The shoulder joint is the most mobile joint in the human body. It allows us to raise our hand, place it behind our back, and reach the back of our head. It is believed that it was thanks to work and his hands that a person became a person, but it would not be an exaggeration to say that the entire variety of functions of the human hand is based precisely on the amazing mobility of the shoulder joint. Movements in the shoulder joint are carried out in all three planes, but for an increase in the range of movements in the joint we have to pay for a decrease in its stability and a high risk of damage to its structures, which include the rotator cuff.
rotator cuff
Rotator Cuff
The shoulder joint is round in shape, allowing for a high range of motion, but at the same time reducing stability. The rotator cuff is responsible for ensuring sufficient strength and stability of the shoulder. It is represented by components that increase the depth of the glenoid cavity. These include the cartilaginous lip, localized along the edges of the cavity, the rotator cuff, supraspinatus, infraspinatus and subscapularis muscles and the corresponding tendons attached to the lesser and greater tuberosity of the humerus. Additional strengthening is provided by the connective tissue capsule, which is a system of ligaments.
Injuries in CrossFit[edit | edit code]
Source: “Cross-training”
Author:
instructor O.B.
Derval, 2021 Rotator Cuff Muscles, Front View
The rotator cuff, or rotator cuff, is put to the ultimate test in CrossFit exercises. Accidental injury can also occur due to an accident, but more often it occurs during the repetition of an incorrect movement, placing the shoulder in a situation of constant conflict. This is what causes inflammation. When the glenoid socket (the glenoid socket of the shoulder), poorly “fitted,” or scientifically, little congruent, is subjected to inappropriate shoulder movement, decentration or lateral displacement of the humeral head can occur. This is what we call "shoulder conflict"
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Rotator Cuff Muscles, Posterior View
The more severe these conflicts are, or the more frequently they occur, the more the rotator cuff muscles are at risk of inflammation.
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Indeed, it is between the coraco-acromial arch and the head of the humerus that the tendons of the rotator cuff muscles pass. And at some point they may become “pinched” between the head of the humerus and the coraco-acromial arch. The coracoacromial arch consists of the acromion, acromioclavicular joint, coracoid process and coracoacromial ligament, the rotator cuff, in turn, consists of 5 muscles: supraspinatus and infraspinatus, teres minor, subscapularis and biceps longus
In practice, shoulder conflicts occur at the end of the movement
, and they are so painful that they interfere with the normal performance of sports movements. They occur due to strenuous and repetitive use of the joint, which, due to biomechanical misalignment, creates friction or displacement of the bone and one or more tendons, or bursae, large amounts of regularly performed strength exercises expose the athlete to the risk of “shoulder conflicts” and are thus , potentially hazardous. Without pretending to cover the issue completely, we will present you here with the most classic cases.
Swing dumbbells to the sides
“First of all, dynamic swings with dumbbells (or with an elastic band) in a standing position are aimed at strengthening the middle deltoid muscle. Most beginners make this technical error spontaneously - and if not corrected, it will inevitably lead to injury. When performed correctly, the final phase of the movement will be the raising of the tip of the elbow to shoulder level. It is the elbow, not the wrist, that will determine the angle and elevation of the arm, assisting in internal rotation of the arm and activation of the trapezius muscle.
High traction
Another example where the shoulder is at risk of conflict in the anterior upper region is the high row often used in “vertical rowing,” or the technical and semi-technical movements of the barbell clean. This very serious mistake can increasingly be observed during cross-training workouts - either during barbell cleans or dynamic vertical rows with a barbell or kettlebell. This error is unacceptable and must always be corrected.
Bench press
And finally, work on the pectoralis major muscle, especially during the most “star” movement in the training halls for bodybuilders - the bench press. Whether performed with dumbbells, kettlebells, or a regular barbell, if performed incorrectly, the stability of the humeral head can be compromised. Very often, diligent practitioners prefer working on a wide bench (since it is more stable) and a wide grip
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The verticality of the load presses the shoulder blades into the bench, while the contraction of the pectoralis major muscle, which causes the head of the humerus to slide forward from the glenoid cavity of the scapula, requires precisely the mobility of the latter. The consequence of this may be anterior decentration of the joint - the cause of the classic lobes in the anterior inner part of the shoulder.
In this case, mastery of the fundamental technical fundamentals of the bench press, coupled with some preventive measures at the equipment level, is also well beyond the scope of this note. But the correct choice of a thin bench and a narrow (called “anatomical”) grip on the barbell, even at the expense of heavy weights, are the first and easiest solutions to make this movement anatomically more comfortable
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When working with dumbbells, you can limit the range of motion, which will cause contraction of the pectoral muscle, and therefore reduce the risk of anterior decentration.
Inflammatory processes in the shoulder, if not taken seriously, can gradually spread to all its muscles
Remember that the shoulder has very multi-directional mobility. This mobility comes at the expense of stability and endurance. Indeed, the humerus fits into the shoulder capsule like a bullet into a hole. There it is held only by a complex and fragile system of muscles and tendons. As long as this system remains strong and responsive, the shoulder is protected.
Most injuries occur during movements that require and fatigue the deltoid muscle.
, forcing the rotator cuff muscles and tendons to exert a level of force beyond their capabilities.
The first risk is chronic inflammation leading to rotator cuff tendinitis. But shoulder fatigue, if not taken seriously, can even lead to severe dislocations. The load on this fragile joint - both in terms of weight and number of repetitions - must be measured with infinite care. Doing the very long series of cleans that some TDs are so fond of directly leads to oversaturation of the shoulder muscles and tendons, depriving the joint of any control and exposing cross-training to the risk of injury. The classic example of a clean is when the supraspinatus muscle is compressed between the humerus and the osteoligamentous vault of the shoulder formed by the inferior surface of the acromion and the coracoacromial ligament; inflammation usually begins in the bursa, which is supposed to protect the supraspinatus muscles from too much friction. It continues with inflammation of first the supraspinatus and then the infraspinatus muscles, the biceps brachii muscle - and, ultimately, the entire rotator cuff, which also becomes inflamed. And then the simplest raising of the shoulder becomes unbearable. Repeatedly moving through the pain can cause calcification or tears, causing permanent damage to the shoulder. In any case, remember that pain is unacceptable
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- Limitation of movement associated with muscle tension should alert you from the very beginning of training and force you to stretch, and if there is no improvement, change the program;
- Restriction in movement associated with new pain should cause you to change your program immediately; cross-training has plenty of exercise options that won't cause harm. Or at least try to find a more comfortable angle until the inflammation calms down;
- An injury sustained during training should make you wonder: what did you do wrong and what should you change to prevent it from happening again?
- Long series are not suitable for complex movements, since motor skills are impaired by fatigue. Therefore, reserve complex movements for short series, and movements involving simpler technique for long ones.
Keep in mind that there are joints - such as the shoulder - which, due to their fragility, are in no way suitable for long series
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Etiological factors
Damage to the rotator cuff can occur due to a wide variety of causes, the most common of which are:
- Injury due to external force - injury often occurs when falling on an outstretched arm or bruising the shoulder area. Often such injuries are accompanied by a dislocation or subluxation of the shoulder.
- A long-term inflammatory process of soft tissues, the cause of which is an infection or autoimmune pathology (a disease accompanied by a pronounced impairment of the functional state of the immune system and the synthesis of antibodies to the tissues of the musculoskeletal system structures).
- Degenerative-dystrophic conditions, characterized by a gradual deterioration in the nutrition of connective and cartilaginous tissue with subsequent destruction of structures. They are of age-related origin, and are also often the result of systematic increased loads on the shoulder (work with the arm up for a long time).
- Congenital pathology with weakening of the connective tissue components of the shoulder or a change in their anatomical relationship to each other.
Clarification of etiological factors is necessary to prescribe adequate treatment, rehabilitation and prevention.
Internal rotation
Stand with your developing hand facing the door. Attach the end of the expander to the door at waist level, take the other end of the expander with your working hand and bend it at the elbow 90 degrees. Keeping your elbow tucked in, rotate your forearm away from the door toward your body and then slowly return to the starting position. It is important to keep your forearm parallel to the floor. 2 sets of 8 to 12 reps.
signs
signs
The division of damage into certain types is carried out according to several criteria. Depending on the main etiological factor, the following are distinguished:
- Traumatic changes, often resulting in damage to the rotator cuff of the right shoulder joint.
- Inflammatory changes.
- Degenerative processes.
Depending on the severity of tissue changes, damage can be combined with complete or partial dislocation. The classification also includes the division of changes by duration; they include acute and chronic damage to the cuff. Of all types, injury to the rotator cuff tendon is the most common.
Why does this muscle group often get damaged?
There are several causes of frequent damage:
- Damage to tendons due to injuries (complete or partial)
- Microtraumas during sports.
- Degenerative changes in tendons due to age-related changes.
- Poor blood supply: These muscles have few blood vessels.
- Congenital disorder of connective tissue development.
- Features of the anatomy of the scapula: in some people, its protruding processes injure the muscles surrounding the shoulder joint.
- Constant movements of large amplitude. This reason plays a particularly important role in athletes and people engaged in heavy physical labor.
- Some occupational hazards, taking a number of medications, including some antibiotics.
- Local administration of glucocorticosteroids
As a result of the action of various factors, degenerative changes occur in the muscles and their tendons. As a result, they gradually become thinner, lose strength, and eventually rupture.
Signs
Certain clinical signs suggest a rotator cuff injury. Symptoms include pain in the shoulder area, the intensity of which depends on the extent of the changes. It usually gets worse when trying to move, especially when raising the arm up.
Damage to the structures is often accompanied by instability of the joint with an excessive increase in the range of motion in it, as well as periodic protrusion of the head of the humerus. Significant changes are accompanied by the development of inflammation syndrome with skin redness, tissue swelling, and a local increase in temperature in the shoulder area.
Rehabilitation
Recovery of the rotator cuff after treatment can take six months if there are no complications. Experts recommend starting movements in the shoulder joint as soon as possible after surgery, but not overdoing it (regeneration and fusion occur). For 3-4 weeks after surgery, a shoulder brace is required, as well as physical therapy and cold application.
The joint capsule should be developed slowly using passive movements (preferably under the guidance of a specialist). You can develop muscles with active movements only after a month and a half (the set of exercises is selected by the attending physician).
Diagnostics
Based on all the identified clinical signs, the orthopedic traumatologist can only make a preliminary conclusion. Reliable determination of the severity of changes is carried out using a special study, which includes various techniques for visualizing structures.
The most widely used in modern institutions are X-ray examination methods, tomography, ultrasound examination of the joint, and arthroscopy. Using arthroscopy, the doctor can also perform therapeutic procedures.
Causes of damage
Compared to other organs and tissues of the human body, tendons are less well supplied with blood. This feature often leads to the development of dystrophic disorders of the rotator cuff. This condition is called tendinopathy. Genetic disorders in connective tissue, that is, collagen, also play a negative role. This is a protein that includes 4 types. It is with a relatively high content of connective tissue types 3 and 4 that the likelihood of developing tendinopathy increases.
This pathological condition can begin in any tendon or even in several, but the supraspinatus muscle tissue is more often affected than others. According to the affected area, pain occurs during movements of the affected element of the shoulder joint. If the supraspinatus muscle is damaged, then pain will appear during abduction of the limb to the side, if the subscapularis muscle, then symptoms will appear during movements that accompany, for example, combing hair, eating with cutlery.
Tendopathies are often identified with glenohumeral periarthritis. But this diagnosis is irrelevant in modern medicine, and doctors have abandoned its use.
The group of tendinopathy also includes ruptures of the rotator cuff tendons. Most often they are promoted by chronic microtraumatization. The reasons for this phenomenon in young and elderly people differ:
- At a young age, it is associated with a high hand position or movement during the throw. People of certain professions are susceptible to tendon microtrauma. This affects athletes involved in baseball, volleyball, tennis, and powerlifting. Persistent damage to the rotator cuff tendons, particularly the supraspinatus muscle, during hitting, serving and throwing results in microscopic tears in the tendon fibers and the muscles become thinner. Subsequently, even with minimal impact on the cuff, it can easily tear. In addition to athletes, similar muscle strain is experienced by people in professions such as teachers, blackboard writers, and many others.
- In the elderly, degenerative-dystrophic processes in the tendons, which manifest themselves in connection with the aging of the body, contribute to the development of tendinopathy. The likelihood of a rotator cuff tear is quite high.
We must not forget about the violation of the integrity of muscles and tendons under strong influence of a traumatic agent. Often, a rotator cuff tear accompanies humerus fractures and joint dislocations. That is, such damage is quite possible to obtain without previous microtraumatization of tissues.
Therapy
Treatment of injuries is necessarily comprehensive. After the examination, the medical specialist individually prescribes conservative tactics or surgery for each patient. If there is a slight injury to the rotator cuff of the left shoulder joint, non-surgical treatment is prescribed. It involves the use of medications (chondroprotectors, anti-inflammatory drugs, vitamins), as well as physiotherapeutic procedures.
Surgical manipulations are justified in case of pronounced changes that require plastic surgery. Today it is possible to reduce tissue trauma and the duration of the postoperative period by performing arthroscopic surgery.
Clinical picture
It is important to note that bladder ruptures or injuries are not always associated with pain or loss of function for the patient. In addition, there is an observation that asymptomatic patients may develop symptoms within a relatively short period of time.
The most common signs of rotator cuff injuries are:
- Pain (may or may not be present). May be localized to the anterior/lateral aspect of the shoulder, radiating down the side of the arm.
- Painful movements: Painful arc (degrees vary - usually above shoulder girdle).
- Painful external/internal rotation/abduction.
These signs are caused primarily by loss of shoulder stability due to rotator cuff dysfunction.
Treatment
There are 2 types of rotator cuff repair: conservative and operative. The first option is acceptable in the case of incomplete ruptures, when there is a real possibility of recovery without surgery.
Conservative treatment
This recovery method includes immobilization of the shoulder joint, that is, rest and complete immobility using a special bandage. In addition, a wide range of anti-inflammatory and analgesic drugs are used. For severe pain, blockades with glucocorticosteroids are used. After a certain period of time, special exercises and physical procedures are prescribed. If there is no effect over a long period of time (3 months), treatment by surgery is indicated.
Surgical treatment
Which surgical option will be used depends on the size, shape and location of the damage. The options are:
- For a partial tear, the best choice is trimming or straightening, this is called debridement.
- In case of a complete rupture, suturing the parts of the torn tendon is effective.
For such operations, several types of access are used - arthroscopic, mini-access, open surgery. During arthroscopy, special video equipment is used, which is inserted into small punctures without making large incisions. The images are displayed on the monitor screen. Mini-accesses are also small-scale operations. In this case, to treat the rotator cuff, a small incision is made, 4 to 6 cm wide. Traditional open access is necessary for severe, extensive and complex injuries. If this does not give effect, you have to resort to prosthetics.
Rehabilitation
To restore the rotator cuff after surgery, the limb is immobilized using a splint. This allows the tendons to heal and prevents re-rupture. The length of time for which the splint is indicated is determined by the doctor. He performs periodic examinations to assess the condition after surgery. Typically, the wearing time for the splint is about 3-5 weeks.
After immobilization, special exercises must be used to better restore limb function. Their frequency, order and intensity are determined by the doctor.
Arthroscopy, repair of the rotator cuff tendons
Symptoms of a cuff injury
Pain is the main symptom of a rotator cuff injury.
The syndrome intensifies when changing certain positions of the hand, which may indicate the location of the damage. Weakness in the arm is common in such a situation, to the extreme, when movements are impossible and are expressed by a barely noticeable trembling of the limb when trying to lift. The extent of the injury directly affects the intensity of the pain. The most common reference to pain refers to a tear of the supraspinatus muscle, which is characterized by the inability to abduct the limb to the side.
Clinical symptoms appear either immediately after the rupture, or gradually in the case of microtrauma, if the person continues to perform systematic actions with the injured hand.
Rehabilitation period
This recovery time at rest is necessary only after surgery. The limb is completely immobilized using a splint, which makes it possible to heal the damaged elements faster and as correctly as possible. The duration of rehabilitation depends on the individual characteristics of the patient’s body, the nature of the injury, as well as the method by which the surgical intervention took place. On average it lasts from 3 to 5 weeks.
Then additional gymnastics are prescribed to restore painless operation of the joint and cuff.