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ROTATOR CUFF INJURIES
By Jamie Nuwer, MD.
Illustrated by Sierra Simmons

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Rotator cuff shoulder injuries are very common in Ultimate. The frequency of laying-out and falling leads to a high probability of landing on your arms. Landing on your hand, forearm or elbow are the most common mechanism for rotator cuff injuries. After such an injury, athletes often fail to fully rehabilitate a “bad shoulder” and end up with chronic pain. Here we will discuss the mechanism, diagnosis, and management of acute rotator cuff injuries, as well as proper rehabilitation to avoid chronic injury.  This column is not meant to replace medical evaluation for your health problems.  Always seek medical help for worrisome or persistent symptoms.

Cross section of the shoulder.
A = supraspinatus,
B = humerus,
C = bursa,
D = canal
There are four rotator cuff muscles. Supraspinatus is the most frequently injured. The supraspinatus muscle lifts your arm from your side to above your head. It attaches to the humerus through a small canal bordered at the top of your shoulder (see Figure 1). The tendon of supraspinatus travels through a fluid-filled sac called a bursa in order to slide smoothly through the canal. When you hit your arm on the ground, the supraspinatus tendon is jammed against the bones of the small canal. In response, the bursa swells to protect the supraspinatus tendon. This makes the canal even smaller, furthering the problem. The other rotator cuff muscles are also frequently injured with the supraspinatus since they all work together to stabilize the shoulder joint.

It’s easy to test yourself for a supraspinatus injury, the most common rotator cuff injury. Raise your arm from your side up to 45 degrees sideways. Then bring it forward 30 degrees. Have someone apply pressure to your forearm while you try to raise your shoulder up from that position. If it is painful or weak then supraspinatus is probably injured. If you cannot even place your arm in the test position, you may have completely torn your supraspinatus tendon and should consult a sports medicine doctor immediately.

Here are some tests for the other rotator cuff muscles. If you have a hard time reaching into your back pocket, a subscapularis injury is likely. To test infraspinatous and teres minor, flex your elbow to 90 degrees while holding it at your side. Rotate your fists outward against pressure. If you have pain or weakness you have likely injured your infraspinatous and teres minor. Your doctor might also try to approximate the amount of swelling in your bursa by testing for impingement, the medical term for the supraspinatus tendon getting smashed against shoulder canal.

Rotator cuff injury can sometimes be confused with a “separated shoulder” or a “shoulder sprain” both of which are injuries of the acromioclavicular (AC) joint. These injuries usually happens when the first point of ground contact is the top of one’s shoulder. A separated shoulder tears the ligaments holding the shoulder to the collarbone together. A shoulder sprain stretches the ligaments without tearing. Either of these injuries will hurt with all the rotator cuff muscle testing explained above. To differentiate a rotator cuff injury from an AC injury, reach across your chest to bring your injured arm’s elbow toward your opposite shoulder. If this hurts you likely have a AC injury. If you think you may have a shoulder sprain or separation, consult a sports medicine doctor before starting rehabilitation exercises.

Acute management of a shoulder injury should involve rest and ice. To rest your shoulder, pull your uninjured arm out of its sleeve and pull the bottom of the shirt up into a sling. If your stomach will tolerate it, use two of Aleve (naproxen) twice a day for 5 days. Take 5 days off and avoid any activities that may cause pain, especially any overhead reaching. Try to sit with good posture to keep your shoulder relaxed.

Shoulder rehabilitation exercises
Rehabilitation can begin immediately as long as the exercises are not painful. Start with the following exercises. Exercises 1-5 are diagramed in Figure 2 Ice afterwards.

1. Wand exercises: Grip the wand with both hands and move it as shown. Use a mirror to make sure both sides are even in A and B. 1 set of 10 for each exercise.
2. Shoulder raises: Shrug your shoulders up and hold for 5 seconds. Then bring your shoulders back as far as you can and hold for 5 seconds. Last bring your shoulders down and hold for 5. 1 set of 10.
3. Internal and external rotation: Keep your elbow at your side. Start with isometrics by pushing your fist against a wall for 5 seconds. Work up to the theraband, 3 sets of 10.
4. Supraspinatus: Make sure to keep your thumbs down! First do these exercises without a theraband. Just hold at the top for 5 seconds. Work up to the theraband, 3 sets of 10.
5. Theraband deltoid: Each exercise works a different part of the deltoid. Work up to 3 sets of 10.
6. Rotation with a weight:
Extend your arm sideways so that your hand is even with your shoulder. Bend your elbow to 90 degrees. Now rotate your fist forward and down without moving the position of your elbow. Return to starting position. 3 sets of 10 with increasing free weights.

You can safely return to playing when your injured shoulder has full range of motion without pain and has regained the same strength of your uninjured shoulder.

REFERENCES
Garrick and Webb. Sports Injuries. 1999

Rouzier, Pierre. Patient Advisor. 2004

Special thanks to Elmo Agatep, MD for his editing comments.




DISCLAIMER: The information contained on this website is not meant to be a substitute for evaluation by a qualified health care professional. The information provided here is meant for educational and informational purposes only. It should in no way be considered as formal medical advice for your health problems. You should consult a qualified health professional if you are seeking medical advice for an injury or illness. Go to the emergency room or call 911 for any severe injury or illness.