior Deltoid and Biceps

The anterior deltoid and biceps are most effectively stretched by the patient himself.  These two muscles both act to flex the arm and are best stretched simultaneously.  Instruct the patient to grasp onto a bar (or rest the wrists on top of a kitchen counter or refrigerator).  Keeping the back as upright as possible, the patient is to sink down slowly feeling for the stretch in the biceps and front shoulder.

Supraspinatus

The supraspinatus is stretched by placing the patient’s arm behind the back (fully internally rotated and adducted) resting the hand on the back of the chair.  The therapist may apply slight pressure at the elbow in a medial direction.  SS is similar except the patient will use their free hand to pull the affected arm medially behind the back.

External Rotators

The external rotators are usually flexible enough to not need stretching.  However, if an individual needs beyond-average external rotator flexibility the following self-applied stretch may be useful.  Bend the right elbow, place the back of the wrist against the ribs, and rotate the elbow forward.  Gently pull across and down.  Keep shoulder down and torso facing forward throughout the stretch.  This is only recommended for healthy shoulders.

Strengthening

     To achieve the proper strength ratio (3:2) between the internal and external rotators, the patient must be advised not only to stretch the internal rotators but strengthen the external rotators which are relatively weak.  Since the majority of muscles at the shoulder are internal rotators, the small teres minor and infraspinatus are often neglected resulting in stronger internal rotators which adaptively shorten over time.  The progressive loss of external rotation-due to adaptive shortening of the internal rotators (or both)-is a common factor in RCT and many rotator cuff injuries.  It is thus imperative to stretch the internal rotators, followed by extensive external rotator resistance exercise.  Keep in mind that it is necessary to strengthen all of the muscles of the shoulder girdle and rotator cuff to maintain a healthy shoulder joint.  However, to maintain brevity, the focus will be towards the deltoid and more importantly (and often overlooked) external rotators.  The deltoids are not part of the rotator cuff, but they interact with the cuff muscles to a great extent.  Weakness of the delts, particularly the rear delt, predisposes the cuff to injury. 

     In rehabilitation, the resistance exercises below should be performed (max. 3 ex.) at 10-12 reps per exercise for a maximum of 2 sets with light weight (2-4lbs) and 7 cycles per week.  As a preventative measure, the following exercises (max. 4 ex.) may be  performed at 10-14 reps per exercise for 2-4 sets with moderate weight (5-15lbs) and 3-5 cycles
per week.  Rest periods are no longer than 1 minute in between sets or until normal breathing has returned.  

Note: Both shoulders are worked one at a time even if only one shoulder is injured. This is best to reduce the risk of future injury to the uninjured shoulder and balancing the strength of both.

Side Delt Flyes (lateral delts)

Hold a dumbbell in each hand, arms at your sides, palms facing in.  Lift the weights out to the sides to about shoulder level.  Lower and repeat.  At the peak of the movement, the palms should be facing down, and hands holding the dumbbells, should be at the same height as the elbows.

Front Delt Flyes (anterior delts)

Hold a dumbbell in each hand, arms at your sides, palms facing back.  Keeping the arms parallel, lift the dumbbells forward to about shoulder level while slightly bending the elbows.  Lower and repeat.

Rear Delt Flyes (posterior delts)

Holding a dumbbell in each hand, bend forward at the waist until your body is parallel with the floor.  Your arms should be hanging in front of you.  Raise the weights up to the side to body level.  Lower and repeat   For optimum performance, keep elbows slightly bent and lift so the weights end up in line with your ears.  The posterior delt acts to some extent with the external rotators.  Increase the effectiveness of this exercise by promoting cuff stability.  Do so by bringing the weights up in a slight arc.

Lying “L” Flyes (external rotators)

This exercise puts maximum stress on the external rotators at the end of the movement.  Lie on your right side on a supine bench.  Your right (supporting) arm should be in one of two positions: either doubled up under your head; or extended down toward the ground.  Begin with your left arm bent 90 degrees at the elbow, upper arm along your side, forearm down across your chest.  Hold a very light dumbbell in your left

hand, left palm facing toward your abdomen.  Maintaining the 90 degree bend in your elbow, slowly lift the weight.  Lower and repeat.  Reverse the position and repeat with the weight in your right hand.

Standing “L” Flyes (external rotators)

   This exercise puts maximum stress on the external rotators at the beginning of the movement.  The Standing “L” Flyes should not be used at the beginning stages of rehabilitation since it requires moderate strength.

   Hold a light dumbbell in your right hand, rest your triceps on a support.  Your right elbow should be bent 90 degrees.  Your body should be at a diagonal to the support as shown in.  The angle at your shoulder should be slightly less than 90 degrees.  Maintaining the right angle at your elbow, lower the dumbbell until your forearm is just below parallel with the floor.  Still maintaining the right angle bend at your elbow, slowly raise the weight back to the starting position.  Repeat with other arm.

Lying Flyes (posterior delt)

Starting position is similar as the Lying “L” flyes.  Begin with your left arm down across your chest.  Hold a very light dumbbell in your left hand, left palm facing toward the bench.  Maintaining a slight but constant bend in your left elbow, slowly lift the weight until your arm is almost pointing straight up.  Resist the tendency to roll back as you do the exercise.  Lower and repeat then reverse position and hand.

Aerobic Activities

      Aerobic exercise or that to strengthen the cardiovascular system is not essential in the rehabilitation or management of RCT.  However, various studies have found that specific muscles (primarily those composed of slow twitch-type I fibers) repond best to endurance type training.  Blackburn et.al (1990) showed that the posterior delt and external rotators are rapidly fatiguing muscles and that higher repetitions (15-40) with lighter weights was more effective in increasing hypertrophy and eventually strength levels than lower reps and higher weights.  Due to their relative size and fiber type, the external rotators have lower endurance levels which cause them to fatigue quickly, often before they reach peak levels of contraction.  Exercises with higher reps may increase local muscular endurance while increasing human growth hormone concentration levels which ultimately results in greater muscle growth.  In essence, traditional weight training methods for the external rotators may produce better results (in terms of strength and endurance) if combined with higher repetitions of the same exercises with shorter rest periods in between each set.  This type of rep/set/rest combo may incorporate oxidative phosphorylation with increased demands from the aerobic energy system.  For this reason, the patient may choose to be active for longer (>15min) exercise periods.

Walking or running within their target heart rate (70% of max (220-age)) will facilitate the aerobic energy system, increasing circulation to other muscles and enhancing the heart’s efficiency in any given task, including anaerobic and resistance training.

- Also see 4 Exercises to Avoid
and What Goes Wrong with Your Rotator Cuff

References

Baechle, Thomas (1994).  Essentials of Strength Training and Conditioning.  Human Kinetics, Nebraska.

Berkow, Robert (1992).  The Merck Manual of Diagnosis and Therapy.  Merck Research Laboratories, N.J.

Blackburn TA. (1990) “EMG analysis of posterior rotator cuff exercises”. J.Sports Med. 10:336

Curwin S. (1984) Tendinitis: Its Etiology and Treatment.  Collamore Press, Lexington, MA.

Gerber C. (1990) “Isolated ruptures of the tendon of the subscapularis muscle”  J.Sports Med. 14:261

Horrigan, J., Robinson, J. (1991)  The 7-Minute Rotator Cuff Solution.  Health for Life, LA, CA.

Kisner, C., Colby, LA. (1985) Therapeutic Exercise: Foundations and Techniques.  2nd Ed. F.A. Davis.  PH.

Kendall, FP., Proverance, P. (1993) Muscles: Testing and Function.  4th Ed.  Williams & Wilkins.  PH.

Magee, D. (1992) Orthopedic Physical Assessment.  2nd Ed. W.B. Saunders Company.  PH

Souza, T. (1994) Sports Injuries of the Shoulder: Conservative Management.  Churchill Livingstone, London.

Travell, J., Simons, D. (1983)  Myofascial Pain and Dysfunction.  Vol 1.  Williams & Wilkins, PH.


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