Ask The Doctor Answers 3
Answers for the 2013-14 Season
Question: What is a torn rotator cuff? How does it occur? Is it a common hockey injury? What are the treatment options?
The rotator cuff tear is a common injury but an injury that is not very common for hockey players at this level. As age and overuse take their toll it becomes more common but not to the degree of overhead/throwing sports like baseball, tennis, and volleyball. The reason for this has to do with the mechanism that causes this injury to occur.
Lets start with what the rotator cuff is and what it means for shoulder function. The rotator cuff is a group of four muscles that work together as dynamic stabilizers of the shoulder’s glenohumeral joint (the ball and socket joint of the shoulder). These muscles (supraspinatus, infraspinatus, subscapularis, and teres minor, along with part of the biceps muscle) stabilize the ball inside the socket through the joint’s wide range of movement. They are critical for proper shoulder function.
Dysfunction in the rotator cuff occurs for a few reasons. Injuries, weakness, and instability all effect and affect each other and cause a decrease in the function of the shoulder. When one element of stabilization stops working properly then the stresses of our activity can cause damage to the involved tissue. This happens either through an inability to handle the stress placed on it directly or being forced to provide more stabilization then was intended as compensation and failing under the pressure.
Tears in the rotator cuff come from a couple different mechanisms. The most direct but least common in younger athletes are acute tears through a fall, usually on an outstretched arm. This is more rare and is usually associated with other shoulder injury as the force damages many tissues at once. Most The muscle that is most often torn is the supraspinatus and there are a few reasons why. The anatomy and role of the supraspinatus make it particularly susceptible to this injury. This tendon passes through a small tunnel underneath the AC joint to reach the shoulder attachment on the humerus. Inside this tunnel is the tendon itself and the bursa (fluid filled lubricating sacs) that can be affected by trauma. This can cause a problem with the gliding of the tendon through this subacromial joint space. This can be caused through activity or more directly through spurring of the bone in this tunnel. Bone spurs can rub on the tendon directly and eventually cause a tear. This type of injury is more common in people middle aged and up or with younger athletes who have some predisposing factors that narrow the tunnel. Other causes of rotator cuff tear are more indirect in nature. Repetitive stress and increased age increase the risk of degeneration of the tendon. Also instability of the ball and socket joint places increased stress on the rotator cuff muscles. This instability can be caused by injury to the labrum and ligaments of the joint or by weakness in the cuff itself that allows subtle instability and increases the tensile forces placed on the weakened muscle.
In hockey, the causes are the same, however, the stresses are different than in overhead sports and that reduces the amount of injuries we see from the sport directly. Weight lifting and shooting along with the trauma of hitting can still lead to injury through one of the previously discussed mechanisms. For the recreational player the demands are a little different than elite players as your job, age, or other sporting activities may be a primary player in what has led to an acute or repetitive stress injury.
The biggest thing is to see a qualified sports medicine physician if you are experiencing pain and/or loss of function. They can determine the severity and best course of treatment once a firm diagnosis is reached. There are three basic assessments of a rotator cuff tear, a partial, full, or avulsion tear of the tendon or tendons. Also worth discussing is why the tendon was damaged in the first place. Are there underlying factors such as muscle imbalance, joint instability, or spurring in the subacromial joint that have contributed to the tear. Once all the information is known a comprehensive plan can be put in place to deal with the injury. MRI imaging can help with the diagnosis when combined with a quality physical exam. This may not be necessary though especially if you are going to pursue conservative treatment. Your physician will be able to make the determination after examining the injury.
Partial tears are often treated conservatively. This would include activity modification, anti-inflammatory medications, and rehabilitative exercise. If Full thickness tears, spurring, or avulsion tears are present surgery comes into play more often. Subacromial decompression is done to create more space in the tunnel and remove the bone spurs and inflamed bursa that restrict normal tendon glide. If conservative treatment has failed then surgical treatment is and option to reattach the tendon and potentially address any instability issues. Surgical techniques vary and depend on the type of tear and the preference of the surgeon based on his/her experience and the latest research.
Recovery from a rotator cuff tear has no specific time frame when treated conservatively however normal tissue repair takes four to six weeks depending on the type of tear. It is progressed on a pain and functional basis not set parameter of time like surgical repairs. When surgery is necessary the time frame can vary depending on what was done to fix the problem. Subacromial decompression by itself takes a little less time but most repairs involving tendon or instability repairs will take months, usually 4-6, to return to normal activity. The rehabe progression typically involves immobilization followed by a return to range of motion followed by a return to strengthening exercises. This usually happens in six week increments and will be aided by an athletic trainer or physical therapist. Once you have healed sufficiently and are strong enough, your PT or ATC will begin some sport or activity specific exercises with you. Once you have meet the requirements physically of your sport or job you will be allowed to return to full activity.
I hope that helps Joel and thank you for your question. If you are suffering from this injury and require more information or an individual exam please do not hesitate to come see us at our office in Renton or Covington.
Phillip Varney, MA, ATC, AT/L
Dr. Michal Allison, MD, MPH