Maven Sports Medicine effectively combines our high standard of orthopedic rehabilitation practice with our clear understanding of elite fitness and sports performance. Maven’s Doctors of Physical Therapy have decades of combined practice experience in orthopedic rehabilitation, sports strength/conditioning, fitness, and athletic training. Our dedication to providing excellent evidence-based care to all our active and athletic patients remains consistent.

As mentioned briefly, the rotator cuff is comprised of four muscles: supraspinatus, infraspinatus, teres minor, and subscapularis (S.I.TS.). These muscles attach to the upper portion of the humerus. Collectively, the primary role of the rotator cuff is to protect the shoulder joint during movement, particularly during overhead activities.

Generally speaking, the rotator cuff is poorly vascularized as compared to other musculotendinous complexes. As a result, when injured, the ability of the rotator cuff to sustain its structural integrity may be more limited.

There are several ways a tear can occur- trauma, overuse with overhead activities, impingement (read above), and tendonitis:

• Trauma: Trauma to the rotator cuff often occurs when an abrupt force is applied to the arm in an overhead or out-to-the-side position.
  
  • Overuse with overhead activities: As with other overuse injuries, tendons undergo high repetition over long periods of time, they may wear down to the point where they begin to weaken. As the activity continues, the tendon may eventually tear, causing significant pain or discomfort. However, rotator cuff tears may occur with performing innocuous everyday activities that involve repetitive reaching.
  • Impingement Syndrome: Though a discussion of impingement syndrome was discussed earlier, chronic impingement syndrome can result in RTC tears, especially when a "hooked" acromion is present; this congenital variant in acromion shape can wear down the RTC tendons further when pathology is present.
  • (Chronic) Tendonitis- When tendonitis is managed early, the repercussions are far fewer than when it lingers and is not managed well. As tendons heal from an acute injury, scar tissue is laid down, causing the area to become more stiffened. Scar tissue itself, is less elastic and therefore, less resilient to stresses and demands that may be placed on the shoulder. As a result, when repetitive stresses continue to be placed on the region, the tissue becomes more likely to tear over time.



• Physical therapy intervention- especially when activity-related, it is imperative to make either ergonomic or movement modifications to the provocative activity. Active rest is greatly encouraged to prevent worsening of pain. Avoiding overhead and reaching activities are also imperative, particularly in the short term. Passive modalities may be used initially to help with acute injury to the tendons. Joint mobilization and soft tissue mobilization may be effective in correcting the positional faults that may be causing the shoulder to be in a provocative position.



• Prognosis- For a rotator cuff tear, the ability of the tendon to repair itself is generally poor, due to its poor vascular supply, but is even worse if the size of the tear is greater than 3-5 mm. Partial-thickness tears can be managed well with physical therapy when the size of the tear is <3-5 mm.

Subacromial Bursitis

Subacromial bursitis may be more difficult to tease out initially after an acute or traumatic injury to the shoulder because other structures may be involved as well. Bursitis occurs when the bursa becomes irritated by activity; the subacromial space is very small and is unforgiving when it comes to repetitive stress. When prior inflammation exists in the region, the bursa may be further compressed during activity, which may lead to irritation and pain.

• Medical intervention- If the symptoms are acute, then a cortisone injection may be indicated.
• Physical therapy intervention- activity modification (rest) is necessary in the acute phase, bursitis is usually treated with passive modalities, particularly, the ultrasound device at a pulsed setting or phonophoresis (transdermal method of cortisone delivery) and cryotherapy. Iontophoresis may also be indicated.
• Prognosis- Typically, a very good outcome can be achieved when addressed early.

References:

D’Hespeel, C. (2004) Orthopedic Physical Therapy Practice, 16(3) pp.9-14
McFarland, H,, Keyurapan, E (2006). The Journal Of Bone & Joint Surgery, 88-A (2).