Rotator Cuff Injury Cycle

There is a frequent pattern of injury amongst those who suffer from rotator cuff inflammation. The shoulder goes through a cycle of injury followed by healing and then the patient will have a certain period of pain-free time only to re-injure it. Soon enough, the periods of pain-free times are less and the movements that cause pain are more and the threshold for re-injuring the rotator cuff lessens.

What is going on is that the rotator cuff will become injured as it is impinged under the coracoacromial arch. The rotator cuff has a very sensitive area on its superior muscle called the supraspinatus. The rotator cuff is made up of four different muscles. 90% of the injuries originate at the supraspinatus muscle. As a person goes through years of this cycling, the rotator cuff becomes scarred; becomes less flexible; it becomes more easily torn; it becomes less subtle. In affect, this rotator cuff prematurely ages and in this cycle of injury, inflammation, healing, scar tissue, the rotator cuff at some point becomes torn. The key to treatment is to break that cycle of repeated injury to allow the rotator cuff to restore some of its flexibility to reduce some of its scar tissue. Constant re-injury needs to be avoided at all cost. It delays the healing process and contributes to scare tissue and overall decreases the range of motion.

If you have a shoulder injury, it is critical to heal it quickly and completely.

Comments

[Ethan]

I first injuried my right shoulder with bench press. Then, I mess it up even more improvasing improper workout to push my elbow against to wall and put my body weight on it. It has been 2 years now. I've been to PT and Orthopedic so many times. But I can still feel pain and I raise my right arm forward and rotate my wrist inward with my thumb pointing to the floor. I avoid to do pushup or anything because I'll just hurt myself again. I've been diagnose with rotator cuff tendonitis, and it is the supraspinatus that's not healing. I understand there may be too much scarrd tissues, what can I do to help removing/heal those scarred tissues?
Please help!

[Dr. Mike]

Ethan,
Your symptoms are consistent with rotator cuff tendonitis. When you extend your arm out in front and point your thumb down you are basically pinching the supraspinatus tendon between the "ball" of the humerus and the coracoacromial arch.

You have spent a long time in physical therapy and seen a few doctors. What you need to do is not "get rid of scar tissue", but instead relieve pressure on the supraspinatus tendon so that the swelling and inflammation resolves.

You relieve pressure by not pinching the tendon between 2 hard objects. Lots of pinching occurs at night, just when the body should be restoring itself. There is a new brace on the market that has been very responsive to recalcitrant tendonitis. You wear it at night when sleeping for about one month. The brace has some very impressive research behind it and can be found at teterop.com

I would recommend you continue your low weight exercises as directed by physical therapy and use the brace at night. Good luck.

[John]

I have a few questions about an injury that I currently have.

On Labor Day Weekend 2007, I had a 2 day basketball tournament. The next day I was not able to fully lift my left arm (dominant) forward or to the side without a sharp pain. I don't recall any sudden impacts but I must say I do play a lot of basketball so it could just be overuse. I went to a Clinic the following week and I was told by the Dr. that it's probably the Rotator Cuff so she prescribed an anti-inflammatory drug (Naproxen) and recommended me to a Physiotherapist. Now I've been attending Physio for almost 2 weeks and have been doing a lot of strengthening exercises and deep tissue massages. I've also done a few ultra sounds in the beginning and have been getting strapped on a 4 pad machine that help circulate blood. At times it seems that the pain is going away slowly but some days it returns. I feel a sharp pain when I do pushups also. The Physiotherapist stated that she believes that I've only strained the Rotator Cuff and not a partial tear.

Would you have any idea how long Rotator Cuff strains take to heal and if my injury could actually be a small tear or something? … or any advise or tests that I could determine if it is indeed just a strain or an actual minor tear? What are the chances of me playing sports again?

Thanks in advance!

John

[Dr. Mike]

John,
Let me give you my 2 cents. The first question is if the diagnosis is correct. About 90% of shoulder pain is caused by rotator cuff. Your symptoms are pretty much consistent with rotator cuff injury so likely your physicians are correct.

I would not get too hung up if there is a small tear versus just inflammation. Most samll tears tend to heal much like an inflammed rotator cuff.

Finally I think you have a great chance of getting back to your sports. Most people get better with physical therapy and those that don't get surgery. The surgery is effective if it comes down to it.

Finally, I will give you a few tricks that I use to help my patients. Get a lifeline usa blue jump and do about 600 jumps a day. It is the best therapy for an ailing RC. Also many people do not get their shoulder better because they are reinjuing at night when they sleep. Avoid this very common cycle by using the nighttime shoulder immobilizer a nighttime brace that unloads force fromthe RC that occurs when you sleep. You only have to wear is a few weeks.

Good luck, Dr. Mike

[John]

Hi, about a month ago I was involved in a motorcycle accident. I currently live in Mexico and the doctors here don't seem to take things very serious and don't do a complete examination as in the U.S. Somehow in the accident, whether it was me falling down on my elbow, or when the taxi that hit me when I was laying on the ground, I managed to damage my left shoulder. The joint in my left arm chipped of a piece of bone and I have two tendons damaged. They aren't sure if they are complete or just partial. The one that is damaged is the one that is right under the clavicle and the other is the one that is connected to the clavicle. Anyways, I have constant pain and swelling. The actual physical anatomy of my shoulder is distinct from my right. I can finally extended it out in front of me but my bicep hurts from doing this because my bicep is the one who is doing most of the work. Should I consider going back to the U.S. or should i just opt for a surgery???

[Dr. Mike]

That sounds tough. The short answer is get back to the US and find a BOARD CERTIFIED ORTHOPEDIC DOC WHO HAS DONE A FELLOWSHIP IN SHOULDERS. Good luck.

[bethlat]

I injured by rotator cuff, I believe, by lifting and carrying (way too far) a 70 lb vise. xmas gift for my husband) Initially, I thought I had just pulled a muscle and it would get better. I am able to put my arm over my head but cannot put it out to the side, reach for anything and particularly pick up anything even on the light side without pain. Six weeks later, I began to get tingling and numbing in my index and middle finger. I went to the Dr. and he told me it was the rotator cuff injury, perscribed an anti inflamatory and physio. The any inflamatory doesn't appear to be doing anything great (only three days in) and in everything I have been reading, there is no mention of the tingling and numbness in fingers. Is this something different or perhaps a different injury? Thanks

[Dr. Mike]

You are correct. You have a C5-6 disc herniation causing some nerve impingement most likely.
Get back to your Dr or find another. Keep in mind that even though there is a disc herniation you have about a 90% chance of avoiding surgery with physical therapy, meds, time etc.
Good luck.

[Stu]

Hi,

I fell on my shoulder about 18 months ago. I now have occasional dull pain and a feeling of looseness in the fwd upper part of the shoulder. I row on an ergonometer regularly fairly strenuosly and strength train my shoulders as well.

I have full movement of my shoulder but am afraid I have failed to treat the original injury and now have bursistis and a possible recuring injury.

Can I continue to workout? Should I see an orthopedic dr?

[Dr. Mike]

Stu,
Great name.
You sound a lot like you have rotator cuff tendonitis to me. Also called bursitis etc.
Never a bad idea to go to a doctor but let me give you some therapeutic interventions that may help.
First, jump rope. Really it is the ideal exercise for rotator cuff. I like the blue jump rope from lifeline fitness. Also, if you are having pain at night go to teterop.com and get the nighttime shoulder immobilizer. Lay off the ergometer for a few weeks. Remember the rotator cuff is small muscles so small exericses work better.

If that does not work then cave in a go to the doctor. Good luck.

[Theron]

I am a baseball player and I injured my shoulder. I went to the doctor and they took x-rays and said I have a strained rotator cuff.
They gave me a steroid shot and I'm going through physical therapy, the season starts on Feb 23 do you think I can be ready to play, also i noticed in your previous post that you talk about a brace for sleeping do you think it will work for me and the blue jump rope is it the weighted one?

[Nadia]

I started feeling a lot of pain on both of my shoulders (the right one worse) after
few weeks of vigourous swimming...i feel pain in the front of the shoulders ..on top..around the shoulder blades...the doctor said it's called swimmer shoulder and she thinks i might have an impigement
problem.I've had chronic pain for the last
6 months..i did physical therapy..it didn't
make the pain go away...I did rotator cuff
strengthning, scapular stabilization, and
streching. The strengthning irritate me and
gives me more pain not less...Do you think
that I will benefit from having surgery?

[Dr. Mike]

Nadia,
The diagnosis sounds like it is right on. We certainly do see a lot of swimmers with RC tendonitis.

I few things would lead me to beleive that you may not need surgery. Firstly your symptoms were fairly acute in onset, over the last 6 months.

Let me make a few recommendations that I do not think will hurt and may allow you to avoid surgery.
1) You did not mention steroid injection of the shoulder. If you have not had that than I would definitely start there. It is very likely that you just have a lot on inflammation in the rotator cuff and not a disruption of the tendon.
2)Forget any physical therapy until the steroids have been on board for at least 5 days. If you are sick of PT then just do the following exercise twice a day: sit on a stool, close your eyes. Stick your arms to the side and pretend you are Rocky jumping rope. Remember he jumps fast and his arms do not move very much. Do 200 going forward and 100 backward.
3)If you are having pain at night go to teterop.com and order a nighttime shoulder immobilizer. Use it at least 3 hours every night to 3 weeks. Try to go all night with it.

Good Luck.

[Dr. Mike]

Theron
Sorry for the delay. Hope baseball is going well. Definitely try the brace. The research on that was presented at the American College of Sportsmedicine meeting 2006. Very impressive. Use the brace for a month. Try to wear it all night for a month. If you can only wear it a few hours then that also works.

Finally I called lifeline and they did change the color of the jump rope. Get the 3/4 pound rope. Good Luck. Throw strikes.

[Bianca Jordan]

Hello,

I have had an MRI showing a SLAP labrum tear, a partial rotary cuff tear (1 cm, I believe) and significant bone marrow edema. I was about to get surgery, but canceled it at the last minute because I was pain-free for the two weeks leading up to the surgery day, plus I moved apartments without any pain, which required using my shoulders A LOT. Of course, I made one small incorrect movement when I shifted positions on my couch this past weekend, and now I'm in pain again. I really would like to avoid surgery if it's truly not necessary. For me it's hard to believe surgeons, who makes a living off a surgery, when they say "either live with the pain or get surgery." In your opinion, will these problems "heal" eventually? And, if I undergo surgery, how likely is it that I will still be "stiff," or limited in motion due to pain or loss of strength? Thank you!

[Diane]

I suffered a hard fall onto outstretched right arm on concrete driveway almost 1 month ago and am concerned that it is taking so long to even get rid of the pain! It seems entire right arm has "soft tissue damage with no breaks" which has also stirred up pain over fracture sites mid-humerus and at my wrist (20 years ago and 2 years ago respectively! Am having physio but the pain and weakness to me are alarming. Medical opinion is it will heal over time, but I need to get back to work and think perhaps I should be seeing some kind of specialist instead of just waiting for months and months to heal. Rotation of arm/wrist outward causes a lot of pain in upper and lower arm and especially around elbow joint. I am new to such injuries and would appreciate some reassurance as to likelihood of total healing and time this could take, etc. Many thanks.

[Diane]

(PLEASE NOTE: I have just sent this message, but forgot to add that I am having a fair bit of pain in the shoulder and scapula areas as well. Physio says this is part of my injuries.)
-----------------------------------------
I suffered a hard fall onto outstretched right arm on concrete driveway almost 1 month ago and am concerned that it is taking so long to even get rid of the pain! It seems entire right arm has "soft tissue damage with no breaks" which has also stirred up pain over fracture sites mid-humerus and at my wrist (20 years ago and 2 years ago respectively! Am having physio but the pain and weakness to me are alarming. Medical opinion is it will heal over time, but I need to get back to work and think perhaps I should be seeing some kind of specialist instead of just waiting for months and months to heal. Rotation of arm/wrist outward causes a lot of pain in upper and lower arm and especially around elbow joint. I am new to such injuries and would appreciate some reassurance as to likelihood of total healing and time this could take, etc. Many thanks.

[Dr. Mike]

Diane,

This is a tough one. Your case is complicated with the previous injuries. All I can say is work closely with your physical therapist and physician. If you feel you are not making progress then by all means communicate this with them. Good luck.

[Dr. Mike]

Bianca,
Basically wait. SLAP lesions and RC tears do not mean you need surgery. Good grief 60% of people over the age of 60 have rotator cuff tears and they are not all in pain and do not all need surgery.

Get a good therapist. Also in my opinion get your hands on a nighttime shoulder restraining brace that can be found at teterop.com

Good luck.

[marina]

Hello I was wondering if you can point me in the right direction, I have RA and have been working out now about 4 months jumping rope, strength training, etc. My right shoulder gives me a pulling sensation when I move it through my chest and back then in the shoulder itself I get a pinching feeling and it goes all the way down my arm and my thumb, pointer finger and middle finger get a tingling numb feeling, when this happens I then my arm it goes away. It seems to be worse in the morning when I wake up. Should I see my RA Doctor or a Shoulder specialist?

[Noah]

I hurt my shoulder by throwing my right arm above my head really hard, a couple of days later i did some bench press and it started to get better within like a week, but i reinjured it in wrestling. and its been 2-3 weeks since that and it still hurts. my range of motion is good. when i try and put my arm behind my head and touch my opposite scapula i can do it, but it hurts under my arm in my scapula, and in the tricep region of my muscle. I've also had trouble sleeping. It hurts alot to push down on the ground, as if i'm getting up from a sitting position or doing dips, and i havent even tried benching or weightlifting since then. I'm hoping time will resolve this issue and i will be able to at least do pushups again in the future.

[Dr. Mike]

Noah,
Good lord lay off the dips. Let me give you a baseball analogy. You need to play small ball for a little while. You have whacked your rotator cuff and those are small muscles so I believe you need "small exercises" to get them better.
Take a look at a shoulder anatomy picture on the web. I am near certain that you have done some damage to the supraspinatus. You need to think about strengthening the rest of the rotator cuff: namely the infraspinatus and teres minor as well at the subscapularis.
Now let me give you some of my opinion here. I think modern physical therapy tends to try to isolate the individual muscles and strengthen them. I think this is balderdash. You should use the shoulder in a functional way when you try to strengthen.
This is a long set-up for my most common delivery. Jump rope every day for 3 weeks as fast as you can imagine, at the very least 300 jumps but you could probably do 800 no problem. Finally, in my humble opinion I think anyone who has nighttime pain should wear a nighttime shoulder immobilizer for a few weeks as the research on this brace has been pretty amazing. Call Chris at Fast Physical Therapy 2319329014 to get one. Good luck.

[Dr. Mike]

Marina,
In my book there is only one cause of pain that goes from the shoulder down through the fingers: cervical radicular pain. This means a pinched nerve in the neck.

I would go to your RA doctor first. The basic approach is physical therapy and meds. If that does not work then your RA doc (in my humble opinion) should consider a role for steroid injection (after a neck MRI to confirm the diagnosis). Your RA doc will know who the best person in your town is to give steroid injections in the neck.

If that does not work then go see the surgeon. Remember we love good surgeons, but only go see them when you need a surgery. Good luck.

[Brent]

Hi,

I wiped out on my bike over a month ago, going over the handlebars and when I landed I injured my left shoulder. It hurts to lift the arm when extended in front of me, to the side and even to reach behind. I am having difficulty sleeping. When I ride the bus I cannot hold onto the hand rails with my left arm as any lurching causes great pain in the shoulder. It hurts to put on a jacket or a backpack, if I do it left arm first.

My doctor saw me the day it happened and then two weeks later but didn't notice anything broken and based on the movement I had thought it might heal itself. He said that I should wait 8 weeks to see if it gets better, then he would send me for ultrasound. Its been 5 weeks and I haven't seen any noticeable improvement. He suspects I partially tore a tendon. A second doctor told me that I sprained my shoulder and gave me two weeks worth of naproxen to deal with the pain. My bicep hurts as well as I get some pain all the way down to my hand. What should I do now? Wait three more weeks or head back for an ultrasound referral right away?

Thanks,
Brent

[Brent]

I forgot to add that when I move my left arm up or down, with it bent at the elbow in front of my chest (like a football blocking position), I feel a pulling sensation toward the middle and more noticeably toward rear of my shoulder. The shoulder is in constant pain when I use it to hold a book, type on a computer or when I try to do any work with my arm extended in front of me. When I extend it in front of me and then return it, the returning causes sharp pains in the muscles and perhaps joint of the shoulder.