Easy Exercises for Rotator Cuff Pain

The rotator cuff, which is often improperly referred to as the rotator ‘cup’, is the section of your shoulder where four different muscles and tendons come together and connect to the upper arm bone or humerus.

These four separate muscles are the Supraspinatus, Infraspinatus, Teres Minor and Subscapularis. These muscles come together to form a fanned-out cone-like shape, which can be likened to a flared shirt sleeve.

Each of these muscles has a slightly different function, and they work together to achieve various ranges of motion. This includes stabilising the head of the humerus in the shoulder joint, abducting or elevating the shoulder joint out to the side, externally rotating the shoulder joint and depressing the head of the humerus.

Essentially, all of the muscles work together to constantly ensure that the humerus remains fixed securely in the shoulder joint throughout the shoulder’s wide range of motion.

What Is a Rotator Cuff Injury?

Rotator cuff injury can occur when any one of the muscles that make up the rotator cuff get damaged. You will know immediately when you have injured your rotator cuff as you are very likely to experience pain or weakness when lifting your arms. However, in some rare instances, people who have a rotator cuff injury have no knowledge of it. Damage to the rotator cuff can be in the form of a rotator cuff tear, rotator cuff tendonitis, shoulder impingement, shoulder bursitis, shoulder labrum tear or shoulder separation.

The most common rotator cuff injuries are in the form of tears and impingements. Impingement happens when one of the rotator cuff muscles becomes inflamed, and the swelling then squeezes the space between the arm and the bone, causing pain. On the other hand, a tear is a more severe type of injury whereby the tendon or muscle gets torn.

These injuries can occur through a single traumatic event such as a fall or during sports or slow, progressive degeneration of the muscles over months or years. It can also happen if a mild injury is not given the proper time to heal.

What Can I do After Injuring My Rotator Cuff?

Following the injury of your rotator cuff, you should apply ice to reduce the pain and swelling. The ice will reduce inflammation and help with the pain. The cold stops cellular atrophy and reduces the formation of scar tissue. The icing should also be followed by ample rest during the initial phase immediately post-injury to prevent further exacerbation of the injury. Light exercises should follow this to regain full range of motion.

When Should I See a Doctor for a Rotator Cuff Injury?

You should see a doctor if your pain and swelling do not improve after the first day or so and you have difficulty raising or sleeping on your arm. This could be indicative that your injury is a tear and not just a sprain or impingement.

A tear that cannot be healed through the use of ice and exercise left untreated could become a permanent problem for you. Very sharp pains upon movement of your shoulder are tell-tale signs of a tear in your rotator cuff, and this should warrant you going to see a doctor as surgery may be required.

What Are Some Easy Exercises for Rotator Cuff Pain?

If your pain starts to fade or you’ve already seen the doctor, and they’ve told you that there’s no tear. You can start these exercises to nurse your rotator cuff back to full health.

We’ve included this video to show you some easy rotator cuff exercises that can be done anywhere and any time.

Alternatively, we’ve listed the steps for some other easy rotator cuff exercises if you’ve suffered from a rotator cuff injury.

Doorway Stretch 

  • Stand with your feet together.
  • Bend your elbows and extend your arms out to your side as if you were about to embrace someone.
  • Place one foot forward, lean into the doorway arches with both hands on the frame, and then grip the sides tightly. Continue leaning into the door and keep your grip tight on the frame.
  • Lean forward until you feel the stretch across your chest.
  • Hold this stretch for 5 deep breaths and repeat this 8 times.
  • Do 3 sets of this at least 3 times a week.

Sleeper Stretch

  • Lie down on your side and place your affected shoulder under your body. With your arm bent and out in front of you, and your fist facing straight up to the ceiling. You may use a pillow should you need to.
  • Use your other arm to hold the affected arm towards the ground. Stop this pressing motion as soon as you feel a stretch in the back of your affected shoulder.
  • Hold this position for 30 seconds, then relax your arm for 30 seconds and repeat this 8 times.
  • Do 3 sets of this at least 3 times a week.

Internal Rotation

  • Lie down on your side, place your affected shoulder slightly out, so it is not exactly under your body, and tuck your elbow into your ribs. You may use a pillow should you need to.
  • Hold your injured arm against your side keeping your elbow bent at a 90° angle. You may carry a lightweight in your arm, but you do not need to.
  • Make sure your elbow is fixed into your ribs, slowly rotate your arm at the shoulder, and raise your arm up and into your body.
  • Slowly lower the weight to the initial position and repeat this 8 times.
  • Do 3 sets of this at least 3 times a week.

Bent-Over Horizontal Abduction

  • Lie down on your belly on a raised platform such as a table or bed with enough space between the platform and the floor so that you can hang the entirety of your injured arm over the side of it.
  • Keep your arm hanging straight down and slowly raise it till it is parallel with the edge of the table and your body.
  • Slowly lower it back to the initial hanging position and repeat the arm raises 8 times.
  • Do 3 sets of this at least 3 times a week.

Reverse Fly

  • Stand with your feet shoulder-width apart and keep your knees slightly bent.
  • Make sure your back is straight but bend forward slightly.
  • You may choose to carry a light weight in each hand (but you do not need to) and extend your arms and raise them away from your body. This should resemble a flapping motion.
  • Do not lock your elbows. Squeeze your shoulder blades together with each rep and make sure not to raise your arms back past your shoulders and repeat this 8 times.
  • Do 3 sets of this at least 3 times a week.

How Can I Condition My Shoulder After a Rotator Cuff Injury?

Rotator cuff injuries affect a large number of people every year and most commonly athletes or active hobbyists. Thus, conditioning the shoulder after the damage is extremely important. Shoulder conditioning is another term for physiotherapy and exercise. 

The better the conditioning program following the injury, the faster you can expect the injury to heal and be ready for full use once again.

 

What Is a Rotator Cuff Injury?

Rotator cuff injury occurs when any of the numerous muscles and tendons that make up the rotator cuff are injured. These are the muscles and tendons of the shoulder that connect to the upper arm bone of the humerus. 

The four separate muscles that make up the rotator cuff are the Supraspinatus, Infraspinatus, Teres Minor and Subscapularis. These muscles come together and form the shape of a ‘cuff’.

 

These muscles all have slightly different uses, and they work together to provide the shoulder with different ranges and directions of motion. Almost all of the movements you can imagine when you feel your shoulders move are controlled by the rotator cuff. 

Primarily they hold together the humerus and the shoulder joint in its position throughout all the different ranges of motion that you use your shoulder to make.

What Is Shoulder Conditioning After a Rotator Cuff Injury?

Shoulder conditioning after a rotator cuff injury is the act of nursing and treating the shoulder through exercises and physiotherapy to reduce further damage and quicken the recovery time of the rotator cuff so that normal use of the rotator cuff can resume. 

These exercises intend to gradually rebuild the strength in the muscles and tendons of the rotator cuff, slowly increasing the strength of the muscles, speeding up the healing process. 

 

Shoulder conditioning after a rotator cuff injury is not an overnight process. A full recovery of the rotator cuff takes time and consistent effort. 

Sticking to a regular conditioning plan after your rotator cuff injury is the surest way to get your shoulder back to full health in the shortest time. It should be followed religiously by anyone who has recently injured their rotator cuff.

 

How Can I Condition My Shoulder After a Rotator Cuff Injury?

You can condition your shoulder after a rotator cuff injury by following these simple conditioning exercises described below. Remember to drink lots of water, eat well and take vitamins that improve your body’s natural healing ability, such as Vitamin C.

Watch this video for some easy rotator cuff exercises that you can do at home or at the office:

Alternatively, we’ve listed out the steps for various other exercises to help condition your shoulder after a rotator cuff injury.

External Rotation with Arm Abducted 90°

You will need an elastic stretch band of a comfortable resistance for this exercise. Depending on how bad your rotator cuff injury is, you can get a few of various resistances and test out which ones feel better for you. Start with the lowest resistance and then move up. 

  1. Make a 3-foot-long loop with your elastic stretch band and tie the ends together. Attach the loop to a fixed object such as a large table leg. You’ll want the object you are connecting it to to be immobile and not shift or move at all. Doorknobs may also be suitable, but you will need to make sure that the door is closed and that you are pulling in the opposite direction required for the door to swing open.
  2. Stand straight facing the object the band is tied to, hold the band and bend your elbow at 90° and raise to your shoulder level. This would mean that your elbow will be at your shoulder level with your arm facing outward in front of you.
  3. Now, while keeping your shoulder and elbow level with each other, pull back on the band until your hand is up to the same level as your head. Slowly return your hand to the starting position after this.
  4. Do 3 sets of 8 repetitions each time and do this 3 times per week as the exercise becomes easier to perform progress to 3 sets of 12 repetitions.

 

Internal Rotation

As with the previous exercise, you will need an elastic stretch band of comfortable resistance. Test which one feels best and then move up if necessary. 

  1. Make a 3-foot-long loop with your elastic stretch band and tie the ends together. Attach the loop to a fixed object such as a large table leg. You’ll want the object you are connecting it to to be immobile and not shift or move at all.
  2. Stand straight and parallel to the object that you tied the band to. This means that the object will be on your side with the elastic stretch band pulled away and your arm bent 90° as if you were holding a mug at your waist. The arm you are using should be the one closest to the object tied to the band.
  3. Now, while keeping your elbow close to your waist, bend your arm inwards and towards your body while keeping it straight. Slowly return your arm to the starting position after this.
  4. Do 3 sets of 8 repetitions each time and do this 3 times per week as the exercise becomes easier to perform progress to 3 sets of 12 repetitions.

 

External Rotation

As with the previous exercise, you will need an elastic stretch band of comfortable resistance. Test which one feels best and then move up, if necessary. 

  1. Make a 3-foot-long loop with your elastic stretch band and tie the ends together. Attach the loop to a fixed object such as a large table leg. You’ll want the object you are connecting it to to be immobile and not shift or move at all.
  2. This exercise is very similar to the previous movement, with the first difference being that the arm you will be using will be the arm that is furthest away from the object tied to the band.
  3. The second difference is that instead of moving your arm inwards towards your body, you move it outwards away from your body and to your side. Make sure to squeeze your shoulder blades together when moving your arm away from your body. Slowly return your arm to the starting position after this.
  4. Do 3 sets of 8 repetitions each time and do this 3 times per week as the exercise becomes easier to perform progress to 3 sets of 12 repetitions.

 

When Should I See a Doctor for a Rotator Cuff Injury?

You should see a doctor for your rotator cuff injury if your injury does not improve after the first few days or so and if you experience great difficulty raising or sleeping on your arm. This could mean that your rotator cuff is torn, and shoulder conditioning may not improve your situation.

Frozen Shoulder in Athletes

Frozen Shoulder in Athletes

An all-too-common malaise that is faced by many athletes is the pain of a frozen shoulder. This injury is often experienced following excessive use of the arm and shoulder during workouts and/or during competition or may even simply arise suddenly with little indication as to how the injury occurred.

 

What Is Frozen Shoulder?

Frozen shoulder is the gradual development of stiffness and pain in and around the shoulder joint area. This stiffness and pain are caused by the inflammation of the joint capsule of the shoulder. 

Frozen shoulder pain is often felt when rotating the shoulder joint or moving one’s arm away from the body. This pain causes limited reaching of the arms above the head or to the side. 

The initial stiffness and pain of a frozen shoulder often lead to the patient reducing shoulder movement, which in turn causes contraction of the joint capsule and decreased elasticity. As the joint capsule shrinks, it diminishes the protective lubricating fluid (synovial fluid) that is present between the upper arm bone (the humerus) and the joint capsule.

As the condition progresses, this joint capsule thickens, becomes inflamed and eventually inelastic. This results in the formation of thick bands of scar tissue forming between the joint capsule and the head of the humerus. 

These bands of scar tissue are referred to as adhesions and are the reason for the medical term for frozen shoulder – Adhesive Capsulitis (AC). 

 

Who Is at Risk of Developing Frozen Shoulder?

Frozen shoulder is predominantly felt by women (4 times more often) between the ages of 40 – 70. People with vascular diseases, diabetes, cancer, and Parkinson’s Disease are also at higher risk. 

It’s important to note here that people with diabetes are at a significantly higher risk compared to the other diseases. This is thought to be because diabetics have an increased formation of collagen due to having a high blood sugar level. This excess collagen goes on to form more numerous and thicker adhesions that are responsible for frozen shoulder.

Individuals who have bad posture or are immobile for long periods due to fractures, broken bones or other sports-related injuries are also at greater risk of developing frozen shoulder.

However, this does not mean that young people, including male athletes, are not at risk. It has been documented that athletes whose workout regime focuses on excessive pectoral (chest) and deltoid (shoulder) training can sometimes increase the risk of frozen shoulder. It is recommended to include periods of stretching before and after exercising to prevent damage to these muscles and the development of a frozen shoulder.

Athletes who are most at risk of frozen shoulder are those who use these muscles the most. Athletes playing games or participating in activities such as tennis, ping-pong, badminton, squash, rock climbing, golf, baseball, volleyball, and swimming will find themselves at the greatest risk. Essentially, any activity that requires intense use of the upper body.

 

Can You Stop Frozen Shoulder From Progressing?

There are three different phases of frozen shoulder; the freezing phase, frozen phase, and thawing phase. It is possible to accelerate the transition from each phase, shorten the time spent in each, and even stop frozen shoulder from progressing if treated quickly and adequately.

 

  • The Freezing Phase (Stage One)
    This is the primary stage whereby the shoulder begins to stiffen up or freeze, and pain is experienced upon movement of the arms and shoulder. Pain will continue to worsen during this phase as the shoulder gets more and more stiff. This phase can last anywhere between 2 to 9 months on average.
  • The Frozen Phase (Stage Two)
    This is the intermediate stage when pain begins to teeter off, but stiffness continues to increase, and those suffering will find their range of movement reduced tremendously. This phase can last anywhere between 4 to 12 months on average.
  • The Thawing Phase (Stage Three)
    This is the final stage and is the beginning of the healing process. Range of movement will improve, and there will be almost no pain at all. This phase can last anywhere between 12 to 42 months on average.
    A small percentage of people may not fully regain the complete range of movement of their shoulder even at the end of this phase.

 

What Treatments Are There for Frozen Shoulder?

There are various forms of treatments available to help stop frozen shoulder from progressing or relieve it more quickly. These treatments are in the form of oral medication, injections, home remedies and physiotherapy.

Doctors will typically prescribe anti-inflammatories, muscle relaxants, and pain killers in the form of tablets to be taken orally to help alleviate symptoms in an attempt to move through the freezing and frozen phases more quickly. 

Besides oral medication, one increasingly popular treatment is cortisone injections. Cortisone is an anti-inflammatory medication that reduces swelling and scarring. It has been found that this form of treatment is best administered during the early stages of the condition. 

Nerve Blocks are also another injection style treatment to relieve frozen shoulder. With these injections, a small injection of local anaesthetic above the spine of the scapula is made, and an infiltration of a long-acting local anaesthetic around the suprascapular nerve is given. 

The long-lasting anaesthetic is usually given in combination with cortisone to reduce the sensitivity of the nerve, thereby reducing pain. This is normally done only when other treatments have failed to provide relief. 

One home remedy that can help with the pain is applying an ice pack to the affected area for 10 -15 minutes several times a day. The cold from the ice pack slows the flow of blood, causing vasoconstriction, which relieves pain. 

The removal of the ice pack then causes vasodilation which is when the blood rushes back into the veins. The blood brings along essential chemicals to the injury site that help speed up the healing process.

Most athletes should be very familiar with physiotherapy as sports injuries are part and parcel of the job. Physiotherapy is almost always recommended together with any other treatments and ultimately will be what helps revitalise the joint capsule’s elasticity and regain the shoulder’s full range of motion. 

The journey to full recovery may be long and arduous, but it is the most effective form of treatment known for this ailment.  

 

What Happens if Frozen Shoulder Is Not Treated?

A frozen shoulder may go away on its own if left untreated, but it may also increase the risk of a permanent loss of a full range of motion after the thawing stage. It could also lead to other ailments developing, such as tendonitis and neck pain – which often may only be resolved with surgery. 

Capsular Release is a minimally invasive surgery whereby the tight capsular tissues surrounding the shoulder joint are cut and then cauterised. The surgery is performed under local or general anaesthetic. 

Recovery time varies, but one can expect to fully recover from 6 weeks to 3 months after the surgery. Doctors will generally recommend not exerting or using the shoulder to carry things or reach above the head for a minimum of 2 weeks.

 

What Movement or Activities Aggravate Frozen Shoulder?

Contrary to what most might think, keeping your shoulder immobile will worsen your condition. This will increase the number of adhesions that form and extend the period by which your shoulder will hurt and be stiff. 

This also does not mean that you should expose the shoulder to pulling, jerky or jarring movements, as these kinds of motions can put extra stress on your tendons and lead to the development of tendonitis. 

The secret here is to find a balance.

 

What Are Some Exercises for Frozen Shoulder?

There are several different types of arm and shoulder exercises that can help increase your mobility and heal your frozen shoulder more quickly. 

These exercises range from various kinds of stretching movements that make use of the arms, shoulders, and elbows. As mentioned, physiotherapy is the best-known form of treatment for getting your shoulder unfrozen and back into shape in the fastest time possible. 

 

What Is the Link Between Cycling and Shoulder Pain?

As an avid and passionate cyclist, Dr Desmond Ong understands  and some of the commonly seen and experienced injuries and pain points of the sport. Dr Desmond explains why some people experience pain when they first begin cycling, and when it would be best to seek medical advice. 

  1. Tell Us a Little Bit About Your Experience With Cycling As a Sport.

I currently ride a rim brake Pinarello Dogma F12 with Dura-ace Di2 and Scope R3c carbon wheels.

I have been riding seriously since 2006 and, over the years, have gotten to know groups such as Cycleworx, Smile Asia, FOTR, New Moon Khcycle.

Dr Desmond Ong, Bowtie Doctor, Shoulder Pain, Cycling,  Shoulder Elbow Orthopaedic Group

My life-long love for sports, the fellowship among cyclists, and the need to push my body to understand its limits drives my passion for road riding.

The discipline of training for better performance on the bike is similar to that needed to excel as a surgeon. Dealing with the physical demands of training and the injuries encountered along the way also helps me understand the difficulties my patients go through dealing with their own ailments and injuries and how best to help them overcome these challenges and achieve their goals.

  1. Can Cycling Cause Shoulder Pain? Is Biking Bad For Shoulders?

Cycling is a sport that engages the whole body. It is, therefore, an excellent sport for building up our core muscle strength and endurance. Therefore, cycling is not necessarily bad for shoulders. However, cycling puts the shoulder at risk of injury and pain because of the load on the upper limbs.

Firstly, a typical riding position would place 40% of a rider’s weight on his upper limbs. This is fairly considerable and may be unique to cycling. Secondly, the body may be placed in the same position for hours, depending on the ride’s duration. 

Therefore like all exercises, excessive stress in terms of frequency, duration and intensity will put the shoulder at risk of injury from overuse or repetitive strain. At the same time, falls and accidents can cause traumatic injury to the shoulder and other parts of a cyclist’s body.

  1. How Do I Stop My Shoulder Pain When Cycling?

Most of us remember cycling as trips taken in our childhood or youth to East Coast or other parks when done on a rental bike. This sense of nostalgia and recognition of cycling’s health benefits have prompted many to pursue the sport in later life. 

The Covid-19 pandemic has seen a global surge in bicycle sales and cycling participation. However, the physical fitness needed to meet more serious cycling demands is often lacking in most sedentary workers. 

Therefore, it is essential when starting out to ride with friends who are of a similar level of experience. This will aid in accommodating a beginner’s needs. At any time during a ride, cyclists should not persist if the shoulders hurt.

Pain is an indication that the load on the shoulder is too excessive. Either due to sub-optimum endurance or strength. Stopping the ride will relieve the burden on the shoulders, allowing the shoulders to get some much-needed rest. Likewise, persisting on may lead to significant injury. 

  1. How to Avoid Shoulder Pain for Cyclists? How to Prevent Sore Shoulders Whilst Cycling?

When starting out, it is important to buy a bicycle from a reputable shop as the initial outlay for a bicycle can be considerable. The shop should be able to fit a buyer with an appropriately sized bike. Additionally, they can make the various adjustments on the different components, e.g stem, handlebar, crank, seat post and saddle. Alternatively, approach a qualified bicycle fitter for a fitting session. 

The multitude of adjustments will ensure that the cyclist’s position on the bicycle is optimum to avoid issues like shoulder pain. A beginner’s position will also be very different from that of an experienced rider. Meaning the shop should adjust the position as one’s experience, and fitness improves. 

As a rule, the beginner’s position may be more upright, and less stretched out so that the load on the shoulders is less. Then as the rider’s experience and fitness improve, the position can be adjusted to a more aerodynamic one desired by the rider.

  1. What Are 3 Common Shoulder Injuries Seen in Cyclists?

Some common shoulder injuries that are associated with cycling include: 

Shoulder Pain, Shoulder Injuries, Clavicle Fracture, Shoulder Elbow Orthopaedic Group

Image of a right clavicle fracture

  • Clavicle Fractures
  • Acromioclavicular Joint Dislocations 
  • Rotator Cuff Tears
  1. When Should I Seek Help From an Orthopaedic Surgeon for My Shoulder Pain?

Cyclists should seek help immediately if they were involved in any crashes or accidents. Some injuries may not be apparent and will only be diagnosed after an investigation by an orthopaedic surgeon. 

Leaving such injuries undiagnosed puts cyclists at risk of worsening the injuries or sustaining further damages. Secondly, any pain persisting more than 2-3 days or affecting simple activities of daily living should be evaluated by an orthopaedic surgeon.

Can Cycling Cause Shoulder Impingement?

As a fellow cyclist, Dr Desmond speaks about the relation between shoulder impingement and cycling. Find out how you can take care of shoulder impingement, stay active while giving your body time to recover, and some forms of treatment available. 

 

  1. Can Cycling Cause Shoulder Impingement

Yes, cycling can cause shoulder impingement. Cycling is an endurance sport, and rides often last more than an hour. The load placed on the shoulders can thus be quite considerable. 

This is especially so for the rotator cuff, which is a key stabiliser of the shoulder. The position of the upper limb on the bike also narrows the subacromial space that the rotator cuff passes through, which can worsen a shoulder impingement.

  1. What Is Shoulder Impingement

Shoulder Impingement, What Is Shoulder Impingement?, Cycling, Shoulder Pain, Shoulder Conditions, Shoulder Elbow Orthopaedic Group

Shoulder impingement is characterised by shoulder pain, weakness and reduced range of movement of the affected shoulder. It is due to the inflammation of the rotator cuff tendon due to the load placed upon it and attritional damage as it passes under the acromial arch.

  1. Is It Ok to Cycle With Shoulder Impingement?

Cyclists with shoulder impingement should seek medical treatment. Your doctor will be able to confirm the diagnosis and exclude other possibilities to render the correct treatment. Persisting to cycle with the pain may make the condition worse. Therefore, it is best to always heed the advice of your medical practitioner. 

  1. How to Maintain Your Fitness Without Making Worsening Your Condition?

If you are suffering from a shoulder condition but want to stay active while giving your body time to recover, try alternative exercises that do not place a load on the upper limbs. For example, one can take up running or activities that avoid overhead movements. 

In general, activities that worsen the impingement will lead to pain, so I would advise avoiding any exercise that triggers the pain.

  1. How Do You Rehabilitate a Shoulder Impingement?

The first step in rehabilitation would be avoiding further damage or aggravation by avoiding painful activities. The next step would be physiotherapy to address the weakness and reduced range of movement.

A good physiotherapist will also look for other contributory factors and address those as well. Finally, subacromial decompression surgery may be needed to improve the available space under the acromial arch.

  1. What Happens If Shoulder Impingement Is Left Untreated?

Untreated shoulder impingement can worsen. This may be seen as an increase in the symptoms felt. It can also be increasing stiffness, progressing to a frozen shoulder which often requires more than a year to improve. 

In more severe cases, the mechanical attrition can actually lead to a tear of the rotator cuff, which will need surgical treatment. In fact, mechanical attrition like that encountered in impingement is widely accepted as a cause of rotator cuff tears. 

Treatment Options For Massive Rotator Cuff Tears | PhysioActive Talk

Date and Time: April 30 2021, 12:30pm – 2:00pm
Guest Speaker: Dr Desmond Ong, Consultant Orthopaedic/Shoulder Surgeon at Shoulder Elbow Orthopaedic Clinic

Dr Desmond Ong joined our partners at PhysioActive to discuss rotator cuff tears and how they are a common cause of shoulder pain.

Rotator cuff tears become more common with age and can rob many of their ability to do the things they enjoy and their independence in their golden years. Dr Desmond touched on how non-surgical treatment options can improve one’s pain.

Learn how to better care for patients suffering from rotator cuff tears and the various treatment options available and how each option brings its own set of benefits. For more information on rotator cuff tears and the respective treatment options go to https://sportsinortho.com/.

Dr Desmond Ong, Shoulder Elbow Orthopaedic, PhysioActive, Massive Rotator Cuff Tears, Treatment Options, Insight and Evidence

Dr Desmond Ong, Shoulder Elbow Orthopaedic, PhysioActive, Massive Rotator Cuff Tears, Treatment Options

Dr Desmond Ong, Shoulder Elbow Orthopaedic, PhysioActive, Joint Preserving Options, Classic Transfers

Latissimus Dorsi Transfer – Tendon Transfer to Repair Rotator Cuff

What Is a Latissimus Dorsi Transfer?

Latissimus dorsi refers to one of the largest muscles in your back. You may have heard it being referred to as your ‘lats’. Your latissimus dorsi, or lats, control the movement of your shoulders. 

The latissimus dorsi transfer is a treatment option for massive or irreparable rotator cuff tears. It involves the “re-routing” of the latissimus dorsi to take over the function of the torn rotator cuff. 

 

Why Would Someone Need a Latissimus Dorsi Transfer?

Rotator cuff tears result from either injury or as a result of degeneration due to overuse or age. They cause pain and loss of shoulder motion, which thus reduces the quality of lives of patients. If picked up early, these can be repaired with arthroscopic, minimally invasive techniques. 

Despite advances in technology and techniques, there remains a group of patients whose tears cannot be repaired. The following reasons contribute to tears that cannot be repaired:

  1. Large tears which have retracted and cannot be reattached
  2. Tears involving two or more muscles of the rotator cuff
  3. Tears that have been left untreated for too long. This length of time varies from individuals to individuals and may be as short as a few months 
  4. Older patients whose tendons may have degenerated beyond repair

Irreparability does not mean living with life-long pain and disability in the right hands. Hence irreparability does not mean untreatable. 

 

How Does a Latissimus Dorsi Transfer Repair a Rotator Cuff Tear?

A latissimus dorsi transfer is a specialised operation performed under general anaesthesia. The latissimus dorsi muscle is first detached from its insertion on the humerus through a small incision in the armpit. 

The muscle is then mobilised to ensure it can reach the new insertion site at the rotator cuff. The tendon of the muscle is then prepared. Finally, the tendon is attached at the rotator cuff insertion arthroscopically using minimally invasive techniques. 

 

Postoperative Management After Undergoing a Latissimus Dorsi Transfer?

Immediately following surgery, patients are placed in a sling for comfort and to reduce the pain. Additionally, painkillers will be prescribed. With modern multimodal analgesia, pain can be reduced to a tolerable level, and most patients may be discharged from the hospital after a night’s stay. 

Patients are allowed to use their hands for simple activities of daily living to reduce the inconvenience following surgery. Shoulder blade movements may commence immediately after surgery. At two weeks, stitches will be removed, and physiotherapy will begin. 

The rehabilitative physiotherapy process is similar to that for rotator cuff repairs. Additionally, the length of time needed to restore function is similar or may even be shorter.

The Reverse Total Shoulder Replacement | How Can It Help Your Patients?

Date and Time: Jan 6 2021, 12:45pm – 2:00pm
Guest Speaker: Dr Ruben Manohara, Consultant Orthopaedic/Shoulder Surgeon at Shoulder Elbow Orthopaedic Clinic,

Dr Ruben Manohara was invited by EISAI to speak to over 65 fellow doctors on the reverse shoulder arthroplasty and how it is considered one of the most significant technological advancements in shoulder reconstructive surgery over the last 30 years.

It reliably decreases pain and improves function for patients with rotator cuff-deficient shoulders. Such has been the success of this procedure, that it has led to a rapid expansion of the indications, to include more complex elective and trauma cases. Initially used in the more elderly patients, there is an increasingly higher demand in active ‘young seniors’.

Ruben Manohara, Shoulder Elbow Orthopaedic, EISAI

Ruben Manohara, Shoulder Elbow Orthopaedic, EISAI Ruben Manohara, Shoulder Elbow Orthopaedic, EISAI

ACL Tears in Tennis players

Tennis players did not admit to significant impairment when performing the majority of tennis strokes such as forehand, backhand, volleys, and serves. The major limitation referred to was landing after hitting a smash. This task has often been perceived by ACL deficient subjects as being difficult to carry out with confidence.8 Many players from the study group referred avoiding the smash entirely.

Interesting information was obtained about displacement while playing tennis. Injured players did not have significant impairment in forward running such as in “serve and volley” or “reaching a drop shot” movements. This finding was in agreement with previous studies—for example, Czierniecki et al found that running in a straight line may not generate sufficient rotational torque to initiate rotational instability in the cruciate deficient knee.9 In contrast, ACL deficient players show major limitation when trying to “stop suddenly and change direction”.

This type of stressful deceleration creates high anterior loading on the tibiofemoral joint.10 Both external varus‐valgus and internal‐external rotation place increased load on the knee joint during cutting movements compared with normal running.11 Varus‐valgus and internal‐external rotational movements are believed to be responsible for increasing knee joint ligament risk of injury. External flexion loads, valgus and internal rotation during sidestepping all have the potential to increase ACL and medial collateral ligament load substantially.11 The ability of normal subjects to undertake deceleration tasks without ACL rupture or giving way of the knee is attributed to the coordinated interactions among the ligamentous and other soft tissue passive restraints, joint geometry and congruency, friction between cartilage surfaces, active muscular control, and tibiofemoral joint compressive forces.10 Approximately 86% of shear forces are considered to be restrained by the ACL12; however, in ACL deficient knees these loads must be restrained by the articulating surfaces and the surrounding soft tissues.10

Most ACL injuries are indirect in nature yet occur during contact sports. Tennis involves tremendous forces during cutting, pivoting, and sudden deceleration manoeuvres; nevertheless ACL injuries are less common in tennis than in contact sports.13,14 In this series, most injuries occurred during contact sports such as soccer or rugby, but the exact mechanism (direct v indirect) was not determined. Sallay et al13 hypothesised that a tennis player is not as likely to sustain an ACL injury because of the ability of the neuromuscular system to coordinate muscular function in anticipation of each movement, with little surprise effect. Many investigators have indicated that anticipating a movement can change reflex responses and postural adjustments to minimise forthcoming perturbation and maintain appropriate posture.

Besier et al15,16 were able to confirm previous hypotheses indicating that knee joint moments increase under unanticipated conditions compared with preplanned manoeuvres, primarily because of a large increase in varus‐valgus and internal‐external rotational moments under unanticipated conditions. It is believed that unanticipated movement alters the external moments applied to the knee by reducing the time to implement appropriate postural adjustment strategies. Tennis may cause a low incidence of indirect ACL injury owing to the absence of frequent complete twisting manoeuvres and high jumping, as well as enough time for the player to anticipate strokes, especially from the baseline.

ACL injured players described significant impairment of their recreational tennis performance compared to preinjury level. Results from the present study may support the need for surgical treatment for competitive tennis players with ACL deficiency. Further studies are needed to determine the true incidence of ACL injuries in tennis, to analyse tennis motion knee biomechanics, and to establish the degree of improvement in tennis ability after ACL reconstruction.

Tennis players with an ACL deficient knee showed a clear incapacity to play on hard courts, where demanding eccentric deceleration motions occur. Frontal and rotational knee moments are thought to be increased when playing on hard surfaces owing to greater friction between the foot and the ground.11,17 Clay courts seem to be a better option for ACL deficient players.

Limitations of this study include problems associated with questionnaires, and shortcomings related to retrospective determination of the preinjury performance level.

In summary, complete rupture of the ACL is a debilitating injury that causes significant alteration of knee joint kinematics. Untreated patients have joint instability, chronic articular degeneration, and knee dysfunction. Tennis specific limitations related to complete isolated ACL rupture were clearly identified. Tennis players with an ACL deficient knee showed significant impairment of subjective sport performance, limitation in landing after smashing, limitation in stopping and changing direction, limitation when playing a three set singles match, and limitation in playing on a hard court surface compared with healthy controls.

Don’t Live with Shoulder Pain

Pain in the Arm 

“You know that feeling in your shoulder. It is a nagging ache and it goes down your deltoid. You cannot lie on your favorite side when you sleep and now you cannot rest well. You are starting to have problems with washing your hair and don’t even get started with putting on T-shirts and hanging up your clothes. This pain is affecting your swing/ stroke/bat. Come to think of it, it is getting to your other shoulder too.”

These are the common problems my patients with shoulder pain have to deal with on a daily basis. Three main issues bother such patients. Pain, Movement, Function which is a symptom translated from the pain and lack on motion.

The pain often radiates down the arm but stops short at the deltoid because the inflammation of the bursae (fluid filled sac) extends there. There is usually no numbness of the arm unlike a pinged neck nerve (cervical spine radiculopathy)

Functionally, the patient cannot raise the arm and thus is unable to wash his/her hair or face. The pain affect his/her sports performance. Often, the patient finds that he/she cannot follow through during the golf swing, have weaker strokes at the baseline or is having a weaker pitch.


Not everyone with Shoulder Pain is Frozen

The shoulder joint is a ball and socket joint. It is akin to golf ball on a golf tee (with the ball 3 times the size of tee) within a House.

Shoulder Pain, Living with Shoulder Pain, Shoulder Elbow Orthopaedic

Looking at the diagram, there is a Roof (Supraspinatus tendon), a Front door (Subscapularis tendon) and a Back door (Infraspinatus and Teres Minor). Above the Roof, there is a Tree Branch (Acromion Spur). One of the reasons why there is a tear is because the Tree Branch keeps hitting the Roof and makes a Hole in the Roof (Cuff Tear). With a Hole, it leaks when it Rains and that can be quite a Pain!!

The Golf Tee (glenoid) is pretty flat and there is a CUP made of material that looks like Young Coconut Flesh (Labrum). This deepens the golf tee and makes the shoulder joint a more congruent one.

Shoulder Pain, Living with Shoulder Pain, Shoulder Elbow Orthopaedic, Biceps Tendon

There are three main common causes I see. These are:

  • Rotator cuff problems
  • Instability (labral problems)
  • Frozen shoulder

In my practice, Rotator Cuff problems outnumber instability 3:1 and Rotator Cuff problems outnumber frozen shoulder 4:1. Therein lies the necessity for a proper diagnosis. This is where a “completely new and innovative INVESTIGATION” technique becomes extremely important.

Let me introduce: a Proper History and Physical Examination

Even before we look into doing any scans, I believe that through a proper understanding of the patient’s problems and symptoms, finding out what exactly is affecting the patient, followed by a targeted physical examination looking for specific signs; a proper provisional diagnosis can be made. Using this knowledge, the X-rays and scans can then guide us like a satellite navigation map to decide what needs to be done for the patient. I believe that patients are the ones to be treated and not the scans.

 

Cuff problems

This is commonly also known as五十肩 (50 year old Shoulder), Urat bahu bengkak and commonly includes:

  • Impingement
  • Cuff Tendinosis
  • Cuff Tears which can be incomplete, complete or
  • Massive tear which can be Irreparable
  • Cuff tear Arthropathy (CTA)

Frozen shoulder

This is also known as Adhesive Capsulitis. As its name suggest, the shoulder is FROZEN. This means that the shoulder is stuck both actively (moves by its own power) and passively (moved by the other arm or someone else). It can be Primary (no one really knows why type) vs Secondary (caused by something else). Risk factors for Primary Frozen shoulder commonly include:

  • Endocrine causes (Diabetes Mellitus, Thyroid problems),
  • Neurological causes (Stroke)
  • Heart (Heart attack)
  • Secondary frozen shoulder can be due to shoulder fractures, Cuff issues or Labral issues too.
  • Labral Injuries

These often occur after an injury. Patients may have had a dislocation or a subluxation (partial dislocation) previously and the symptom of the shoulder being unstable is recurrent now. The labrum may tear at different areas and in additional to instability; patients may often complain of pain and may have painful clicks in the shoulder during certain movement. A proper examination will include looking for signs of instability, other types of labral tears and signs of generalised hyperlaxity (Loose jointed).


Don’t live with it!  

“See your doctor cos something can be done”

I cannot emphasize enough that a Proper History and Physical Examination leading to targeted Investigations will then bring about a Proper Diagnosis. This will include locating the source of pain, Range of Motion tests and Special tests. For labral injuries, we look out for Hyperlaxity Signs too. Thereafter, Xrays, Ultrasound and/or MRI/ CT scans are done and interpreted together with looking at the patient’s problems.

 

Get back your Swing

This will be based on the diagnosis and looking at what exactly is bothering the patient. (At Roland Shoulder & Orthopaedic Clinic, We Help Patients not Treat Scans)

Cuff problems

This depends on whether there is a hole in the roof or not and how big the hole is and if it is a complete hole.

If there is no hole, an incomplete hole or small hole, NON OPERATIVE management lasting for 3-6 months is often started. (There is nothing CONSERVATIVE about not operating)

This includes

  • Controlling Inflammation and pain – Analgesia (pain killers) and/or  NSAIDs (Non Steroidal Anti Inflammatory Drugs)
  • Subacromial (below the tree branch) Hydrocortisone & Lignocaine injections (I usually use 1% lignocaine with Triamcinolone)
  • Physiotherapy
    • Mobility Exercises
    • Strengthening of the
      • External and Internal Rotators

  Biceps

  Triceps

  Deltoid

  Scapular Stabilisers

For patients with Acute tears (occurring after an injury), Large Complete tears or patients that have failed non operative management, Surgery is offered. In my practice, a large majority of cuff problems which require surgery is done through Key Hole techniques now. This includes

  • Arthroscopic Subacromial Decompression and rotator cuff repair which is shaving down the offending tree branch above the roof and repairing the roof and/or repairing the front door too if that is torn.
  • Arthroscopic Mumford procedure (distal clavicle resection) if that is giving the patient problems .
  • Addressing the Biceps tendon (Tenotomy/Tenodesis) if that is giving patients problems .

Shoulder Pain, Living with Shoulder Pain, Shoulder Elbow Orthopaedic

A large majority of shoulder problems are treated using key hole (Arthroscopic) techniques as they are can usually produce equal results to open surgery. Patients often have less pain, a shorter hospital stay and the scars are cosmetically more pleasing.

 

Shoulder Pain, Living with Shoulder Pain, Shoulder Elbow Orthopaedic

However, this is not suitable for all cases and this depends of the condition and severity of the problem.

 

Frozen Shoulder

Primary Frozen shoulders follow a process of Freezing, Frozen and then Thawing. The thawing process can occasionally, unfortunately, last for a very long time of up to a year or 2. Seeing a doctor early will allow us to:

  • Ensure that the it is truly a Frozen shoulder. (again through a proper history/ physical examination/ appropriate scan/s)
  • Find out if it is cause by another shoulder problem (Secondary Frozen Shoulder)
  • Speed up the thawing process or if necessary, BREAK the ICE!

Speeding up the thawing process includes:

Non operative management of Glenohumeral H&L (injecting into the house itself), Physiotherapy, Medication like pain killers and anti-inflammatory medications. It is important to treat underlying issues if it is a secondary cause.

In my practice, if all else fails, I offer to break the ice but under direct vision. I kinda like to see what I intend to break. As such, I offer an Arthroscopic Capsular Release

 

Instability

For patients with labral injuries, if recurrent instability is the main problem, surgery should be considered early. This is because in younger patients, the risk of persistent instability is very high. With each dislocation, the risk of getting a large piece of the golf tee being broken off (Bony Bankart) or the golf ball being cored in (Hil sachs Lesion) becomes higher. As such, I offer Arthroscopic Shoulder Stabilisation (Keyhole stabilisation surgery) where the torn labrum can be repaired. This is for patients without a large piece of the golf tee that is broken off or a large part of the golf ball being cored. Unfortunately, if that happens, open procedures to restore the bone loss usually at the side of the golf tee may then be suitable.  

For some patients with a SLAP (Superior Labrum Anterior Posterior) tears (top part of the cup) or a posterior labral tear (back part of the cup), pain and clicking is the main problem. For patients with SLAP tear, I believe that a trial of non operative Management should first commence. This must include Scapular Stabilisation exercises so as to provide a stable platform for the shoulder joint to mobilise. Only if that fails, I will then offer surgery to address the SLAP tear. In patients with posterior labral injuries complaining of pain and clicks, ASS can be offered to repair the cup.

 

What if the Whole House is Damaged?

For patients with Cuff Tear Arthropathy (damage to the shoulder cartilage due to prolonged roof tendon tear) and usually for patients > 65years, the option of a joint replacement is offered. This is because with the cartilage being worn out, a repair or replacement of the roof tendons will not resolve the arthritis causing the pain. In patients with CTA, a Reverse Shoulder Arthroplasty (RSA) is usually offered.

 

Shoulder Pain, Living with Shoulder Pain, Shoulder Elbow Orthopaedic

This is a replacement surgery and it offers excellent pain relieve, a good functional Range of Motion of 140-150 degrees of forwards flexion. Patients can return to daily upper limb activities like comb/ wash hair, wash face, brush teeth after surgery.

 

In conclusion, you don’t have to live with your shoulder pain. Seek help early if the shoulder strain simply doesn’t go away after 2-3 weeks. A proper History and Physical Examination and Appropriate Investigations will usually lead to a Diagnosis and proper Treatment.