Rotator Cuff — “Overuse Syndrome” and Tears
What they are and what to do about them.
September 2014 — I’ve just about cured my bad rotator cuff this summer, driving a short-haul truck in the metropolitan area, or that’s what it feels like. Constantly hauling left and right on that big wheel, for one thing, works those upper back muscles as recommended in Rotator Cuff Exercises. All the other physical upper-body work helps, strengthening those upper-back and shoulder muscles we often overlook in workouts aimed at the so-called “mirror muscles” on the front.
Tears of the rotator cuff are rare in teenagers and unusual in the 20s and 30s. An elderly person can tear it just by picking up a suitcase. About 30 % of people over 70 have a tear in the rotator cuff. Most rotator-cuff repair operations – around 55 %, according to one survey – are done on people in the 45-64 age range.
Luckily, even though my chances of injuring a rotator cuff have worsened as I’ve gotten older, new advances in shoulder surgery have dramatically improved doctors’ ability to treat this tricky problem, and without the need for general anesthesia. And most tears can be treated by “conservative measures,” which means mainly exercise. According to a recent study, in fact, three out of four people even with “massive tears” were able to forego surgery in favor of conservative measures, and with better results than those who underwent surgery.
The rotator cuff is a group of four muscles and their associated tendons that help hold the shoulder joint in place and fine-tune its movement, and there’s a great illustration on good old WebMD. Deep within the shoulder, beneath the deltoid, the cuff sits between a rock and a hard place: Below it is the ball-and-socket joint; above it is the acromion, the flat bone projection of the collar bone that roofs the joint. Movement of the rotator cuff against the acromion is lubricated by the bursa, a layer of fibrous tissue like that unchewable white stuff in a steak.
By 40, the tendons of the cuff are losing blood supply; their tissues are beginning to break down; and the collagen that composes them is becoming thicker, less elastic and more vulnerable. The muscles of the shoulder can be out of balance by this age too, some strong from the weight bench or the basketball court, some weak and fatty. The bursa may be thickened from irritation, and the space between the cuff and the acromion pinched by slumping posture. Combine all this with the current generation’s drive to thrive through physical fitness, and aging rotator cuffs get pushed beyond their stress limits.
Rotator cuff tears aside, the most common rotator-cuff affliction is not a specific injury but “overuse syndrome” – problems resulting from too much repetitive, overhead-reaching activity. Olympic gold medal swimmer and actor Johnny Weismuller once said he never had a problem until he started swinging from trees as Tarzan, but most swimmers do.
Dr. Darren Johnson, chairman of orthopedic surgery and chief of sports medicine at the University of Kentucky School of Medicine, once told gave me the following analogy. “The shoulder joint is like a golf ball on a tee. The most common reason when I see an 18-year old swimmer with a loose shoulder is that the ball wants to move out of the socket, and the rotator cuff tries to hold the ball in.”
Overuse syndrome expresses itself in tendonitis or impingement syndrome, in which excessive overhead activity means excessive rubbing of the rotator cuff against the acromion, and inflammation.
Doctors typically recommend a conservative program of physical therapy to increase strength and flexibility and endurance of the shoulder muscles, anti-inflammatory drugs, and sometimes an injection of cortisone. They also say that rotator problems can be prevented by more balanced workouts.
“The shoulder is a complex joint with more mobility than any other joint in the body,” Dr. Johnson said. “There are really 17 muscles that help control it. People think that if they have a rotator-cuff problem, they should concentrate on the four rotator-cuff muscles, but they’re forgetting all those other muscles, particularly around the scapula. If you forget those, you will have problems, and you won’t get better.”
It takes a comprehensive approach to having health shoulders, a whole upper-body prevention program, according to Dr. Nicholas DiNubile, an orthopedic surgeon and best-selling author of the “Framework” series, including FrameWork for the Shoulder: A 6-Step Plan for Preventing Injury and Ending Pain. “Now the rage is to really work the scapular stabilizers for a healthy shoulder, the upper back. It’s about how people create imbalances in the body, whether that be through a sport or workouts at the gym.”
“A lot of guys talk about the ‘mirror muscles,’” he says. “They tend to do more front-of-body work to get big biceps and pecs and shoulders, but the mid deltoids and rear cuff and scapular stabilizers are out of balance, and that’s how you get in trouble. The rotator cuff is a balancing act.”
“The same is true with overhead athletes, if they’re throwing over and over and not allowing recovery,” he says. “We now know the importance of recovery. It’s easy to overload the rear cuffs, which are decelerators. The rear cuffs are the reins that put the brakes on. They fatigue very easily, and once they do there’s a much higher risk of injuring the shoulder. Pitchers have to stop because their velocity is off, because they didn’t allow recovery.”
I sometimes feel the result of imbalanced exertion in my own bad shoulders, but I have noticed that after skiing – downhill or cross-country – and spending a day pushing back with those poles, my shoulders actually feel better!
“That’s because you’re using your shoulders and getting lots of blood flow, and there’s lubrication going on, and you’re using them out of the impingement arc, which is above the shoulder,” says Dr. DiNubile. “You’re using those muscles in a safe range, and that’s a big part of getting over shoulder issues: using them in a range where you’re not provoking the issues. Most cuffs, when you get to shoulder height or higher, you’re provoking it.”
Dr. DiNubile is a big advocate of a relatively new device called the MarkPro, for which he did some of the contributory research, “the first device of its kind to get FDA clearance for muscle recovery.” It evolved from technology used in rehab settings, he says, using “H waves,” like the “H waveforms” of nerve signals, for deep penetration of low-frequency current.
“A significant number of the top major league pitchers are using this all the time,” he says. “After workout, they put it on. Recovery is the new frontier in training, how to do it faster, trying to accelerate and enhance repair in tissues that don’t have a lot of blood supply. Cyclies were the first group who embraced it. On the California racing team and the U.S. cycling team, they put pads on both thighs and lay down and let it pump the muscle. The low-grade twitch, contraction, enhances blood flow and gets out the waste products. We don’t know exactly how it clears the lymphatics, but it helps.”
Some folks do need surgery for rotator cuff tears, which are most-often partial tears that leave rough edges on the rotator tendon, increasing friction, snagging and catching on the bony structures. These tears tend to be a small flap of tissue, like a hangnail, according to one description. “You know how you tug on a hang nail and it smarts? Similar things can happen when you go through ranges of motion with the shoulder. It can become irritated, more painful, trigger conditions like bursitis.”
For those who do need surgery for rotator cuff tears, arthroscopic surgery has become more advanced, with better tools and instrumentation, better ways of fastening and repairing the cuff. Diving through small puncture holes down where only the arthroscope can see, they can connect torn tissues, smooth out rough edges, remove bone spurs from the acromion and contour it to give a crowded rotator more clearance, and even remove a troublesome, thickened bursa to allow a new one with a nice smooth surface to grow back.
MRIs (Magnetic Resonance Imaging) have also become better and can get a better look in advance, so surgeons can go in with more knowledge of what they will be facing, says Dr.DiNubile. “It not only shows the type of tear and location but the quality of tissue around it. Is it really beat-up tendons and avascular tissue, or just a surface problem. Is it a full-thickness tear. Is it retracted? It really helps the surgeon understand what he’s heading for and understand the anatomy.”
But most rotator cuff problems, again, result from overuse, and it takes for many active people a change of attitude. “Past generations were not as active as our current aging population, and they’d stop if something hurt,” says Dr. DiNubile. “When people in their 70s get a tear, they’re more likely to live with it, which is often the right treatment in that age group. The younger generation wants to keep going.”