Rotator cuff Xrays

Pop quiz! Where is your rotator cuff? Oh wait, is it rotator “cuff” or “cup”? Nevermind that for now. What does it do? And why does it cause so many people (particularly older adults) so much pain? Do rotator cuff exercises actually do anything?

How’d you do? If you’re like many people, you’ve heard the word “rotator cuff” thrown around quite a bit.

You know it’s a source of pain, but its importance to shoulder mobility and why it can be so painful aren’t clear.

I’m sure many of you have even heard horror stories about the state of your rotator cuff. Things like, “It’s fraying like a rope!” or “It’s holding on by a thread!” Those aren’t exactly comforting images, am I right?

The frustrating truth is that not all healthcare providers explain to their clients what the rotator cuff actually is, how it changes with age, and what can be done to help reduce pain or prevent injury.

In this article, we will explore all of those topics and help you to better understand how you can keep your rotator cuff as healthy, strong, and functional as possible!

Is It Cup or Cuff?

Shirt cuff and coffee cup

You’ve likely heard it said both ways (hopefully not by a medical provider), but it’s actually the rotator cuff.

Think of it like this: you have cuffs on your sleeves, and you put your arms into sleeves.

It’s the cuff that goes around your shoulder joint, or as it’s called in the medical world, the “glenohumeral joint”.

It gets its name from the bones that come together to make it- the glenoid (part of the scapula) and humerus (arm bone). The shoulder joint (AKA glenohumeral joint) is a ball-and-socket joint.

More About the Glenohumeral Joint

Glenohumeral joint

We have two ball-and-socket joints in the body- the hip and the shoulder. This formation allows for a greater variety of movements, as compared to joints like the knee, which just allow for bending (flexion) and straightening (extension).

The hip socket is very deep, giving it lots of stability, which is a good thing. Standing on our legs is much easier than standing on our hands, because of the stability in that hip joint.

The shoulder joint has a shallow socket, making it less stable, but more mobile.

For the most part, this is good too. We need our shoulders to move so we can reach overhead to grab a mug out of the cabinet, wash our hair, put our seatbelt on, pick up a grandchild, etc.

The tradeoff is that we have to create stability with our muscles surrounding the shoulder joint, otherwise the joing becomes too loose and can’t function properly.

So it’s important to understand the rotator cuff muscles and all that they do for the shoulder.

What Muscles Make Up the Rotator Cuff?

Rotator cuff muscles

There are four muscles that make up the rotator cuff:

  1. Supraspinatus
  2. Infraspinatus
  3. Subscapularis
  4. Teres Minor

The muscle belly of each muscle is attached to the shoulder blade and their tendons attach to the arm bone (humerus) near the glenohumeral joint. The tendons are about one centimeter thick and two-three centimeters wide.5

What Does the Rotator Cuff Do?

Older man playing tennis

Collectively, These muscles work together to stabilize the shoulder joint during movement.

When you bring your arm overhead, the rotator cuff is supporting the movement from about 60-180 degrees of movement (just below shoulder height to when your arm is all the way up by your ear).

If your rotator cuff is too weak or damaged, doing overhead motions is very difficult or even not possible.

In addition to supporting the shoulder joint, the supraspinatus, infraspinatus, and teres minor allow the humerus to externally rotate. This is the motion a baseball pitcher does to wind up. It’s also the motion for washing our hair, to put hair into a ponytail, or to scratch our upper back.

The subscapularis helps with internal rotation. This movement is needed to get your wallet out of your back pocket, or fasten your bra.

What Causes a Rotator Cuff Tear?

Rotator cuff tears may be caused by repetitive overhead movements (like pitching a baseball or spiking a volleyball), trauma (like a car accident or fall), or can be age-related.

Injuries to the rotator cuff are common and the risk does increase with age.1

What Happens to the Rotator Cuff with Age?

Woman holding shoulder

Not only has research shown a higher incidence of rotator cuff tears among older adults, but it’s also found that the rates of more serious tears (i.e. larger tears) are higher among older adults. These tears are typically more difficult to repair surgically.1

But why is this?

Honestly, this is not clearly understood in the medical field, however there are multiple factors which are likely at play.

Tendons have decreased water content with age, which causes increased stiffness and decreased ability to handle stress. The tendons surrounding the shoulder joint may experience a thinning over time.3

The thinning tendons is likely where the “fraying rope” analogy comes in, as the tendon is not as strong and thick as it was when it was younger, so if surgery is required, it’s more difficult to reattach the tendon without high risk of it detaching again.

Additionally, atrophy, or a reduction in muscle mass, occurs with aging.

Research has found that some muscles of the rotator cuff experience more atrophy than others. The cross-sectional area of the supraspinatus and subscapularis have been found to decline throughout adulthood, and the cross-sectional area of the infraspinatus begins to decline in midlife and continues into older adulthood. Whereas the cross-sectional area of the teres minor doesn’t appear impacted by age.2

Tears are mostly commonly seen in the supraspinatus tendon, which is likely based on its location in the shoulder joint and the atrophy that occurs with aging.

Essentially, the majority (and largest) muscles of the rotator cuff are experiencing atrophy, in addition to changes that are occurring in the tendons, which contributes to decreased stability of the shoulder joint, decreased strength, and increased risk for injury/tears.

Are There Different Types of Rotator Cuff Tears?

Imaging of rotator cuff

Yes.

Rotator cuff tears are commonly classified as either a “partial-thickness tear” or a “full-thickness tear”.

A partial-thickness tear (as the name implies) only goes partially into the tendon. It’s usually further classified by how deep it is in millimeters.

Partial tears may be the result of age-related changes to the tendon (see below).

Actually, some adults 60 and over have a partial rotator cuff tear and have no symptoms.4

Before you run to your doctor’s office and demand an MRI, don’t panic! If you don’t have symptoms, treatment is not necessary!5

In fact, for those over 40, it’s fairly common for an MRI to show a partial rotator cuff tear.5 Just because something shows up in imaging, doesn’t mean action is required. Symptoms are very important when it comes what needs or doesn’t need treatment.

A full-thickness tear occurs when the tear is completely through the tendon.

What Are the Symptoms of a Rotator Cuff Tear?

As always, please see your doctor for an actual diagnosis. The following list of symptoms are typically associated with a rotator cuff tear.

  1. Trouble lifting arm
  2. Pain with overhead movement or when lying down
  3. Weakness of the shoulder
  4. Difficulty lifting objects
  5. Clicking or popping when moving the arm

Does a Torn Rotator Cuff Require Surgery?

Surgical tools

Not necessarily.

For partial-thickness tears, it’s unlikely that surgery will be needed.

Physical therapy can retrain the muscles and bones to regain function and reduce pain without surgical intervention.8

For a full-thickness tear, surgery is usually recommended to those with “healthy” tissues.6

This is where things can get frustrating for older adults.

For a number of older adults, the risk of re-tear is concerning, so many seniors have a reverse total shoulder arthroplasty (AKA a shoulder replacement surgery) instead of a rotator cuff repair.

However, there is emerging evidence out of Cedars-Sinai Medical Center that older adults (75+) with “repairable, full-thickness tears can experience a significant clinical benefit from arthroscopic rotator cuff repair.” In this type of repair, the surgeon utilizes cameras to perform the surgery, rather than a large incision to open the joint.7

In his research, Dr. Michael Stone followed 83 patients 75 years or older for five years following arthroscopic rotator cuff repair.

At five years, 93.5% (77 patients) had improved range of motion and had not undergone any additional shoulder surgeries.7

To summarize, partial-thickness tears can be treated effectively with physical therapy. Full-thickness tears may require surgery, and it’s important to talk with your doctor about all the options that are available.

How Long Do Rotator Cuff Tears Take to Heal?

Healing times vary, depending on severity, as well as overall health and age.

Mild rotator cuff tears typically take around 4 weeks.

Whereas severe tears can take four to six months.

Complete recovery (i.e. returning to prior level of function/sports) may take up to a year.8

However, that doesn’t mean you’ll be in this much pain for that whole recovery time.

As you do your exercises, pain will decrease and motion and function will improve.8

Even if you and your doctor decide that surgery isn’t the best option, physical therapy can be very helpful in reducing pain and improving functional capacity.8

Can Rotator Cuff Injury/Tears Be Prevented?

Rotator cuff exercises

While nothing is guaranteed, you can definitely decrease your risk of rotator cuff injury!

Ways to Prevent Rotator Cuff Injury9,10:

  1. Strengthen the muscles of the shoulder joint, including the rotator cuff. (Please note: this is #1 for a reason! It’s highly effective!)
  2. Practice good posture in order to maintain proper alignment of shoulder joint.
  3. Warm-up prior to activity (especially overhead activity like tennis, or swinging motions, like golf,etc.)
  4. Try to avoid sleeping on your shoulder with your arm stretched overhead.
  5. Avoid smoking, as that will result in decreased blood flow to the tissue.

7 Exercises to Prevent Injury/Decrease Pain in Rotator Cuff

Check out this video of Dr. Katie completing all of the rotator cuff exercises:

Please note that while these exercises may be used to prevent injury and/or decrease pain, it’s necessary to see a physical therapist and your doctor if you suspect you have a tear. Consult them prior to performing exercises.

These exercises are intended to strengthen the muscles around the shoulder, including muscles of the rotator cuff, to allow for improved strength and range of motion.

For shoulder exercises, it’s important to move slowly and with control. If you experience pain with any exercise, please stop the exercise and consult your physical therapist.

1. Scapular Retractions

  1. Stand up tall (if you want some feedback, stand with your back to a doorway), with feet hip distance apart
  2. Moving your shoulder blades only (people try to move their arms to achieve this movement, which defeats the purpose) bring the shoulder blades together
  3. Hold for 3 seconds Return shoulder blades to starting position
  4. Repeat 8-10 reps, rest for 30 seconds, repeat for 3 sets total

2. Wall Washes

  1. Have two small towels close by
  2. Face a wall with feet hip distance apart
  3. Place towels under wrists against the wall, so elbows are at shoulder height (start with elbows lower if unable to get to shoulder height)
  4. Slide both arms up the wall, slowly and with control, only to where you don’t have pain
  5. Hold for 5 seconds at the top, slide back down slowly and with control
  6. Repeat 8-10 reps, rest for 30 seconds, repeat for 3 sets total
  7. Move arms out slightly to a “V” position
  8. Slide both arms up the wall, slowly and with control, only to where you don’t have pain
  9. Hold for 5 seconds at the top, slide back down slowly and with control
  10. Repeat 8-10 reps, rest for 30 seconds, repeat for 3 sets total

3. Serratus Push Ups

  1. Place hands against stable surface (recommend starting with hands on wall, then progressing to hands on countertop as strength increases)
  2. Straighten arms so your elbows are not bent
  3. Step each foot back, so you are in an angled plank position
  4. Lower chest towards the wall/stable surface without bending elbows.
  5. Repeat 8-10 reps, rest for 30 seconds, repeat for 3 sets total

4. Sidelying External Rotation

  1. Lie down on your side (if one side is injured, lie on uninjured side)
  2. Place a small towel roll under your arm, somewhere between your armpit and elbow
  3. Bend your elbow to 90 degrees
  4. Maintaining the bend in your elbow, bring your hand down towards your belly button
  5. Rotate your arm at the shoulder to bring the hand back up towards the ceiling.
  6. Repeat 8-10 reps, rest for 30 seconds, repeat for 3 sets total
  7. Repeat on other side if able

5. Serratus Punches

  1. Lie down on your back
  2. Lift hands overhead so fingers are pointing towards the ceiling
  3. Reach fingertips towards the ceiling (it will feel like your shoulder blades are moving apart in the back)
  4. Return to starting position
  5. Repeat 8-10 reps, rest for 30 seconds, repeat for 3 sets total

6. Rows

  1. Step on the middle of the resistance band
  2. Stand upright with feet hip distance apart, keep a slight bend in both knees
  3. Hold the resistance band so palms are at knee-height facing each other
  4. Tip forward at the hip (**Don’t round your back!- Movement only comes from the hip!)
  5. Maintaining your tipped forward position, bring your shoulder blades together in the back as your elbows bend and you pull the resistance band to your hips.
  6. Return resistance band to knee height.
  7. Repeat 8-10 reps, rest for 30 seconds, repeat for 3 sets total

7. Flashers

  1. Stand or sit with feet flat on the floor
  2. Bring arms down by the sides, bend elbows to 90 degrees with palms facing the ceiling
  3. Hold the resistance band with both hands
  4. Using your shoulder blades, pull the resistance band taut (think about moving your pinky fingers away from each other)
  5. Return to starting position
  6. Repeat 8-10 reps, rest for 30 seconds, repeat for 3 sets total

Have the Strength to Live Life to the Fullest!

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Sources:

  1. Geary, M., & Elfar, J. (2015). Rotator Cuff Tears in the Elderly Patients. Geriatric Orthopaedic Surgery & Rehabilitation, 6(3), 220-224. doi: 10.1177/2151458515583895
  2. Raz, Y., Henseler, J., Kolk, A., Tatum, Z., Groosjohan, N., & Verwey, N. et al. (2016). Molecular signatures of age-associated chronic degeneration of shoulder muscles. Oncotarget, 7(8), 8513-8523. doi: 10.18632/oncotarget.7382
  3. Effects of Aging – OrthoInfo – AAOS. (2021). Retrieved 30 August 2021, from https://orthoinfo.aaos.org/en/staying-healthy/effects-of-aging/
  4. Dines, J. (2019). Rotator Cuff Tears: Can They Happen at Any Age?. Retrieved 30 August 2021, from https://www.hss.edu/playbook/rotator-cuff-tears-can-they-happen-at-any-age/
  5. Partial Rotator Cuff Tear. Retrieved 29 August 2021, from https://www.hopkinsmedicine.org/health/conditions-and-diseases/partial-rotator-cuff-tear
  6. Repair of Rotator Cuff Tears. Retrieved 29 August 2021, from https://orthop.washington.edu/patient-care/articles/shoulder/repair-of-rotator-cuff-tears.html
  7. Arthroscopic Rotator Cuff Repair Can Be Considered in Older Patients. (2020). Retrieved 4 September 2021, from https://www.aaos.org/aaosnow/2020/aaos-now-special-edition/research/597_shoulder_elbow/
  8. How long does it take for a torn rotator cuff to heal without surgery?. (2021). Retrieved 6 September 2021, from https://www.hyderabadshoulderclinic.com/how-long-does-it-take-for-a-torn-rotator-cuff-to-heal-without-surgery/
  9. How to Avoid a Rotator Cuff Injury | OrthoNY. (2021). Retrieved 6 September 2021, from https://orthony.com/posts/news/how-to-avoid-a-rotator-cuff-injury/
  10. Rotator cuff injuries are a common cause shoulder pain. (2021). Retrieved 6 September 2021, from https://www.inovanewsroom.org/expert-commentary/2020/06/skip-the-shoulder-pain-how-to-prevent-rotator-cuff-injuries/

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