What most people call the shoulder is really several joints that
combine with tendons and muscles to allow a wide range of motion
to the arm—from scratching your back to throwing the perfect pitch.
Mobility has its price, however. It may lead to increasing problems
with instability or impingement of soft tissue resulting in pain.
You may feel pain only when the shoulder is moved, or all of the
time. The pain may be temporary and disappear in a short time, or
it may continue and require medical diagnosis and treatment.
Tendinitis—A tendon is a cord which connects muscle to bone
or other tissue. Most tendinitis is a result of the wearing process
that takes place over a period of years, much like the wearing process
on the sole of a shoe which eventually splits from overuse. Generally,
tendinitis is one of several types:
- acute tendinitis following some overuse problem such as excessive
ball throwing and other sports- or work-related activities.
- chronic tendinitis resulting from degenerative disease or repetitive
wear and tear due to age.
- the splitting and tearing of tendons which may result from acute
injury or degenerative changes in the tendons due to advancing age.
Rotator cuff injuries are among the most common of these disorders.
The rotator cuff is the arrangement of muscles and their tendons
which provides shoulder motion and stability.
Rotator Cuff Tendinitis (Also see Rotator
Cuff Tendinitis Report)
The rotator cuff is a confluence of tendons that insert on the superior
lateral aspect of the upper arm. The tendons are what permit the
shoulder muscles (subscapularis, supraspinatus, infraspinatus, teres
minor) to attach to bone, and therefore raise and lower the arm,
and rotate it in and out. The tendons are broad, measuring approximately
5 centimeters in width, and form a cuff encapsulating the articular
surface of the top of the humerus.
The rotator cuff runs under a bony and ligamentous arch formed by
the acromion,(the bone felt when you put your left hand on top of
your right shoulder) and is bordered by the acromioclavicular ligament,
the coracoid (the bone in front of the shoulder), the acromioclavicular
joint (where the clavicle joins the acromion. The rotator cuff muscles
are the subscapularis anteriorly, the supraspinatus superiorly,
and the infraspinatus and teres minor posteriorly.
Due to the narrowness of the space provided for the cuff, any inflammation
or swelling of the tissue leads to pain. Any significant tearing
of the cuff, weakens the ability of the muscle to move the arm,
and eventually permits the articular cartilage in the shoulder joint
to impact against the bony confines of the space, leading to pain
Signs, Symptoms and Diagnosis
Initially, pain occurs only when the athlete participates in any
sport that requires him to hold his arm over his head and forcibly
bring it forward. 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. To palpate the
rotator cuff, abduct the arm backward and away from the body in
internal rotation with the elbow straight. The patient will complain
of tenderness over the tendons, especially when the arm is raised
above the shoulder, but often not when the arm is held down by the
side. 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. An arthrogram is usually not sensitive enough to
diagnose a partial tear of the rotator cuff.
If the cuff is bruised only, bleeding into the tendons occurs, the
tendons swell, and pain increases. This entrapment of the swollen
cuff may persist for months, increasing and decreasing in intensity
usually related to activity. The entrapment of the rotator cuff
is called the "impingement syndrome."
If the rotator cuff is torn, the problem is significantly more serious.
The symptoms are the same as for the impingement syndrome, with
pain at night often being more prominent. The size of the tear must
be determined by an arthrogram (where radiographic dye is injected
into the shoulder joint and x-rays taken; how much leaks out as
seen on x-ray, determines the size of the rotator cuff tear) or
by magnetic resonance imaging (MRI) (where pictures are taken in
a magnetic field showing the internal structures of the joint.)
If the cuff tear is significant, then surgery is generally recommended
in order to prevent the humeral head from poking up through the
rotator cuff tear to rub against the bony acromion. This superior
migration not only produces pain and limited motion, but leads to
significant arthritis of the shoulder joint. At surgery, the torn
cuff is sewn back to itself, and reattached to the bony insertion
on the lateral border of the humerus. Fortunately, many times this
can be performed arthroscopically. We routinely repair torn rotator
cuffs under local (regional anesthesia) as an outpatient. Exercises
are started the next day and the patient usually can return to full
sporting activities within months.
Rehabilitation and Treatment
Treatment of inflammation of the rotator cuff begins with an accurate
diagnosis to rule out a tear of the cuff, followed by a combination
of anti-inflammatory and strengthening maneuvers. An anti-inflammatory
agent such as ibuprofen or aspirin is ingested daily and continued
for six weeks. Regular dosing is required to build up blood level
and to maintain that level throughout the initial treatment time
to obtain the optimum anti-inflammatory effect. By diminishing the
inflammation, further strengthening and stretching exercises can
Stretching of the shoulder rotator cuff muscles is easily performed
both as treatment for inflammation and as a warm up before skiing.
With a ski pole held firmly with one hand at the basket and one
hand on the handle, with the arms held out straight, bring the pole
from the waist to above the head, repeating the motion slowly to
the limits of the range of motion. With the arms above the head,
lean a ski pole as far as possible to the left and then to the right.
This motion should be repeated with the arms in front of the body,
both held out straight and in the flexed position. Many other shoulder
stretches are available and most are helpful as long as sharp pain
Strengthening of the shoulder rotator cuff muscles is best performed
by isolating each muscle group and selectively training that muscle.
The subscapularis is the anterior stabilizer of the rotator cuff
and responsible for internally rotating the shoulder. It is best
strengthened by holding a hand weight in front of the body, with
the arm flexed to 90 degrees, and rotating the hand to touch the
belt. The exercise can be performed while lying on your back with
the elbow close to your side and flexed ninety degrees. Lift the
weight until it is pointing toward the ceiling and then lower it
slowly. The supraspinatus is strengthened by holding a light weight
(initially 3-5 lbs) out straight in front of the body, with the
thumbs pointed toward the floor. Slowly elevate the weight to above
the head. Stop if pain is produced in any portion of this motion,
as the rotator cuff is under maximal stress in this position. The
infraspinatus is strengthened by holding the weight in the position
of the ski pole just prior to planting the pole. By rotating the
arm from the neutral straight ahead position, to the externally
rotated (out to the side) position, the infraspinatus and teres
minor are strengthened. Again, this exercise can also be performed
while lying on your side with the elbow close to your hip, and flexed
ninety degrees. Rotate the weight until it is pointing toward the
ceiling. Shoulder exercises are best performed with relatively light
weights and multiple repetitions.
The logic behind stretching and strengthening the inflamed rotator
cuff in order to speed healing and functional performance is as
follows: the inflamed tissue is characterized by increased fluid
between the cells, increased numbers of new blood vessels and inflammatory
type cells. As a result of this inflammatory reaction, new collagen
tissue is laid down in an effort by the body to heal the injured
tissue. If the shoulder is immobilized during this time, the new
collagen is laid down in a disorganized fashion, creating scar.
The goal of gentle stretching, strengthening and anti-inflammatory
medication, is to stimulate the cells to lay down collagen along
the lines of stress, forming normal strong tendons. The combination
of a good warm up, gentle stretching, strengthening below the limits
of pain, icing after working out and anti-inflammatory medication
has been consistently shown to speed recovery time in the strongest
As "chance favors the prepared mind" so does injury haunt the unprepared
athlete. Shoulder injuries can be diminished by careful warmup,
stretching, strengthening of the shoulder muscles. The exercises
described above for treatment of the injured shoulder are superb
for a general conditioning program. When shoulder injury symptoms
begin, early evaluation and treatment can prevent mild inflammation
from becoming full blown rotator cuff impingement, or worse, a tear
of the rotator cuff. A program of twenty minutes a day, of shoulder
stretches and muscle strengthening exercises is recommended to increase
performance and decrease injuries.
The rotator cuff muscles are susceptible to injury from skiing falls.
The injuries are usually treatable with stretching, strengthening,
and anti-inflammatory medication with full return to sports expected.
Careful differentiation between inflammation and tearing of the
rotator cuff is mandatory. If the cuff is torn early arthroscopic
or open repair is often helpful. Preventive conditioning exercises
can diminish the frequency of these injuries.
Reference Source 7,91