We’ve done a few blogs on the rotator cuff. Either it’s because we like writing about the shoulder or a lot of people in Burlington have shoulder pain. Regardless, this week’s blog will clarify a very important function of the rotator cuff for our readers (including our Burlington patients)…compression and depression.

We frequently see ultrasound reports at our Burlington physiotherapy and chiropractic clinic describing damage to the rotator cuff. This ranges from complete tears to partial tears, or simply just tendinopathy (or tendinitis as many call it). The pain and weakness experienced by these patients can vary. Perhaps the most obvious sign of significant rotator cuff injury would be difficulty with movements like abduction, internal and external rotation. What many people don’t realize is that another, very important function of the rotator cuff can be affected; compression and depression.

If you look at the picture below, you’ll see the arrows of force that I drew on the scapula (also known as the shoulder blade). These arrows show a downward and inward force that the rotator cuff muscles provide. This is very important for normal shoulder movement. This force allows a smooth contact of the shoulder joint surfaces. If this doesn’t happen, the humerus (bone in the upper arm) sits too high in the joint. When this occurs (and when we elevate our arms) everything above that bone in the shoulder gets squished, a condition called impingement. A person with shoulder impingement may report pain with overhead activities or exercises (like shoulder press or bench press). Think of it another way; imagine the bone sits in a groove that is shaped like a pear. At rest, the humerus (arm bone) sits in the top, narrow portion of the pear. When the rotator cuff muscles contract, they pull the humerus (arm bone) down into the wider portion of the pear. This gives the bone a larger area to move in. When the rotator cuff is dysfunctional, the humerus (arm bone) may still be sitting in the narrow portion of the pear while trying to move. Not surprising then that your shoulder gets sore with repetitive overhead work or even push-ups!

Compression and Depression of the bone into the bottom portion of the pear to avoid impingement of the shoulder during arm movement…

So what is the solution? Treatment is often geared toward restoring normal movements of the shoulder and eliminating muscle imbalances. This gives the humerus a fighting chance at moving in the normal part of the “pear”. In most cases, this requires clinical treatment. Along with this treatment though, strengthening of the rotator cuff muscles is usually an essential component of care. If the rotator cuff muscles aren’t performing their role of compression and depression, it’s unlikely that normal joint motion can occur and is therefore more than likely that pain and dysfunction will persist or occur at some point.

References

Hyde TE, Gengenbach MS.  Conservative Managememt of Sports Injuries 2nd Ed. 2007  Jones and Bartlett.

Many people don’t realize that our shoulder muscles (in particular the rotator cuff muscles) can wear down with time. The concept of rotator cuff degeneration is now a well established explanation for shoulder pain for many patients over the age of 40.

Rotator Cuff Injury is Progressive

There are different theories as to how the aging rotator cuff gets injured. Sure, there can be a spectacular event which initiates all the pain, but there doesn’t have to be. For many people, an “event” of injury is what they relate the symptoms to, but there was years of tendon degeneration already occurring which perhaps made the injury inevitable.  Tendon degeneration can be considered progressive.  Over time it gets worse and worse, where at the far end of progression is a complete tear of a rotator cuff tendon.

Causes of Rotator Cuff Degeneration

The factors that cause rotator cuff degeneration can be divided into two main categories; intrinsic factors and extrinsic factors.  An example of an extrinsic factor would be a surrounding structure compressing a rotator cuff tendon, whereas an intrinsic factor would be that the tendon is degenerating because of the inherent characteristics of that tendon itself.  This may be a little too technical for our average reader, so we’ll just review some of the basic reasons our shoulder muscles (namely the rotator cuff muscles) degenerate. This may assist you in learning how to keep your shoulders healthy!

Tendon Compression

Rotator cuff tendons are susceptible to degeneration when they are repeatedly subjected to compression.  This can occur for various reasons.   Some of us have a unique shape to the bones in our shoulder which can lead to tendon compression.  For others, degenerative arthritis (and the bone spurs related to arthritis) are the real problem.  These bone spurs have the ability to compress muscles and tendons leading to advanced tendon degeneration.  Muscle tightness can also cause problems.  For various reasons, some of us get tight in certain areas of the shoulder.  This can lead to the development of altered movement patterns in the joint and can eventually cause tendons to get compressed. In each of these scenarios, the tendon gets compressed and is subjected to wearing down or degeneration.

Age Related Shoulder Pain

For many of us, the activities we choose place an enormous demand on our shoulder muscles. This demand can often outweigh the ability of the tendon to repair itself. What results is a net breakdown of the tendon…this is rotator cuff degeneration in a nutshell. Unfortunately age plays a large role. The literature suggests that those people over the age of forty have a reduced ability to keep up with this degeneration / rebuilding process and perhaps explains the prevalence of shoulder pain in those over forty.

Treatment for Rotator Cuff Degeneration

With respect to treating rotator cuff degeneration, it’s important to combine all the information and formulate a plan that reflects your specific situation. For example, if you’re over the age of 40, have bony changes in the shoulder joint on your x-rays, you show altered movement patterns on examination and you like doing dumbbell shoulder press exercises, it may be necessary to get some professional help. Consulting with one of our physiotherapists or chiropractors may be helpful in limiting the rate of degeneration. This can be accomplished through the prescription of the appropriate rehabilitative exercises, guidance with exercise selection or therapeutic treatment using modalities like laser therapy or active release technique.

For more information about our services and the ways we treat rotator cuff degeneration, shoulder pain or shoulder impingement, please call us or email at info@burlingtonsportstherapy.com.

References
Nho S, Yadav H et al. Rotator cuff degeneration etiology and pathogenesis. American Journal of Sports Medicine. 2008; 36(5): 987-993.
Seitz AL, McClure PW, Finucane S et al. Mechanism of rotator cuff tendinopathy: intrinsic, extrinsic or both? Clinical Biomechanics 2011; 26: 1-12.

The rotator cuff is a general term used to describe four muscles in the shoulder that lie deep to the deltoid muscles. These muscles include the infraspinatus, supraspinatus, teres minor and subscapularis. Of these muscles, the supraspinatus is the most commonly injured.

Supraspinatus Tendon

The supraspinatus muscle is located on the top and back of your shoulder / shoulder blade. It does various functions, most notably bringing your arm up from your side. Shoulder pain is often due to supraspinatus Injury. It can occur in the tendon area of the supraspinatus tendon and can range from tendinosis to a tear.

Typical Pain Pattern For the Supraspinatus

Strengthening for the Supraspinatus

Traditionally it has been thought that “empty can” movement is what best challenges the supraspinatus muscle. To perform this exercise you would move your arm to approximately 45 degrees between your front and side and bring your arm upwards (with your thumb down).

What is the best way to Strengthen the Supraspinatus?

A 2007 study published in the Journal of Athletic Training investigated the activity of the supraspinatus during various exercises. The exercises investigated were the standing full can (thumb up), standing empty can (thumb down) and prone full can (lying on the stomach with the thumb up). The results found that each exercise activated the supraspinatus to the same extent; however the standing full can isolated the supraspinatus the best.

Conflicting Results?

To cloud the picture, a different study published in 2009 found that the supraspinatus was activated equally with various exercises but the deltoid activity was decreased with the prone full can exercise. Unfortunately, this is an example of two studies with different results and therefore different specific recommendations for isolating the supraspinatus. Regardless, it seems that either the standing full can exercise or the prone full can exercise may be your best options, depending on the patient’s symptoms. It seems that the balance of the literature is no longer advocating empty can testing or strengthening for specifically isolating the supraspinatus muscle. Keeping the thumb upwards (full can) seems to be a better option for rehabilitating or investigating the integrity of the supraspinatus.

Treatment for Shoulder Pain

Our clinic uses a variety of treatment methods for injury to the rotator cuff muscles (like the supraspinatus). Active Release, Laser Therapy, Graston, IFC (interferential current) and acupuncture are frequently used for this condition.

For more information or for an appointment with our chiropractor or physiotherapist, please call or email us. info@burlingtonsportstherapy.com

References
Boettcher CE, Ginn KA, Cathers I. Which is the optimal exercise to strengthen the supraspinatus? Medicine & Science in Sports & Exercise 2009; 41(11): 1979-1983.
Brookham R et al. Construct validity of muscle force tests of the rotator cuff muscles: an electromyographic investigation. Physical Therapy 2010; 90(4): 572-580.
Hughes PC, Taylor NF, Green RA. Most clinical tests cannot accurately diagnose rotator cuff pathology: a systematic review. Australian Journal of Physiotherapy 2008; 54: 159-170.
Kibler WB et al. Electromyographic analysis of specific exercises for scapular control in early phases of shoulder rehabilitation. American Journal of Sports Medicine 2008; 36(9): 1789-1798.
Reinold MM, Macrina LC, Fleisig GS, Ellerbusch MT. Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises. Journal of Athletic Training 2007; 4: 464-469.
Reinold MM, Escamilla R, Wilk KE. Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature. Journal of Orthopaedic and Sports Physical Therapy 2009; 39(2): 105-117.
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The supraspinatus, infraspinatus, teres minor and subscapularis muscles are often referred to as the rotator cuff muscles. Injury to the rotator cuff musculature is one of the more common conditions affecting the shoulder, ranging from mild strains to complete tendon rupture.

Symptoms of Supraspinatus Tear

Rotator cuff injury (including rotator cuff tear) can cause significant pain, weakness and reduced range of motion. Quite often, it causes difficulty with common daily tasks like putting your arm in a coat sleeve, putting your seat-belt on or reaching in the back seat of your car. Of course, there are many different conditions affecting the shoulder that can make these daily activities difficult and painful, so it is important to have this condition properly diagnosed.

Diagnosing Shoulder Pain

Soft tissue imaging (like diagnostic ultrasound or magnetic resonance imaging) is the optimal way to diagnose rotator cuff tears. Unfortunately, there is often a waiting list for these diagnostic tests so the preliminary diagnosis is made clinically in your health practitioner’s office. This is not always a simple step, since the commonly used clinical tests are not always easy to interpret. According to the scientific literature, there does not seem to be a reliable correlation between symptoms and tearing of the rotator cuff muscles. In other words, studies have found that many patients with minimal pain and normal function of the shoulder often have imaging results indicating partial thickness tear of the supraspinatus or full thickness tear of the supraspinatus.

Rotator Cuff Treatment

Consulting with a knowledgeable and skillful diagnostician can eliminate wasted time by deciphering which tissue is likely damaged and focusing treatment on the appropriate structures as quickly as possible.  That’s the first step as it helps to determine what avenue of treatment is best.  For some, surgery is necessary.  For most, conservative treatment like physiotherapy or chiropractic is the best choice.  What is right for you?  There are many factors to consider and we can assist you with that process.  For example, a recent injury might benefit from laser therapy or gentle exercises with our physiotherapist.  For others with more chronic rotator cuff injury (like supraspinatus tendinosis or tendinopathy) active release or graston technique with one of our chiropractors would be the best treatment.  Unsure?  Give us a call or send us an email…we can help you!  905.220.7858  email - info@burlingtonsportstherapy.com

References

Ainsworth R, Lewis JS. Exercise therapy for the conservative management of full thickness tears of the rotator cuff: a systematic review. British Journal of Sports Medicine 2007; 41: 200-210.

Uhthoff HK, Sarkar K. An algorithm for shoulder pain caused by soft-tissue disorders. Clin Orthop Relat Res 1990; 254: 121-127.

Frost P, Andersen JH et al. Is supraspinatus pathology as defined by magnetic resonance imaging associated with clinical sign of shoulder impingement? Journal Shoulder Elbow Surgery 1999; 8(6): 565-568.

Schibany N, Zehetgruber H, Kainberger F et al. Rotator cuff tears in asymptomatic individuals: a clinical and ultrasonographic screening study. Eur J. Radiol; 2004; 51(3): 263-268.

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There is no question that the bench press is a very popular exercise for strengthening the pectorals. Although effective, this exercise can prove painful for many people so attention needs to be given to proper technique. Here are a few tips that are supported by published research…

Shoulder Tendons and Benching Too Low…

That burning stretch you feel at the bottom of the bench press is not necessarily the good type of “burn”. If you lower the bar to touch your chest, you’re likely to be straining the end of the pectoral muscle at the musculotendinous junction instead of targeting the pectoral muscle tissue. It’s recommended that you keep the bar 4 to 6 centimetres above your chest when performing this exercise. You can roll up a towel and place it on your chest if you need the reminder!

Shoulder Ligament Injury and a Wide Grip

A grip that is too wide forces your shoulder into excessive external rotation. This can damage the passive structures in the front of your shoulder joint leading to chronic capsular laxity. If you’re someone who has dislocated your shoulder in the past or if you are known to have “loose” joints, a wide grip may increase the likelihood for certain types of injury. The recommended grip width is no wider than 1.5 times your acromial width (the acromions are the bumps on the top of your shoulder). Worried that this will reduce your strength too much? According to the literature, you should expect only a 5% deficit in strength with this change.

Chronic Shoulder Injury and Flat Bench Press

When you place the bench on an incline it forces your shoulder into external rotation. If you’re someone with a structural deficit in the front of the shoulder joint (perhaps due to the aforementioned laxity or a history of dislocation) you’ll find that this increases the likelihood of pain or injury. Try keeping the bench flat and see if that makes a difference. Worried about strengthening your upper chest? According to some literature, inclining the bench does not alter the activity of the upper pectoral. Instead, it decreases the activation of the sternal portion of the pectoral (in the midline of your chest).

Treatment for Shoulder Pain

Our chiropractic and physiotherapy clinic in Burlington can help you with your shoulder pain. We offer various methods of treatment; which one is best for you depends on a variety of factors. For more information please contact us at 905.220.7858 or email us at info@burlingtonsportstherapy.com

References

Glass SC, Armstrong T. Electromyographical activation of the pectoralis muscle during incline and decline bench press. Journal of Strength and Conditioning Research 1997; 11: 163-167.

Green C, Comfort P. The affect of grip width on bench press performance and risk of injury. Strength and Conditioning Journal 2007; 29 (5): 10-14.

Lantz J, McCrain M. Modifying chest press exercises for athletes with shoulder pathology. Strength and Conditioning Journal 2005; 27 (3): 69-72.

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Shoulder pain attributed to swimming is very common and there are many different causes. Listing all of these causes and conditions is beyond the scope of any blog as it is a very complex topic.  Nevertheless, this article will address one of the more common scenario’s; impingement of the shoulder.

Impingement of the Shoulder

Although there are different types of impingement and many different shoulder abnormalities that are related to the condition, we often see a “functional” impingement in our practise. In this condition, various soft tissue structures are compressed during shoulder movement. The repetitive overhead nature of swimming is notoriously linked to impingement of the shoulder. When impingement is present in a swimmers shoulder, it is definitely a situation where a relatively small problem can turn into a large one if not managed properly.

Shoulder Pain and the Rotator Cuff

Since degeneration of the rotator cuff tendons is now considered a relatively normal process of aging, it is safe to assume that many of you who are reading this will already have some changes in these tendons. Subjecting these degenerating tendons to repeated compression (as with impingement and swimming) has been found in the literature to accelerate the degenerative process. Advanced tendon degeneration has also been linked to rotator cuff tearing and untreated rotator cuff tears have the potential to accelerate the progression of arthritis in the shoulder. Given this vicious snowballing effect of shoulder injury, preventative exercises are obviously a great idea!

Exercises for Shoulder Pain

The following exercises can help to prevent or reduce impingement for some individuals as they target some of the common weaknesses that are linked to this condition. As we always recommend, your best course of action (whether you’re in pain or not) is to have your shoulder examined by a suitable healthcare practitioner (like a chiropractor) who can identify any weaknesses or factors that may predispose you to impingement and who can tailor a strengthening program specific to your needs. Call our clinic today! 905.220.7858  info@burlingtonsportstherapy.com

Retraction – Pinch your shoulder blades together. Hold for 10 seconds and relax.

Depression and Retraction – Combine the motion above (pinching your shoulder blades together) while pulling them downward. Hold for 10 seconds and relax.

Low Row – The low row is performed by pulling backward at the shoulder while pinching your shoulder blades back and down.

References

Cools, AM., Cambier D. Witvrouw E. Screening the athlete’s shoulder for impingement symptoms: a clinical reasoning algorithm for early detection of shoulder pathology. British Journal of Sports Medicine 2008; 42: 628-635.

Kannus P., Jozsa L. Histopathological changes preceding spontaneous rupture of a tendon. A controlled study of 891 patients. Journal of Bone and Joint Surgery (American) 1991: 73(10): 1507-1525.

Kibler WB, Sciascia AD, Uhl TL, Tambay N, Cunningham T. Electromyographic analysis of specific exercises for scapular control in early phases of shoulder rehabilitation. American Journal of Sports Medicine 2008; 36(9): 1789-1798.

Nho, S., Yadav H., Shindle M., MacGillivray J. Rotator cuff degeneration. American Journal of Sports Medicine. 2008; 36: 987-993.

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