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Rotator Cuff Roadmap: Navigating Injury, Treatment, and Exercise for Optimal Healing

Updated: Apr 2


Woman Holding Shoulder

Rotator cuff injuries are a common occurrence, impacting both the athletic and the not-so-athletic individuals. Early diagnosis is paramount in pinpointing the root cause, initiating the correct treatment plan, and averting further damage. So, let's delve into the intricacies of rotator cuff muscles with a touch of humor and a healthy dose of optimism!


This article will traverse through the anatomy of the rotator cuff muscles and their role in shoulder-related functions. Additionally, we'll delve into essential diagnostic steps before embarking on the journey to recovery, alongside discussions on both soft tissue and osseous treatment and exercises.


Article Index:


Introduction

Anatomy & Biomechanics

Examination & Diagnosis

Treatment

Exercise

Conclusion & References

 

Man Failing Off Ladder

Rotator Cuff Injuries


Rotator cuff injuries can occur for various reasons, including micro-trauma, wear and tear, traumatic events (think: falls with outstretched hands or dislocations), and secondary dysfunctions. We're looking at tears, tendinitis, tendinopathy, and impingement syndrome!


A few factors might make you more prone to rotator cuff tears, such as smoking, Type 1 Diabetes, joint capsule inflammation, frozen shoulder, rheumatoid arthritis, thyroid conditions, and poor vascularization.


Signs You Might Have a Rotator Cuff Injury If you're experiencing a rotator cuff injury, you might notice the following symptoms:

  • Pain when reaching overhead or flexing your arm forward

  • Intense pain during the injury and at night

  • A positive Painful Arc Sign (a test used to spot possible subacromial impingement, although it's not foolproof)

  • Weakness in the affected muscle

  • Pain specific to a certain location, like the supraspinatus

  • Complaints of clicking, catching, stiffness, and crepitus

Practitioners: When discussing pain with a patient, getting the full picture is essential. Ask about:

  • Location (as specific as possible)

  • Radiation

  • Quality

  • Severity and quantity (including any functional limitations)

  • Precipitating factors

  • Relieving factors

By understanding the ins and outs of rotator cuff injuries, we can better diagnose, treat, and prevent these injuries!


 

Anatomy & Biomechanics


Prepared for a quick journey through the anatomy and biomechanics of our reliable rotator cuff (SITS) muscles? Let's delve in!

Rotator Cuff Anatomy

Supraspinatus Muscle

  • Origin: Supraspinous fossa on the scapula

  • Insertion: Superior facet of the greater tubercle

  • Action: Abducting the humerus

  • Innervation: Suprascapular nerve (C5)

Infraspinatus Muscle

  • Origin: Infraspinous fossa on the scapula

  • Insertion: Middle facet of the greater tubercle

  • Action: Externally rotating the humerus

  • Innervation: Suprascapular nerve (C5-C6)

Teres minor Muscle

  • Origin: Middle half of the scapulae's lateral border

  • Insertion: Inferior facet of the greater tubercle

  • Action: Externally rotating the humerus (again!)

  • Innervation: Axillary nerve (C5)

Subscapularis muscle

  • Origin: Subscapular fossa on the scapula

  • Insertion: Lesser tubercle

  • Action: Internally rotating the humerus

  • Innervation: Upper and Lower subscapular nerves (C5-C6)


In wrapping up this section, let's reflect on the functional marvels of our rotator cuff muscles. The Supraspinatus initiates the arm's first 15 degrees of abduction, setting the stage for the deltoid muscle to carry on the motion. The Infraspinatus and Teres Minor excel in external rotation, vital in actions like throwing a ball. Conversely, the Subscapularis, the powerhouse among them, leads in internal rotation, aiding in tasks like turning a doorknob. Their collaborative effort underpins the seamless synchronization of shoulder movements, displaying a remarkable blend of strength and flexibility in every gesture.


 

Examination and Diagnosis


A shoulder examination should include both comprehensive orthopedic and neurological assessments. Diagnostic imaging is crucial for traumatic cases where manual therapy hasn't worked within 3 to 6 weeks and for our more experienced, mature folks (I was born in the late 50s).


When diagnosing a shoulder injury, remember to:

  1. Take a thorough history to pinpoint the issue accurately.

  2. Confirm that you're dealing with a musculoskeletal injury rather than a visceral disorder or a serious, potentially life-threatening condition.

  3. Conduct a complete workup involving orthopedic, neurological, and vascular tests.

  4. Consider a differential diagnosis.

By following these steps, you'll be well on your way to understanding the nature of the shoulder injury and providing the most effective treatment possible.



Exam Demonstration Videos


Shoulder Examination - Orthopaedic Testing

This video teaches some common causes of shoulder pain and how to diagnose them using orthopaedic examination procedures.



Upper Limb Neuro Exam

The upper limb neurological examination is part of the overall neurological examination process and is used to assess the motor and sensory neurons which supply the upper limbs. This assessment helps to detect any impairment of the nervous system.


Peripheral Vascular Examination - Key Points

A peripheral vascular examination is a valuable tool for ruling out signs of vascular-related pathology. The detection and subsequent treatment of PVD can potentially mitigate cardiovascular and cerebrovascular complications.



Shoulder X-Ray

Imaging


When further insight is needed post patient history and physical examination, advanced diagnostic imaging techniques are enlisted. These methods are crucial for identifying fractures (from trauma), infections, degenerative joint issues, osteoporosis, and stubborn pathologies resistant to conservative treatment.


MRI (Magnetic Resonance Imaging) is favored for shoulder imaging due to its superior soft tissue contrast and multi-planar capabilities. It facilitates precise assessments of shoulder structures like the rotator cuff tendons, muscles, labrum, and capsule, aiding in the detection of partial or complete tears, tendinopathies, and inflammation.


Additional imaging techniques such as X-rays, CT (Computed Tomography), and ultrasound may also be employed. X-rays are effective for evaluating bone alignment, identifying fractures, and detecting arthritis. CT scans provide a more intricate view of bones, useful in visualizing complex fractures and assessing joint integrity. Ultrasound offers a non-invasive, real-time examination of tendons, muscles, and other soft tissues, especially during shoulder movement.


 

Differential Diagnosis Image

Differential Diagnosis


When it comes to shoulder injuries, it's important to differentiate between various conditions. Some of the differentials to consider include the following:

  1. Acromioclavicular injury: Damage to the AC joint, often from direct impact or falls. Symptoms include pain, swelling, and limited movement.

  2. Adhesive Capsulitis: AKA frozen shoulder, marked by stiffness, pain, and restricted range of motion due to a thickened and tightened joint capsule.

  3. Biceps Tendonitis/tendinopathy: Inflammation or degeneration of the biceps tendon, causing shoulder and upper arm pain and weakness.

  4. Bursitis: Inflammation of the bursa, leading to pain, swelling, and limited movement.

  5. Calcific Tendonitis: Calcium deposits in rotator cuff tendons, causing inflammation, pain, and restricted range of motion.

  6. Cervical nerve root injury, Cervical Radiculopathy, Cervical Spondylosis: Cervical spine-related conditions, often causing radiating pain, numbness, or weakness from the neck to the arm.

  7. Glenohumeral ligament tears: Damage to the shoulder-stabilizing ligaments, causing pain, instability, and potential dislocation.

  8. Glenoid labrum tear: Damage to the shoulder socket's fibrocartilaginous rim. SLAP and Bankart lesions are specific types of labral tears. Symptoms include pain, instability, and clicking or catching sensations.

  9. Myocardial Infarction: A heart attack which can cause referred pain to the shoulder and arm, along with chest pain, shortness of breath, and other symptoms.

  10. Nerve entrapment: Compression of shoulder-adjacent nerves, causing pain, numbness, or tingling radiating down the arm.

  11. Osteoarthritis: Joint cartilage degeneration, leading to pain, stiffness, and reduced range of motion in the shoulder.

  12. Shoulder dislocation: The humeral head slips out of the shoulder socket, usually due to trauma, causing severe pain, swelling, and an inability to move the joint.

  13. Subacromial Impingement: Compression of the rotator cuff tendons and/or bursa, causing pain, inflammation, and limited range of motion.

  14. TOS (Thoracic Outlet Syndrome): Compression of nerves and blood vessels, causing pain, numbness, and weakness in the shoulder, arm, and hand.

Considering these differential diagnoses, you can help pinpoint the underlying cause of a shoulder injury and develop an effective treatment plan.


 

Treatment Overview


The good news for most people is that, according to medical studies, 8 out of 10 rotator cuff injuries can be effectively treated without surgery. This means that manual therapy and exercise are often the first courses of action to consider for recovery. Before we get into a discussion on manual therapy, let take about the three phases of treatment:


Conservative therapy and exercises for shoulder injuries can typically be divided into three phases. Patients need to show functional progress before moving on to the next treatment phase:

  1. Phase 1: Acute Phase

  2. Phase 2: Intermediate Phase

  3. Phase 3: Athletic Training


Phase 1, 2, 3 Image

Phase 1 - The Acute Phase


During the Acute Phase, our objectives are to:

  • Reduce pain and inflammation.

  • Minimize muscle tightness and spasms through heat, manual therapy, and potentially pharmaceutical intervention (based on healthcare provider recommendations).

  • Enhance pain-free range of motion for active and passive movements, often achievable with soft-tissue therapy, joint manipulation, and exercise.

  • Introduce exercises to prevent muscle atrophy using appropriate isometric exercises involving static muscle contractions without visible joint angle movement.

  • Incorporate exercises to improve proprioception (body awareness).


Practitioner Measuring AROM

Phase 2 - The Intermediate Phase


Before progressing to the Intermediate Phase of rehabilitation, the patient should demonstrate the following:

  • Improved range of motion with minimal pain.

  • Enhanced static stability.

  • Better muscle and nerve control.

During the Intermediate Phase, our treatment goals are to:

  • Increase strength and muscle control by introducing isotonic exercises, where the muscle changes length against constant weight, like lifting a dumbbell.

  • Enhance proprioception and muscle control through specialized exercises focusing on balance and coordination.

  • Boost dynamic stabilization (control during movement) with exercise.

  • Ensure normal shoulder joint surface movement through hands-on therapy and exercise.

  • Apply manual therapy techniques to alleviate muscle tightness and spasms, improve blood flow, and support better shoulder joint stability.


Triathlon Swimmers

Phase 3 - The Advanced Phase (Athletic Training)


Before advancing to the Athletic Training Phase of rehabilitation, the patient should demonstrate the following:

  • Normal range of motion with little or no pain.

  • Good flexibility and movement in the shoulder area.

  • Strong muscles that assist with shoulder blade (scapula) movement.

During the Advanced Phase, our treatment goals are to:

  • Continue building strength with exercises involving changing muscle length while lifting weights.

  • Practice advanced exercises focusing on muscle control and coordination.

  • Work on activity or sport-specific exercises targeting strength, endurance, and power.

  • Increase the time, weight, and number of repetitions for exercises.

  • Introduce exercises involving quick, powerful movements (plyometrics).

  • Maintain the use of manual therapy techniques to enhance body movement and performance.


 


Manual Therapy of Rotator Cuff

Manual Therapy


Manual therapy employs hands-on methods to evaluate, diagnose, and treat musculoskeletal injuries and conditions. In the context of shoulder injuries, manual therapy plays a vital and effective role in treatment for several reasons:

  1. Pain relief: Techniques like soft tissue mobilization and joint mobilization in manual therapy can alleviate shoulder pain by enhancing circulation, reducing inflammation, and relaxing tight muscles and tendons.

  2. Improved range of motion: Manual therapy can help enhance the shoulder joint's range of motion by mobilizing stiff joints and muscles. This restores normal movement patterns and lowers the risk of additional injuries.

  3. Promoting healing: Manual therapy methods can trigger the body's natural healing response by boosting blood flow and oxygen delivery to the injured area. This contributes to shorter recovery times and facilitates tissue healing.

  4. Addressing underlying issues: Manual therapy can also tackle underlying factors that might contribute to shoulder injuries, such as improper posture, muscle imbalances, and joint dysfunction.


CONTRAINDICATIONS TO MANUAL THERAPY:


Before getting into the nuances of manual therapy, practitioners must confirm that the issue is musculoskeletal (MSK) before applying any manual therapy techniques. Proper patient screening is crucial to determine the likelihood of serious pathology.

Common contraindications for shoulder manual therapy include:

  1. Active inflammatory or septic arthritis.

  2. Signs of vascular disease or serious conditions mimicking MSK issues (e.g., aortic aneurysm).

  3. Joint and ligament instability.

  4. Excessive swelling or pain.

  5. Active bone disease or malignancy (cancer).

  6. Non-mechanical causes of pain.

  7. Indications of cervical spine pathology.

  8. Progressive neurological deficit.

  9. Signs of visceral pain referral patterns.

  10. Fracture or dislocation.

By considering these contraindications, healthcare professionals can ensure they provide safe and effective treatment for shoulder injuries.


Article Index
 

Man Holding His Shoulder

Soft Tissue Mobilization


Soft tissue mobilization can help to ease pain and enhance function by breaking down scar tissue, adhesions, and knots in the soft tissue, boosting circulation, and minimizing inflammation. Soft tissue mobilization techniques encompass many procedures, such as Motion Specific Release (MSR), massage, myofascial release, trigger point therapy, pin and stretch modalities, and many other methods.


During soft tissue mobilization sessions, the therapist employs pressure and manipulates the soft tissue structures using techniques like kneading, stretching, and compression. The therapist might use their hands, fingers, or specialized instruments to apply pressure and work with the tissues.


Motion Specific Release Demonstration Video


Rotator Cuff Roadmap: Overcoming Injury

In this video featuring Dr. Abelson, the creator of Motion Specific Release, and Miki Burton RMT, you will see demonstrations of soft tissue techniques and targeted exercises to address a rotator cuff injury.


Soft tissue treatments start at the time stamp of 01:29.


 

Osseous Mobilization


The shoulder complex is a sophisticated anatomical system consisting of the glenohumeral joint and four additional joints. Contrary to popular belief, the shoulder is not composed of just one joint. Instead, it encompasses five distinct joints that work together to facilitate movement. These specific structures must be addressed if they are affected, which often occurs in a rotator cuff injury.


Effective Shoulder Joint Mobilization - MSR Protocol - Part 1

In this video, Dr. Abelson (the developer of MSR) demonstrates highly effective procedures for mobilizing the shoulder joint using the MSR technique. It's also essential to remember that no joint works in isolation, and a restriction or dysfunction in one area can lead to compensation elsewhere in the body. Therefore, addressing these compensations along the joint's kinetic chain is often necessary to resolve a shoulder injury.


 

Rotator Cuff Treatment Frequency


The frequency of manual treatment is tailored to the severity of the injury. Mild injuries often require less intensive therapy, allowing for an early transition to self-managed care. Moderate injuries demand a more structured approach to navigate through healing phases and initiate rehabilitation. Severe, especially post-surgical injuries, necessitate intensive, prolonged therapy to ensure optimal recovery, manage scar tissue, and restore function while preventing secondary complications. Each injury grade thus dictates a distinct therapy approach and frequency, aligning with individualized therapeutic needs for optimal healing and functionality restoration.



Grade 1 Tear (Mild):

  • Initial: Weekly to bi-weekly visits

  • Duration: 2-3 weeks, transitioning to home exercises and self-management

  • Approximate Total Treatment Appointments: A total of 3 to 6 appointments, followed by 1 or 2 follow-up appointments, depending on patient response.


Grade 2 Tear (Moderate):

  • Initial: Weekly to bi-weekly visits

  • Duration: 3-6 weeks, then tapering off as symptoms improve and home exercises progress

  • Approximate Total Appointments: 3 to 12 appointments, followed by 1 or 2 follow-up appointments, depending on patient response.


Grade 3 Tear (Severe - Requires Surgery):


In severe cases, post-operative rehabilitation begins with managing pain and swelling, and immobilizing the ankle. Early rehabilitation introduces weight-bearing and basic exercises. Intermediate rehabilitation advances strengthening and proprioception. Late rehabilitation intensifies strength training and introduces sport-specific exercises. Finally, a gradual return to full activities commences.



 

Woman Performing Cobra Pose

Rotator Cuff Exercises


Every shoulder injury should be evaluated and managed as a unique issue specific to the individual. This principle extends to the creation of a personalized exercise program. For rotator cuff injuries, exercise regimens should be organized into three main components:

  1. Mobility and flexibility: Enhancing mobility and flexibility is crucial for a full recovery from a rotator cuff injury, as it helps restore the shoulder's normal range of motion, alleviates pain, and prevents the development of compensatory movement patterns that can lead to further issues.

  2. Strengthening: Strengthening exercises are vital for rebuilding the injured rotator cuff muscles and surrounding supportive structures, which in turn improves shoulder stability, reduces the risk of re-injury, and helps patients return to their daily activities and sports with confidence.

  3. Proprioception: Focusing on proprioception during recovery from a rotator cuff injury is essential for restoring the body's awareness of the shoulder's position and movement, enhancing neuromuscular control, and preventing injury recurrence by promoting more efficient and coordinated movement patterns.


Rotator Cuff Roadmap: Overcoming Injury

In this video featuring Dr. Abelson, the creator of Motion Specific Release, and Miki Burton RMT, you will see demonstrations of soft tissue techniques and targeted exercises to address a rotator cuff injury.


The exercise portion of this video starts at a time stamp of 08:00. Note that these exercises could be prescribed for a rotator cuff injury and are not recommendations for a specific case.


 


Woman Performing Deadlift

Rotator Cuff Roadmap Conclusion


In conclusion, rotator cuff injuries can be effectively managed through a comprehensive approach involving a thorough assessment, personalized exercise programs, and manual therapy techniques. By focusing on mobility and flexibility, strengthening, and proprioception, patients can experience significant improvement in pain, function, and overall recovery.


It's essential for healthcare professionals to consider each patient's unique needs and circumstances when developing a treatment plan and to monitor progress throughout the rehabilitation process closely. Through this individualized and multidimensional approach, most rotator cuff injuries can be successfully treated without surgery, leading to improved quality of life and a return to normal activities for patients.


 

DR. BRIAN ABELSON DC. - The Author


Photo of Dr. Brian Abelson

Dr. Abelson's approach in musculoskeletal health care reflects a deep commitment to evidence-based practices and continuous learning. In his work at Kinetic Health in Calgary, Alberta, he focuses on integrating the latest research with a compassionate understanding of each patient's unique needs. As the developer of the Motion Specific Release (MSR) Treatment Systems, he views his role as both a practitioner and an educator, dedicated to sharing knowledge and techniques that can benefit the wider healthcare community. His ongoing efforts in teaching and practice aim to contribute positively to the field of musculoskeletal health, with a constant emphasis on patient-centered care and the collective advancement of treatment methods.


 


MSR Instructor Mike Burton Smiling

Join Us at Motion Specific Release


Enroll in our courses to master innovative soft-tissue and osseous techniques that seamlessly fit into your current clinical practice, providing your patients with substantial relief from pain and a renewed sense of functionality. Our curriculum masterfully integrates rigorous medical science with creative therapeutic paradigms, comprehensively understanding musculoskeletal diagnosis and treatment protocols.


Join MSR Pro and start tapping into the power of Motion Specific Release. Have access to:

  • Protocols: Over 250 clinical procedures with detailed video productions.

  • Examination Procedures: Over 70 orthopedic and neurological assessment videos and downloadable PDF examination forms for use in your clinical practice are coming soon.

  • Exercises: You can prescribe hundreds of Functional Exercises Videos to your patients through our downloadable prescription pads.

  • Article Library: Our Article Index Library with over 45+ of the most common MSK conditions we all see in clinical practice. This is a great opportunity to educate your patients on our processes. Each article covers basic condition information, diagnostic procedures, treatment methodologies, timelines, and exercise recommendations. All of this is in an easy-to-prescribe PDF format you can directly send to your patients.

  • Discounts: MSR Pro yearly memberships entitle you to a significant discount on our online and live courses.


Integrating MSR into your practice can significantly enhance your clinical practice. The benefits we mentioned are only a few reasons for joining our MSR team.


 

References


  1. Neer, C.S. (1972). Anterior acromioplasty for the chronic impingement syndrome in the shoulder: A preliminary report. Journal of Bone and Joint Surgery, 54-A(1), 41-50.

  2. Codman, E. A. (1934). The Shoulder: Rupture of the Supraspinatus Tendon and Other Lesions in or about the Subacromial Bursa. Boston: Thomas Todd.

  3. Yamaguchi, K., Tetro, A.M., Blam, O., Evanoff, B.A., Teefey, S.A., & Middleton, W.D. (2001). Natural history of asymptomatic rotator cuff tears: a longitudinal analysis of asymptomatic tears detected sonographically. Journal of Shoulder and Elbow Surgery, 10(3), 199-203.

  4. Rees, J.D., Wilson, A.M., & Wolman, R.L. (2006). Current concepts in the management of tendon disorders. Rheumatology, 45(5), 508-521.

  5. Roy, J.S., MacDermid, J.C., Woodhouse, L.J. (2010). A systematic review of the psychometric properties of the Constant-Murley score. Journal of Shoulder and Elbow Surgery, 19(1), 157-164.

  6. Lewis, J.S. (2010). Rotator cuff tendinopathy/subacromial impingement syndrome: is it time for a new method of assessment? British Journal of Sports Medicine, 44(5), 264-268.

  7. Page, P., Labbe, A., & Topp, R. (2012). Clinical Assessment of the Shoulder. Journal of Orthopaedic & Sports Physical Therapy, 42(5), 493-505.

  8. Mather, R.C., Koenig, L., Acevedo, D., Dall, T.M., Gallo, P., Romeo, A., & Tongue, J. (2013). The societal and economic value of rotator cuff repair. Journal of Bone and Joint Surgery, 95(22), 1993-2000.

  9. Tashjian, R.Z. (2012). Epidemiology, natural history, and indications for treatment of rotator cuff tears. Clinical Sports Medicine, 31(4), 589-604.

  10. Jobe, F.W., & Moynes, D.R. (1982). Delineation of diagnostic criteria and a rehabilitation program for rotator cuff injuries. The American Journal of Sports Medicine, 10(6), 336-339.

  11. Michener, L.A., Walsworth, M.K., & Burnet, E.N. (2004). Effectiveness of rehabilitation for patients with subacromial impingement syndrome: a systematic review. Journal of Hand Therapy, 17(2), 152-164.

  12. Itoi, E., Kido, T., Sano, A., Urayama, M., & Sato, K. (1999). Which is more useful, the "full can test" or the "empty can test," in detecting the torn supraspinatus tendon? The American Journal of Sports Medicine, 27(1), 65-68.

  13. Kelly, B.T., Kadrmas, W.R., & Speer, K.P. (1996). The manual muscle examination for rotator cuff strength: an electromyographic investigation. The American Journal of Sports Medicine, 24(5), 581-588.

  14. Smith, J., Kotajarvi, B.R., Padgett, D.J., & Eischen, J.J. (2002). Effect of scapular protraction and retraction on isometric shoulder elevation strength. Archives of Physical Medicine and Rehabilitation, 83(3), 367-370.

  15. Ellenbecker, T.S., & Davies, G.J. (2000). The application of isokinetics in testing and rehabilitation of the shoulder complex. Journal of Athletic Training, 35(3), 338-350.

  16. Holmgren, T., Bjornsson Hallgren, H., Oberg, B., Adolfsson, L., & Johansson, K. (2012). Effect of specific exercise strategy on need for surgery in patients with subacromial impingement syndrome: randomised controlled study. British Medical Journal, 344, e787.

  17. Kuhn, J.E. (2009). Exercise in the treatment of rotator cuff impingement: a systematic review and a synthesized evidence-based rehabilitation protocol. Journal of Shoulder and Elbow Surgery, 18(1), 138-160.

  18. Manske, R.C., & Prohaska, D. (2008). Diagnosis and management of adhesive capsulitis. Current Reviews in Musculoskeletal Medicine, 1(3-4), 180-189.

  19. Donatelli, R., Ruivo, R.M., Thurner, M., & Ibrahim, M.I. (2014). New concepts in restoring shoulder elevation in a stiff and painful shoulder patient. International Journal of Sports Physical Therapy, 9(2), 274-290.

  20. Hegedus, E.J., Goode, A., Campbell, S., Morin, A., Tamaddoni, M., Moorman, C.T., & Cook, C. (2008). Physical examination tests of the shoulder: a systematic review with meta-analysis of individual tests. British Journal of Sports Medicine, 42(2), 80-92.


 

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