August 18, 2013
Rotator cuff tendinopathy – what, why and how?
So, we established in last week’s blog that evolution has entrusted the shoulder joint with a vast workload. The level of mobility we demand from our shoulders has inevitably left them less stable. For most of us, most of the time, however, our shoulders cope with our demands impeccably well. But when they do break down, what are the common injuries, what do they feel like and what is the best approach to treatment? Let’s tackle perhaps the most common injury this week, rotator cuff tendinopathy.
Rotator cuff tendinopathy:
It only takes about 4% tendon stretch to start causing micro trauma within tendon fibres. When you consider the varying degrees of internal rotation that most of us inflict on our shoulders via our forward / rounded shoulder postures – it’s not hard to imagine the degrees of stress we put through our tendons in everyday life. The most common site of tendinopathy in the shoulder is the rotator cuff and 1 rotator cuff muscle in particular – the suprispinatus. An anatomical anomaly is to blame for this. There is a ‘critical zone’ about 1cm from the attachment of the suprispinatus that happens to sit at the junction of 3 blood supplies. Although this may sound as though the muscle has an abundance of fresh oxygenated blood to enjoy, it is actually quite the opposite. It is almost as though the 3 arteries can’t quite agree whose responsibility this small area is and consequently they all rather rudely ignore it. This leaves this section of muscle tendon more susceptible to damage and less able to repair itself.
Feeling pain when raising a straight arm above your head, or when reaching behind your back to put on a jacket? These are classic symptoms of rotator cuff tendinopathy. It may be due to a single incidence of trauma, such as over reaching during sport – but more often it is caused by continued small micro-trauma that builds up over time. The ‘Iceberg Theory’ of tendon pathology considers tendon pain to be, as the name suggests, the tip of the iceberg. By the time pain raises its head above the surface, you can be assured that the tendon has already been through a fair amount. Small cycles of inflammation and repair due to everyday stresses finally take their toll. The tendon does its best to deal with it without letting you know but eventually it concedes that a problem shared is a problem halved. The problem with this chronic development over time is that tendinopathy becomes quite mature and stubborn and recovery can take a while. So what are the best approaches to treatment?
Appropriate movement is the blueprint for repair. Inactivity doesn’t really cut it. If you rest a tendon too long, collagen will be laid down haphazardly and lead to a shortening of the tendon and a susceptibility to further injury. Movement encourages the tendon to lay down repairing collagen fibres in the appropriate lines of stress, the tendon will then be stronger in those planes of movement that we most often ask it to follow.
Before you can start appropriate movement and stretching, however, you may first need old adhesions and collagen patterns in the tendon to be broken down; this will provide a nice clean slate for appropriate repair. This is where manual therapy comes in. Tendon inhibition, soft tissue release and various other manual techniques will encourage break down of shortened painful adhesions and encourage blood flow to the area to kick start the repair and regeneration process – out with the old, in with the new.
Being aware of posture is also fundamental. A forward shoulder posture, which will be further aggravated by a desk based job or long periods in front of a computer, will put continual stress and strain through the rotator cuff tendons of the posterior shoulder. The shoulder joint is in the middle of a muscular tug of war between the posterior rotator cuff and the anterior pectoral and bicep muscles. If your shoulders are internally rotated, the anterior muscles are winning and the posterior rotator cuff muscles are weakened. By stretching shortened, strong pectorals you will be helping out team rotator cuff and giving them a fighting chance of re-addressing the optimum balance of the shoulder joint.
- Cailliet, R., 1991. Shoulder Pain. 3rd ed. Jaypee Brothers, New Delhi, India
- Chila, A., 2010. Foundations of Osteopathic Medicine. 3rd ed.
- Lederman, E., 1997. Fundamentals of Manual Therapy: Physiology, Neurology and Psychology. Churchill Livingstone