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Rotator
cuff injury includes strain, tendinitis, and partial or complete
tears.
The rotator cuff, consisting of the supraspinatus, infraspinatus, teres minor, and subscapularis (SITS) muscles, helps stabilize the humerus in the glenoid fossa of the scapula during many athletic overhead arm motions (eg, pitching, swimming, weightlifting, serving in racket sports). Disorders can involve strain, tendinitis, or a partial or complete tear.
Tendinitis typically results from impingement of the supraspinatus tendon between the humeral head and coracoacromial arch (the acromion, acromioclavicular joint, coracoid process, and coracoacromial ligament). This tendon is thought to be particularly susceptible because it has an undervascularized region near its insertion on the greater tuberosity. The resultant inflammatory reaction and edema further narrow the subacromial space, accelerating the process. If the process is not interrupted, tendinitis, fibrosis, and sometimes partial or complete tear may result. Degenerative rotator cuff tendinitis is common among older (> 40 yr) nonathletes for the same reason. Subacromial (subdeltoid) bursitis commonly results from rotator cuff injury.
Symptoms,
Signs, and Diagnosis
Symptoms of bursitis include shoulder pain, especially with overhead activity, and weakness. The pain usually is worse between 80° and 120° (painful arc of motion) of shoulder abduction or flexion and is usually minimal or absent at < 80° or > 120°. Signs vary by severity. Incomplete tendon tears and tendinitis produce similar symptoms.
Diagnosis is by history and physical examination. The rotator cuff cannot be palpated directly, but it can be assessed indirectly by maneuvers that test specific muscles; significant pain or weakness is considered a positive result.
The supraspinatus is assessed by having the patient resist downward pressure on the arms held in forward flexion with the thumbs pointing downward (“empty can” test).
The infraspinatus and teres minor are assessed by having the patient resist external rotation pressure with the arms held at the sides with elbows flexed to 90°; this position isolates rotator cuff muscle function from that of other muscles such as the deltoid. Weakness during this test suggests significant rotator cuff dysfunction (eg, a complete tear).
The subscapularis is assessed by having the patient resist internal rotation pressure or by having the patient place the back of the hand on the back and then try to lift the hand off (lift-off test).
Other tests include the Apley scratch test, Neer test, and Hawkins test. The Apley scratch test checks shoulder range of motion by having the patient attempt to touch the opposite scapula: Reaching overhead, behind the neck, and to the opposite scapula with the tips of the fingers tests abduction and external rotation; reaching under, behind the back, and across to the opposite scapula with the back of the hand tests adduction and internal rotation. The Neer test checks for impingement of the rotator cuff tendons under the coracoacromial arch; it is done by placing the patient's arm in forced flexion (arm lifted overhead) with the arm fully pronated. The Hawkins test also checks for impingement; it is done by elevating the patient's arm to 90× while forcibly rotating the shoulder internally.
The acromioclavicular and sternoclavicular joints, cervical spine, biceps tendon, and scapula should be palpated to check for any tenderness or deformity and to exclude problems associated with those areas.
The neck always should be examined as part of any shoulder evaluation because pain can be referred to the shoulder from the cervical spine (particularly with C5 radiculopathy).
Suspected rotator cuff injury can be further evaluated with MRI, arthroscopy, or both.
Treatment
In most cases, rest and strengthening exercises are sufficient. Surgery may be necessary if the injury is severe (eg, a complete tear), particularly in a younger patient.
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| Exercises to Strengthen the Shoulders |
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Downward lateral pulls
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The “lat” machine has a weight on the floor. A rope or cable is attached to the weight and passes over a pulley ≥ 1 ft over the head. The rope comes down toward the head and is attached to a bar that is held in the hands.
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1. Hold the bar over the head with the elbows bent (elbows should not be higher than the shoulders).
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2. Pull the bar down toward the head and slowly let the weight raise the bar.
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3. The set should last about 90–120 sec for rehabilitation and about 50–70 sec for general strength and conditioning.
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4. As strength improves, increase the weight, not the number of repetitions or tension time.
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External Rotation
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1. Lying on the left side, grasp a light dumbbell in the right hand with the right arm pronated and bent in 90°. Maintain this position throughout the set.
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2. Using the right elbow as a pivot point against the side of the waist, externally rotate the arm upward until it is almost vertical.
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3. The set should last about 90–120 sec for rehabilitation and about 50–70 sec for general strength and conditioning.
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4. Repeat with the opposite arm.
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5. As strength improves, increase the weight.
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Incline chest press
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(CAUTION: Start with a very light weight because the injured muscles are being stressed. This exercise is hard on the shoulders. Many people opt to use an incline bench with upright supports.
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1. Lie on the back with a special bench or strong friend to help lift the weight when finished with this exercise.
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2. Hold the barbell in the hands with the thumbs held medially.
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3. Slowly raise the weight from the chest, and then slowly lower it.
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4. The set should last about 90–120 sec for rehabilitation and about 50–70 sec for general strength and conditioning if both shoulders are healthy.
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5. As strength improves, increase the weight.
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Last full review/revision November 2005
Content last modified November 2005
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