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Shoulder Rehab 101: Rotator Cuff Rehab Doesn't Mean External Rotation

How common is it?

Rotator cuff tear is a common injury (classified as a disease) that many affects almost 1 in 4 of us over 50 years old and 1 in 4 over 20 years old. So it is a very common disease. Despite this many people having tears, only 1 in 3 are symptomatic, this is similar to spinal injuries, in that the majority of people have some form of spinal disk damage but not all of them are painful or symptomatic. The sad part is that only 1/5 people with symptomatic shoulders seek help to get better. If you have pain I would urge you to seek professional help, even if the advice in this blog helps you to resolve your symptoms just to make sure it’s nothing more serious.

Are you affected?

There are some typical signs that can allow you test yourself for having a rotator cuff tear (RCT), Unless checked by a professional you may get some false positives. Meaning that just because you tick all the boxes for a typical RCT, doesn’t mean you have one. It could be a nerve problem, could be a bone injury, could be a fat pad problem, the list goes on.

Typically having difficulty with overhead activities like getting things down off a high shelf, drying your hair, even lifting your arm above your head can be painful and cause you to drop things. This is tested with the painful arc:

  1. standing with your hands by your side, raise them up above your head.

  2. A RCT of the supraspinatus will be aggravated by this test, causing pain at the top of your arm where the humerus meets the shoulder joint.

An inability to externally rotate your arm, or keep your arm rotated outwards would suggest a tear in the infraspinatus (or teres minor). This can be noticed with actions like putting your seatbelt on, closing the car door or putting on a t-shirt. Any action that causes you to move your hand away from your torso without lifting it up.

  1. Stand arms by your side

  2. Flex both arms

  3. Move the hands outwards

  4. Can one go further than the other?

The least likely rotator cuff to be damaged (from experience not research) is the subscapularis, this muscle sits underneath your shoulder blade and we can’t see or touch it unlike the other 3. If this one is damaged it would likely be form playing a sport like tennis, squash or baseball where you are swinging inwards to hit something. This causes your arm to internally rotate at the moment you are hitting the ball. If this is the action that is painful, it’s likely to be your subscapularis that is the culprit.

The test here would be:

  1. Put the top side of your hand in your lower back and try to push it away from your back.

  2. If you can’t get into this position then press into your belly keeping your elbow and wrist in a straight line.

  3. If this causes pain or is not doable then it is likely to be the subscapularis that is the problem muscle.

How do you fix it?

If this is you, then we break it down into 3 phases.

1st phase: Healing

We want to create an environment that is healthy for the shoulder to heal in, this starts with heat. So whenever you get the chance, place a heat pack, wheat bag or hot water bottle on it (be careful not to burn yourself). Keep the joint moving but stop playing your sport if it is heavily shoulder reliant such as squash or tennis. Playing your sport early in the rehab phase will only make it worse and increase the likelihood that you will need surgery.

Any daily activities that cause pain should be reduced as little as possible by using the other arm or getting someone else to help you out.

2nd phase: Range of Movement (ROM):

This is not a no pain no gain scenario

This starts with just keeping the joint moving, try to avoid immobilising the shoulder because this will reduce available ROM.

This progresses into using the other arm to move the injured shoulder, a walking stick can work wonders here because unless you’re stretch arm strong there is no way you’ll be able to get that injured shoulder into full flexion above your head.

Supraspinatus

If it’s the supraspinatus that you think is the culprit, side flexion is your main target, so with the stick in hand, help your injured arm through as much of the ROM as you can WITHOUT PAIN.

Infraspinatus

If it’s the infraspinatus that you think is the culprit, external rotation is your main target, so with the stick in hand, help your injured arm through as much of the ROM as you can WITHOUT PAIN.

Subscapularis

If it’s the subscapularis that you think is the culprit, internal rotation is your main target. However due to the number of muscles that aid this movement you may not need to worry about ROM at all and skip happily ahead to phase 3! However if it is affecting you then grab that sick and help it into the ROM with your uninjured arm

3rd Phase: Strengthening: start ASAP

This is not a no pain no gain scenario

Graded exercises are crucial for two reasons:

  1. So you get back to your sport

  2. So when you get back you can stay back

Always, Always, Always start rehab of any injury with isometric exercises. In this case they will be isolation exercises for the following movements; internal rotation, external rotation and side flexion.

All we need for this is a corner piece of wall or doorway and 5 minutes of time, you won’t (shouldn’t) even break a sweat.

For all these exercises it is very important that we are strict with positioning, posture and no pain!

Supraspinatus

  1. Stand parallel to the wall

  2. Arm by your side, palm facing inwards

  3. Press gently against the wall (pain free)

  4. Hold for a count of 15

  5. Rest for a count of 10

  6. Repeat 4 times

Infraspinatus

  1. Stand parallel to the wall

  2. Arm by your side, palm facing inwards, elbow flexed

  3. Push gently against the wall (pain free)

  4. Hold for a count of 15

  5. Rest for a count of 10

  6. Repeat 4 times

Subscapularis

  1. Stand facing doorway/corner

  2. Arm by your side, palm facing inwards, elbow flexed

  3. Press gently against the wall (pain free)

  4. Hold for a count of 15

  5. Rest for a count of 10

  6. Repeat 4 times

Closing statement:

The faces were covered with smiley faces not because i am camera shy but the 10 second wait for the picture meant it always captured a resting face looking rather bored. For a happy picture of my mug look here.

Activate Sports Therapy

0784 644 2339

Activate Sports Therapy, 60a Washway Road, Sale, United Kingdom, M33 7RE

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