All About the Rotator Cuff

by Ryan
Andrews
, August 30th, 2010.
Hi Everyone,
I hope you have enjoyed some of the post on my blog.Howver to clean up the site and give it better credibility it will be closing and reopening here at our new bog The Core Matrix.
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What is acupuncture?

It might start with mild shoulder pain. So you avoid certain exercises. No
biggie. But this leads to atrophy of shoulder muscles and instability.
Then you start to notice impingement due to the atrophy. Then you notice
strength and posture imbalances. The downward spiral has begun.
Next thing you know, your kids are dropping you off at the nursing home in
time for Thursday afternoon shuffleboard. You’ll have the posture of Quasimodo
and arms like T-Rex.
What is the rotator cuff?
The shoulder has an immense range of motion — the most of any joint in the
body. But this comes with a catch: because of its range, it’s also the most
unstable.
As a result, nearly 70% of us will experience some sort of shoulder disorder
in our lifetime. Often, the injury includes one of the rotator cuff muscles.
Of all the injuries that take place during resistance training, 36% occur at
the shoulder complex. The supraspinatus muscle is most often involved.

Yeah, we're pretty sure that her arms are facing the wrong way too.

The rotator cuff is made up of four muscles (or you could think of them as
“active ligaments”) that collectively compress, depress, protect and stabilize
the glenohumeral joint, helping to keep the upper ball of the humerus (think of
this as a golf ball) in the glenoid fossa (think of this as a tee). Weak rotator
cuff muscles prevent the humeral head from rotating properly on the glenoid
fossa.
images-image_popup-arth7_shoulder2 golf ball tee
The supraspinatus, infraspinatus, teres minor, and subscapularis (the 4
rotator cuff muscles) originate on the scapula (shoulder blade) and help with
various movements like bringing your arm out to the side, internal rotation
(turning your arm inwards), external rotation (turning your arm outwards), and
so on.
RC muscles

Attachments and functions of rotator cuff muscles

Source: Ronai P. Exercise modifications and strategies to enhance shoulder
function. Strength and Conditioning Journal 2005;27:36-45.
Why is the rotator cuff important?

The challenge of stabilization

Shouder stabilization is a dynamic activity. Many muscles, from small to
large, fire in a coordinated effort to stabilize the shoulder as it moves
through a range of motion. Along with the rotator cuff, this includes:
  • Serratus anterior
  • Rhomboids
  • Trapezius
  • Levator scapulae
scap-muscles1 serratus diagram
When looking at shoulder problems, it’s important to understand the complex
roles that all of these muscles play. If they don’t work together — or more
likely, if some muscles are strong and some are weak or inhibited, they can’t
work together effectively in order to keep that golf ball on the tee.
The result: imbalance and eventually, injury.
68% of people with scapular instability have rotator cuff problems. If these
muscles are weak or not firing properly, it’s harder to control that golf ball
on the tee. Typically, the shoulder blades and the top of the humerus (upper
arm) start to slip forward, which shrinks the subacromial space between the
humerus and the acromion (bony structure at the top of the shoulder).
subacromial-space
Many tendons pass through this space. When it’s constricted, these tendons
can become inflamed. Over time, with repeated trauma, the tendons may become
damaged or even — eventually — tear.
In addition, the surfaces and structures of the joint (such as the cartilage
that lines the joint capsule) can become inflamed.

Shoulder injuries: You could be next

desk_work

Barring an acute event (like falling on an outstretched arm), most shoulder
injuries come from repeated, cumulative damage.
The bad news: Almost everyone is at risk for shoulder injuries.
The subscapularis tends to get plenty of stimulation in our
“front-of-the-body-internal-rotation” happy gyms. This means it’s usually pretty
tight and strong. Combine this with things like:
  • desk work
  • driving
  • using a mouse/keyboard
  • stress (which often makes people tighten up their traps and hunch their
    shoulders)
  • sitting/standing in “hunchback” posture
  • lack of attention to the muscles you can’t see in the mirror
…and you have the perfect storm for shoulder pain.
Many people ignore the warning signs of shoulder trauma (such as pain and
limited mobility) until the situation is serious.
Don’t go like that.
Whether you feel pain while bench pressing, reaching overhead, throwing,
punching, paddling, or all of the above… if your shoulder hurts, take the time
to deal with it immediately. Don’t push through the pain. It will not
get better if you ignore it, and will probably get worse.
The good news: A strong, stable and flexible rotator cuff can preserve
shoulder health and increase upper body strength.

Preventing injury

One of the keys to injury prevention is developing flexibility of the subscap
and pecs while building strength and endurance in the opposing external
rotators.
You are at risk for a rotator cuff/shoulder
injury if you have:

  • Anterior (front) shoulder instability, limited internal rotation mobility,
    and posterior (rear) shoulder tightness
  • Excessive external rotation mobility
  • Internal rotators stronger than external rotators
  • Weak lower traps (usually combined with over-active and tight upper traps)
  • Poor proprioception

Anterior shoulder instability, limited internal rotation mobility
and posterior shoulder tightness

Remedy – Need to improve posterior shoulder flexibility
Discussion – If you can’t do this, you have some tightness in the back of your shoulder.
Posterior shoulder tightness may be a contributing factor in impingement and
labral tears. This tightness doesn’t allow adequate internal rotation or
horizontal adduction.
Exercises to consider:
Cross arm
adduction stretch

Internal
rotation sleeper stretch

Scapular wall
slides

Shoulder
dislocates

Unilateral presses and pulls (one side at a
time)
Medicine ball
wall tosses

Drop and catch
push up
(advanced)

Excessive external rotation mobility

RemedyNeed to increase internal shoulder rotation
Discussion – This is a rare shoulder problem to have; though it’s often seen
in “overhead athletes”: folks whose sport involves throwing or pressing
overhead, such as pitchers. With poor internal rotation flexibility, posterior
shoulder tightness ensues. This can lead to the posterior rotator cuff muscles
contracting with more force in an attempt to pull the humeral head back into
place, leading to rotator cuff muscle fatigue and injury.
Exercises to consider:
Cross arm
adduction stretch

Internal
rotation sleeper stretch

Internal rotators stronger than external rotators

RemedyNeed to strengthen the external rotators
Discussion – The teres minor and infraspinatus are major external rotators
involved with abduction and overhead motions.
Exercises to consider:
Face down Y
exercise

Face down T
exercise

Band external
rotation at 30 degrees abduction

Seated press ups (advanced)
Power wheel
crawls
(advanced exercise – starts at 1:42 in video)
Pushup
plus

Reverse push
up

Cable external
rotations at 90 degrees

Side lying
external rotation at 30 degrees abduction

Scarecrow
Notes on the above exercises:
Performing these exercises on unstable surfaces can further enhance
sensorimotor control.
Placing a towel between the arm and body during internal/external rotations
can decrease deltoid activity, relax the supraspinatus, and lessen pain – all
good for the prehab/rehab process.

Weak lower traps

Remedy – Need to strengthen the lower traps
Discussion – An important sign of good shoulder function during pushing and
pulling movements is the ability to keep the shoulders down and away from the
ears.
Shrugged-Shoulders
If the shoulders move up toward the ears during a pushup or row (as in the
left-hand photo above), it signifies greater upper trap activity. This yanks the
humerus out of alignment within the glenoid cavity (the golf ball on the tee)
which results shoulder complex muscle weakness and limited range of motion. This
is a particular problem because the upper traps can be so strong relative to
other muscles.
Another screening tool is kyphotic posture, aka “the Quasimodo” or “E.T.” Again, this
suggests the upper traps are considerably stronger than the mid- to low traps,
serratus anterior and levator scapula.
Exercises to consider:
Balance out all of your pushing exercises with pulling exercises (using
retracted shoulder blades)
push-up w shrug 1008-chest-pushup-2
Push up with some shrugging – not good Push up without shrugging – good

Poor proprioception

Remedy – Need to build proprioception — awareness of where the body is in
space.
Discussion – Damage to ligaments around the shoulder cause less sensory
information coming in. Without proper incoming information, the shoulder isn’t
protected from extreme ranges of motion.
Exercises to consider:
Swiss ball
pushups
(advanced)
1 arm ab
plank on swiss ball
(advanced)
Medicine ball
wall dribbles
or this option
Quadruped
rhythmic stabilization

The following are advanced plyometric exercises helpful for later stages of
rehab/prehab.
Deceleration med
ball catches

Med ball
external rotation toss to wall

Tips on rehab/prehab exercises

When shoulder muscles become fatigued, the joint becomes hyper mobile, and
prone to injury. Thus, building endurance is important.
When doing shoulder stabilization exercises, use higher reps (10-20), and/or
longer duration (e.g. 30-60 sec).
Also, it’s important to train external rotators with an emphasis on the
eccentric phase. Use the “4-6” approach for the direct rotator cuff exercises.
Use a 4 second count on the concentric phase and a 6 second count on the
eccentric phase.

Don’t try this at home

A dangerous position for the rotator cuff (and the shoulder), is the “high
five position.” The humerus is abducted (held away from the body) and externally
rotated. This overloads the anterior capsule.
Beyond actually high fiving with buddies, this position is often replicated
in the gym during old-school machine chest flies, behind the neck pulldowns, and
behind the neck presses.

Could cause shoulder injury

Other exercises that may increase shoulder injury risk include bench press
(flat and incline), dips, barbell back squats, upright rows, dumbbell flies, and
arm curls.
The empty can position (raising the arms up with the palms down/back) can inflame the
shoulder by reducing the subacromial space and causing impingement. Instead, use
the full can exercise (raising the arms up with palms forward in the plane of the
scapula).

Modifying exercises to improve shoulder health

Here are some tips to help you adjust common exercises to maximize shoulder
health.

Bench press

Change your squat

Instead of standard barbell back squats, try
front, zercher, dumbbell front or goblet squats, which put less stress on the
shoulders.
Front
Zercher
Dumbbell
Goblet

Pulldowns and overhead presses

  • Bring elbows slightly forward instead of flared out
  • Always go to the front of the body

Keep it scapular

When raising your arm out to the side, don’t force
it back so it’s directly in line with your body. Keep it in the natural range of
motion with the scapula – like this: Scapular Plane Lateral Raise, Neutral Grip

Upright rows

Not worth it. Try face pulls instead.

Posture

Keep a proud chest, tight shoulder blades, engaged
core, and overall “good posture” when exercising (and with daily life).

Other exercise modifications

exercise modification strategies

Summary and recommendations

  1. If it hurts your shoulders, avoid it. And don’t work through
    pain.
  2. Activate your serratus (see shoulder circuits below) to save your shoulders.
  3. Move around during the day. Check your posture.
  4. If you do a push, follow with a pull. If you work your front, follow with
    your back. In fact, try to do more pulling than pushing — about a 2:1 ratio if
    possible.
  5. Don’t be afraid to nix shoulder day. Between other exercises, the shoulders
    get plenty of work.
  6. Use massage or active release therapy to keep soft tissues happy.
  7. As much as possible, alternate which hands you use for daily-life tasks,
    such as brushing your teeth.
  8. Foamroll the thoracic spine.
  9. Be cautious with explosive overhead lifts.
  10. Develop shoulder flexibility/mobility/strength with the circuits below.

Shoulder health training plan

Here are two sample preventive stretching/strengthening circuits for shoulder
health.
Do each circuit 1-2 times per week.
Aim for 1-2 sets of about 10 reps per exercise. If the exercise works one
side at a time, make sure to do 10 reps for the other side too. If it’s a timed
exercise, aim for 15-20 seconds.
On your regular workout days, try this circuit before or after your scheduled
workout (or, if you want, at a completely different time than your workout). On
your non-workout days, try the routine any time of day. It shouldn’t take longer
than 10 minutes once you’ve got it down.
All of these exercises should be nice and easy. Resistance should be light;
this is not a max strength workout.

Circuit A

A: 1 arm ab
plank on Swiss ball
(advanced – don’t break your nose)
B1: Reverse push
up

B2: Pushup
plus

C: Scarecrow (4
seconds concentric, 6 seconds eccentric)
D: Foam roll
the thoracic spine

Circuit B

Extra credit

“There is a fine line between physiotherapy and the training of the elite
athlete.” – Dan Pfaff

Co-activation of the traps and serratus anterior are thought to have
significant influence on scapulohumeral rhythm.
The infraspinatus and teres minor are extremely active during the
“follow-through” with overhead throwing motions (or some overhead exercises like
medicine ball slams). Train these muscles eccentrically.

Further resources

References

Wagner P. A comprehensive approach to shoulder-complex maintenance. Strength
and Conditioning Journal. 2003;25:65-70.
Kolber MJ, et al. Shoulder injuries attributed to resistance training: a
brief review. J Strength Cond Research. 2010;24:1696-1704.
Kritz M, et al. Screening the upper-body push and pull patterns using body
weight exercises. Strength and Conditioning Journal. 2010;32:72-82.
Corrao M, et al. Addressing posterior shoulder tightness in the athletic
population. Strength and Conditioning Journal. 2009;31:61-65.
Ronai P. Exercise modifications and strategies to enhance shoulder function.
Strength and Conditioning Journal. 2005;27:36-45.
Tyson A. Posterior rotator cuff strength: part 1 and 2. Strength and
Conditioning Journal. 1995:21-23; 37-38.
Cressey E. Clearing up the rotator cuff controversy. January 2010.
Kolber MJ & Beekhuizen KS. The empty can exercise: considerations for
strengthening the supraspinatus. Strength and Conditioning Journal.
2009;31:38-40.
Cressey E. Cracking the rotator cuff conundrum. T-nation.
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About dkpilates

Pilates Instructor, Yoga Instructor, Personnel trainer and Group Fitness Instructor. Don teaches Contemporary and the Authentic forms of Pilates, in the later 90's, Don began his study of Yoga. His study of Yoga includes the Hatha, Iyengar, Bikram, and Astanga disciplines. His other areas of interest in fitness include Martial Arts, Spin, Boot Camp Training, and Weight Training. Don has extensive training and certifications from AFFA, IDEA, MadDog, B-Fit and Polestar. Don Continues his of Pilates education with Michelle Larson in Santa Fe New Mexico. His personal philosophy related to fitness is to aid students in a personalized balance of strength, stamina and flexibility. He is dedicated to design a program specifically for his students independent of the season of their life to create functional movement and help them reach their fitness goals.
This entry was posted in BODY, HEALTH, LIFE, MAJOR MUSCLE GROUPS, Pilates Anatomy, The Shoulder and tagged , , , , , , , , , , , , , , , , , , , , , . Bookmark the permalink.

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