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August 1999 Issue
Rotator Cuff Injuries: Not Just for Quarterbacks
by Michael Fick
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It makes the news when John Elway or Joe Montana injures a rotator cuff, but nobody pays any attention when legions of you’s and me’s sustain similar injuries. Quarterbacks tear up their shoulders for millions of dollars and great glory, but the rest of us do it by the millions for nothing but great pain. Rotator cuff injuries are considered the main cause of chronic shoulder pain, and even the most dedicated couch potatoes can sustain them.

Why do we do it so often, for no good reason? Because it's so easy to do, and because, like Elway and Montana, we're not getting any younger. We can injure a rotator cuff through years of abuse from athletics or physical labor, by waxing the car or painting a wall once, or with a single incident such as a fall.

All those roads lead to the same result: a shoulder injury that makes reaching overhead very painful or downright impossible even if you're getting paid millions of dollars to do it. Washing your hair? Getting a hat off a closet shelf? Forget it ... you'd rather join the great unwashed and frozen than experience the agony of reaching above shoulder height. Throwing a ball for your kid or pup? You'd rather wreck your car or kick a 250-pound cop in the shins. Throwing overhand is out of the question, so the backup quarterback gets called into the game or your game of catch or fetch is replaced by bowling or checkers ... anything that keeps the shoulder low. It's embarrassing for a big man to cry out in pain and have to ask his wife or granddad to get a box of cereal off the top shelf.

Here's why the rotator cuff gets injured so easily. Our shoulder joint resembles a fist in an open palm, with no pronounced socket to solidly restrain the upper arm's upper ball. We have merely a girdle of muscles and tendons -- the rotator cuff -- trying to keep the fist centered in the open palm (i.e., the upper arm bone centered in the shallow shoulder "socket"). Reaching overhead with our upper arm above the horizontal forces rotator cuff muscles against a bony "roof" or overhang. This contact, called impingement, is OK when the arm is static, but not when the hand and arm move back and forth as we wax the car, paint a ceiling or upper wall, throw a ball, swing a racquet, or rearrange a closet shelf.

Those actions, or any others that involve arm motion while the shoulder is raised (basically any position that raise the upper arm more than 90 degrees above the body's centerline), grind the rotator cuff against the shoulder joint's bony roof, abrading the muscle. This impingement leads to irritation, inflammation, swelling, increased impingement, bleeding, scar tissue, and ultimately to permanent damage if we don't stop the cycle.

From that, you can guess the best way to prevent rotator cuff injuries: do not perform repetitive motions with your upper arm above shoulder height. If your elbow is above your shoulder and/or your shoulder is raised/shrugged, you're asking for trouble when moving your hands around. Increased effort, repetitive motions, and age all exacerbate the problem. Swimming is a bear on the rotator cuffs; throwing, racquet sports, weight lifting, golf, and so forth are little better.

So pay somebody else to wax the RV or paint the ceiling. Hit or throw the ball sidearm to exercise the dog. In a nutshell, stop doing anything that hurts. With any luck, a pampered rotator cuff injury may heal in just a year or two.  Of course, any muscle loses a lot of strength in a year or two of inactivity, so a few weeks or months of proper rehabilitation is highly preferable to a year or two of doing nothing and hoping it heals naturally.

Once you injure your rotator cuff, however slightly, start icing it a few times a day to reduce the swelling that increases the impingement. Stop doing whatever hurts. If the show must go on, at least position yourself and/or the task so you're doing it below shoulder level, and consciously lower your shoulder to avoid the shrug that increases the impingement. Lowering your shoulder as though trying to shed a shoulder strap will make more room between the rotator cuff and its bony impingement point.

Do not immobilize the shoulder, neither in a sling nor on the arm of the couch, for days at a time. It can freeze, virtually fusing so it can't be moved, in as little as a couple of weeks. If the shoulder pain becomes chronic, or starts hurting when inactive, it's time to see the doctor for analysis and the therapist for rehabilitation. Don't just read a book and begin self-treatment, because the limbering and strength-building exercises critical to recovery must be done with great precision to focus their benefits on the injured muscles. A conscientious PT will correct your arm and shoulder motions by fractions of an inch to isolate just the right muscles, so the money spent on professional rehab can shorten the process by months and even prevent further injury. What's a few hundred bucks or an insurance claim compared to months of agony or avoidable surgery?

As you can see, rehab doesn't come from a whole book, let alone from this brief column. What this column can offer is strong urging to visit a sports medicine physician for diagnosis (and a surgeon if necessary) and a physical therapist for rehab. If your PT rushes the rehab, just gives you a list of exercises, or is not effective in providing relief, switch to a more meticulous PT who will guide you slowly and methodically through the recovery and strengthening processes. There are no significant shortcuts to rotator cuff rehab or impingement reduction.

So the next time you feel your shoulder start to ache over time, or hurt during or after a round of tennis or waxing the car, test your shoulder for impingement. Look for pain or weakness when raising a straight arm, palm down, near and above shoulder height, or local tenderness in the meaty part of the shoulder just past the bony tip of the shoulder. If it gets severe or lasts more than a couple of weeks, paying the doctor and PT now can avoid paying the surgeon later. Proper rehab and strengthening can do what surgery cannot: make the shoulder as good as new again. Then proper use and a little proper exercise can keep it sound so you can ... Play Ball!



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