By Jamie Nuwer, MD.
Illustrated by Sierra Simmons
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Rotator cuff injuries are very common in Ultimate. The frequency of diving and falling leads to a high probability of banging your arm and shoulder when landing, the most common mechanism for rotator cuff injuries. Often players 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.

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 by the bones at the top of your shoulder and their ligaments (see Figure 1). The tendon of supraspinatus, like most tendons, travels through a fluid filled sac called a bursa in order to slide smoothly through the canal. When you hit your arm and shoulder on the ground, the supraspinatus tendon is likely to be jammed up 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 using the “empty can” test. Fully extend your arm to shoulder height at your side, then rotate it forward 30 degrees. Point your thumb down (empty the can) and have someone press down on your hand. Then put your thumb up and have someone press down on your hand again. If it was weaker and hurt more the first time, then supraspinatus is probably involved in your shoulder injury. If you cannot even place your arm in the “empty can” test position, you may have completely torn your supraspinatus tendon -- consult a physician. 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. If you flex your elbow to 90 degrees at your side, you can test infraspinatus and teres minor by rotating your fists outward against pressure. Look for pain and weakness. 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 the bones and ligaments in the canal.

Rotator cuff injury can sometimes be confused with another diving/falling injury: shoulder separation also called acromioclavicular (AC) joint separation. This injury usually happens when the first point of contact is the front of one’s shoulder, and involves the ligaments holding the top shoulder bones together. This injury can hurt with the empty can test too. In this case you will also have pain when you reach across your chest and when you push on the involved bones. If you think you may have a shoulder separation, consult a medical professional before initiating rehabilitation exercises.

Acute management of a shoulder injury should involve RICE (Rest, Ice, Compress, and Elevate). 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 600-800 mg of ibuprofen for its anti-inflammatory and analgesic effects 3 times a day for 5 days. When using ibuprofen, do not play! Take those 5 days off and avoid any activities that may cause pain, especially any overhead reaching. Ice for 15 minutes 1-3 times a day or more if it hurts. Try to sit with good posture to keep your shoulder relaxed.

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.