eMedicine Specialties > Sports Medicine > Shoulder

Rotator Cuff Injury: Follow-up

Author: Gerard A Malanga, MD, Founder and Director, New Jersey Sports Medicine Institute; Director of Pain Management, Overlook Hospital; Director of Sports Medicine, Sports Medicine Fellowship Director, Mountainside Hospital; Clinical Chief, Rehabilitation Medicine and Electrodiagnosis, St Michael's Medical Center; Medical Director, Consultant, Horizon Healthcare Worker's Compensation Services, Blue Cross and Blue Shield Worker's Compensation
Coauthor(s): Christopher J Visco, MD, Staff Physician, Department of Rehabilitation, Kessler Institute for Rehabilitation, University of Medicine and Dentistry of New Jersey; Stephen G Andrus, MD, Sports Medicine Fellow, Department of Physical Medicine and Rehabilitation, Kessler Institute for Rehabilitation, University of Medicine and Dentistry of New Jersey; Jay E Bowen, DO, Assistant Professor, Clinical Coordinator Sports Medicine Fellowship, Department of Physical Medicine and Rehabilitation, Kessler Rehabilitation Corporation
Contributor Information and Disclosures

Updated: Jan 29, 2009

Follow-up

Return to Play

Return to play criteria should be individualized for every player.27 General criteria require the athlete to experience no pain with rest or activity, full strength in muscles across the affected joint, pain-free shoulder ROM with normal ST motion, and negative provocative tests (eg, Neer impingement test, Hawkins impingement test).

An athlete who returns to his or her sport too soon tends to alter throwing mechanics and risks injuries not only to the same shoulder, but also to the elbow, hip, and spine. Resumption of activities should be gradual, and activity intensity may need to be modified in response to recurrence of symptoms. Imaging findings alone should not be used to determine return to play.

Complications

When treatment is delayed in rotator cuff injuries and shoulder discomfort persists, the patient can develop symptomatic stiffness of the GH joint, which is called adhesive capsulitis. In this condition, the patient consciously or subconsciously limits the use of the shoulder because of pain, leading to the development of soft-tissue tightness or stiffness in one or more planes. The chance of developing adhesive capsulitis can be minimized through prompt diagnosis of painful problems in the shoulder, such as rotator cuff injuries, and the institution of early shoulder ROM as part of the rehabilitation program.

Severe supraspinatus and infraspinatus muscle atrophy is often associated with massive rotator cuff tears, but an underlying entrapment of the suprascapular nerve should always be considered. Symptoms of suprascapular nerve entrapment include shoulder pain that is described as a deep dull ache localized to the posterolateral aspect of the shoulder. Weakness of the shoulder and arm is common, with visible wasting and atrophy of the supraspinatus and infraspinatus and normal bulk in the deltoid. Clinical differentiation of suprascapular nerve entrapment from rotator cuff injuries may be difficult, especially if both are present simultaneously. EMG is the single most helpful test for diagnosing this condition.

Prevention

Following rotator cuff injuries, patients must pay careful attention to the use of proper mechanics during athletic activities and avoid harmful adaptations (eg, changing arm position when throwing a baseball). The nature of many overhead sports makes the athlete susceptible to injury and dysfunction because of the repetitive high-velocity stress that is required.

Athletes should maintain balanced shoulder ROM, paying particular attention to shoulder internal rotation, which can be limited by increased posterior capsular tightness. Dynamic stabilizers should be strengthened, including the rotator cuff muscles and the scapula stabilizers. This decreases demands on the static stabilizers (eg, bony structures, labrum, ligaments, capsule) and helps the athlete minimize the risk of injury. Maintaining proper trunk and lower extremity strength is also important, because these muscles generate significant force for athletes performing overhead motions and reduce stress on the shoulder girdle muscles.

Prognosis

Most athletes with primary outlet impingement without full-thickness rotator cuff tears respond well to nonoperative treatment. Rehabilitation is also effective in the majority of athletes with rotator cuff pathology due to other causes (eg, instability), except when instability is caused by trauma. When surgery is performed for rotator cuff injuries not responding to conservative treatments, results vary depending upon patient age, size and pattern of the tear, degree of retraction, tissue quality, and quality of repair.

Education

Proper sport technique can be of great importance in the prevention and rehabilitation of rotator cuff injuries. This includes proper hand position on water entry in swimming, changes in paddling technique in canoeing and kayaking, and evaluation of pitching mechanics by coaches and trainers in throwing athletes. Encourage the importance of maintaining proper trunk and lower extremity strengthening in athletes performing overhead motions, because these muscles generate significant force during overhead activities and serve to reduce stresses on the shoulder stabilizers.

Miscellaneous

Medicolegal Pitfalls

  • Diagnosis of rotator cuff injuries can usually be made on the basis of a good history and physical examination. However, shoulder pain can also be referred from the cervical spine. A thorough examination of the cervical spine should always be carried out in patients presenting with shoulder pain, especially in those who have symptoms that are not improving.Proper attention to the cervical spine can prevent unnecessary shoulder surgeries in some instances and prevent associated medical and legal complications that may follow. Shoulder pain can also be the presenting symptom in some more serious conditions, such as cardiac angina pectoris or myocardial infarction, and these causes also need to be considered in the differential diagnosis.
 


More on Rotator Cuff Injury

Overview: Rotator Cuff Injury
Differential Diagnoses & Workup: Rotator Cuff Injury
Treatment & Medication: Rotator Cuff Injury
Follow-up: Rotator Cuff Injury
Multimedia: Rotator Cuff Injury
References
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Further Reading

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Keywords

rotator cuff tear, rotator cuff tendonitis, rotator cuff tendinitis, supraspinatus tendonitis, subacromial tendonitis, subacromial tendinitis, impingement syndrome, shoulder injury, shoulder pain, loss of shoulder motion, supraspinatus atrophy, infraspinatus atrophy, entrapments of suprascapular nerve,

scapular winging, scapulohumeral rhythm, adhesive capsulitis, dropping of the arm, scapula rotators, drop-arm test, Neer impingement test, Hawkins-Kennedy impingement test, apprehension test, relocation test, intrinsic tendinopathy, curved acromions, hooked acromions, rotator cuff tendinopathy

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Contributor Information and Disclosures

Author

Gerard A Malanga, MD, Founder and Director, New Jersey Sports Medicine Institute; Director of Pain Management, Overlook Hospital; Director of Sports Medicine, Sports Medicine Fellowship Director, Mountainside Hospital; Clinical Chief, Rehabilitation Medicine and Electrodiagnosis, St Michael's Medical Center; Medical Director, Consultant, Horizon Healthcare Worker's Compensation Services, Blue Cross and Blue Shield Worker's Compensation
Gerard A Malanga, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, North American Spine Society, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Coauthor(s)

Christopher J Visco, MD, Staff Physician, Department of Rehabilitation, Kessler Institute for Rehabilitation, University of Medicine and Dentistry of New Jersey
Christopher J Visco, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Medical Association, and American Medical Student Association/Foundation
Disclosure: Nothing to disclose.

Stephen G Andrus, MD, Sports Medicine Fellow, Department of Physical Medicine and Rehabilitation, Kessler Institute for Rehabilitation, University of Medicine and Dentistry of New Jersey
Stephen G Andrus, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, American Medical Association, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Jay E Bowen, DO, Assistant Professor, Clinical Coordinator Sports Medicine Fellowship, Department of Physical Medicine and Rehabilitation, Kessler Rehabilitation Corporation
Jay E Bowen, DO is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American College of Sports Medicine, and American Osteopathic Association
Disclosure: Nothing to disclose.

Medical Editor

Andrew L Sherman, MD, MS, Associate Professor of Clinical Rehabilitation Medicine, Vice Chairman, Chief of Spine and Musculoskeletal Services, Program Director, SCI Fellowship and PMR Residency Programs, Department of Rehabilitation Medicine, Leonard A Miller School of Medicine, University of Miami
Andrew L Sherman, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American College of Sports Medicine, American Medical Association, American Paraplegia Society, American Spinal Injury Association, and Association of Academic Physiatrists
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Henry T Goitz, MD, Fellowship Director, Sports Medicine, Department of Orthopedic Surgery, Henry Ford Hospital
Henry T Goitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons and American Orthopaedic Society for Sports Medicine
Disclosure: Nothing to disclose.

CME Editor

Jon B Whitehurst, MD, Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner and Executive Board Member, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital
Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

Chief Editor

Craig C Young, MD, Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Sports Medicine Fellowship Director, Medical College of Wisconsin
Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, Phi Beta Kappa, and Wilderness Medical Society
Disclosure: Nothing to disclose.

 
 
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