The shoulder has the greatest range of motion of any joint in the body. It is our shoulders that allow us to put our hands where they need to be for work, play, and all of our daily activities. To manage this, the shoulder has to have the right balance of strength, flexibility, and stability. Loss of this balance can lead to pain and injury. Maintaining this balance through exercises aimed at stretching and strengthening can help avoid shoulder problems.

The rotator cruff muscles

Without learned muscle control, any overhead activity, let alone just lifting the arm, would be impossible. The muscle group for this control is the rotator cuff (RC) muscles – the infraspinatus, supraspinatus, teres minor, and subscapularis muscles. The muscles primarily designed to position the scapula for overhead movement are the trapezius, and serratus anterior. The larger and more powerful muscles that generate movements of the arm are the deltoids, latissimus dorsi, and pectoralis major.

The shoulder is at risk for injury in many sports. The rotator cuff can be injured through overuse or through trauma. Rotator cuff tendinitis is common in volleyball. Rotator cuff tears can occur if the tendons are overloaded in weight lifting or football. There are ligaments which hold the shoulder bone in its socket. The shoulder has a very large range of motion, and needs some flexibility of the ligaments to allow for that range. But if the ligaments become stretched or torn, this can lead to instability. A mild amount of instability will allow the shoulder to slip part way out of socket, called a subluxation. When the shoulder comes completely out of its socket this is called a dislocation.

Prevention

Shoulder injuries can be diminished by careful warmup, stretching, and strengthening of the shoulder muscles.

• Flexibility

The purpose of flexibility varies for the different muscles around the shoulder. For the major power muscles, it is important that flexibility allows freedom of movement for the pelvis, trunk, scapula, and humerus. Too much flexibility at the expense of strength and control can be dangerous because of the excessive shear forces causing wear and tear in the joint. Too much flexibility at the expense of muscle control puts strains on the soft tissues and causes injuries.

• Stretching

Stretching to increase flexibility should never be done prior to training or competition, but instead done during ‘down’ times in the week. This is because of the suppression of the ‘stretch reflex’ that takes place during sustained passive stretching of muscle tissue (ie, repeated holds of 20-30 seconds). If one were to do rapid forceful movements such as throwing straight after such passive stretching, there would be an increased chance of muscle and tendon tears.

• Warm-up

Before stretcing the shoulder should be warmed up thoroughly with gradually increasing movements – big circles, across body movements, trunk twists, shoulder blade rolls and forward and backward squeezes. The purpose of this is to increase blood flow and temperature, thereby increasing the elasticity and ‘give’ in the soft tissues.

Symptoms

Rotator cuff injury symptoms may include:

• pain and tenderness in your shoulder, especially when reaching overhead, reaching behind your back, lifting, pulling or sleeping on the affected side
• shoulder weakness
• loss of shoulder range of motion
• inclination to keep your shoulder inactive

The most common symptom is pain. You may experience it when you reach up to comb your hair, bend your arm back to put on a jacket or carry something heavy. Lying on the affected shoulder also can be painful. If you have a severe injury, such as a large tear, you may experience continuous pain and muscle weakness.

Tests and diagnosis

If your injury appears to be severe or your doctor can’t determine the cause of your pain through physical examination, he or she may recommend diagnostic imaging tests to better delineate your shoulder joint, muscles and tendons. These may include:

• X-rays
• a magnetic resonance imaging (MRI) scan
• an ultrasound scan

Treatments

Most of the time, treatment for rotator cuff injuries involves exercise therapy. Your doctor or a physical therapist will talk with you about specific exercises designed to help heal your injury, improve the flexibility of your rotator cuff and shoulder muscles, and provide balanced shoulder muscle strength. Depending on the severity of your injury, physical therapy may take from three weeks to several months.

Other rotator cuff injury treatments may include:
Steroid injections. Depending on the severity of your pain, your doctor may use a corticosteroid injection to relieve inflammation and pain.
Surgery. If you have a large tear in your rotator cuff, you may need surgery to repair the tear. Sometimes during this kind of surgery doctors may remove a bone spur or calcium deposits. The surgery may be performed as an open repair through a 2 1/2- to 4-inch (6- to 10-centimeter) incision, as a mini-open repair through a 1 1/4- to 2-inch (3- to 5-centimeter) incision, or as an arthroscopic repair with the aid of a small camera inserted through a smaller incision.

Arthroplasty. Some long-standing rotator cuff tears over time may contribute to the development of rotator cuff arthropathy, which can include severe arthritis. In such cases, your doctor may discuss with you more extensive surgical options, including partial shoulder replacement (hemiarthroplasty) or total shoulder replacement (prosthetic arthroplasty).