Shoulder Injuries
rotator cuff
tears
 The
rotator cuff is a group of four muscles (supraspinatus, infraspinatus, teres
minor, and subscapularis) that work together to rotate the shoulder and to hold
the humerus in the center of the glenoid socket. These muscles are small, and
lie underneath the larger muscles of the shoulder such as the deltoid, trapezius,
and pectoral muscles. They connect to the humerus via tendons. It is the tendon
part of the rotator cuff that is usually inflamed or torn.
rotator cuff
tendonitis
Anytime a muscle / tendon is overworked, it will become
inflamed. The rotator cuff is frequently inflamed in throwers, along with the
bursa that sits on top of the cuff. This tendonitis and bursitis is usually not
dangerous but can be painful. The diagnosis requires a
 physical examination by a
qualified Sports Medicine physician, and occasionally an MRI. The MRI is
actually to rule out more severe problems such as a rotator cuff tear. The
treatment is usually relative rest (decreasing but not stopping activities), anti-inflammatory activities, and physical therapy. The idea is to allow the
overworked cuff a chance to recover and heal, diminish the inflammation, and
strengthen the cuff so it can better tolerate the activities in the future.
If the rotator cuff is overworked for a long time, it may
start to fray or tear, just as a rope that is pulled too hard too many times may
fray and tear. In the thrower it is rare for the cuff to suddenly tear through
and through, but it can happen gradually. Usually, the pain gets too great to
pitch long before the tear penetrates all the way through the cuff tendon. It
is interesting that this fraying is not always painful. Sometimes it is the
inflammation (rather than the fraying) that hurts. Most Major League pitchers
will have some visible evidence of fraying of the rotator cuff on their MRI’s,
but this is not always painful! A thorough evaluation by an experienced shoulder
physician is necessary to determine this. A MRI can tell us if the rotator cuff
is frayed or partially torn, but it can’t tell us if that actually hurts! The
history and physical examination are just as important in diagnosing a shoulder
problem in a thrower.
internal
impingement
Internal impingement is one of the problems seen in
thrower’s shoulders. If the shoulder goes too far in ER/extension during the
cocking phase (i.e. elbow behind the chest with the shoulder externally rotated)
the rotator cuff will get pinched inside the shoulder (impinged
internally)between the glenoid and humerus. This can result in some partial
tearing of the rotator cuff which can progress to a serious tear. The internal
impingement is made worse by an unstable shoulder, SICK Scapula, and also by
loss of internal rotation (GIRD, see below). Since most of these risk factors
can be addressed by physical therapy and improving throwing mechanics, surgery
can be avoided if it is detected early enough.
rotator cuff
surgery
If the rotator cuff tendon is partially torn, sometimes
rehabilitation doesn’t work and surgery is necessary. IF the rotator cuff is
torn completely, surgery is almost always needed. The surgery is arthroscopic
and done as an outpatient. The rotator cuff must be repaired and reattached to
the bone from which it detached, and any underlying problems must be fixed too.
Sometimes the rotator cuff tears because of instability in the shoulder (see
below)—if this is the case the shoulder must be tightened or the cuff will
re-tear.
I reattach the rotator cuff tendon to the bone using
“suture anchors”. These are dissolvable screw tips that I embed into the bone.
They fasten the suture to the bone, then the suture can then be sewn into the
rotator cuff tendon to tie it to the bone until it heals.
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