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What is the Rotator Cuff?
Many people are under the impression that the Rotator Cuff is an actual structure in the shoulder, and there could be many reasons for this. People come in for massage and tell me, through self diagnosis, that they have an injury to their “rotator cuff”. Sometimes their doctor gave them a diagnosis of a “rotator cuff” tear and this is what they present to me. And sometimes if you do not ask the doctor which rotator cuff muscle was injured, you will not know which one has been compromised. Or, you may be told which muscle, but the term is foreign, the concept unfamiliar, and you just don’t remember what was said exactly about the “rotator cuff”. So, let me offer some simple and technical information about this place in the shoulder, and the possibilities for injury and repair.
The rotator cuff is a name given to a group of four muscles. It is comprised of the Supraspinatus, the Infraspinatus, Teres Minor, and Subscapularis. They are often also called the SITS muscles… letters that stand for the first letter of each muscle (not to be confused with the “sit” bone, which is the bone we sit on at the base of our pelvis where our hamstrings attach). Before we explore these four muscles in greater detail, let’s first take a look at the shoulder in general.
The shoulder is the most vulnerable joint in the body; there is no ball and socket union, as in the hip. The humerus, or upper arm bone, literally just hangs off of the main skeleton. The support and general structure of the shoulder is held together by important ligaments and tendons. Ligaments are bone to bone attachments and tendons are bone to muscle attachments. There are also two bones that have similar attachments to the axial skeleton, or main skeletal structure. These two bones are the scapula or “wing bone” and the clavicle. The clavicle has a similarly vulnerable attachment to the sternum or “breast bone”, and the scapula is held in place over the rib cage by muscles and tendons only. So the shoulder is actually the union of the clavicle, the scapula, and the humerus via musculotendonous units and ligaments.
The most vulnerable position for the shoulder is when the upper arm is parallel to the shoulder and the lower arm is raised up with a 90 degree bend at the elbow (as if you were trying to make an L with your lower and upper arm bones, when the upper bone is above the head). This expression is often seen when the arm is in the middle range of a throw. Interestingly enough, we have created many sports that throw a ball, placing the shoulder in its weakest position with a great force.
There can be a wide range of other conditions that fall under the category of rotator cuff tears. The most frequent problems with these happen to the supraspinatus and the infraspinatus muscles. The infraspinatus is often injured because of heavy mechanical demands placed on it during the motion of abduction (or lifting of the arm at your side). In addition, it may be susceptible to chronic tearing of fibers form impingement underneath the acromion process (a boney prominence that extends from the scapula toward the shoulder).
Rotator cuff tears also occur form constant eccentric loading. One example of how this frequently happens is the deceleration of the shoulder and arm in the flow through phase after throwing something. The big powerful muscles of the front of the shoulder, such as pec’s major and the anterior deltoid are responsible for generating acceleration of the throwing arm. It is the responsibility of the teres minor and the infraspinatus, along with a few others, to slow down that motion during the follow through. This is a tremendous amount of force that these much smaller muscles are trying to decelerate; this is what is meant by eccentric loading. That is why the rotator cuff group of muscles are often torn.
The best means of determining the presence of a rotator cuff tear form physical examination will be a careful mix of blending together information from the active, passive, and manual resistive tests of the different motions of the shoulder in conjunction with a thorough history.
There are a number of ways to treat rotator cuff tears depending on their severity. A severe tear will often need to be treated with surgery. However, other conservative measures are often effective in gaining improvement. Strengthening other muscles of the shoulder girdle so that they can help in the mechanical demands is very useful. However, strengthening exercises which are engaged in too early may aggravate the problem more. It is most effective to address the soft tissue injury with stretching, massage, or some other treatment like acupuncture, that will allow the damaged tissue to heal properly first. Deep transverse friction massage and some other methods that involve massage with active or passive motions will get good results. Stretching, mobilization and range of motion exercises can then be encouraged. Once a degree of tissue repair and flexibility have returned, strengthening is much more likely to be effective.
And remember always, that increasing your circulation is key for the healing process. Bone itself has the greatest blood supply, tendons second because of there muscular union, and lastly, ligaments then have the poorest blood supply. Therefore, the healing process is greatly dependent on a great blood supply. You can always enhance your circulation with movement of any kind that does not aggravate the injury… use heat or heat and ice… get acupuncture and or massage… eat spicy foods…and don’t stop moving!
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