prevention and treatment of the rotator cuff injury....

 

Treatment:

Treatment of rotator cuff injuries focuses on decreasing pain and swelling of the tendon, preserving normal range of motion, and strengthening the shoulder muscles. The first goal of treatment is to preserve the ability to move the shoulder. In many people, a decreased ability to move the shoulder means that they use the joint less frequently, which can further reduce range of motion and lead to a frozen shoulder.

There are two basic options for treatment: conservative, non-surgical treatments and surgery.

Nonsurgical Treatment

In about 50% of patients, nonsurgical treatment relieves pain and improves function in the shoulder.

Nonsurgical treatment options may include:

• Rest. Your doctor may suggest rest and and limiting overhead activities. He or she may also prescribe a sling to help protect your shoulder and keep it still.

• Ice — Ice can be used to reduce the inflammation that often occurs in rotator cuff injuries. Ice can be applied over the upper and outer portion of the shoulder muscle for 15 to 20 minutes every four to six hours. The response to ice is variable since the rotator cuff tendons are located deep within the shoulder

• Activity modification. Avoid activities that cause shoulder pain.

• Non-steroidal anti-inflammatory medication. Drugs like ibuprofen and naproxen reduce pain and swelling.

• Steroid injection. If rest, medications, and physical therapy do not relieve your pain, an injection of a local anesthetic and a cortisone preparation may be helpful. Cortisone is a very effective anti-inflammatory medicine.

A cortisone injection may relieve painful symptoms.

Physical therapy:

Physiotherapy is often effective in treating acute (short-term) inflammation and chronic (long-term) degeneration of the cuff where a tear is not present. The first aim of treatment is to reduce the amount of inflammation using ice therapy, active rest and avoidance of exacerbating positions / postures.

 Small and medium size rotator cuff tears usually heal successfully with appropriate conservative management and physiotherapy treatment.

Once the inflammation and pain has settled, exercises to regain full movement can begin, followed by a carefully-graded strengthening and stabilising programme

 physical therapy should help to steadily develop your muscle flexibility and to strengthen and balance the shoulder muscles where necessary. The length required for the therapy will depend on the severity of the condition.

Your physiotherapist will discuss your goals, time frames and training schedules with you to optimise you for a complete return to sport or work.

  physical therapy interventions may include:

• Electrotherapy (e.g. ultrasound) ,electrical stimulation,TENS,other electrical modalities {depends on patient condition}
• Exercise therapy and range-of-motion exercises may be helpful in maintaining shoulder function and strength
• joint mobilization
• ice or heat treatment
• the use of a sling
• Taping
• progressive exercises to improve flexibility and strength (particularly the scapular stabilizers and rotator cuff muscles)
• hydrotherapy
• education
• training and activity modification advice
• postural correction

•  Restore High Speed, Power, Proprioception & Agility,
• devising and monitoring a return to sport or activity plan.

The following exercises are commonly prescribed to patients with this condition. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them.

 Generally, they should be performed 2 - 3 times daily and only provided they do not cause or increase symptoms.


Your physiotherapist can advise when it is appropriate to begin the initial exercises and eventually progress to the intermediate, advanced and other exercises. As a general rule, addition of exercises or progression to more advanced exercises should take place provided there is no increase in symptoms.

Exercises for your shoulder

The goal is for you to function as well as possible with little or no pain. To do this, your physical therapist will:

• Help you strengthen and stretch the muscles around your shoulder
• Teach you proper ways to move your shoulder, for everyday tasks or sports activities

Most exercises for your shoulder either stretch or strengthen (make stronger) the muscles and tendons of your shoulder joint.
Exercises to stretch your shoulder include:

• Stretching the back of your shoulder (posterior stretching)

 

• Hand up your back stretch (anterior shoulder stretch) 

• Anterior shoulder stretch - towel

• Pendulum exercise[codmans exercises]

 Begin leaning forwards with your uninjured forearm supported on a table or bench. Keeping your back straight and your shoulder relaxed, gently swing your injured arm forwards and backwards as far as you can go without pain and provided you feel either nothing, or, no more than a mild to moderate stretch Repeat 10 times provided the exercise does not cause or increase symptoms. Repeat the exercise swinging your arm side to side provided it is pain free. 

Pendular Circles

Begin leaning forwards with your uninjured forearm supported on a table or bench. Keeping your back straight and your shoulder relaxed, gently swing your arm in circles clockwise as far as you can go without pain and provided you feel either nothing, or, no more than a mild to moderate stretch . Repeat the exercise swinging your arm counter clockwise. Repeat 10 times in each direction provided the exercise does not cause or increase symptoms.

• Wall stretches

Foam Roller Stretch

Place a foam roller under your upper back as demonstrated . Breathe normally keeping your back and neck relaxed. Hold this position for 15 – 90 seconds provided it is comfortable and does not cause pain. 

Exercises to strengthen your shoulder 

• Wand exercise, Flexion: Stand upright and hold a stick in both hands, palms down. Stretch your arms by lifting them over your head, keeping your arms straight. Hold for 5 seconds and return to the starting position. Repeat 10 times.

• Wand exercise, Extension: Stand upright and hold a stick in both hands behind your back. Move the stick away from your back. Hold this position for 5 seconds. Relax and return to the starting position. Repeat 10 times.

• Wand exercise, External rotation: Lie on your back and hold a stick in both hands, palms up. Your upper arms should be resting on the floor with your elbows at your sides and bent 90 degrees. Use your uninjured arm to push your injured arm out away from your body. Keep the elbow of your injured arm at your side while it is being pushed. Hold the stretch for 5 seconds. Repeat 10 times.

• Wand exercise, Shoulder abduction and adduction: Stand and hold a stick with both hands, palms facing away from your body. Rest the stick against the front of your thighs. Use your uninjured arm to push your injured arm out to the side and up as high as possible. Keep your arms straight. Hold for 5 seconds. Repeat 10 times.

Basic Rotator Cuff Exercises

·         To begin with, the following basic rotator cuff strengthening exercises should be performed approximately 3 times daily. As your strength improves, the exercises can be progressed by gradually increasing the repetitions, frequency or duration of the exercises provided they do not cause or increase pain.

·         Static Rotator Cuff Push Out 

·         Begin this exercise standing with your back and neck straight and your shoulders back slightly. Keeping your elbow at your side and bent to 90 degrees, push your hand out against the other hands resistance as hard as possible provided it is pain free . Hold for 5 seconds and repeat 10 times. Perform on each side.

·        

·          Static Rotator Cuff Push Out (right arm)

             Static Rotator Cuff Push In 

·         Begin this exercise standing with your back and neck straight and your shoulders back slightly. Keeping your elbow at your side and bent to 90 degrees, push your hand in against the other hands resistance as hard as possible provided it is pain free . Hold for 5 seconds and repeat 10 times. Perform on each side

·        

·        Static Rotator Cuff Push In (right arm)

isometric exercises to the shoulder

Resistance exercises with the thera band:

 

• The following rotator cuff strengthening exercises should generally be performed 1 - 3 times per week provided they do not cause or increase pain. Ideally they should not be performed on consecutive days, to allow muscle recovery. As your strength improves, the exercises can be progressed by gradually increasing the repetitions, number of sets or resistance of the exercises provided they do not cause or increase pain.

Internal rotation exercise - with band 

External and internal lateral rotation using cables or stretch bands. With the arm bent at the elbow, swing outward (rotation), then inward by reversing stance. Load the cable or band so that some light resistance is applied.

• External rotation exercise - with band

• Wall push-ups 

• Shoulder blade (scapular) retraction - no tubing

Begin this exercise standing or sitting with your back straight. Your chin should be tucked in slightly and your shoulders should be back slightly. Slowly squeeze your shoulder blades together as hard and far as possible provided it does not cause or increase symptoms. Hold for 5 seconds and repeat 10 times.

• Shoulder blade (scapular) retraction - tubing

• Arm reach

Empty the can. Hold a very light dumbbell out in front (anterior raise) and rotate the arm inward (medially) to simulate pouring fluid from a can.

Before doing exercises at home, ask your doctor or physical therapist to make sure you are doing them properly. If you have pain during or after an exercise, you may need to change the way you are doing the exercise.

Taping to the shoulder/rotator cuff:

Using your shoulder

Learn how to care for your shoulder to avoid placing extra stress on it. This can help you heal from an injury and avoid re-injury.


Your positions and posture during the day and night can also help relieve some of your shoulder pain:

• When you sleep, lie either on the side that is not in pain or on your back. Resting your painful shoulder on a couple of pillows may help. 

• When sitting, use good posture. Keep your head over your shoulder and place a towel or pillow behind your lower back. Keep your feet either flat on the floor or up on a foot stool.

Other tips for taking care of your shoulder include:

• Do not carry a backpack or purse over just one shoulder.
• Do not work with your arms above shoulder level for very long. If needed, use a foot stool or ladder.
• Lift and carry objects close to your body. Try not to lift heavy loads away from your body or overhead.
• Take regular breaks from any activity you do over and over again.
• When reaching for something with your arm, your thumb should be pointing up.
• Store items you use everyday in places you can reach easily.
• Keep things that you use a lot, such as your phone, with you or close by to avoid reaching and re-injuring your shoulder.

Returning to sports

It is best to avoid playing sports until you have no pain during rest or activity. Also, when examined by your doctor or physical therapist, you should have:

• Full strength in the muscles around your shoulder joint
• Good range of motion of your shoulder blade and upper spine
• No pain during certain physical exam tests that are meant to provoke pain in someone who has rotator cuff problems
• No abnormal movement of your shoulder joint and shoulder blade

Returning to sports and other activity should be gradual. Ask your physical therapist about the proper technique you should use when doing your sports or other activities that involve a lot of shoulder movement.

 Exercises that place higher stress on the rotator cuff should probably be avoided or at least performed with lighter weights if you know your shoulder is susceptible to injury, or if an injury is already present. Avoid these and similar exercises:

• Lateral raise -- lifting weights (dumbbells, kettlebells) to the side
• Anterior raise -- lifting weights to the front
• Overhead press -- this exercise is probably not as stressful as the previous two
• Bench press done with excessive range of motion. Don't lower the elbows below parallel; pretend you're on a flat surface.

If a rotator cuff muscle has become severely torn then a doctor might recommend minor surgery.

The chief advantage of nonsurgical treatment is that it avoids the major risks of surgery, such as:

• Infection
• Permanent stiffness
• Anesthesia complications
• Sometimes lengthy recovery time

The disadvantages of nonsurgical treatment are:

• No improvements in strength
• Size of tear may increase over time
• Activities may need to be limited

Surgical Treatment

Your doctor may recommend surgery if your pain does not improve with nonsurgical methods. Continued pain is the main indication for surgery. If you are very active and use your arms for overhead work or sports, your doctor may also suggest surgery.

Other signs that surgery may be a good option for you include:

• Your symptoms have lasted 6 to 12 months
• You have a large tear (more than 3 cm)
• You have significant weakness and loss of function in your shoulder
• Your tear was caused by a recent, acute injury

Surgery to repair a torn rotator cuff most often involves re-attaching the tendon to the head of humerus (upper arm bone). There are a few options for repairing rotator cuff tears. Your orthopaedic surgeon will discuss with you the best procedure to meet your individual health needs.

Summary

Chances are you will suffer a shoulder injury of the rotator cuff or capsule at some time. As we age, such injuries seem to be more frequent, sometimes occurring for no discernible reason. As inconvenient as they are, don't panic, be patient, and seek medical advice at first signs. Moderate rotator cuff injuries are inconvenient and sometimes painful and disabling, but rarely without remedy.

Injured Rotator Cuff of the Shoulder

The shoulder joint (and its connective muscles, tendons, and ligaments) has a greater range of motion than all other joints. It can allow your arm to move outward to the side, forward and back, do circles in a windmill fashion, and rotate your arm from palm up to palm down. No other joint allows all these movements.

However, the complex anatomical structure that allows such flexibility of movement also makes the shoulder joint somewhat susceptible to injury. The cluster of muscles and connections that facilitates this movement is called the rotator cuff. 

    The muscles of the rotator cuff are:

• Teres minor 
  
• Subscapularis

• Infraspinatus  

•    Supraspinatus (SITS) muscles, helps stabilize the humeral head in the glenoid fossa of the scapula during overhead arm motions (eg, pitching, swimming, weightlifting, serving in racket sports)

 These muscles control the shoulder girdle and its movement. Injury can occur when muscles are strained, torn, or inflammation occurs in the joint as a result of damage.

Description:

When one or more of the rotator cuff tendons is torn, the tendon no longer fully attaches to the head of the humerus. Most tears occur in the supraspinatus muscle and tendon, but other parts of the rotator cuff may also be involved.

There are different types of tears.

• Partial Tear. This type of tear damages the soft tissue, but does not completely sever it.
   
• Full-Thickness Tear. This type of tear is also called a complete tear. It splits the soft tissue into two pieces. In many cases, tendons tear off where they attach to the head of the humerus. With a full-thickness tear, there is basically a hole in the tendon
  
  
  
  
  

           A rotator cuff tear most often occurs within the tendon.

Cause:

There are two main causes of rotator cuff tears: injury and degeneration.

Acute Tear:

If you fall down on your outstretched arm or lift something too heavy with a jerking motion, you can tear your rotator cuff. This type of tear can occur with other shoulder injuries, such as a broken collarbone or dislocated shoulder.

Degenerative Tear:

Most tears are the result of a wearing down of the tendon that occurs slowly over time. This degeneration naturally occurs as we age. Rotator cuff tears are more common in the dominant arm. If you have a degenerative tear in one shoulder, there is a greater risk for a rotator cuff tear in the opposite shoulder -- even if you have no pain in that shoulder.

Several factors contribute to degenerative, or chronic, rotator cuff tears.

• Repetitive stress. Repeating the same shoulder motions again and again can stress your rotator cuff muscles and tendons. Baseball, tennis, rowing, and weightlifting are examples of sports activities that can put you at risk for overuse tears. Many jobs and routine chores can cause overuse tears, as well.

• Lack of blood supply. As we get older, the blood supply in our rotator cuff tendons lessens. Without a good blood supply, the body's natural ability to repair tendon damage is impaired. This can ultimately lead to a tendon tear.

• Bone spurs. As we age, bone spurs (bone overgrowth) often develop on the underside of the acromion bone. When we lift our arms, the spurs rub on the rotator cuff tendon. This condition is called shoulder impingement, and over time will weaken the tendon and make it more likely to tear.

      

 Tendinitis  typically results from chronic impingement of the supraspinatus tendon between the humeral head and coracoacromial arch (the acromion, acromioclavicular joint, coracoid process, and coracoacromial ligament). Activities that require the arm to be moved over the head repeatedly, such as pitching in baseball, lifting heavy weights over the shoulder, serving the ball in racket sports, and swimming freestyle, butterfly, or backstroke, increase the risk. 

·                                         The resultant inflammatory reaction and edema further narrow the subacromial space, accelerating tendon irritation or damage. If the process is not interrupted, the resulting inflammation can lead to partial or complete tear of the rotator cuff. Degenerative rotator cuff tendinitis is common among older (> 40 yr) people who are not athletes for the same reason.

·        

        subacromial bursitis  (inflammation, swelling, and fibrosis of the bursal area above the rotator cuff) commonly results from tendinitis of the cuff.

Risk Factors

Because most rotator cuff tears are largely caused by the normal wear and tear that goes along with aging, people over 40 are at greater risk.

People who do repetitive lifting or overhead activities are also at risk for rotator cuff tears. Athletes are especially vulnerable to overuse tears, particularly tennis players and baseball pitchers. Painters, carpenters, and others who do overhead work also have a greater chance for tears.

Although overuse tears caused by sports activity or overhead work also occur in younger people, most tears in young adults are caused by a traumatic injury, like a fall.

Symptoms and signs:

The most common symptoms of a rotator cuff tear include:

• Pain at rest and at night, particularly if lying on the affected shoulder
• Pain when lifting and lowering your arm or with specific movements
• Weakness when lifting or rotating your arm
• Crepitus or crackling sensation when moving your shoulder in certain positions

Tears that happen suddenly, such as from a fall, usually cause intense pain. There may be a snapping sensation and immediate weakness in your upper arm.

A rotator cuff injury can make it painful to lift your arm out to the side.

Tears that develop slowly due to overuse also cause pain and arm weakness. You may have pain in the shoulder when you lift your arm to the side, or pain that moves down your arm.

 At first, the pain may be mild and only present when lifting your arm over your head, such as reaching into a cupboard. Over-the-counter medication, such as aspirin or ibuprofen, may relieve the pain at first.

Over time, the pain may become more noticeable at rest, and no longer goes away with medications. You may have pain when you lie on the painful side at night.

 The pain and weakness in the shoulder may make routine activities such as combing your hair or reaching behind your back more difficult

Subacromial bursitis, rotator cuff tendinitis, and partial rotator cuff tears cause shoulder pain, especially when the arm is moved overhead. 

The pain usually is worse between 60° and 120° (painful arc of motion) of shoulder abduction or flexion and is usually minimal or absent at < 60° or > 120°. The pain may be described as a dull ache that is poorly localized. Complete rotator cuff tears result in acute pain and weakness of the shoulder. In larger tears of the rotator cuff, weakness of external rotation is particularly apparent.

Suspected rotator cuff injury can be further evaluated with MRI, arthroscopy, or both Medical History and Physical Examination

Diagnosis is by history and physical examination, including provocative maneuvers. The rotator cuff cannot be palpated directly, but it can be assessed indirectly by provocative maneuvers that test its individual components; significant pain or weakness is considered a positive result

Other areas that may be the source of shoulder pain include the acromioclavicular and sternoclavicular joints, cervical spine, biceps tendon, and scapula. These areas should be assessed for any tenderness or deformity indicating a problem in those areas.

The neck is examined as part of any shoulder evaluation because pain can be referred to the shoulder from the cervical spine (particularly with C5 radiculopathy).

 Imaging Tests

Other tests which may help your doctor confirm your diagnosis include:

• X-rays. The first imaging tests performed are usually x-rays. Because x-rays do not show the soft tissues of your shoulder like the rotator cuff, plain x-rays of a shoulder with rotator cuff pain are usually normal or may show a small bone spur.

• Magnetic resonance imaging (MRI) or ultrasound. These studies can better show soft tissues like the rotator cuff tendons. They can show the rotator cuff tear, as well as where the tear is located within the tendon and the size of the tear. An MRI can also give your doctor a better idea of how "old" or "new" a tear is because it can show the quality of the rotator cuff muscles.

please refer  my next blog:

Prevention and Treatment of the rotator cuff Injuries to the Shoulder.........