A Rotator cuff tear is one of the most feared injuries but shouldn’t be. Here’s what you need to know about rotator cuff tears to get them stronger, faster.
Just how common are they?
A rotator cuff tear is present in over 20% of the population, but don’t let that number fool you because not 1 in 5 of us actually have painful rotator cuffs. This is because, just like you can and probably do have joint degeneration in your knee that gives you no pain at all, you can have rotator cuff tears that are pain-free (asymptomatic).
So the real number you should be interested in is the number of symptomatic tears; 35% of rotator cuff tears on radiology are symptomatic, which is still very common!(1)
What is the rotator cuff?
Put simply, it is a group of muscles which come from the front, back and top of your shoulder-blade and wraps around that ball and socket of your shoulder. Their job is to coordinate between themselves to help keep the ball positioned nicely in the socket while you move your arm.
Rotator cuff tears often happen in the tendon, close to the shoulder joint.
Does a rotator cuff tear need surgery?
Really, it is case by case but most rotator cuff injuries do not need surgery.
As a good guideline, with all rotator cuff tears, it is best to trial 12 weeks of conservative rehab and if that has not much improved the injury, then you look at seeing the surgeon.
A recent study actually showed that there was no difference between surgery and active physiotherapy at 1-year follow-up(2)
Physio Rehab exercises for a rotator cuff tear needs to cover three things:
Regaining range of motion and muscle activation
Regaining full control and function
We are going to cover these stages in three posts and here is Stage 1, which starts after 3-4 days of rest, or more if needed:
Stage 1: Regaining range and muscle activation
1. Pendular circles
2. Regular movement
Using a broomstick or a pulley, this is a great active-assisted exercise for regaining movement and stopping the shoulder stiffening up.
Hold onto the end of the stick with your injured side and help lift it up with the other hand.
Repeat this 20 times 5 times per day without pushing into pain.
3. Rotator cuff activation
These exercises activate the rotator cuff in a safe way by doing gentle wall pushes. It is essential to load the rotator cuff in a safe way and gently to encourage strong healing and minimizes scar tissue formation.
Read for Stage 2 rotator cuff rehab? Follow this link to the next post in the series.
Trochanteric bursitis is a an all too common cause of hip pain throughout the population, from athletes to the elderly. In this post I will clearly explain, what trochanteric bursitis is, what causes it, and what the best rehabilitation exercises and self-treatment techniques that can be done at home to help you get back to your best!
Also often called: Greater trochanteric bursitis, trochanteric pain syndrome
Anatomical location/body part affected: Trochanteric bursa lies over the greater trochanter of the femur, deep to the tensor fascia lata-iliotibial band (ITB) and the attachment of the gluteus medius/minimus muscles.
Where is the bursa and what does it do: The bursa lies over your greater trochanter which is the bone you can feel on the outside of your upper thigh (right behind your side pocket). All bursa in your body (there are about 160 of them!) work to help all the structures in your body move smoothly. The bursa is like a small balloon of fluid – normally a very thinly filled one – and in this case it lies over the greater trochanter so your iliotibial band (as seen in the picture to the right) can glide over the bone smoothly.
What is the cause of trochanteric bursitis?
The two main causes are:
The most common cause is repetitive friction or compression of the bursa by the structures/tissue that glide over it. This is what I am going to tell you about in more detail below as there are some main contributing factors that lead to the excessive friction and compression on the bursa which have to be addressed to get long term results.
The other is direct trauma such as a fall on to you hip.
Both of these cause the inflammation within the bursa so that if is blown up by the inflammatory fluid like a balloon and the walls of the bursa thicken.
Contributing factors (lets find the real reason you get bursitis!): The simple mechanism of injury in cases without direct trauma is excessive friction/compression of overlying tissues on the trochanteric bursa. What leads to this excessive friction/compression is the important thing – if we find this, we can treat this very well!
Osteoarthritis – of the hip or low back
Tightness of the ITB – The iliotibial band crosses over the bursa, so if this is tight it will cause excessive compression and friction.
Leg length discrepancy – Causing a muscle imbalance and glute dysfunction in the pelvis.
Weak hip abductors (glutes medius and gluteus minimus) – These are the muscles that stop your leg going inwards while walking and stop your hip dropping – so if these are weak you will have poor hip stability and biomechanics – putting more pressure on the bursa.
Tight or over active and tensor fascia latae – This muscle attaches on to the iliotibial band and so if this is working too hard (such as when your hip abductors are weak) it causes tension on the ITB.
Higher prevalence in women than men; 4 times more likely! This is due to decreased oestrogen post-menopause decreasing muscle tone and also broader hips and a narrow stance in women.
How do you know if it is trochanteric bursitis and what else could it be:
Presentation/signs and symptoms
The main complaint is aching in the upper lateral(outside) thigh. If acute/quick onset, pain can be sharp and intense. However, pain in chronic hip bursitis is usually dull and diffuse and may radiate down to or below the knee, mimicking low back radicular symptoms.
There is tenderness with direct pressure, such as when lying on the affected hip. Pain can disturb sleep and general mobility(walking). Painful activities include prolonged standing, squatting, and the first steps after rising from a chair. Pain increases with hip flexion and external rotation – as in crossing affected leg over the other while sitting. The main and most accurate test during physical exam is intense or sharp tenderness on deep palpation of the greater trochanter.
Lateral hip pain is far too often diagnosed as trochanteric bursitis, even if there is no bursal inflammation. The primary (most common) cause of lateral hip pain is tendinopathy or dysfunction of the Gluteus Medius and Gluteus Minimus muscles(you can see in the image to the right that they attach straight onto the Greater Trochanter). In a new study where over 800 patients with trochanteric pain syndrome were scanned, 50% had gluteal tendinopathy and just 20% had trochanteric bursitis. So given that often gluteal tendinopathy is the primary cause of lateral hip pain it is important for long-term pain relief, rehabilitation exercises and correction of any biomechanical deficiencies (muscle imbalance, leg length discrepancy, poor foot mechanics etc) are followed through with and addressed.
So, because lateral hip pain can be caused by both trochanteric bursitis and tendinopathy – the following rehabilitation exercises and self-treatment will help both of these!
1. Glute strengthening:
Side lying hip abduction: Making sure to keep your top elbow down to stop your hips rolling back.
3 sets of 12 repetitions
Clams: Top elbow down again, keep your ankles together, lift the top knee up about 20cm.
If you find it is too easy, roll your pelvis forward more.
If it hurts your hip then place a towel or small pillow between your knees
Your Goal is 50 repetitions, nice and slow
2. Advanced hip strengthening: This is for really getting the hips strong and balanced out and best to start when you are recovering well and pain free.
Bulgarian split squat: Don’t get scared off by the name – you can do this! Just remember the back leg is just for balance – not to help you up and down.
Tips: Make the front leg work. Start a good distance out from the step/chair. Take it slowly and control it.
3 sets of 8 repetitions.
3. Myofascial release of your tight TFL (tensor fascia latae muscle)
It is a great to loosen off this muscle as it can really add compression over the bursa. The TFL is, as you can see the image below a little muscle at the side of your hip. to find it, place your fingers on your ASIS which are the bones on either side of your pelvis at the front. From the side of these, drop down a couple of inches and you should be right on it!
Lie on your side and place a ball under your TFL – you can use any ball you like, massage ball, lacrosse ball, tennis or golf ball. Then slowly roll the ball around that area, working out all the knots and tight spots – this can take 2-5 minutes but is well worth your time!
And remember, a bit of trigger point pain is expected here.
You can also check out this mobility WOD video – The main bit I want you to do is the ball work from about 3 mins and 36 seconds. This is a great release to do and will give your awesome relief!
4. Footwear: Supportive footwear (with arch and heel support) is a huge plus – it stops your foot over pronating or supinating which would put your hip in a bad position (try standing in bare feet and rolling your feet in and out and notice what it does to your hip position). Alternatively you can go to the podiatrist and see if you need orthotics.
Maintenance and prevention – This is big, you cannot stop the exercises once the pain has gone – you can do them less, absolutely, but you need to persevere.
Steroid injections: If you get one for your bursitis, remember it takes away the inflammation but it does not fix out the things that caused it (such as hip stability) and there is a high chance it will come back if you don’t rehab it. Also it is important to get a clear diagnosis before injection as cortisone is basically poison for tendons (and remember only 20% of lateral hip pain is actually Bursitis – a lot more are tendinopathies).
Back pain? Low Back Pain and dysfunction can have a big impact and even cause lateral hip pain so make sure you address this also.
For more reading on lateral hip pain – This is a good resource.
Why does your shoulder pain not get better or keep coming back?? Scapula stability and control is often overlooked yet it is absolutely necessary for good shoulder function. Here we will increase shoulder girdle strength, stability and control to get rid of and minimise the chances of:
Rotator cuff impingement
Neck pain and Headaches
And much more
Scapula Dyskinesia is a very very common response to shoulder pain and leads to ongoing, prolonged and frustrating shoulder pain. This is basically abnormal movement of your shoulder-blade. For more detail: Skapula dyskineia
Normal shoulder movement, strength, control and performance is fully dependent on the scapula – and not just movement but it’s stability as well. The scapula is the base that your arm works off and if you don’t have a stable base, you will be much more likely to have shoulder and neck pain – It would be like trying to walk in an earthquake!
Normally when you lift your arm, your shoulder blade rotates upwards as seen in the picture below. If your shoulder-blade doesn’t rotate – your shoulder gets jammed against it, leading to pain and tightness.
So given that Scapula Dyskinesia occurs in 68-100% of shoulder injuries, this is something that needs to be addressed in EVERY PERSON WITH SHOULDER PAIN. So below is your exercise regime to address this yourself at home or the gym.
1. Push-up Plus:
keeping your body and arms straight, push your shoulders forward(body upwards and then control your shoulders back to the starting position).
Too easy? do a push up and add the press at the top of each push-up (this is the plus!)
2×12 reps (to start with!)and start on your knees if you need to.
2. Shoulder external rotation:
Remember to always keep your elbow into your side and at 90degress.
You can also do theses in side lying with a 1-2kg dumbell in your upper hand.
2 x 12reps, increase the stretch to progress.
3. Chariot Pull:
Keeping your arms straight and shoulder back and down, take your arms back untill they are level with your body.
2 x 12reps, increase the stretch to progress.
4. Thoracic Mobility: I have included this as if you have a stiff spine, your shoulder blades are always going to be in a bad position, so it is important to address this so that you don’t get stuck at 95%!
Using either a full or preferably 1.2 foam roller (high density!) lie on it, placed below your shoulder blades as shown, bridge up and extend your arms overhead and then elbows down to your sides.
Tip: Keep your head up and chin tucked in.
spend 1-2minutes working on your spine.
Do these exercises two times daily (Ideally!) for 6 weeks for awesome shoulder stability and a pain-free shoulder.