rotator cuff paper
TRANSCRIPT
CONSERVATIVE REHAB IN THE OVERHEAD THROWING ATHLETE 1
Principles of Conservative, Non-operative Management
for Rotator Cuff Tears in the Overhead Throwing Athlete
Macy Franklin
Wingate University
CONSERVATIVE REHAB IN THE OVERHEAD THROWING ATHLETE 2
Abstract
Rotator cuff muscles work together with multiple structures in the shoulder girdle to help
the body efficiently function with proper kinematics. The overhead throwing athlete, such as a
baseball pitcher, uses this concept in extreme amounts. The motion created by the pitcher causes
concentric and eccentric contractions during each phase of throwing mechanics. The most
common types of injuries related to rotator cuff tears in this type of athlete will result from
chronic overuse of these muscle during the deceleration and follow-through phases of throwing.
After an injury has occurred, it is important to determine what structures are included in the
damage within the shoulder structures to better understand the steps needed to treat and
rehabilitate the area. Depending on the age, sport, and effected areas, the athlete may decide to
treat the tear with surgery. The most efficient ways to determine the injury is by performing
manual muscle testing and special testing of specific muscles. The first steps of conservative
rehabilitation will be treating the inflammation in this first stage of healing. Modalities such as
ice and electrical stimulation can help promote this healing and prevent the continuation of cell
death from inflammation. Regaining full range of motion will begin immediately as well which
will increase with the decrease of pain and swelling. The progression to strength training will
begin in the proliferation phase of healing and continued into the remodeling phase. In this final
phase of healing, the beginning of proprioception and functional exercises will be demonstrated.
Lastly, sports specific exercises will be the most beneficial tract to returning the athlete to
throwing. There may need to be a throwing program demonstrated to the athlete along with
proper progression. These sports specific exercises will be the last steps in the rehabilitation
process before the athlete will be able to return to play.
CONSERVATIVE REHAB IN THE OVERHEAD THROWING ATHLETE 3
Principles of Conservative, Non-operable Management
For Rotator Cuff Tears in the Overhead Throwing Athlete
The overhead athlete is susceptible to many overuse injuries because of the repetitive
motion that they perform every day during activity. In the United States, the incidence of rotator
cuff tears is 4.5 million cases each year, including traumatic related tears, chronic overuse tears,
and degenerative tears (Lazarides et al., 2015). Tennis, volleyball, swimming, and baseball are
very common sports to see shoulder injuries such as a rotator cuff tear. The overhead athlete is
thought to be capable of generating angular velocities of over 7,000 ̊ per second in the throwing
arm (Dodson, Brockmeier, & Altchek, 2007; Dugas & Andrews, 2002). This extreme force,
repeated over years of athletics can put an athlete at high risk for rotator cuff tears, especially if
the throwing form or posture is not correct. Once this tear is determined, the athlete can decide
whether to seek surgical or non-surgical treatment in order to return to play quickly. Discussed in
this paper will be the non-operable management of the rotator cuff, including treatment and
rehabilitation to get the overhead athlete back in the game as soon as possible.
The bones of the shoulder include the clavicle, scapula, and humerus. There are multiple
joints of this region: glenohumeral (GH), sternoclavicular (SC), acromioclavicular (AC), and
scapulothoracic joints. All of these joints together are known as the shoulder girdle and work
together for their main purpose: positioning the hand for proper function (Houglum, 2010). Since
this is a big chain of movements working together, injuring one area can affect the kinematics of
another because of the muscle compensation (Pabian, Kolber, & McCarthy, 2011). The rotator
cuff is composed of four muscles that all arise from the scapula and insert on the humeral head.
The infraspinatus, supraspinatus, teres minor, and subscapularis are all considered as a group
known as the rotator cuff (Cooper & Ali, 2013; Talbot & Limb, 2012). These muscles form a
CONSERVATIVE REHAB IN THE OVERHEAD THROWING ATHLETE 4
cover over the humeral head acting as dynamic stabilizers. The shoulder, or glenohumeral joint,
is a ball-and-socket joint. However, it is incredibly shallow, giving the shoulder more mobility
but in taking away from the stability making it potentially unstable and prone to overuse injuries
(Dissmore & Michael, 2015).
The muscles of the rotator cuff are not just responsible for stabilizing the humeral head in
the glenoid fossa; however, they also work together in a complex manner to perform specific
movements throughout the shoulders different degrees of freedom (Ainsworth, 2006).
Supraspinatus, infraspinatus, and teres minor originate from the posterior surface on the scapula
and insert on the greater tuberosity of the humerus. The subscapularis alone assists the deltoid in
abduction but these three muscles together are referred to as the external rotators of the shoulder
(Cooper & Ali, 2013). The Subscapularis is underneath the scapula, located on the anterior
portion of the scapula and inserts on the lesser tuberosity of the humerus. During shoulder
abduction, the rotator cuff muscles act together to compress the humeral head in the glenoid,
which is a process known as concavity compression and resists upward translation of the
humeral head during abduction from the deltoid (Cooper & Ali, 2013; Pabian et al., 2011; Talbot
& Limb, 2012). The complex locations of these muscles make their movements specific and each
location is important in the efficiency of the throwing action.
The mechanics of overhead sport activities are complex in nature and have many specific
steps needed for ensuring proper technique. Pitching for example, it is known that the pitcher
uses his entire body to complete the pitching motion. It starts with the lower body and advances
to the trunk, shoulder, elbow, and finally, the wrist. The most commonly used phases of throwing
include the wind-up, followed by early cocking, late cocking, acceleration, and lastly, the follow-
CONSERVATIVE REHAB IN THE OVERHEAD THROWING ATHLETE 5
through (Houglum, 2010). The diagram below depicts each of the phases of throwing through a
model to better understand before going into further detail on each phase.
Figure 1.1: The
six stages of the overhead throw. (Jones, Osbahr, Schrumpf, Dines, & Altchek, 2012)
The wind-up phase is when the thrower positions the body so that the glove is facing the
target and the two hands are placed together. The thrower will be in the process of taking a step
back, making the leg contralateral to the throwing arm. This leg is considered the stride leg while
the ipsilateral leg is the support leg (Houglum, 2010). This is where the body will then rotate
towards the throwing shoulder shown in the second throwing figure above leading then into the
early-coking phase. Early-cocking begins when the hands start to separate and the phase will end
when full abduction is obtained along with maximal external rotation. This is not a natural
movement of the shoulder and will put strain on the rotator cuff muscles which are responsible
for performing these motions. Late-cocking begins when the stride foot hits the ground and both
arms are elevated to about 90̊ putting anterior stress on the GH joint (Houglum, 2010). The
rotator cuff is maximally rotated during this phase and into the early acceleration phase. This
CONSERVATIVE REHAB IN THE OVERHEAD THROWING ATHLETE 6
means that the rotator cuff is in a position to be impinged between the humeral head and the
posterior superior glenoid labrum (Dugas & Andrews, 2002). Acceleration phase begins with this
maximum external rotation and ends when the ball is leaving the fingers. This motion does not
just include the GH joint but during this phase, scapular protraction, humeral horizontal flexion
and medial rotation, and elbow extension occur (Houglum, 2010). In the deceleration phase
discussed by Jeffrey Dugas and James Andrews, the rotator cuff experiences great amounts of
tensile load as the muscles and tendons are working to bring the arm from 7,000̊ per second to
zero, making this phase the most likely cause for injury (2002). Lastly, the follow-through phase,
starts when the ball is released to the point where the support leg moves and makes contact with
the ground to stop forward movement (Houglum, 2010). The deceleration and follow-through
have an important concept of eccentric contractions to consider. The eccentric muscles of the
shoulder are responsible for decelerating the body and bringing the arm back to zero degrees
from 7000̊. Eccentric contractions are usually the most powerful and have the ability to adapt to
high stresses increasing their strength and power, making these muscles adapt in a protective
manner rather than a common cause of damage (LaStayo, et al., 2003). It is important to consider
each step in throwing mechanics in order to understand where the tension damage has resulted
from and how to more efficiently rehabilitate the affected and weakened area.
Incorrect throwing mechanics and repetitive stress are the main causes of rotator cuff
tears in overhead athletes. There are many types of rotator cuff tears that can occur and they are
based off of intrinsic and extrinsic theories. Extrinsic, or impingement theory, is damage related
to repetitive micro trauma of the tendons under the acromion process (Talbot & Limb, 2012).
The acromion process covers the humeral head and therefore its shape affects the space in
between. The acromion process can be three different shapes based off of genetic disposition.
CONSERVATIVE REHAB IN THE OVERHEAD THROWING ATHLETE 7
Type I is a flat acromion which provides the most space for the tendons to move, while Bigliani
type II (curved) and Bigliani type III (hooked) acromions have been proven to obtain more
rotator cuff injuries because of the compromised space between the acromion and the humeral
head (Talbot & Limb, 2012). This theory could also be affected by the athletes posture and
throwing mechanics. If these factors are not considered, the athlete could have severe
compensation of other muscles predisposing them to rotator tears. These extrinsic theories are
common in overhead throwing athlete; however, tears are most common because of the intrinsic
factors related to increase in age. This theory is the consideration of the rotator cuff injuries due
to aging and relative devascularization of the tendon (Seida et al., 2010; Talbot & Limb, 2012).
Due to the focus of this paper and the topic of throwing athletes, age will not be considered in
this paper; therefore, the extrinsic theories will be more likely the cause of these rotator tears. In
reality, some cases will be a mixture of both factors and is related to impingement along with a
rotator cuff tear.
Signs and symptoms can vary greatly in each athlete depending on which muscle the
athlete has affected and the severity of the tear. The majority of tears involve the supraspinatus
and the infraspinatus tendons and are described as posterosuperior tears. The anterosuperior tears
are less common and involve supraspinatus and subscapularis tendon (Cooper & Ali, 2013). The
most common symptoms of rotator tears are pain and limited range of motion with internal
rotation. In the older or non-athletic population, some tears may be asymptomatic. The pain in
the shoulder is usually a product of the inflammation from the tear (Itoi, 2013). Typically
patients will feel pain between 60̊- 120̊ of elevation. Anterior pain along the joint line can be
associated with injury to the subscapularis and anterolateral pain along the deltoid is very
common and can be related to a tear in the supraspinatus tendon (Dodson et al., 2007). Patients
CONSERVATIVE REHAB IN THE OVERHEAD THROWING ATHLETE 8
who have partial-thickness rotator cuff tears and/or internal impingement usually have pain
during the early cocking phase of throwing along with the follow-through phase. Along with
pain, posterosuperior tears usually have functional loss from weakness during abduction and
external rotation (Dodson et al., 2007). The manual muscle testing will not appear equal
bilaterally because of weakness and instability in the shoulder from the tear. Many of the
symptoms will overlap with different types of shoulder injuries such as a labral tear, therefore, it
is important to understand diagnostic and special testing to rule out all other differential
diagnosis.
The gold standard for diagnosing a rotator cuff tear is a procedure called arthroscopy;
however, an MRI or an ultrasound can also show presence of a tear. The athletic trainer is
usually on of the first to see the injury in the athlete and will typically perform an evaluation to
determine an idea of a differential diagnosis (Dodson et al., 2007). The history is a big part of the
evaluation to determine the athletes throwing mechanics and determining if there has been past
pain or injury. The next step is the inspection of the shoulder. The clinician will be looking for
atrophy of the muscles along with any obvious deformities. Passive range of motion is the first
step to see if there is any limited movement and test everything bilaterally. It is important to
remember that one of the biggest findings of a rotator cuff tear is increased external range of
motion and very limited internal range of motion (Dodson et al., 2007). Strength assessment and
comparison is the next step, testing the deltoid along with the internal and external rotators
bilaterally. As stated previously, impingement is an often finding of rotator cuff repairs and
frequently tests positive in the Neer and Hawkins tests in overhead athletes with rotator tears
(Dodson et al., 2007). There is a very large range of special testing and palpation techniques that
can help determine the injury and extent of rotator cuff tear.
CONSERVATIVE REHAB IN THE OVERHEAD THROWING ATHLETE 9
One of the best ways to determine a rotator cuff tear is palpating the tendon. The tip of
the finger is placed on the tendon, anterior to the acromion. A defect may be palpated when the
shoulder is in extension, but will disappear once the shoulder moves into flexion. The sensitivity
and specificity to this technique is equivalent to an MRI and ultrasonography (Itoi, 2013). A tear
of the rotator cuff can also be determined by multiple special tests that are specific to certain
muscles of this group. An empty-can test and a full-can test will test the supraspinatus. Empty-
can is when downward force is applied to the arm which is at 90̊ in scaption and internal rotation
with the thumb pointed down. If there is a tear present, the patient will not be able to resist the
force. Full-can test is the same concept, however, the arm is externally rotated with the thumb
pointed upwards (Itoi, 2013). Dropping sign or external lag sign, is a special test that detects a
tear in the infraspinatus. This test is performed by passively placing the patient in external
rotation with the elbow at 90̊. When the clinician lets the arm go, the effected side will be unable
to hold the arm in the externally rotated position which give the test its name: the drop test (Itoi,
2013). The subscapularis is the last muscle tested to decide the type of tear in the rotator cuff.
This type of tear is tested by what is called the Gerber lift-off test. This is performed by placing
the hand behind the back to where the shoulder is internally rotated. The patient will then push
the hand away from the back, increasing internal rotation. The patient will be unable to perform
this task, or experience pain if there is a tear present (Itoi, 2013). Each of these special tests will
help the athletic trainer accurately decide what part of the shoulder is affected even if there is
more than one injury such as a labral tear or impingement.
Conservative treatment is going to be the first route of treatment in a rotator cuff tear.
The rehabilitation will first work to regain range of motion before starting the deltoid and rotator
cuff strengthening program (Cooper & Ali, 2013). Athletes also have the choice of receiving
CONSERVATIVE REHAB IN THE OVERHEAD THROWING ATHLETE 10
surgery depending on the extent of the tear and if conservative treatment fails. Surgical treatment
is used to attempt the restoration of previous anatomy of the shoulder, however, it has shown that
the athlete has an unacceptably high rate of failure in pitchers who try to return to play (Dodson
et al., 2007; Lazarides et al., 2015). This is not surprising considering these athletes rely on
coordination of all the muscles and tendons so any change in the muscles, will inevitably change
the kinematics of their throwing. These elite throwers should be managed through conservative
treatment instead of surgical repair. This can be accomplished through better organized
rehabilitation programs to attempt the return of the athlete to preinjury levels while remembering
the challenges the patient will face along the way.
The rehabilitation will start with regaining range of motion and controlling pain and
inflammation. The range of motion with grow as the pain and inflammation decreases. The
program will most likely involve 1-4 weeks of rest depending on the intensity and the duration of
the symptoms along with the amount of weakness (Dugas & Andrews, 2002). Joint mobilization,
where the clinician will loosen the joint capsule by manually manipulating the GH joint. This
will most likely begin after the inflammation stage where pain and swelling has subsided
(Dodson et al., 2007). During these first couple of weeks the patient may also want to use anti-
inflammatory over the counter drugs to help with pain and inflammation. Modalities can also
help promote healing in the rotator cuff by aiding the body in reabsorption of the fluids from the
swelling. Cold application through infrared modalities along with possible non-thermal
ultrasound during the early stages of injury can help prevent the increase of cell death due to
inflammation (Seida et al., 2010). Regaining full range of motion is the first steps before
progressing to the strengthening program. Usually internal rotation is the most effected
movement after a rotator cuff tear and should be a major goal of rehabilitation using first passive
CONSERVATIVE REHAB IN THE OVERHEAD THROWING ATHLETE 11
range of motion, followed by active assisted, active, and lastly, resisted range of motion. After
the inflammation stage has passed, strengthening the surrounding muscles will be the next step.
It is important to remember, once reaching the strengthening stages of rehabilitation, to focus on
restoring functional ability and not solely treating and relieving symptoms (Kibler, McMullen, &
Uhl, 2012). However, understanding what the symptoms represent in the healing phases is
critical to understanding when to progress to the next stages.
The next steps in the rehabilitation program is to incorporate strength training after range
of motion is restored and the pain is under control. Focusing on movements that will help
stabilize the scapula is critical in rehabilitation. Isometric exercises will be the first type of
exercise in order to prevent progressing too quickly. These exercises should involve the muscles
that stabilize the scapula as well as the deltoid, latissimus dorsi, and the pectoralis muscles
(Pabian et al., 2011). Exercises such as isometric shoulder flexion, extension, abduction, external
rotation, and internal rotation. The patient will use the wall to place the body part slightly in each
position. The patient will press the hand against the wall with force using the wall as resistance.
This will inhibit the arm from the force of moving through the full range of motion while
continuing to gain strength (Houglum, 2010). After the patient has completed these exercises
with no pain, the clinician should consider progressing them to the next stage of rehabilitation.
Isotonic is the next form of strengthening and will permit the joint to resist weight while
continuing the movement through full range of motion. This type of exercise will increase
strength in the concentric muscles of the exercise. Push-Ups with a plus is an exercise that a
patient performs by leaning forward against the wall and performing push-ups. At the end of the
push-up the athlete will then press slightly more which will protract the scapula working the
surrounding muscles as well (Houglum, 2010). Using the Thera bands, 4-way shoulder exercises
CONSERVATIVE REHAB IN THE OVERHEAD THROWING ATHLETE 12
can be performed which includes: adduction, abduction, flexion, and extension. Then the athlete
can perform internal and external rotation with the elbow at the side and a towel tucked under the
axilla. This position elevates activity of the infraspinatus by almost 10%, increases the
subacromial space, and prevents decreased blood flow to the supraspinatus (Pabian et al., 2011).
Using these same bands, the patient can perform D1 and D2 exercises to regain strength through
every degree of shoulder movement. This is specifically important to the throwing or pitching
athlete for the entire body is used in the throwing process along with the arm moving through
extreme ranges of motion. The rotator cuff has shown to use type I and type II muscle fibers at a
ratio of 50:50 (Pabian et al., 2011). This is important to consider in the rehabilitation process,
and the exercise prescription should be adjusted accordingly.
Each exercise prescription should have clear goals and means of progression in order to
continuously challenge the athlete and improve strength. An increase in time, intensity, weight,
or a modified exercise are considerations to consider when deciding to progress. The scapula
should be maintained in a position of retraction in order to increase strength, position, and
stability in order to increase to the last stages of rehabilitation (Houglum, 2010). Isokinetic is the
most advanced stage of strengthening where the athlete has continual resistance along the
concentric and eccentric contractions moving the joint through a full range of motion. This can
be accomplished through a machine such as a Biodex or even from manual resistance applied by
a clinician. D1 and D2 patterns with manual resistance through each motion is one of the most
common exercises applied at this point in rehabilitation.
Proprioception will be the next step in the rehabilitation program which can also be
combined with the previous strengthening exercises to help increase balance, agility, and
coordination. An example of an exercises that includes this concept of proprioception is ABC’s
CONSERVATIVE REHAB IN THE OVERHEAD THROWING ATHLETE 13
using a ball. The athlete can flex the shoulder to 90̊ and write the ABC’s using the ball and
pressing it against the wall in full elbow extension with the scapula in retraction. Further
stabilization can come from the patient lying supine on the table with the shoulder at 90̊ of
flexion and elbow fully extended with the hand in a fist (Houglum, 2010). The clinician will then
try to tap the arm out of this position using the distal segment of the forearm to increase
difficulty. These exercises will force all stabilizers in the shoulder to fire and strengthen to
increase stability. The last steps in the rehabilitation program will include functional and skill-
related exercises in order to retrain the shoulder to return to its former throwing ability. This will
include a strict throwing interval training program along with core and trunk strengthening in
order for the patient to reach former throwing capability within using the entire body to create
more force (Dodson et al., 2007). The kinematics of the throw should be observed before having
the athlete begins the actual throwing of an object. This program will be directed towards the
athlete’s specific sport and position.
The pitching athlete may return much slower than the average throwing athlete
considering the repetitive motion constantly performed in competition and practice. The pitching
athlete requires higher forces along with incredible precision. Wrong kinematics and form can
increase the risk of injury to do this force. Precision will need to be retaught after injury and
repetitively practiced before the athlete can return to pitching. As discussed previously, the
pitcher can throw up to 8000̊ per second causing extreme stress on the tendons of the rotator cuff.
Therefore, specific strengthening for the eccentric muscles used in the deceleration and follow-
through phases of throwing need to be a prime focus in the exercises prescribed to maximize the
probability of returning to full pre-injury performance level. Strengthening is one of the most
important steps in conservative treatment of the rotator cuff; however, there are also an adequate
CONSERVATIVE REHAB IN THE OVERHEAD THROWING ATHLETE 14
amount of steps that have to be considered to prevent set-backs for the patient in the return of to
full strength and skill level for competition. With every important aspect of conservative
rehabilitation, it is important to recognize the complex structures of the shoulder and their
functions in order to properly and efficiently treat the rotator cuff tear in an overhead throwing
athlete.
CONSERVATIVE REHAB IN THE OVERHEAD THROWING ATHLETE 15
REFERENCES
Ainsworth, R. (2006). Physiotherapy rehabilitation in patients with massive, irreparable rotator
cuff tears. Muskuloskeletal Care.
Cooper, A., & Ali, A. (2013). Rotator cuff tears. Surgery (Oxford), 31(4), 168–171.
http://doi.org/10.1016/j.mpsur.2013.01.017
Dissmore, J., & Michael, T. (2015). Orthopedics; Getting athletes back in the game sooner
following shoulder injuries. Medical Devices & Surgical Technology Week, 249–253.
Dodson, C. C., Brockmeier, S. F., & Altchek, D. W. (2007). Partial-Thickness Rotator Cuff
Tears in Throwing Athletes. Operative Techniques in Sports Medicine, 15(3), 124–131.
http://doi.org/10.1053/j.otsm.2007.05.006
Dugas, J. R., & Andrews, J. R. (2002). Treatment of rotator-cuff pathologyin throwing athletes.
Operative Techniques in Orthopaedics, 12(3), 186–190.
http://doi.org/10.1053/otor.2002.36301
Itoi, E. (2013). Rotator cuff tear: Physical examination and conservative treatment. Journal of
Orthopaedic Science, 18(May 2012), 197–204. http://doi.org/10.1007/s00776-012-0345-2
Jones, K. J., Osbahr, D. C., Schrumpf, M. A., Dines, J. S., & Altchek, D. W. (2012). Ulnar
Collateral Ligament Reconstruction in Throwing Athletes: A Review of Current Concepts.
The Journal of Bone & Joint Surgery, 94(8), e49. Retrieved from
http://jbjs.org/content/94/8/e49.abstract
Kibler, W. Ben, McMullen, J., & Uhl, T. (2012). Shoulder Rehabilitation Strategies, Guidelines,
and Practice. Operative Techniques in Sports Medicine, 20(1), 103–112.
CONSERVATIVE REHAB IN THE OVERHEAD THROWING ATHLETE 16
http://doi.org/10.1053/j.otsm.2012.03.012
Lazarides, A. L., Alentorn-Geli, E., Choi, J. H. J., Stuart, J. J., Lo, I. K. Y., Garrigues, G. E., &
Taylor, D. C. (2015). Rotator cuff tears in young patients: a different disease than rotator
cuff tears in elderly patients. Journal of Shoulder and Elbow Surgery / American Shoulder
and Elbow Surgeons ... [et Al.], 24(11), 1834–43. http://doi.org/10.1016/j.jse.2015.05.031
Pabian, P. S., Kolber, M. J., & McCarthy, J. P. (2011). Postrehabilitation Strength and
Conditioning of the Shoulder: An Interdisciplinary Approach. Strength and Conditioning
Journal, 33(3), 42–55. http://doi.org/10.1519/SSC.0b013e318213af6e
Seida, J. C., Leblanc, C., Schouten, J. R., Mousavi, S. S., Hartling, L., Vandermeer, B., … Sheps,
D. M. (2010). Review Annals of Internal Medicine Systematic Review : Nonoperative and
Operative Treatments for Rotator Cuff Tears. Annals of Internal Medicine, 153(4), 246–
255. http://doi.org/10.7326/0003-4819-153-4-201008170-00263
Talbot, J. C., & Limb, D. (2012). (i) The management of irreparable rotator cuff tears.
Orthopaedics and Trauma, 26(6), 367–373. http://doi.org/10.1016/j.mporth.2012.07.002