The Rotator Cuff…Hanging By A Thread

Nearly everyone is familiar with rotator cuff tears (RCTs) these days. The prevalence of RCTs is not surprising given the fact that people tend to fall into deleterious postures throughout the day, consistently overload their arms while performing routine activities, and often assume harmful overhead positions for an extended period of time while sleeping. Furthermore, most people, who engage in a strength training regimen, tend to perform high risk exercises with too much resistance and improper form while lacking adequate stability at the scapulothoracic articulation (where the shoulder blade interfaces with the rib cage). The cumulative effect of these forces and positions is rotator cuff pathology. As a physical therapist, I often use metaphors to teach physical therapy interns and patients to help them better understand rotator cuff injuries. In the case of rotator cuff disease, I liken the rotator cuff tendons to a piece of rope that has started to fray. The last thing that the tendons or rope want to see is repetitive motion, especially when coupled with external resistance. The rotator cuff tendons would more appropriately benefit from a greater balance in the surrounding elements, proper mechanics at the joints of the spine and shoulder girdle complex, and more fluid motion. So how does this affect the rehabilitation process? Rather than jump to prescribe shoulder exercises involving 3 sets of 10 repetitions, first identify the major impairments that may be contributing to the problem. For example, is the thoracic spine able to adequately extend and are the ribs able to externally torsion on the side of the involved shoulder? Is the scapula able to posteriorly tip or tilt as the arm elevates? Is there posterior shoulder tightness that may cause anterosuperior migration of the humeral head, which alters the arthrokinematics of the glenohumeral joint. Is there adequate scapulothoracic stability that will afford the arm a stable base to move from? Are there altered length tension relationships in the surrounding soft tissue, which may predispose one to subacromial impingement. Do the periscapular muscles possess adequate strength? Are there postural considerations such as forward head and/or rounded shoulders that need to be corrected? By addressing such impairments, an ideal environment for healing will be created for the damaged rotator cuff tendon(s) and patients will most likely enjoy improved function of this vital muscle group. Lastly, remember that the rotator cuff is a group of precision muscles that are best trained from a resistance standpoint of 40-60% of one’s maximum voluntary contraction (MVC) so make sure not to excessively overload them as it will only add insult to injury. I should also reminder readers that not all rotator cuff tears are amenable to conservative management and sometimes surgery is indicated. Long live in the shoulder!