Rotator Cuff Tendinitis

Rotator Cuff Tendinitis

• Rotator Cuff Tendinitis

Rotator Cuff Tendinitis in the Overhead Athlete

Overhead athletic activities can be classified as those movements that require repetitive motions with the arm in at least 90 degrees of forward flexion or abduction or a combination of the two. Athletes who participate in activities such as swimming, tennis, or throwing sports experience this type of repetitive trauma to the shoulder and, as a result, are prone to shoulder disorders. The frequency of injury is related to the athlete’s age and level of competition. These patients present a significant diagnostic and treatment challenge to the physician. They usually demonstrate a degree of hyperlaxity of the GH joint resulting from an increased anterior laxity of their shoulder capsule, which is required to perform these overhead motions, as well as a compensatory tightening of the posterior capsule. Symptom-free function in the setting of substantial GH joint “laxity” or looseness is accomplished by the proper development of the dynamic stabilizers crossing the GH joint.

During overhead sports, the rotator cuff is continually being challenged to keep the humeral head centered in the glenoid and prevent pathologic displacement owing to the extreme forces acting on the shoulder (see Table 3–2). As a result of this highly stressed environment, the joint capsule and rotator cuff can develop a secondary inflammatory response. Prolonged rotator cuff tendinitis can result in decreased muscular efficiency with loss of dynamic stability, with a final pathway of functional instability and progressive tissue failure. Posterior capsular tightness, which manifests as a loss of internal rotation, is often present in overhead throwers and may lead to anterior-superior humeral head translation, further contributing to irritation of the rotator cuff.

The biomechanics of throwing has been closely analyzed. As a result, it serves as an appropriate model to examine the motions and arm positions of overhead athletic activities. The throwing motion and its related biomechanics is divided into six stages: wind-up, early-cocking, late-cocking, acceleration, deceleration, and follow-through (Fig. 3–49).

• Wind-up: Serves as the preparatory phase. Includes body rotation and ends when the ball leaves the nondominant hand.
• Early-cocking: As the ball is released from the glove hand, the shoulder abducts and externally rotates. The body starts moving forward, generating momentum. Early-cocking terminates as the forward foot contacts the ground.
• Late-cocking: As the body rapidly moves forward, the dominant shoulder achieves maximal abduction and external rotation. Significant torques and forces are placed on the shoulder restraints at this extreme range of motion.
• Acceleration: Begins with further forward body motion, internal rotation of the humerus leading to internal rotation of the throwing arm. Acceleration ends with ball release.
• Deceleration: Begins after ball release and constitutes 30% of the time required to dissipate the excess kinetic energy of the throwing motion.
• Follow-through: Completes the remaining 70% of the time required to dissipate the excess kinetic energy. All major muscle groups must eccentrically contract to accomplish this result. Follow-through ends when all motion is complete.

Athletes who experience pain in the late-cocking phase usually localize the symptoms to the anterior aspect of their shoulder. The position of the arm during the late-cocking phase is maximal abduction and external rotation, which challenges the anterior stability of the GH joint. Pain during this stage can be the result of anterior instability or from the rotator cuff owing to secondary impingement related to the anterior instability. Discomfort during the late-cocking and early acceleration stages can be experienced posteriorly, and may be secondary to the irritation of the posterior capsule and rotator cuff as it tries to balance out the increased anterior laxity. Another potential cause is trauma to the posterior-superior glenoid labrum and associated articular surface of the rotator cuff related to the hyperabduction and rotation that occurs during overhead sports. This condition has been labeled “internal impingement” and may be another consequence of subtle increases in anterior GH joint laxity. Furthermore, a considerable amount of energy is absorbed during the follow-through stage of throwing. The posterior shoulder structures and the eccentrically contracting muscles experience an enormous amount of repetitive stress during this phase and as a result are at risk for injury.

These patients are a diagnostic challenge to the physician. A considerable amount of information can be obtained from the history (see the Importance of History-Taking section). It is important to identify the specific throwing phase associated with the onset of symptoms.

• Localization of pain is important, as well as documenting any recent change in the athlete’s training routine. This includes both the general conditioning program and the throwing regimen.
• On physical examination, one needs to examine for shoulder instability, posterior capsular tightness, primary impingement, and rotator cuff tendinitis.
• Findings on physical examination that are indicative of a rotator cuff tendinitis include tenderness and possibly weakness with resisted external rotation or abduction in the scapular plane.
• Pain with resistance is known as “tendon signs” and at a minimum represents inflammation of the cuff tendons. Resolution of the symptoms and recovery of strength after injection of lidocaine in the subacromial space strongly suggest cuff tendinitis rather than a cuff tear.

Rotator cuff tendinitis can lead to a secondary type impingement and also make a primary impingement syndrome more symptomatic. Rehabilitation focuses on resolution of the inflammation, recovery of motion, and careful strengthening of the rotator cuff muscles and the scapular stabilizers.

Figure 3–50 depicts a classification system for shoulder pain and dysfunction in the overhead athlete. Rehabilitation programs for pitchers, position players, tennis players, and golfers are included in the Interval Throwing section. These programs should be implemented for all patients returning to their sport after a period of inactivity. For sports-specific rehabilitation programs to be successful, the entire body must be re-educated in a stepwise fashion to perform the various activities related to the sport. This encourages a smooth transition for the athlete back to sport. These protocols are appropriate for all patients recovering from a shoulder injury, regardless of their treatment. Diagnosis and treatment will dictate when patients can begin sport-specific exercises and at what level they enter into the rehabilitation program. The important factor requires the treatment team to begin these exercises after the patient has recovered the appropriate motion and strength in the shoulder following the more traditional physical therapy programs as outlined in this chapter. The team has to advance the patient appropriately. If discomfort develops as the result of “too much” being done, the athlete should take a few days rest. Additional treatment may be required to decrease inflammation, and a return to the previous exercise level may be needed until symptoms have resolved. The details outlined in these protocols are to help the athlete and the trainer move along a progressive course to achieve a full recovery and return to competition. Objective data that can be acquired before resumption of throwing is outlined in Table 3–4.

Our throwers rehab regimen includes:

• Self-stretching techniques for pathologic changes in “tightness” of the capsule (see Fig. 3–51).
• Off-season adherence to rotator cuff, scapulothoracic, and shoulder girdle strengthening with the “Thrower’s Ten” program (Fig. 3–52).
• Excellent conditioning of the “entire” athlete.
• Warm-up and cool-down period with practice and games.
• Avoidance of “overuse”—throwing while fatigued.
• Use of the throwing program described in Wilk and coworkers (1998).
• Use of the Fundamental Shoulder Exercises program developed by Health-South Sports Medicine and Rehabilitation of Birmingham, Alabama (Fig. 3–53).

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