ROTATOR CUFF

(Keywords: rotator cuff syndrome, chiropractic help, shoulder pain, frozen shoulder)

The rotator cuff is the name given to a group of four muscles that act to stabilize the shoulder. Shoulder pain and the so-called frozen shoulder often involve these four key shoulder muscles.

They are the

1. Subscapularis (which lies UNDER the shoulder blade),
2. Supraspinatus (which lies ABOVE the spine of the shoulder blade),
3. Infraspinatus (which lies BELOW the spine of the shoulder blade) and
4. Teres Minor (which attaches to the side of the shoulder blade.

   
   

   To these four muscles we will add the

5. Biceps muscle for simplicity, since it also a common offender and cause of shoulder pain.

For some pictures of these muscles, and their anatomy, terms like "acromion" and "clavicle" click here. SHOULDER ANATOMY ...

These shoulder muscles allow you to raise your arm, turn it and move the arm into many different positions, each carefully controlled and coordinated, as in throwing a ball accurately, for example. Unlike the hip joint though, the shoulder socket is very shallow to allow for greater range of motion of the shoulder. This makes the shoulder more vulnerable to injury, leading to shoulder pain, strains, tears and sometimes frozen shoulder. FROZEN SHOULDER ...

Rotator cuff syndrome. What's that?

Rotator cuff muscle tears cause pain and weakness in the shoulder. Usually it starts as a small strain with heavy lifting, or not warming up properly before tennis, for example, or a fall on the outstretched arm.

This may be followed some weeks or months later by a partial tear if the initial minor injury was not correctly addressed. The shoulder will be painful, but you can still move the arm in a normal range of motion. Obviously, the larger the tear, the more weakness and the more pain the injury will cause.

Complete rupture is fairly rare, often occurring after cortisone injections, which should be considered only after chiropractic (or other) conservative treatment has been exhaustively tried without success.

Regular stretching before activity is the key to the healthy functioning of the shoulder muscles and joints. Otherwise wear and tear, or degeneration, of the muscles and tendons occur. Tearing of the rotator cuff tendons is an especially painful injury. A torn rotator-cuff creates a very weak shoulder. Most of the time patients with torn rotator cuff are in late middle age. But rotator cuffs tears can happen at any age.

What causes Rotator Cuff Syndrome?

Rotator cuff muscle tears can occur from a single traumatic injury, for example a fall on the outstretched arm, causing immediate severe shoulder pain. If a fracture, or torn ligaments occurs at the same time, then of course the rotator-cuff injury may be missed, and the treatment of the fracture (immobilisation) may unavoidably be the very worst treatment for the muscle injury. It can't be helped. Just rehab of the shoulder, once it comes out of the sling, will be further prolonged and more difficult.

Most tears, however, are the result of overuse of these muscles and tendons over a period of years, starting with a minor injury that is not adequately cared for. People who are especially at risk are those who engage in repetitive overhead sports such as tennis and weight lifting.

This nasty shoulder syndrome frequently starts after a whiplash injury, usually many years ealier and long forgotten. It is indeed difficult to prove the link. WHIPLASH CHIROPRACTIC ... long forgotten. Progressive irritation of the nerves from the neck that supply the shoulder by a Chiropractic Subluxation weakens the shoulder muscles and makes them vulnerable to sprains and strains.

For unknown reasons, smokers are more prone to RIGHT shoulder pain.

A muscle tear usually doesn't occur unless the muscle is already weakened by some other problem, either in the neck and sometimes in the acromioclavicular joint. ACROMIOCLAVICULAR JOINT ... and in impingement syndromes.

CHIROPRACTIC HELP

Nonsurgical Treatment

The first goal is the correct diagnosis of the condition. This will include an examination of the neck. NECK PAIN ... to see if the underlying cause may be an irritated or pinched nerve.

Classically, in a muscle injury, an ISOMETRIC test (the benchmark test) causes pain. In this examination, the rotator cuff muscle is tested against resistance, WITHOUT movement of the arm.

An echo (Doppler) examination or an MRI may be required in more serious cases of shoulder pain to help with the diagnosis.

Treatment is then addressed at your chiropractor’s findings. Classically this will include a gentle adjustment of your neck, rest from vigorous activities, and ice (if acute), gentle stretching perhaps if the tear is not serious, and finally vigorous, active rehabilitation. ROTATOR CUFF STRENGTHENING ... of the shoulder and neck, so that the tear in the rotator cuff does not re-occur as soon as you return to sport.

Carrying your wallet in your back pocket? A red rag to your chiropractor. BACK POCKET WALLET ...

ANTI INFLAMMATORY DRUGS ... should not be used in the first instance because in the initial stage this is not an inflammatory condition, and ice is more effective and safer. 14 000 people DIED in one year in the USA alone from gastric bleeds after using NSAIDs, as they are called.

Cortisone injections are freely acknowledged to be a cause of rotator-cuff tendon rupture and, together with surgery, should only be considered after all conservative treatment has been exhausted.

Other factors to consider

Depending how serious the strain is, it may take 6-8 weeks to heal. Graduated return to sport is essential.

As a rule of thumb, if your shoulder is not improving to your satisfaction, think of the following:

• Has your neck been considered as a possible cause of your arm pain? In particular, the lower cervical facet anatomy should be considered, that's where the nerves to the arm emerge. LOWER CERVICAL FACET ANATOMY ...
  
  NECK PAIN TREATMENT ...
  
  
• Has the AC joint been examined?
• In the author's experience, the SUBSCAPULARIS muscle is often the offending rotator-cuff miscreant. Has it been examined?
• Are you following a daily exercise program? Daily stretching and strengthening is vital is you wish to regain the function of your shoulder.

Shoulder surgery

A complete tear (most uncommon) will not heal. Complete ruptures usually require surgery if your goal is to return your shoulder to optimal function, and particular if you have competitive sport in mind.

Elderly patients, and those who have other diseases that increase the risks associated with anaesthetics, should avoid surgery, (in my opinion!) and accept the limitations of a weak shoulder. Far more sensible than risking losing your marbles!

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"I'm sick of pain - 1 year later after wrist and shoulder surgery I still have chronic pain on right side and it moves to left back of neck and scapular where I have knots.

I can hardly turn my neck - no insurance now."

Hello Wendy,

You were probably badly advised. The primary cause of the pain in your arm was most likely in your neck - all the surgery in the world in your wrist and shoulder couldn't possibly fix the pain radiating down your arm from a chiropractic subluxation in your neck.

Start saving your pennies, and see a local chiropractor.

Dr B

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From the medical literature

Complications of open acromioplasty: The rate of complications after open acromioplasty is predictably quite low. Reported complications have included acromial fracture, persistent pain, postoperative glenohumeral stiffness, lengthy rehabilitation, delayed return to work, weakness, superficial or deep wound infection, detachment of the deltoid, and dysfunction.

McShane et al., in a study of twenty-nine patients who had an acromioplasty for the treatment of impingement syndrome, reported a high percentage of complications (including acromial fracture and prolonged convalescence) after procedures involving detachment of the deltoid. Most of the problems were related to technical errors.

Ogilvie-Harris et al. evaluated sixty-seven shoulders in sixty-five patients who had had persistent pain for more than two years after an open anterior acromioplasty. Although the total number of acromioplasties performed at their institution was not documented, twenty-one of the failed acromioplasties had been performed by the authors and the other forty-six had been performed elsewhere. All patients had a thorough examination to determine the reason for failure. Arthroscopy revealed that the original diagnosis had been incorrect for twenty-seven shoulders (40 per cent), that an error had been made during the operation on twenty-eight shoulders (42 per cent), and that only twelve shoulders (18 per cent) had had the correct diagnosis and procedure. Even after the appropriate procedure had been performed, however, only thirty-one (60 per cent) of fifty-two shoulders that had a reoperation had a good result. No explanation was provided for this disappointing finding. Journal of Bone and Joint Surgery 1854 ...

FROM THE COAL FACE

In December, whilst my colleague was on leave for a month, and I was working seriously overtime, I developed a rotator cuff strain. Such that for about two weeks I had to work out other ways of giving an adjustment to the spines of patients.

THEREAFTER, I developed neck pain. Chicken and egg.

But it was a learning curve for me. I developed new exercises for my shoulder, that I could then share with patients. I realised, perhaps for the first time, that a rehab exercise must REACH the painful activity, but not cause searing pain.

Fortunately a couple of treatments of my neck after my colleague returned, and my own home-grown exercises, the pain soon passed over. It's now three months since I had any pain, but I'm still doing the exercises every morning ... my work is dependent on a strong shoulder.

CHIROPRACTIC HELP Questions

There's no substitute for a thorough examination when it comes to a shoulder condition, but we do try to answer some of your basic questions. In the end though most likely the advice will be to consult your local chiropractor to make the diagnosis... is the problem primarily in your shoulder? Or is it in your neck? Or both? CHIROPRACTIC HELP Questions ...

USEFUL LINKS

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