Category Archives: Shoulder

Injuries and exercises relating to the shoulder

Rotator Cuff Tendonitis and Rotator Cuff Tendonosis

Rotator Cuff (RTC) Tendonitis:

Rotator cuff tendonitis refers to the acute (recent) irritation of the tendon of the rotator cuff and often the surrounding bursa (not shown in picture but it sits between the rotator cuff tendon and the bottom of the acromium).  There are many possible causes, and unfortunately gymnastics tends to involve a little of them all:

  • Keeping the arm in the same position for a prolonged period of time, especially overhead positions (such as prolonged hanging, handstand holds/training, one-arm supports, etc).
  • Weight bearing on the same arm repetitively. (For the average population – this means sleeping on the same arm.  In gymnasts, this could be relying on one arm to do a lever, a single-arm handstand, a one-arm giant, or the supporting arm in a handstand pirouette.)
  • Placing force through the arm in an overhead position (velocity and intensity play a factor).
  • Poor coordination/weakness of the shoulder muscles during movement (this is known as scapulothoracic rhythm – the so-called pairing of the shoulder blade’s motion with that of the humerus).
  • Often shoulder “impingement” is cited as a cause.  While this can be the case, it is not the belief of this author that impingement is a true diagnosis.  Shoulder impingement is defined as “the pinching of the subacromial structures, such as the rotator cuff, bursa, and surrounding nerves/vasculature, between the humeral head and acromium with movement.”  After extensive study, I feel the term impingement actually refers to “a narrowing of the subacromial space by inflammation and poor glenohumeral mechanics.”  That definition leads me to think that rotator cuff tendonitis is actually the cause of impingement.
  • Poor posture (through the thorax, shoulders, and neck)
  • And yes, general overuse (a sudden increase in training or the addition of a new skill) is no doubt a cause.

Symptoms of RTC tendonitis:

Generally, pain occurs with overhead activities and lifting your arm to the side.

  • Pain is more likely in the front/top of the shoulder and may radiate to the side of the arm (traditionally the lateral/posterior aspect). However, this pain ALWAYS stops before the elbow. If the pain travels beyond the elbow, this may indicate a pinched nerve or more serious pathology.
  • The pain may be worst at the beginning of an activity and then “ease off” as you warm-up.  This is because the tendon and muscles get more circulation and the inflammation is pushed away.  Often though, there will be an increase in your pain toward the end of or after the activity.  This “after” pain can last into the next day.
  • There may also be pain with lowering the shoulder from a raised position.

At first, this pain may be mild and occur only with certain movements of the arm. Over time, pain may be present at rest or at night, especially when lying on the affected shoulder.

As the pathology progresses, weakness can develop and sometimes a secondary loss of motion is apparent.  The shoulder will be stiff at rest and the skin around the shoulder will become tender to palpate.

Tendonitis vs Tendonosis:

Simply put, tendonitis is a new or recent injury.  The tendon has recently been injured or overused, and the inflammation is new.  There is no long-term or permanent damage and the affected tendon can fully recover if rested and the causative factor is removed.

Tendonosis is chronic (long-term) degeneration of the tendon.  It basically means that the tendon is diseased.  The tendon is breaking down and is at a greater risk for tear (due to microtrauma and small fiber tears).  Tendonosis usually occurs when tendonitis does not resolve (something to think about when you’re “pushing through the pain”).  With tendonosis, the tendon may no longer be inflamed, but rather it can be re-aggravated and turned back into a tendonitis.  This “recurrent tendonitis” is often more painful and of quicker onset than the original tendonitis was.

In the case of the rotator cuff, think of this progression (with severity increasing from 1-4):

  1. tendonitis
  2. tendonosis
  3. partial tear
  4. full tear

Here, you can pass from 1 to 4 in a progression, or pass back and forth from 1, 2, & 3 which will eventually get you to 4, or in the rare case, you can encounter sudden trauma and just be a 4 (sudden rotator cuff tear).  In gymnastics, most rotator cuff tears are gradual, the result of slow and repetitive degradation of the rotator cuff tendon over weeks, month, and years.

Still want to push through the pain?  I thought not…

Treatment for Rotator Cuff Tendonitis:

RICE:

As in all things, think RICE for the rotator cuff when you suspect an early tendonitis.

  1. Rest: I know, you’ve got a show/meet/big thing coming up, but ultimately this isn’t up to you.  If you’re having these symptoms, your rotator cuff is telling you that there is a problem.  Initially, try reducing the number of skill/routine repetitions and focus on drills to strengthen the body (conditioning works great as long as it’s not over-dosed).  If that’s not enough and after 1-2 weeks you’re still having pain, STOP the offending activity for a few days.  Then re-introduce it on a LIMITED basis (2-3 reps a practice and build back up).
  2. Ice: This is a must!  After ANY activity that uses the arm sit with ice on it for 15 minutes. (and this can include even the non-athletic pursuits of housework and personal hygiene).  The cause of tendonitis is inflammation, and though the rotator cuff is deep in the shoulder, just decreasing the flow of blood to that area (the arterial vasculature narrows in response to cold) will give the lymphatic and venous system a chance to pull out some inflammation.  Plus, ice cools the nerves down and numbs them (by impeding the pain signal up the nerve).  As a nerve cools down, it becomes less effective at sending signals.  Plus, the nerve that carries pain also carries temperature – and it can’t carry both at the same time.  (This is known as the “Gate Theory of Pain.” Think of 495 at rush hour.  All the cars want to go, but they can’t all fit.)  Since temperature is the faster of the two signals, pain has to sit this one out.
  3. Compression: You can try to compress and support the rotator cuff, but this doesn’t usually work well with gymnastics.  The bracing is bulky and severely limits mobility – so just skip this for now.
  4. Elevation: Not something you need to worry too much about since the rotator cuff is above the heart in sitting.  The reason we elevate is to help gravity push the inflammation (a.k.a. swelling) back to the heart so it can be removed from the body.  That said, it may be more effective to ice while sitting in a chair.  You can also rest the affected arm on a desk/table to “open” the shoulder joint a little and allow some more room for circulation.

Stretching/Strengthening:

Now that we’ve got the treatment started, the next step in the process is stretching and strengthening.  Even though it’s the tendon that is inflamed, the true cause it the musculature – so that’s what we have to re-educate. There are many ways to go about this, but I recommend starting with the basics and working up.  The focus in the beginning should be on stretching out the anterior shoulder muscles (pectorals, biceps, and anterior deltoid) and strengthening the posterior shoulder and postural muscles (rhomboid, teres minor, infraspinatus, middle, and lower trap).  This will help to put the rotator cuff in the ideal position, and also help to improve scapulothoracic rhythm.

Below is the introductory level. (this is also listed as a separate blog – Beginning Rotator Cuff Exercises).  Start here and progress to the intermediate and advanced levels after a few weeks of continuous exercise.

Beginning Rotator Cuff Exercises:

Doorway Stretch:

Pectoral Stretch

Standing in a doorway, place your arms on the frame (the shown positions A, B, and C all stretch a different portion of the pectorals). With one leg in front, step through while keeping your head and chest up. You should feel a stretch across your chest and into the front of your arms. Hold for 30 seconds. Perform 3-4 times a day.

Posterior Capsule Stretch:

Grab the back of the arm and pull it across the chest until a stretch is felt in the back of the shoulder. Hold for 30 seconds. Do 3-4 times a day.

Posterior Shoulder Rolls:

Shrug the shoulders up and backward and then relax down and forward.  The goal is a backward circling motion. Do 10-20 times, 1-2 times a day.

Shoulder extension stretch:

Standing, slowly bring the arms back and squeeze the shoulder blades together. You should feel a stretch across the chest and muscle contraction between the shoulder blades (postural strengthening). Hold for 10-15 seconds. Do 5-10 times, 1-2 times a day.

Shoulder PREs: (with therapy resistance bands)

Using the resistance band (choose a color that allows you to complete the full sets with mild-moderate difficulty). Perform 2 sets of 10-15 repetitions in a PAIN-FREE range of motion.  Do these 3 times a week (and never before practice – always on off days or after).

External Rotation: Stand facing to the side with the arm across the stomach.  Keeping the elbow still and at your side (think of it as the hinge on a door) pull the band out.  Be sure to keep the elbow bent to 90 degrees throughout (so only go as far out as you can without breaking form).  Return the arm to the starting position slowly.

Abduction: Stand facing the side with the band anchored across the body.  With the elbow bent, raise the arm out to the side.  If more of a challenge is needed, perform with the arm straight. Only go as high as the shoulder.  Return slowly.

Rows (labeled extension): Stand facing the anchor-point of the band.  With the arms bent, pull the hands STRAIGHT back against your sides as you pinch your shoulder blades together.  (Think of sliding your hands across a level table). 

Internal Rotation: Stand with the band to your side, elbow bent to 90 degrees.  Pull the arm in to your stomach.  Again, keep the elbow in one place (think of it as the hinge on a door) and rotate the arm around it.  Return slowly to the starting position.

Postural Awareness:

Good posture puts the neck, head, shoulders, and thorax in the ideal position for muscular efficiency.  It also ensures that the weight is distributed correctly and that the forces placed on each structure are tolerated.  While gymnasts tend to have good standing posture, they also spend a great deal of time strengthening positions that are not (such as hollow body – which involves significant scapular tipping and protraction – a.k.a. pulls it up and forward).   These “alternate postures” often put the traditional postural muscles on stretch (in a weakened position) and can alter muscle function with arm movement, so some basic postural training and practice is a must.

The ideal resting posture looks like this:

The head is aligned and looking straight ahead with the ear over the lateral shoulder. The arms are relaxed at the side and the weight falls through the hips, just behind the knees, and over the balls of the feet. There is also even weight on both feet.

Medication:

Pain medication can be useful if the pain is so severe that it limits your regular (non-gymnastics) activities.  If possible, use an over the counter NSAID to help decrease inflammation further.  Be sure to only use the recommended dosage, take with food, and do not do so for more than a day or two (unless recommended by a doctor).

Summary:

  • Rotator Cuff Tendonitis is an acute irritation of the rotator cuff tendon.
  • It is caused by overuse, poor posture, repetitive overhead motion, and poor scapulothoracic rhythm (muscle weakness and poor coordination of the scapula and humerus with arm movement).
  • Treatment involves: rest, ice, stretching, and strengthening.  A focus on good resting posture is also important.  NSAIDs (like Motrin, Advil, and Aleve) can be used intermittently (and as recommended by MD) for pain and management of inflammation.

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Beginning Therapeutic Exercise for the Rotator Cuff

Doorway Stretch:

Pectoral Stretch

Standing in a doorway, place your arms on the frame (the shown positions A, B, C all stretch as different portion of the pectorals so try them all). With one leg in front, step through while keeping your head and chest up. You should feel a stretch across your chest and into the front of your arms. Hold for 30 seconds. Perform 3-4 times a day.

Posterior Capsule Stretch:

Grab the back of the arm and pull it across the chest until a stretch is felt in the back of the shoulder. Hold for 30 seconds. Do 3-4 times a day.

Posterior Shoulder Rolls:

Shrug the shoulders up and backward and then relax down and forward.  The goal is a backward circling motion. Do 10-20 times, 1-2 times a day.

Shoulder extension stretch:

Standing, slowly bring the arms back and squeeze the shoulder blades together. You should feel a stretch across the chest and muscle contraction between the shoulder blades (postural strengthening). Hold for 10-15 seconds. Do 5-10 times, 1-2 times a day.

Shoulder PREs: (with therapy resistance bands)

Using the resistance band (choose a color that allows you to complete the full sets with mild-moderate difficulty). Perform 2 sets of 10-15 repetitions in a PAIN-FREE range of motion. Do these 3 times a week (and never before practice – always on off days or after).

External Rotation: Stand facing to the side with the arm across the stomach.  Keeping the elbow still and at your side (think of it as the hinge on a door) pull the band out by twisting the arm out.  Be sure to keep the elbow bent to 90 degrees throughout (so only go as far out as you can without breaking form).  Return the arm to the starting position slowly.

Abduction: Stand facing the side with the band anchored across the body.  With the elbow bent, raise the arm out to the side.  If more of a challenge is needed, perform with the arm straight (this puts greater torque on the rotator cuff). Only go as high as shoulder level.  Return slowly.

Rows (labeled extension): Stand facing the anchor-point of the band.  With the arms bent, pull the hands STRAIGHT back against your sides as you pinch your shoulder blades together.  (Think of sliding your hands across a level table).

Internal Rotation: Stand with the band to your side, elbow bent to 90 degrees.  Pull the arm in to your stomach.  Again, keep the elbow in one place (think of it as the hinge on a door) and rotate the arm around it.  Return slowly to the starting position.

The Rotator Cuff

Arguably one of the most injured and dysfunctional muscle groups in the shoulder, the rotator cuff is essential for all shoulder motions.

Anatomy of the Rotator Cuff:

The rotator cuff is composed of four small, short muscles that originate on the scapula and pass around the shoulder where their tendons fuse together and attach on the humerus. Known as the “SITS” muscles, they are:

  1. supraspinatus – anchors the humeral head in the glenoid.  It is thought to assist with abduction (lateral raising of the shoulder) in the early phase of the motion. Of the four rotator cuff muscles, this is the most often torn.
  2. subscapularis – this muscle sits between the shoulder blade and the back of the rib cage (on the anterior surface of the scapula).  It’s main functions are internal rotation (twisting the arm in) and adduction (bringing the arm tight against your side).  It is the largest of the rotator cuff muscles.  It is also assisted by the pectoralis major muscle, and thus not as susceptible to injury.
  3. infraspinatus – this muscle sits on the back of the scapula (shoulder blade) and under the supraspinatus and scapular spine (that bony ridge you can feel if your reach over your shoulder and touch the top of your shoulder blade.  It’s main function is external rotation (twisting the arm out) and it assists with extension (bringing the arm back) and horizontal abduction (pulling the arm back at shoulder height).  It is much smaller than the subscapularis.
  4. teres minor – this muscle sits just inferior to the infraspinatus.  It is also an external rotator of the shoulder and assists with extension and horizontal abduction.  This muscle is about the same size as the subscapularis.

As a group, these muscles have two main functions:

  1. First, they stabilize the joint and help center the humeral head in the glenoid fossa (important in preventing pain and injury). During abduction (raising up sideways) of the arm, the rotator cuff anchors the humeral head, forcing it to pivot while the deltoid contracts to raise the arm.  If the deltoid were to work without the rotator cuff, the humeral head would be pulled up and  toward the top of the glenoid fossa – causing it to bump into the acromium and making the motion of abduction limited (by joint space and ultimately pain).
  2. Second, the rotator cuff muscles control rotation of the shoulder and allow for complex movements.  They are some of the prime movers with external rotation and internal rotation of the shoulder.

Injury to the Rotator Cuff:

There are several mechanisms by which the rotator cuff can be injured/damaged.  These include:

  1. Direct trauma: such as a fall or unexpected force through the joint
  2. Overuse/repetitive stress: this can include chronic impingement (slowly saws through the rotator cuff tendon), chronic tendonitis, and even degenerative joint disease (the arthritis and loss of cartilage changes the joint space and thus how the rotator cuff can contract).
  3. Pathologic weakness: Pathologic weakness (such as systemic muscular/joint disease and nerve injury) can this make it more susceptible to injury.  The rotator cuff is innervated (controlled by the nerves) C5-C6 which exit the neck just under the clavicle.  If there is any compression on these nerves, the signals they send to control the rotator cuff can be decreased, and the muscles become functionally weaker.  If that’s the case, even a small stress can  cause a traumatic tear (reaching for a purse, lifting a pot, doing a muscle up, etc)

Gymnastics and the rotator cuff:

Warning: the following contains some complex thinking and is mostly personal theory (so take what you want from it and ignore the rest).

It should come as no surprise that gymnastics puts a huge strain on the rotator cuff.  The various body positions required often bias the gymnast’s arm and shoulder into positions where the rotator cuff is disadvantaged or put in stretched position and forced to contract to stabilize the joint (and sometimes act as a prime mover).

In gymnastics, the shoulder is required to be a weight bearing joint.  (Warning: this is not what it was designed for).  There are two types of weight bearing encountered by the shoulder in gymnastics: compression/approximation & traction/distraction.  Compression is the traditionally accepted term for weight bearing.  Compression can be defined as the force of gravity and weight as they pass through and approximate the bones of the joint  (as in a handstand).  The term I’m adding as a “weight bearing” activity is traction/distraction.  In this case, the force is through the joint capsule, the ligaments, and the surrounding muscles. In the shoulder, arguably the rotator cuff plays a huge role in traction weight bearing – it is the muscular stabilizer!

Structurally and anatomically, weight bearing is not what the shoulder is designed for.  If you look at the hip, a truly weight bearing joint, the joint congruity (the amount of surface area in contact between the 2 bones of the joint)  is very high.  This spreads the forces out and gives stability.  The hip also has significant musculature (specifically the gluteals and hip rotators)  that assists in stabilizing and adding congruity to the joint.  This is an evolutionary upgrade – something we took on when we began to walk upright on two legs as our primary means of transport.  This is NOT the case in the shoulder.  It has a very low level of congruity (think tennis ball balanced on a quarter) and is designed for mobility.  It also does not have as thick of a joint capsule and has less dense and less numerous ligaments around it than the hip.  Finally, in the hip, the gluteal muscles and the hip rotators are some of the thickest muscles in the body.  Thier “analogous” structures in the shoulder – the pectorals and the rotator cuff are itty bitty in comparison.

See the dilemma? We gymnasts are fighting the evolutionary chain of events and trying to return to the activities of our now far-estranged primate ancestors.  Swinging, standing, jumping, and walking on our hands and arms comes at a price that the shoulder isn’t structurally able to pay on cash.

Drum roll for some fun structural facts:  According to a study published in the Journal of Clinical Sports Medicine, the shoulder capsule (the ligaments surrounding the shoulder) have s tensile strength of 100-180 lbs at full maturity.  This means that any force through the joint that exceeds that amount requires the rotator cuff to contract and provide enough force to protect the joint.

Now – think about a giant swing on uneven bars or a dislocate on rings.  For all you physics whizzes out there – combine your body weight with gravity (F = ma) and then add in torque (T = Fd) and factor in some momentum ( p = mv) and TADA! Your rotator cuff just tried to provide enough force to substitute for a cable on the nearest suspension bridge.  Potential for injury? I should say so….

Coming up next:

  • Common rotator cuff injuries
  • And Angie, I don’t care why – just tell me how to fix them!

Basic Anatomy of the Shoulder

 

Osteology: (the bones involved)

The two main bones of the shoulder are the humerus (the upper arm) and the scapula (shoulder blade).

The point where they meet (aka the joint cavity) is cushioned by articular cartilage covering the head of the humerus and face of the glenoid.   This cartilage helps guide movement and protects the joint surfaces.  As in any joint, it is suseptible to injury and general “wear and tear.”

The scapula is located on the back of the thorax (along the mid back) and extends to the top and the front of the shoulder via a projection known as the acromium.  This bone can be thought of as the “roof” over the glenohumeral (aka shoulder) joint.

Important to note is that the scapula (and thus the arm) are only attached to the bony skeleton by ONE connection – the clavicle.  All the rest of the arm and shoulder’s stability comes from muscle, ligament, and fascia (connective collagen tissue).  For all of you gymnasts out there, now how much more impressive is an iron cross or a handstand?

The joint articulation:

The end of the scapula, called the glenoid, meets the head of the humerus to form a glenohumeral cavity that acts as a flexible ball-and-socket joint.  Because the humeral head is so much larger than the glenoid, the arm has a tremendous ability to move.

The mobility thus requires secondary stability, so the joint is stabilized by a ring of fibrous cartilage surrounding the glenoid called the labrum.  This makes the glenoid seem larger and increases stability, while being flexible and elastic enough to stretch and allow the shoulder to maintain almost 360 degrees of mobility (after all it is the most mobile joint in the body).

Ligaments and the joint capsule:

Ligaments connect the bones of the shoulder (giving it stability), and are mixed with and encased in a joint capsule that seals of the inside of the joint from the outside of the joint.  Think of the joint capsule as a saran-wrap like covering that holds joint fluid (synovial fluid) in and seals out the rest.  There are also tendons around the shoulder that join the bones to surrounding muscles. One of the most visible and important in this area is the biceps tendon which attaches the biceps muscle to the shoulder and helps to stabilize the front (anterior) portion of the shoulder joint.

The rotator cuff:

The rotator cuff is composed of four small, short muscles that originate on the scapula and pass around the shoulder where their tendons fuse together and attach on the humerus. Known as the “SITS” muscles, they are:

  1. supraspinatus
  2. subscapularis
  3. infraspinatus
  4. teres minor

These muscles have two main functions.  First, they stabilize the joint and help center the humeral head in the glenoid fossa (important in preventing pain and injury),  And second, they control rotation of the shoulder and allow for complex movements.  Thus, they are very important to shoulder function, especially in gymnasts where the shoulder often becomes a weight-bearing joint (something most people don’t often require).

Other musculature:

The shoulder is also crossed and affected by many other muscles and each will be discussed in the appropriate injury section.  Just know that it is one of the most complicated joints and is hard and lengthy joint to rehab – so be patient if you have shoulder problems!