Over the years we’ve seen countless rotator cuff injuries. Some respond well to some simple strengthening exercises or stretching. Yet many refuse to get better. Some even get worse when you try to strengthen them. Why would this be?
In this article we give you the benefit of our experience looking beyond the obvious rotator cuff muscles themselves to the whole body and onto the reasons why they are over worked in the first place. Giving you a more holistic outlook to help you get your rotator cuff issues fixed for good.
What Are The Rotator Cuff?
In short the rotator cuff are small intrinsic muscles that co-ordinate the movement of your arm bone (humerus) in relation to your shoulder blade (scapular). Allowing you full free flowing shoulder movement. This is why when they are dysfunctional in any way they can significantly restrict the range of motion in the shoulder. Commonly leading rotator cuff issues to be mistaken for frozen shoulder.
There are 4 rotator cuff muscles not just one as the grouping ‘rotator cuff’ may suggest. They are supraspinatus, infraspinatus, teres minor and subscapularis – as shown here to the left. The one most people have heard of is supraspinatus. Probably most known as this is the most commonly injured one. Or at least, the most commonly blamed.
How Do You Injure Your Rotator Cuff?
There are two kinds of injury that affect the rotator cuff. One is where something goes twang, snap or pop. You will certainly know about this kind of injury. It hurts a lot and can be very debilitating very quickly. This should however get gradually better. Though with rotator cuff muscles being particularly fickle they can sometimes refuse to get better in the timely manner that would want and expect.
The second type are the ones that come on gradually. Perhaps over the course of weeks, months, even years. These are generally termed chronic injuries. All this means is that it has been around for more than 6 weeks. I talked in detail about the difference between these 2 types of injury in a presentation at our local F45 gym here in Brighton which you can watch here.
So why can rotator cuff issues be so painful?
Sensitisation may have a lot to do with it. There are quite a few nerves running through the rotator cuff muscles. As a result of the high level of nerve innervation in the rotator cuff the overall sensitivity of our nervous systems can increase how sensitive the condition is. Grossly simplifying the more stress or fear around our condition we have then more pain we feel. We go into detail on this concept in our article What Is Pain.
The more sensitised we are the more likely we are to having long term issues. The unpleasantness causes us to change the way we move to avoid the pain. When the tissues that were damaged have knitted back together (assuming they were damaged in the first place) the movement pattern stays as it was. Leaving you with a less than perfect movement pattern which keeps you in pain. As I mentioned fear is a large factor in the pain we feel. Summarised nicely by the following definition of pain from one of the world’s leading pain scientists Lorimer Moseley:
“Pain is an unpleasant conscious experience that emerges from the brain when the sum of all the available information suggests that you need to protect a particular part of your body.”
This definition is very useful. But everyone’s pain is unique to them. Part of what we do here at the clinic is to try to understand what obstacles are in the way for each person with rotator cuff issues. Helping them to find the most effective way through their pain.
What Not To Do With Your Rotator Cuff Injury
I have a real bugbear about one of the standard strengthening exercises that is dished out for rotator cuff issues. I talk about this in the video below:
As I mention in the video the reason for my opinion is the large number of people I’ve seen for whom this exercise has made the condition worse rather than better. It does work for some people, sure. And, I do see a skewed percentage of the population who are looking for alternatives when the ‘normal’ stuff hasn’t worked. But still, I’ve seen a lot.
As I also mention in the video it’s normally the rotator cuff that is the scapegoat. Not the cause. If your movement pattern means you are already overusing a muscle should you try to use it more and strengthen it? Surely that just means you’re using an overused muscle even more? It’s so important to analyse and assess why the rotator cuff is over working and address overall sensitisation and the biomechanical pattern that is keeping the rotator cuff over working and in pain.
But what should you do instead? Read on…
Being the ‘last resort’ clinic that we are we see a lot of people who have had persistent problems and are considering surgery. I would always say avoid surgery whenever possible. Not because it’s good for business, although of course that is true, but because of the varying degrees of success post operatively and amount of time rehabilitation takes.
Don’t get me wrong. Surgery can be absolutely the right thing to do. But it should always be our last option. We can’t guarantee the success of our treatments just as surgery can’t guarantee it’s success. But our treat doesn’t involve opening you up and a lengthy rehab programme. This is particularly true of the rotator cuff issues that have come on gradually with no specific start point. If you spectacularly injured your shoulder then the more likely you have done something that may benefit from surgery over a conservative approach. Still, never underestimate the healing capabilities of us humans.
Scans are really useful for those spectacular injuries to check whether anything is ‘hanging off’ and needs reattaching. I find scans for more gradual onset issues less helpful. In fact they can do more harm than good as it gives us something to fear and protect. Remember the definition of pain above. I talk about the potential issues with imaging in this article here.
Don’t be afraid of scan results. Pretty much every MRI report I’ve seen on shoulders mentions wear and tear on our supraspinatus tendon! In my experience when your body is lined up correctly and you are in a good place emotionally (as in your nervous system is calm and your sensitivity is good) this can, in the majority of cases, be entirely symptom free.
This very interesting piece of research here is in a similar vain. It tells us that only 50% of findings on MRI scans were actually confirmed when going in for an operation. As in what they were expecting to find off the back of imaging wasn’t what they found. Research, an excerpt of which is shown in the table to the left, shows how we can exist symptom free when we have all kinds of issues in our low back.
The same is true for degeneration of rotator cuff tendons and even partial ruptures of tendons. This research here took over 600 people of varying ages from the same village and on imaging found the incidents of partial rotator cuff tears to be 22%. Twice as many were NOT symptomatic as were symptomatic! Back up by this research which compared symptomatic and asymptomatic tears in the general population. Which found that again two thirds of rotator cuff tears are asymptomatic.
Anecdotally I have seen a few clients over the years who have ruptured their rotator cuff tendons and not noticed. Saying they thought ‘something felt a bit funny.’ But actually had very good function despite a rotator cuff not being attached anymore. As I said previously the human body is great at healing and adapting. Please note a very key difference between the meaning of adapting and compensating. Similar meaning but two very different outcomes.
What You Can Do About Your Rotator Cuff Injury?
Before we go into the good stuff I feel obliged to put in the usual disclaimer. Obviously the best thing to do is come and see us at Brighton Sports Therapy. We can assess what works and what doesn’t for you. With our treatment we can work out what is the most effective combination of treatment and exercises specifically for you. Other rehabilitation providers do exist!
For the best outcome please do get it checked out by a professional. Have a chat with whoever you choose over the phone and ask them how they can help you. If they sound knowledgeable, talk sense and you like them book in. If you don’t like them don’t book! Find someone else. If you don’t like your therapist it really isn’t going to work. Trust us we know!
Here we cover the exercise part of what can done but this abstract here suggests a combination of hands on treatment and exercises is the best for impingement conditions. Impingement being a common symptom of rotator cuff problems.
Any exercises or stretches should always be performed painlessly! In the following video I talk through some of the wider concepts and common biomechanical causes of rotator cuff over use to help reduce the load on the rotator cuff muscles:
Here’s a link to the seated row exercises with TheraBand! This video was shot at the in-laws and not at the clinic so I found myself in the unusual situation of not having any TheraBand to hand!
Additional to those demonstrated in the video here’s another couple of whole body exercises and stretches that can help. This first one (shown to the left) uses the fact that your pectorals which directly affect the shoulder, and so the rotator cuff, are continuous into your ‘six pack’ (rectus abdominus) muscles in your stomach. When we release these muscles off with our hands on work at the clinic we often see a significant improvement in symptoms in the rotator cuff. Especially for those who sit too much. Don’t jump straight to the picture shown! Start just by lying on the edge of your bed and having your arms over head and progress to this video here which demonstrates cobra type opening. If you still want more stretch then find yourself a Swiss ball and arch back over it. If your shoulder is too painful to have the hands above the head simply bring it back to a level that is comfortable.
Next is the half moon a video of which is here. If pain in the shoulder limits how much you lift your arm just take the arms as high as you are comfortable with. It’s an extension of the idea I was talking about in the video using the knowledge that your lats are an extension of your obliques which is shown in this great picture from Grey’s Anatomy. When the lats are tight the rotator cuff have to work harder. Most commonly this stretch will be tighter on the same side as your rotator cuff issue.
Rotator Cuff Stretch
Finally. This is unlikely to fix the underlying cause of the problem but sometimes it just feels good to stretch the bit that hurts. This may be useful for temporary symptomatic relief which over time will lead to a less tight rotator cuff. Go to the point before you feel pain, not to it or into it! Simply stand and pull the arm across the body as shown in the video below and breathe in a nice relaxed fashion:
In my opinion stretches should be held for minutes rather than seconds.
So is strengthening the rotator cuff the only way to go? Absolutely not. I hope I’ve managed to give you hope that your rotator cuff issue isn’t here forever and can be sorted with the right individual approach to treatment and rehab. Strengthening your rotator cuff in isolation may be part of that solution but it shouldn’t be the whole solution. Especially if you’ve already tried it and it’s made things worse.
We find the solution is to combine the exercises above, some hands on treatment and detailed biomechanical analysis which feeds into specific treatment and exercises for you. Helping you to change those movement patterns that are overworking those poor rotator cuff muscles and causing them to complain. The exercises and ideas we give here work for many cases but you can’t beat being assessed a treated by a professional ourselves or anyone else.
If you’d like to speak to one of our therapists about how we can help with your rotator cuff problem (or any other problem) then click on the button below. Don’t suffer in silence. Lots can be done about these types of conditions even if previous approaches haven’t worked.
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