Improving the Strength and Range of Motion in the Rotator Cuff

The term rotator cuff refers to the complex of tendons and muscles that make up a portion of the shoulder joint. The rotator cuff is comprised of four muscles: Infraspinatus, Supraspinatus, Subscapularis, and Teres Minor. Their primary purpose is to stabilize the arm’s connection to the torso (the shoulder joint) and to control movement of the arm. Tendons link the four main muscles of the rotator to the bones that comprise the shoulder joint including the shoulder blade, the upper arm bone (humerus), and the clavicle (collar bone). Ligaments further support the shoulder joint in connecting the bones together. (Ligaments are tough and rope-like and are not as flexible as tendons). In addition to the ligaments & tendons, muscles and bones there is a bursa sack in the shoulder joint. Almost every joint in the body has a bursa; it is a fluid-filled sack that acts as a pillow between bones, cushioning against impact or rubbing.

An injury to one or more of these muscles can occur in many different ways. If the tendons become over stretched a dislocation of the humerus from the joint may occur. Constant rubbing with the joint out of alignment, or sudden impact can cause inflammation or rupture of the bursae (commonly referred to as Bursitis). The most common forms of shoulder injury are:

Tendinitis: According to Wickipedia, Tendons are a sinuous band of fibrous connective tissue, made up mostly of Collagen, that connect muscle to bone. If a joint is improperly aligned, than stress can be places on the tendon it was not designed to take.Over-use in this manner, can result in inflammation. Inflammation of the tendon, tendinitis, can also occur, if one tried to lift a weight that was heavier than the muscle could bear.

Bursitis: The Bursa is a fluid filled sack that resides between bones in a joint, to prevent rubbing. In the event of poor alignment, or impact the Bursa can become inflamed, or ‘burst’ loosing some of its viscous fluid. This will result in the bones of the joint rubbing together. Severe damage to the Bursa might require surgery to seal the tear.

Strain or tear: Tendinitis that isn’t treated properly, or if a mis-alignment (poor postural alignment) is left over time, the Tendon might weaken, allowing it to be pulled out of shape, or tearing. Severe tears or strains might require surgery to strengthen.

Arthritis: arthritis by definition is ‘inflammation of the joint”, therefore the Tendinitis or a Strain of the tendon is a form of arthritis.

NOTE: The term impingement refers to the tendon rubbing continuously against bone. This can be the result of poor aliment (posture) and can result in Tendinitis.

There are five common causes for the afore mentioned injuries:

Age:As we age Collagen begins to break down. This is seen in the tautness of the skin as well as the loss of strength of Tendon’s. Therefore, even a joint that hasn’t been mis-treated, may acquire Tendinitis.

Postural Alignment: There is very little ‘free space’ in any joint. That space is meant to house veins and nerves to the limbs. The rotator cuff is no different. Poor posture of the shoulder complex results in a slumping forward of the shoulders – meaning the distance from one shoulder across the chest to the other becomes less. As a result of the shortening of the chest-line, the chin tends to jut forward. This results in the cervical spine (neck) bunching (space between vertebrae limited), and the space alloted to circulation and nerves in the rotator to be choked off.

Impact: Jamming of the rotator may result from breaking a fall or impact, such as in a car accident. This can bruise the area, flooding it with blood and fluid. This is meant to protect an injury while the body heals, but will lead to undue pressure on the tendons and nerves.

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Overload: Pulling or lifting something too heavy for the support structure (muscle and bone) will strain the connective tissues (tendons). For instance pulling a couch across a carpet may momentarily strain the tendon resulting in tendinitis and the area being flooded with protective fluids.

Overhead Work: The further from your torso your arms are the more force is placed on the joint. Generally, if working with proper weight restrictions and alignment, and for short periods of time, this is fine. But, repeatedly extending the arms out wide or overhead, can strain the tendons – for instance, painting a ceiling, the rollers aren’t heavy, but the act of working your muscles with your arms so far overhead can strain the tendons. The main symptom is shoulder pain of gradual or sudden onset, typically located to the front and side of the shoulder, increasing when the shoulder is moved away from the body. A person with tears to the rotator cuff tendons may not be able to hold the arm up because of pain. With very severe tears, the arm falls due to weakness ( what physicians and personal trainers refer to as the positive drop sign.) Anyone suffering pain, of any kind, should consult their physician. If you have a muscle or tendon tear, or if you have burst your bursae, than surgery might be required to fix the problem before you can proceed with the following techniques. For those who have suffered for a long while, an injection of corticosteroid (commonly referred to as Cortisone) may be administered to decrease inflammation and pain, which will make the following techniques more successful.

Don’t give up hope. After being treated by your physician, there are several techniques you can utilize in your own home to improve the stability of the shoulder joint. Most joint structural imbalances, are caused by the relationship between tight muscles and weak muscles. Therefore, the focus of your home training should be to strengthen the weaker muscles and stretch the tight ones. This will make it possible for you to move the joint back into its proper alignment, decreasing inflammation and pain.

Flexibility:

The areas you most want to focus on in your flexibility training are the chest and front of the shoulder. If you slump forward, the area between the shoulder and chest decreases. Over time the muscles tighten, thus making it more difficult to roll the shoulders back into the proper position. Furthermore, the elbows lift slightly behind the body, this shortens the muscles of the top of the triceps (back of the arm) and the latisimus dorsi (the big muscle that wraps from the spine to under the arm). Ironically, when we first start to slump, we feel discomfort around the shoulder blade, or in the neck. This makes us want to stretch those areas. Sadly, while stretching those areas feels good, those muscles are being pulled taut merely by the position of the slump. So, no benefit comes from stretching those areas. Hold all stretches for a minimum count of 10. I suggest to my clients to repeat these stretches 2 – 3 times a day, generally when you awaken, before bed, and once in the afternoon.

Rotators:

1) Stand or sit tall, with the shoulders rolled back (sticking the chest out slightly) and the abdomen tight. Bring both arms behind your lower back. Grip each fore-arm or elbow with the opposite hand. Make sure you keep the proud chest with the shoulders back, to ensure you stretch the rotators.

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2) Using a Towel or Strap: Stand or sit tall, with the shoulders rolled back (sticking the chest out slightly) and the abdomen tight. Drape strap over one shoulder. The same hand comes up to grip the strap behind the shoulder (elbow points toward ceiling). Bring the other hand around behind your back to grip the strap. Using upper hand pull the strap toward the ceiling – Relax shoulder, elbow and arm, of arm behind your back, (its like your trying to bring the behind hand up between your shoulder blades.) Keep shoulders rolled back and abs tight!

Triceps and Latisimus Dorsi:

1) Stand (or sit) tall. Roll back your shoulders and tighten your abs. Lift one arm straight out in front of you, straight out from the shoulder. Lift the arm straight up toward the ceiling. Bend the elbow, so the hand touches your shoulder or shoulder blade. Use the opposite hand to help push the arm further back. (Elbow points toward the ceiling) Repeat on the other side.

2) Using a Towel or Strap: Stand or sit tall, with the shoulders rolled back (sticking the chest out slightly) and the abdomen tight. Drape strap over one shoulder. The same hand comes up to grip the strap behind the shoulder (elbow points toward ceiling). Bring the other hand around behind your back to grip the strap. Relax the higher arm. Using the hand behind your back, pull the strap toward the floor. Remember to not let the strap slide through your fingers, keep a tight grip on it.

Chest:

1) Stand (or sit) tall. Roll back your shoulders and tighten your abs. Lift both arms straight out to the side. Swing them around behind you clasping your hands at the small of your back. Roll your shoulders back and look up at the ceiling as you try to push both hands down toward the floor. Keep the arms straight the entire time.

2) Using a Doorway: Stand with feet and body just behind the threshold of the door frame. Place arms on frame so that elbows are level with your shoulders.
Tighten abs and roll back shoulders. Slowly lean your body forward until you feel the stretch through the the front of the chest/shoulder area.

Strength

The areas that have most weakened are the upper back and rotators. Chances are, unless you were in a sudden impact which injured the rotator cuff, your shoulders have been out of alignment for some time. Driving, typing on the computer, etc, are all activities that encourage poor posture. Once the trend of shoulder slumping begins the upper back muscles begin to weaken from lack of use. Their primary purpose are to pull and hold the shoulders back into the proper proud posture, once we no longer recruit them for that activity, weakness sets in. Once the shoulder or rotator begins to pain us, we are hesitant to use it for fear of causing more pain or injury. Thus, these muscles also weaken. As stated above, consult you physician before training an injured areas. I recommend performing only one short set (10 repetitions) with very light weight, the first time you try a new activity. Then wait two days. If your joint pain does not increase, you may increase the weight slightly and up the repetitions to the full 12 – 15 in a set. Again wait two days to monitor your pain levels. If the activity does not exasperate your condition, you may proceed with the full 2-3 sets. Always be conscious of your position. Allowing your posture to slacken just to complete a full set will not benefit the joint, and may re-injure it. We are training the mind as much as the muscles. Re-conditioning the neuro-muscular communication, so the brain again learns which muscles control posture and shoulder movement.

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Rotators:

1) Wall Push-up Rotation: Stand about a foot away from the wall in Set position. Place hands on the wall at about shoulder height and wider than shoulder width. Lift onto your toes slightly (like your heels are on an air-hockey table). Slowly bend your elbows to bring your face toward the wall – stopping at 90. Keep your spine straight – don’t dip your head toward the wall. Push through palms to straighten your arms. Slowly swing one arm out wide to point behind you – turning your whole body in the process to look down the line of your arm (Like a ballerina). Untwist, placing your hand back on the wall. Repeat. (OPTION:
hold a medicine ball against the wall with one hand).

2) Slow Horizontal Elbows: Stand tall in fighting stance, right leg back, hands under the chin so your forearms for an inverted V. Roll back your shoulders and tighten your abdomen. With the elbow bent at 90, slowly swing right hand wide (like you’re gonna throw a Hook but miss) then around in front of you so that you bend your elbow (max of the movement) until it is pointed in front of you. Relax back to the start position. After completing 1 set, repeat on the other side.

Upper Back:

1) Bow – Up Right Row: Stand tall with a weighted bar or dumbbells in each hand. Roll back shoulders and keep abs tight. Slowly tip over
from the hips, bending knees slightly, letting the weights dangle toward the floor – Maintain the straight spine, do NOT let the shoulders slump. Push through the heels to raise the torso up tall. Slowly lift the bar to your mid-chest line. Elbows out wide, like you’re lifting off a sweater. Release the weights back in front of you by straightening your arms back toward the floor.

2) Seated Row: Sit on the edge of a sturdy bench or chair. Hold a weight in one hand. Roll back your shoulders and tighten your abdomen. Lean forward over your legs, resting your free forearm across your lap. Maintain the straight spine and proper posture, even though your inclination will be to slump the shoulders. Let the weight dangle toward the floor, keeping your shoulders square. Slowly, lift the weight toward the ribs, lifting the shoulder blade. (This is like starting a lawn mower). Release the arm back to straight.

References:
(1) Wickipedia, The Free Encyclopedia; The Arm, http://en.wikipedia.org/wiki/Arm/ , October 19, 2007 Wickimedia Foundation Inc.
(2) The Mayo Clinic, Rotator Cuff Dissection 2, 3, and 6, http://www.mayoclinic.com/health/ , 1998 – 2007 Mayo Foundation for Medical Education and Research.
(3) Revolution Health, Rotator Cuff Signs and Symptoms, http://www.revolutionhealth.com/, a subsidiary of FamilyDoctor.org, Revolution Health Group, LLC