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August 29, 2018

By John Baker, Physiotherapist at HealthBay Orthopaedic and Physiotherapy Centre 


Setting the scene…

As you reach behind you towards the back seat of your car, suddenly you feel a sharp searing pain that radiates like a flash from the shoulder down your arm! The pain lingers for a few minutes, feeling like a dull tooth ache only to settle down and feel normal again. Later that day, you reach up in the cupboard for that cup….DAMN….it’s got you again! You head to bed and realize that you can’t find a comfortable position, the shoulder is aching and there’s no chance you’re getting to sleep anytime soon! Sound familiar? You go to your doctor and get a diagnosis of subacromial impingement syndrome, but what does it mean and what can we do? 

First let me start by saying that the shoulder is an incredibly complex joint and impingement is only one way of trying to explain what mechanism is causing someones shoulder pain. Before I go off on a medical tangent, what is shoulder impingement? It is hypothesized that shoulder impingement is caused by compression of the rotator cuff tendons against the acromion or coracoacromial ligament during arm elevation.  

There’s theories that suggest that the acromion is the offender, by impeding down into the rotator cuff tendons during arm elevation. On the flip side, there’s credible evidence that poor control of the humeral head may allow excessive upward displacement against the acromion, resulting in rotator cuff impingement. To add more confusion, studies have consistently found that the majority of tendon tears are occurring underneath the tendon (away from the acromion) and not at the outer surface where the tendons would in fact be compressing against the acromion!

What is the rotator cuff and what does it do?  

The rotator cuff is made up of 4 muscles that attach from the shoulder blade and connect to the head of the humerus. In other words, the muscles that keep the head relatively centered on the socket during arm elevation. Unlike the hip joint which has a deeper and more stable socket, the shoulder is an inherently unstable and shallow socket that lacks a lot of the passive stability from the ligaments. You can now start to appreciate that importance of a good functioning rotator cuff to keep the shoulder healthy!

Lets now consider the function of the rotator cuff. As I mentioned earlier, one of the main roles of these four small muscles is to stabilize the shoulder ball and socket during elevation of the arm. Meaning, the higher you elevate your arm, the harder the rotator cuff has to work to maintain stability of the ball and socket. Start adding some rotation and complexity to the movement, the rotator cuff has to work EVEN harder. You might now appreciate that people who have a weak and dysfunctional rotator cuff, might have pain and problems when lifting anywhere above 80-90 degrees. It might even be worse when when throwing a ball for example.   

There could be hundreds of different reasons why the rotator cuff does not do its job properly but let me give just one example. We have a painter and decorator who works with his arms elevated above 90 degrees most of the day, this put great demands through the rotator cuff. He’s hammering nails into walls, painting and reaching into awkward positions. Hours to days later, the muscles and tendons of the rotator cuff become overly fatigued and aggravated, which hinders their function to control the ball on the socket and withstand normal load when lifting. This irritability and background weakness can lead to excessive upward movement of the humeral head and cause impingement of the rotator cuff tendons against the acromion. 

The downward spiral

Repeated episodes of impingement may cause further aggravation to the tendon and bursa resulting in swelling, thickening and further inhibited muscle function due to pain. This may make impingement more painful and more frequent. To regain control and function, one of the most important parts of the treatment intervention is to gradually regain good rotator cuff control, endurance and strength. 

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