Rotator cuff injury
Your rotator cuff is a group of muscles that facilitate movement and help to stabilise the shoulder joint. In fact, it’s arguably the most important group of muscles around the shoulder as they control the fine movement, rotation and leverage of the arm. These four main muscles travel across the shoulder and insert into the top of the humerus (upper arm bone). They all merge and come into one larger conjoined tendon or hood, which all then work together.
The rotator cuff is made up of relatively small muscles but there is a lot of force that goes through the shoulder. Inevitably you’re therefore going to get natural wear and tear. Because the shoulder is so mobile, you can quite often put those muscles on a stretch or in an awkward position, or really load them, and then you get this sudden burst of energy. This makes it more likely they’ll be overloaded which can lead to injuries.
Also, the repetitive nature of racket sports may have an effect on increasing wear within them. Age can be a factor with the shoulder tendons too, with patients in their 60s and above generally more susceptible to injury. An injury could be caused by a particular trauma or impact, such as a fall or lifting something heavy. Or it could be a subtle tweak that causes an initial pinch, such as a mis-hit serve, which causes some inflammation. This inflammation then takes up what little room there is left for the shoulder to move around freely so the joint starts rubbing. This then progresses into a longer term injury.
Rotator cuff injuries can be split into two main types – structural damage (e.g. tear) and tendinopathy (e.g. impingement).
When the shoulder is structurally damaged, such as a tendon tear, this changes the mechanics of the shoulder joint. This may not heal on its own, as there is a poor blood supply to those tendons. Once it’s torn, and is causing significant problems, surgery may be required. The tear can be triggered by many things, but it’s usually a trauma or impact that has caused it.
The other type of injury is a tendinopathy, or irritation to the shoulder complex. A common issue is called “impingement”, where the tendons above and below are rubbing against the shoulder joint causing irritation and resultant degeneration (wear) of the tendons. This generally calms down over time with correct management and the right exercises, but can rumble on as an on-going injury for some time and be hugely frustrating if you’re trying to return to a sport.
The main symptom of any rotator cuff injury is pain. If you have structural damage from a tear then it’s likely you’ll have weakness and difficulty moving the shoulder, which won’t get any better no matter how high you lift your arm. It’s worth noting that some older patients may have been living with a rotator cuff tear for many years, but have never had symptoms. This in itself may not require treatment, but if an impact then starts to cause pain, then different treatment options will be explored.
In contrast, although you will still experience pain with an impingement issue, this is usually worse in the mid-arc point when you raise your arm around shoulder height. Once you move past this particular point, the arm will often move more freely again. It’s important to note that pain is often not felt at the exact source of the issue. Many patients describe feeling pain in the upper arm, which is a classic sign of what we call “referred pain” from the shoulder. The pain may settle down after a while, but a trigger such as lifting something onto a shelf can cause your symptoms to flare up again.
In both cases you can also expect some swelling and a dull aching sensation when it’s aggravated. Many patients also describe difficulty sleeping at night, so the injury can be both intrusive and frustrating.
The first step in an assessment is to get a detailed, subjective history of how the injury happened. Details such as how the injury happened, whether it was sudden or progressive, and ways you have managed the injury to date are a great starting point. The patient’s age and activities will also be taken into consideration, as rotator cuff tears are quite rare for patients in their teens and 20s for example.
There are lots of different shoulder tests which a physiotherapist can use to form a picture of what the issue is. This can involve observing your range of movement and a hands-on assessment to feel for any unusual movements in the joint. Tests and scans, such as ultrasound, can help too so your physiotherapist may recommend you seek a referral for other tests if necessary.
The first step will be to control your current pain. By its nature, pain inhibits muscle function so other exercises won’t be as effective unless this is at a manageable level. In the shorter term, your physiotherapist can do hands-on massage or manipulation to try to relieve some pain in the joint. You can also speak to your local pharmacist for advice on medication to manage the pain. Further tips and advice are in “What can I do at home to help?” section below.
The next step in your treatment plan will be to get the muscles working correctly. When a muscle has been working through pain it often does not work as effectively or efficiently. The aim of the initial basic exercises is to retrain the muscles, and to reconnect the brain’s control centres with any parts of the muscles which aren’t functioning correctly. This usually won’t involve any weights or resistance bands at this point.
After this stage is complete, a programme of targeted strengthening exercises will be recommended to help with your recovery. These are graded so you can gradually progress and build back up to activities such as racket sports. Resistance bands can be used to facilitate the muscles to work in the right way and also to strengthen them, but not every patient will necessarily need them.
For some more chronic conditions, your physiotherapist may recommend you are referred to see a consultant orthopaedic shoulder surgeon. They then may recommend targeted injections or even surgical options if other treatments haven’t been effective up until that point.
Your physiotherapist will work with you to create a personalised treatment plan, and will advise on initial steps to do at the start of your treatment. As a guide, here are some tips they may recommend initially to help control your symptoms:
- Stop or modify the motion that’s causing the pain.
- Avoid prolonged overhead activity in the short term.
- Manage your symptoms using an ice pack, as this will help to control swelling and initial inflammation. Further down the line, you could apply heat to help with shoulder stiffness and soreness.
- Massaging the shoulder yourself may be helpful and it shouldn’t do any harm.
- Supporting your elbow with a cushion when you’re sitting can help too, while keeping your shoulder in a relaxed position.
- Propping yourself up at night with pillows can help you sleep more comfortably.
- Making use of the lumbar support in office chairs can help, so ask to see if you can get another workplace assessment.
After a diagnosis of shoulder impingement for instance, you can usually expect some improvements after six weeks of physiotherapy. However, this varies very much on the patient as the treatment may involve you retraining your muscles to do modified movements from what you’re used to. Motivation to do your exercises plays a key role in your recovery too, so we will work with you to set realistic timescales and goals, explain why you’re doing certain exercises and show your trends in improvement along the way. It may also help to strengthen your core, as this can have an impact on your shoulder joint. Circle Rehabilitation also run classes such as Clinical Pilates, run by physiotherapists, which can help with your recovery process.