Rotator cuff injuries

How it began tells us a lot. A fall on skis or a bike points one way; pain that crept in over seasons of overhead work, paddling or climbing points another.

Then we examine the shoulder: its range on its own and when we move it for you, and each cuff tendon under a strength test. We watch the shoulder blade, because a blade that moves poorly crowds the tendons under the bony roof of the shoulder (the acromion). We also check your neck, since a stiff neck or an irritated nerve can send pain and weakness into the shoulder.

The pattern points to the cause. A pinch at one height as the arm lifts, easing above it, suggests the tendon catching (impingement). A sore tendon that still tests strong suggests tendon pain without a tear; clear weakness, especially after a fall, suggests a tear. If we suspect a full tear, we say so. A doctor or nurse practitioner can then order a scan and refer you to a surgeon if needed.

Exercise is the main treatment for most rotator cuff problems, including many tears, and it builds in stages:

• Settle it: we ease off what flares the pain, such as reaching overhead, heavy carrying and sleeping on that side, without resting the arm completely.
• Load the tendons: a tendon gets stronger when it is worked a little harder than usual. We start light, for the cuff and the shoulder blade muscles, and add load a little at a time. Each step should make the pain no more than a little worse.
• Hands-on treatment: joint and soft-tissue mobilization can free up a stiff, sore shoulder so the exercises work better. See manual therapy.
• Shockwave therapy: one option for a tendon that has stayed sore a long while, including calcium deposits in it (calcific tendinitis). We use shockwave therapy alongside the exercises.
• Strength and conditioning: once the shoulder moves well, strength and conditioning builds the strength to push, pull, lift overhead and catch a fall.

If you are having a repair

Rehab follows your surgeon's protocol: a sling and protected movement first, then range of movement, then strength, with the surgeon's timing counting alongside testing.

Testing decides when you go back, not a date on the calendar. We compare strength, range and control with your other shoulder, in the positions your sport uses.

Before that, we train the shoulder for its job. On a snowboard, every fall ends with a push up off the snow, a sudden load through the cuff with the arm out wide. Biking means bracing through the bars on rough trail and, in a crash, landing on the arm. Paddling and climbing load the cuff overhead, stroke after stroke and move after move.

Book an assessment if shoulder pain is stopping you lifting, reaching or sleeping, or if the arm has been weak since a fall. Tendon pain that has hung around all season and is holding back work, study and sport belongs here too. Book before a repair, and after one when your surgeon says physiotherapy can start.

Go to the emergency department right away, or call 911, if any of these happen:

• the shoulder looks out of shape
• you cannot move the arm at all after a fall
• the arm or hand is numb, cold or pale
• a hot, red, swollen shoulder with a fever
• chest pain or pressure, shortness of breath, or pain spreading into the jaw