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Rotator-Cuff Injury: Prevention & Protection

Dr. Alexander Jimenez, shoulder injury specialist and sports injuries explains how overhead athletes may prevent chronic shoulder pain.

Does your shoulder ache after overhead activity? Is it getting worse and now restricting that action? Has a span of rest apparently resolved the issue just for the pain to recur when you return to the game? Chronic shoulder pain is unfortunately an all-too-common consequence of repetitive 'overhead activity', such as serving and smashing in tennis, freestyle or butterfly swimming, bowling in cricket, javelin, or baseball throwing and above-shoulder weight-training exercises. Chronic pain in the 'overhead' athlete is normally the consequence of damage to the rotator-cuff muscles of the shoulder (a group of four, small, deeply located, strap-like muscles). This article will look at how such repetitive damage is caused and how the athlete could have the ability to prevent it happening in the first place.

Structure Of The Shoulder

The shoulder joint complex is in fact made up by four joints: the glenohumeral joint (the ‘ball-and socket’ joint between the upper arm or humerus and the shoulder blade or scapula, which most non-experts consider to be the shoulder joint), the acromioclavicular joint (the joint between the lateral end of the collar bone or clavicle and the scapula), the sternoclavicular joint (the joint between the medial end of the clavicle and the breast bone or sternum) and the scapulothoracic joint (the ‘virtual’ joint between the undersurface of the scapula and the chest wall). Problems at any of these four joints may result in ineffective function of the shoulder-joint complex and consequently pain.

There is more movement possible in the shoulder joint than at any other joint in the human body. Over 1,600 places in 3- dimensional space can be assumed from the shoulder. The price to be paid for this extreme selection of movement is an inherent lack of stability.

To attain peak performance during overhead activity, there has to be optimum balance between mobility and stability. It is well-known that swimmers who over-stretch their shoulders in an effort to boost the range of their stroke, without improving their functional stability, are at heightened risk of injury to the rotator cuff.Tennis players and throwing athletes, actions which are essentially asymmetrical, often develop greater shoulder external rotation in their dominant shoulder and this is often associated with functional instability. Shoulder-injury prevention strategies need to concentrate on improving shoulder stability.

Impingement & The Rotator Cuff

The bony anatomy of the glenohumeral joint includes a large chunk (the head of the humerus) and also small socket (the glenoid of the scapula) together with all the muscles of the rotator cuff and scapular rotating (stabilizing) muscles acting as the most important dynamic stabilizers of this joint. The muscles of the rotator cuff envelop the glenohumeral joint itself, and include the supraspinatus, infraspinatus, teres minor and subscapularis muscles. Supraspinatus abducts the arm (moves it laterally away from the face of the body), infraspinatus and teres minor externally rotate the shoulder, and subscapularis is chiefly an inner portion of the shoulder. Sitting above the cuff is that the coracoacromial arch, composed of the coracoid and acromion bony processes of the scapula and a ligament connecting the two processes. Since the arm is abducted away from the human body or flexed (brought forward), 'impingement' or squeezing of the rotator cuff involving the head of the humerus below along with the coracoacromial arch above can happen. The healthy, conditioned rotator cuff functions effectively as an integrated component to stabilize and depress the head of the humerus, opposing the activity of the big deltoid muscle and thus preventing impingement.

Any overhead activity that includes the arm being taken regularly enough from below the shoulder level to over shoulder level has the capacity to damage the rotator cuff. With recurrent impingement, a badly ventilated cuff may get damaged, along with a cycle of cuff damage, diminished function, additional impingement and worsening cuff harm is initiated.

This form of primary impingement is most commonly found in weight coaches who overemphasize the development of the 'prime moving muscles' (pectoralis major, latissimus dorsi and deltoid) in the expense of their rotator cuff. It looks increasingly prevalent in athletes as they reach their thirties. Primary impingement is preventable and, even if the cuff is suitably conditioned, exercises like behind-the-neck press, incline bench press and also prolonged front laterals, won't lead to pain.

Differences in the shape and bony configuration of the undersurface of the acromion may dispose an athlete to this particular injury. A Type II (curved) or Type III (hooked) acromion will reduce the effective space through which the supraspinatus tendon slides during abduction. Plain X-rays should enable these two variations to be identified.

Secondary impingement refers to impingement secondary to underlying glenohumeral instability, when the rotator cuff is fatigued by its own attempts to maintain the humerus centered on the glenoid and thus allows the head of the humerus to ride up, reducing the subacromial space. This is possibly the most common mechanism of cuff injury found in younger athletes, especially those with increased joint laxity, and is observed frequently in swimmers and throwers. The principal difficulty here is instability and, unless that is treated, pain will probably be ongoing and progressive.

Scapular Stability

A strong and healthy rotator cuff is essential to the overhead athlete. In recent decades, the function of the scapula-stabilizing muscles in positioning the glenohumeral joint for optimum rotator-cuff work has been increasingly highlighted. Coordinated action of the set of muscles is needed to supply a stable base for pain-free overhead activity. The excessively simplistic 'ball and socket' model of the shoulder joint has been superseded by a model similar to the acting seal that could balance a ball on its nose. The seal equates into the scapula, and constant little adjustments by the seal (scapula) are required to avoid the ball dropping off its nose (glenoid). Overhead athletes must be able to effectively control the position of their scapula for optimum cuff function.

Injury Prevention Plans

Most cuff injuries can be prevented relatively simply. The crucial point is not to overwork the rotator cuff by increasing shoulder work too quickly. Keeping increases in workload to less than 10 percent per week will significantly reduce the risk of injury.

The key balance between stability and variety of shoulder movement has already been emphasized. Athletes with access to sports medicine support will benefit from an official evaluation of dynamic shoulder function. This should encompass an extensive overview of static and dynamic anatomy, range of movement at all four joints of the shoulder joint complex, muscle strength and balance (particularly of the rotator cuff and scapular stabilizers) and an assessment of inherent glenohumeral stability in all three planes. Significant abnormalities detected should be addressed and fixed. Such screening is becoming more and more regular for the more elite overhead athlete and validated evaluation and treatment protocols have been defined.

Strategy should be evaluated by the trainer and appropriate technical changes incorporated into the rehab program.

The Function Of The Kinetic Chain

More importantly, the use of force generation by other body parts has been assessed. For instance, the power generated by the shoulder at the tennis serve was preceded by power generated by the legs, trunk and back. The muscular mass of this shoulder is comparatively modest, and if insufficient power is generated by the previous connections in the kinetic chain the shoulder has to perform 'catch-up' and generate power rather than acting as a power regulator. Improving the server's leg activity, spinal strength and trunk rotation during the function will reduce the prevalence of rotator-cuff injury. Such biomechanical evaluation is difficult however, in skilled hands, is a crucial and effective component in injury prevention.

How Can An Athlete Prevent Injury?

Though shoulder rehab protocols after injury need to deal with subtle muscle imbalances and joint restrictions, and so require oversight, isolated rotator-cuff strengthening exercises can be very effective as part of a pre-participation conditioning program and can be performed using the next three simple exercises. The key is to strengthen the inner ozone (subscapularis), external rotators (infraspinatus and teres minor) and abductor (supraspinatus) muscles of the shoulder. This is most easily and safely performed using the varying resistance of a cliniband -- a length of flat rubber available from large chemists in varying resistances. You'll need about two meters; begin with the lowest resistance and workout!

To strengthen the right scapularis muscle, begin by holding your right arm from the side of your body with your elbow bent/ flexed at 90 degrees (the forearm will be at right angles to the upper arm and the line of the forearm points forward). Attach or loop one end of this cliniband above a door handle to the right of your own body and hold the other on your right hand. Internally rotate your humerus against the resistance of this cliniband (seen from above, the forearm moves in anti-clockwise direction towards the left) while maintaining your elbow bent at 90 degrees and at the side of your body. Let your forearm return to its starting place by the pull of the cliniband in a controlled manner.

The external rotators are strengthened from the opposite actions. From the same starting place but using the cliniband looped over a door handle to a left, externally rotate your right humerus from the immunity of the cliniband (viewed from above, the forearm moves in a clockwise direction to the right) while the elbow is again retained to the side of your system in 90 degrees. The forearm is again allowed to come back to the beginning position in a controlled fashion. Single sets include a minute of either internal or external rotation exercises and can be replicated three to five times a day. The cliniband needs to follow you around during the day! To strengthen the internal and external rotators of the left shoulder demands similar but mirror-image maneuvers.

Supraspinatus conditioning requires abduction work and initially should be carried out under shoulder level. The beginning position is quite different from the previous two exercises. To strengthen your proper supraspinatus, put one end of this cliniband beneath your left foot and then extend (keep straight) your right elbow. Hold the other end of the band on your hand and then internally rotate your right arm so that your right thumb points towards the floor and the back of your right hand faces forwards. Then, keeping your elbow extended, move your right arm away from your body (keeping the elbow straight) against resistance to just below shoulder level, and then let it go back to the beginning place in a controlled manner. An easy refinement is to unite pure abduction with just a little flexion so that you bring the arm forwards as you move it away from your side.

Pinch Your Scapulae Together

Pain shouldn't be felt through any of the three exercises. Three- to-five minute sets over the course of a day will generate a conditioning effect. By shortening the length of the band you will have the ability to progressively increase resistance. There are a massive number of variants on the exercises clarified that attain similar conditioning gains, and I make no claims for the superiority of their chosen three. But they have functioned well in my medical practice and infrequently cause unanticipated issues. Similar exercises could be performed using the pulley systems found in most gyms and with further adaptations can be done with free weights. Maintaining scapular retraction (the scapulae are 'pinched together' towards the middle of your spine and 'pushed down') while carrying out these exercises enables you to develop your scapular stabilizing muscles at the same time.

Strengthening the scapular stabilizers without specialist supervision is more difficult, but there is benefit from integrating wall leans (standing push-ups against a wall), knee push-ups and regular push-ups in any conditioning program. Seated rowing will strengthen the latissimus dorsi and should be undertaken while trying to keep scapular retraction.

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The information herein is not intended to replace a one-on-one relationship with a qualified health care professional, licensed physician, and is not medical advice. We encourage you to make your own health care decisions based on your research and partnership with a qualified health care professional. Our information scope is limited to chiropractic, musculoskeletal, physical medicines, wellness, sensitive health issues, functional medicine articles, topics, and discussions. We provide and present clinical collaboration with specialists from a wide array of disciplines. Each specialist is governed by their professional scope of practice and their jurisdiction of licensure. We use functional health & wellness protocols to treat and support care for the injuries or disorders of the musculoskeletal system. Our videos, posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate to and support, directly or indirectly, our clinical scope of practice.* Our office has made a reasonable attempt to provide supportive citations and has identified the relevant research study or studies supporting our posts. We provide copies of supporting research studies available to regulatory boards and the public upon request. We understand that we cover matters that require an additional explanation of how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please feel free to contact us. Dr. Alex Jimenez DC, MSACP, CCST, IFMCP*, CIFM*, ATN* email: phone: 915-850-0900 Licensed in: Texas & New Mexico*