rotator cuff paper

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


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.


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


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-


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


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.


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


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.


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


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


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


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


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


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.


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rotator cuff paper

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