Question
Dear doctor:
An injury occured on my left rotator cuff a couple years ago when im out on the driving range hitting golf balls. I hit a lot of balls on that day and it was right after a heavy weight lifting workout. The next day i cant lift my arm and felt pain right in the armpit area. After 3 years the pain would come back when im careless and hit too many balls or swing the club too hard.

I try to do strength training 3 session a week but everytime i finished the 2nd day, the rotator cuff and lat muscle would not heal fast enough for the final day workout because of soreness, and i would wait a few more days and sometimes weeks for the soreness to completely go away. The more i procrastinate on working out the weaker the muscle get and the weaker the muscle the more prone for injury. Its just a never ending process for me this past few years.

Any suggestions?  
Thank you

Answer
Hi Will and thanks for writing,

Rotator cuff injuries in sports are usually a result of microtrauma from repetitive movements. Classic, or primary, impingement results directly from overhead motions, and secondary impingement is related to underlying shoulder instability. A variety of physical maneuvers are used to assess pain, muscle weakness, and shoulder stability. The workup also includes plain x-rays, supplemented by other imaging tests if a cuff tear is suspected. Nonoperative treatment, which may include steroid injections, is often effective for an inflamed rotator cuff tendon. Surgery is indicated if the patient has no improvement after at least 6 weeks of physical therapy.

For competitive or recreational athletes involved in baseball, tennis, or swimming, shoulder disorders--especially rotator cuff injuries--can be debilitating. Though medical understanding of rotator cuff injuries has improved greatly, successful diagnosis and treatment of patients still depend on understanding the mechanisms of injury and ruling out shoulder instability, particularly in athletes who use overhead motions. The keys to success include tailoring the treatment to the diagnosis and prescribing appropriate rehabilitation programs, either alone or in combination with surgery.

Several different mechanisms of rotator cuff injury are presently recognized. These can be divided into acute traumatic injuries (macrotrauma) and the more common repetitive overuse injuries (microtrauma) seen in overhead activities.

Acute macrotraumatic rotator cuff injury, although uncommon, can result in partial- and full-thickness tears from a direct contact injury to the shoulder in patients under 40 years old (8). In addition, partial and complete tears of the rotator cuff can occur with traumatic anterior instability of the glenohumeral joint in the over-40 population; rupture of the subscapularis should especially be considered among these patients (9).

Four microtraumatic mechanisms of rotator cuff injury have been described, and several may occur simultaneously in the same patient.

Nonoperative management is often effective for treating acute and chronic inflammation of the rotator cuff, and a supervised program of physical therapy is the mainstay. The first phase of therapy aims to reduce rotator cuff inflammation and improve range of motion. Rest from the inciting activity is often accompanied by cryotherapy and short-term nonsteroidal anti-inflammatory drugs, if not contraindicated. The glenohumeral joint is mobilized with passive and active assisted range of motion; the arc of motion should be increased as pain permits. Overhead athletes commonly have limited internal rotation (and therefore a tight posterior capsule) and increased external rotation. However, a tight posterior capsule may aggravate impingement because it forces the humeral head against the anteroinferior acromion as the shoulder is forward flexed (5). Therefore, local heat or ultrasound followed by gentle stretching of the posterior capsule in cross-body adduction and internal rotation can be helpful.

Surgical treatment of chronic inflammation of the rotator cuff is indicated only if the patient fails to progress after a minimum of 6 weeks of supervised physical therapy (5). Individuals with a flat acromion (type I), demonstrated on a scapular Y view, are likely to have secondary impingement, and the underlying instability will need to be addressed. Those with a type II (curved) or type III (hooked) acromion may undergo subacromial decompression whereby the anterior inferior acromion is resected, converting it to type I. This is also referred to as an anterior acromioplasty. Subacromial decompression can be performed through open or arthroscopic approaches. Arthroscopic subacromial decompression has an overall patient satisfaction rate of 92% (20). The only disadvantage of the arthroscopic technique is its technical difficulty.

Coaches and athletic trainers can help develop and carry out sound programs for preventing rotator cuff injuries. Preseason conditioning should address the flexibility, strength, and endurance of the shoulder muscles, particularly the scapular stabilizers and external rotators of the rotator cuff. The conditioning program must be tailored to the sport and fitness level of the athletes. Learning the correct mechanics of the sport and choosing proper equipment are also important. In-season training must be adjusted to avoid overuse injuries, and a proper warm-up and cool-down period should be routine with practice or competition. Such measures will not only help prevent injury, but will also make athletes more successful.

Hope this helps,

Margot