Rotator Cuff Injury Follow-up

  • Author: Gerard A Malanga, MD; Chief Editor: Craig C Young, MD   more...
 
Updated: Nov 16, 2011
 

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.

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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.

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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.

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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.

One study evaluated 51 patients, aged 60 years or younger, with nonoperatively treated rotator cuff tears and found that full-thickness rotator cuff tears tended to increase in size in about half of the patients. The study suggests that surgery be considered to prevent an increase in size tear, and those treated nonoperatively should be monitored for tear size increase.[28]

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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.

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Contributor Information and Disclosures
Author

Gerard A Malanga, MD  Director of Pain Management, Overlook Hospital; Director of PM&R Sports Medicine Fellowship, Atlantic Health; Clinical Professor, Department of Physical Medicine and Rehabilitation, UMDNJ-New Jersey Medical School; Clinical Chief, Rehabilitation Medicine and Electrodiagnosis, St Michael's Medical Center; Fellow, American College of Sports Medicine

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, American Institute of Ultrasound in Medicine, International Spine Intervention Society, and North American Spine Society

Disclosure: Cephalon Honoraria Speaking and teaching; Endo Honoraria Speaking and teaching; Genzyme Honoraria Speaking and teaching; Prostakan Honoraria Speaking and teaching; Pfizer Consulting fee Speaking and teaching

Coauthor(s)

Christopher J Visco, MD  Assistant Professor, Department of Rehabilitation and Regenerative Medicine, Columbia University College of Physicians and Surgeons; Assistant Residency Program Director, New York Presbyterian Hospital

Christopher J Visco, MD 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 Medical Student Association/Foundation, Association of Academic Physiatrists, and International Spine Intervention Society

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, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry- Newark, NJ

Jay E Bowen, DO is a member of the following medical societies: American Academy of Osteopathy, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, American Osteopathic Association, American Osteopathic College of Physical Medicine and Rehabilitation, North American Spine Society, and Physiatric Association of Spine, Sports and Occupational Rehabilitation

Disclosure: Nothing to disclose.

Specialty Editor Board

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, University of Miami, Leonard A Miller School of Medicine

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 Medical Association, and Association of Academic Physiatrists

Disclosure: Pfizer Honoraria Speaking and teaching

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Henry T Goitz, MD  Academic Chair and Associate Director, Detroit Medical Center Sports Medicine Institute; Director, Education, Research, and Injury Prevention Center; Co-Director, Orthopaedic Sports Medicine Fellowship

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.

Jon B Whitehurst, MD  Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner, 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, Director of Primary Care Sports Medicine Fellowship, 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, and Phi Beta Kappa

Disclosure: Nothing to disclose.

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Rotator cuff, normal anatomy.
Rotator cuff tear, anterior view.
The acromioclavicular arch and the subacromial bursa.
Neer impingement test. The patient's arm is maximally elevated through forward flexion by the examiner, causing a jamming of the greater tuberosity against the anteroinferior acromion. Pain elicited with this maneuver indicates a positive test result for impingement.
Hawkins test. The examiner forward flexes the arms to 90° and then forcibly internally rotates the shoulder. This movement pushes the supraspinatus tendon against the anterior surface of the coracoacromial ligament and coracoid process. Pain indicates a positive test result for supraspinatus tendonitis.
Rotator cuff injury.
 
 
 
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