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Tag Archives: Rotator Cuff

David Wright: Lesson Learned?

David Wright and the Mets got some very good news when the right-handed third baseman’s MRI was negative for structural damage in his left shoulder and revealed only bruising of the rotator cuff (view image). Wright was reexamined on Monday after sitting out the weekend, and the plan now calls for him to rest until rejoining the team on Friday.

Manager Terry Collins had previously been quoted as saying it didn’t appear to be a DL situation. Prior to his MRI, Wright reportedly said that though the shoulder had been problematic for the previous three weeks, “We’ll follow the protocol like normal…and hopefully it would just be some rest and an injection. Hopefully I’ll be back in a couple days.”

Evidently Wright, who pushed through his symptoms since incurring the injury in a slide on an attempted stolen base, didn’t quite learn the lesson his stubborn hamstring should have taught him last season. It was only after tweaking the shoulder further on June 26th that Wright was shut down. He might have ensured a faster recovery and avoided exacerbation of the injury had he rested and received treatment at the outset. But Wright did what most athletes seem to do, regardless of how counterproductive that might be.

A bruise, if that’s all it is, will heal without significant intervention but has to be allowed to do so. Wright had hoped an injection would take care of the matter, but learned yesterday that it wasn’t called for.

Though cortisone can be an effective tool when used appropriately, it doesn’t work miracles and in most cases isn’t the best first line treatment. This is especially so when there is an underlying pathology or causative structural or functional factors that must be addressed to prevent recurrence.  Sometimes though, an injection is an effective adjunct for controlling inflammation so that a more comprehensive treatment program can be progressed. With bruising, which results from direct trauma to the tissue, the antidote is rest.

Without benefit of more detailed information specific to Wright’s condition, one can only speculate. However It doesn’t seem prudent for him to rush back, especially without time to first see how his shoulder responds to ramping up his activity. With the All Star Break less than two weeks off, it would seem that would be a better time to reassess Wright’s progress. After all, the Mets aren’t in a playoff race…

Keep in mind too that MRIs are not 100% definitive. Hopefully Wright’s is accurate, however there is no guarantee. It is only after his shoulder successfully rebounds from this injury that discussion of any contributing pathology will be fully laid to rest.

Follow Abby Sims on Twitter @abcsims.

Understanding Michael Pineda’s Teres Major Strain

The plan was for Michael Pineda to stay on schedule by pitching simulated games in Tampa while serving a ten-day suspension for having pine tar on his neck. However, instead of missing one or two starts, he’ll reportedly be out three to four weeks with what was diagnosed on MRI as a Grade 1 strain of the teres major.

The good news is it is a Grade 1, which means there is no significant disruption of the

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involved tissue (Grade 2 involves some degree of tearing, while Grade 3 is a complete rupture). The bad news is that inflammation still has to resolve, the injury demands some rest, and rest results in deconditioning. The teres muscle – as

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well as the entire shoulder girdle – then requires strengthening to avoid overuse from the demands of pitching.

So what is the teres major muscle?

The teres major originates at the bottom of the scapula (shoulder blade) and attaches to the humerus at the inner lip of the groove that contains the biceps (see image). It is one of the primary internal (or medial) rotators of the shoulder, though it also contributes to adduction (drawing the arm toward the body), as well as extending the shoulder (drawing the arm behind the plane of the body).

The primary internal rotators of the shoulder are, in total, stronger than the external (outward) rotators because of their overall mass. Other primary internal rotators include the lat (latissimus) and the pec (pectoralis major), while the subscapularis and anterior deltoid muscles contribute secondarily.

Despite being a primary rotator, the teres major is not a part of the rotator cuff (view image). The muscles of the cuff, all of which also originate at the scapula, form a common tendon that inserts at the humerus covering the top, front and back of the humeral head. These include: the supraspinatus, infraspinatus, teres minor and subscapularis muscles. All have significant roles to play in addition to simply acting to rotate the shoulder. Most importantly, it is the external rotators that help to stabilize the humeral head during shoulder activities. For more on the rotator cuff, take a look here.

It is during the acceleration phase of the pitching motion that the internal rotators are most engaged. If you are interested, a wonderful article detailing shoulder muscle recruitment patterns during each phase of baseball pitching can be found here (note: pg. 3 (571) has a table that summarizes the information).

Let’s hope Michael Pineda gets back on track soon, resumes his spot in the rotation and stays there for the long haul. After two seasons spent recovering from a shoulder injury and surgery, he is definitely poised to make a major contribution.

Follow Abby Sims on Twitter @abcsims.

Jon Niese's Shoulder Woes

Jon Niese, the New York Mets 26-year-old leftie, is reportedly back in New York to see team doctors and get an MRI on the shoulder that caused him to leave the game early in the fourth inning yesterday. Niese noted that he’d felt great after missing a start and having 12 days of rest in late May and early June due to what was reported to be tendinitis. Though he apparently also expressed that he was not overly concerned about the shoulder despite the reappearance of symptoms, it seems logical for Mets fans and management to worry.

Though I’ve no information about the particular tendon previously involved for Niese, I assume it is one of his rotator cuff tendons. Like most non-traumatic sports ailments, tendinitis is an overuse injury. Tissues are simply subjected to more demand than they can tolerate. The result? Breakdown. Sometimes the cause entails weakness of specific muscles or strength imbalances. Insufficient muscular endurance to undertake a repetitive activity might be another issue. This is particularly true with overhead motions, such as those common in throwing and racquet sports, which involve complex dynamics. At the shoulder, variants in the shape of the acromion, a portion of bone overlying the joint (view image) can place additional stress on a tendon, making it more vulnerable. Another outcome of any of the above factors could be impingement on a tendon, which also plays into a cycle of inflammation.

Niese reportedly complained of weakness in the shoulder before being removed from the game. Though he’d rested for only 12 days before his prior start, the rest that alleviated his symptoms might have contributed to further weakening from disuse.

As I’ve written about in previous columns, rest and treatment of inflammation – with or without cortisone – may relieve pain, but don’t address the causes. That is why we see so much recurrence of injury amongst players who may feel well enough to return to the field but find they can’t stay out there. Healing is often incomplete and underlying factors have not been sufficiently addressed – nor can they be – in the limited time allotted. In fact, if the healing is incomplete, the boundaries of function cannot be pushed in rehab to fully simulate the demands of competition. Then of course there are the many athletes who play through the pain, whether silently and without complaint or because they are encouraged to do so.

Niese’s numbers this season may be evidence that something is holding him back. His command is not as sharp as it had been, resulting in more walks and fewer strikeouts. Now – even before the midpoint of the season – he is out for the second time due to the left shoulder. The diagnosis may not turn out to pinpoint significant pathology, but that doesn’t mean it should be taken lightly.

Follow Abby Sims on Twitter @abcsims.

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Carmelo Anthony’s Shoulder Issues: Not Simply A Warning Sign

Though his knee issues have not entirely faded into the past, Carmelo Anthony’s first post-playoff doctor visit will evidently focus on his left shoulder, according to the New York Daily News. Melo hurt his shoulder on April 14 and exacerbated it in the first round against Boston. Naturally though, at the time — and with the Indiana series ahead — Anthony said only that “(I)t really just kind of popped in and out a little bit, but I’m fine.”

Anthony’s comment was more revealing than he may have intended for it to be. The implications are that he experienced either a shoulder subluxation or dislocation that reduced (went back in place) without assistance. A subluxation is a partial dislocation, and the fact that the humeral head popped out only “a little bit” is what likely enabled the spontaneous reduction.

This means that Anthony’s shoulder joint is lax, meaning it is unstable. The likelihood is that he has an anterior instability — the displacement of the head of the humerus was in the front of the joint. It implies

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that one or more of the supports of the joint have been stretched or torn. This type of instability is more common than that at the posterior (rear) of the shoulder joint, or instability that exists in multiple directions.

The primary supports at the shoulder include ligaments (which connect bone to bone) and the labrum, (which provides a deeper and more stable socket for the humeral head). The fit at the labrum also contributes to the negative pressure within the joint that secures the humeral head in its socket.

Other stabilizers include the shape of the socket itself as well as the rotator cuff and scapular muscles. Different muscles or

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ligaments are stressed in different shoulder positions, placing variable demand on each to contribute to stability.

Surrounding the joint is a capsule, which, when torn because of a traumatic dislocation, does not heal without surgery. The labrum and ligaments also require surgery if the tears are sufficient enough to result in recurrent dislocation.

Even repeated tweaking of the shoulder from mild episodes caused by instability may be an indication for surgery. These lower grade injuries still result in inflammation and require recovery periods that entail re-strengthening of the surrounding musculature before returning to full activity.

Additional complications of an unstable shoulder include wear and tear on the rotator cuff (known as tendinosis or tendinopathy) or lesions on the bone itself (at the humeral head) from friction. Surgery may be advised to prevent further damage.

Young athletes who experience traumatic dislocation before the age of 18 are those most destined for surgery. Their injuries generally become recurrent and subsequently restrict activity. However, surgery to restore anterior shoulder stability is common across the board. Unfortunately, even I’ve had it, as has one of my sons — and his was on both sides.

As to the outcome of Anthony’s exam? Neither a wait-and-see approach nor surgery would be surprising. However, this injury is more than a warning sign and it doesn’t bode well.

Follow Abby Sims on Twitter @abcsims

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Ben Roethlisberger’s Rotator Cuff

Took a look at the current NFL injury report and had to mention that (including a few due to suspensions) it is 80 men deep – as of August 1st!

Not on the list is Steelers’ quarterback, Ben Roethlesberger, who yesterday just happened to mention that he has been playing with some shoulder pain due to a partial rotator cuff tear since sustaining the injury in a loss to Baltimore on November 6th, 2011. As with many of his prior injuries, Roethlisberger evidently has no intention of sitting this one out and is simply limiting his throwing in practice. I saw no mention of any medical treatment in the media. Though he reportedly laughed off the possibility of the tear worsening, that outcome wouldn’t be shocking.

The rotator cuff muscles are important to the overall function of the shoulder girdle, and particularly so for a throwing or overhead athlete.

What is the Rotator Cuff?

Four muscles that originate on the shoulder blade (scapula) all essentially converge into a common tendon to attach at the front, top and back of the head of the humerus (the bone of the upper arm). Collectively, they constitute the rotator cuff. You may recall that tendons connect muscle to bone. Those of the rotator cuff are no different.

The muscles that contribute to this tendon are responsible for different actions. The Subscapularis tendon is the foremost. Its muscle belly is on the undersurface of the scapula and the tendon wraps around the front of the humeral head. The action of the muscle is to internally (inwardly) rotate the humerus By virtue of its location, the subscapularis tendon also helps to protect the front of the shoulder. The Supraspinatus, insertion is the uppermost of the cuff tendons. When it contracts, the supraspinatus raises the arm out to the side (abducts). Infraspinatus & Teres Minor, the next two in order of attachment, are the primary external rotators of the shoulder. These tendons come around the back of the head of the humerus, thereby providing the leverage to rotate the bone outwardly.

Why is the Cuff so Important and how is it Injured?

In addition to enabling the shoulder to move in the directions described, the muscles of the rotator cuff help to foster normal mechanics of the joint. Weakness and strength imbalances of the cuff lead to abnormal mechanics, which then result in injury. This is particularly so when combined with the increased demand of sports or other repetitive overhead activities.

When they have rotator cuff problems, younger people tend to suffer from tendinitis, which is simply an inflammation of a tendon. The cuff tendon most likely to be involved is the supraspinatus tendon because of its uppermost position immediately below the hood of the shoulder, known as the acromion.

The narrow space below the acromion (the “subacromial” space) can be narrowed even further by poor posture (forward head, forwardly tilted shoulder blade/rounded shoulders), by variations in the shape of the acromion itself, and by the presence of bone spurs. This space also becomes smaller when the outward rotators are weak and do not adequately control the position of the head of the humerus when the arm is elevated overhead. The end result is impingement of the cuff tendons.

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“Impingement” is as it implies – a pinching of the structures involved. At first the tendons just become inflamed. The swelling that accompanies this inflammation can further diminish the subacromial space” and create a vicious cycle. Over time, the wear and tear from impingement leads to degenerative changes of the tissue, and that is called tendinosis. Tendinosis can be likened to gliding a rope back and forth over a rock until the rope begins to fray. Give it a little more time and overuse, and the fraying of the cuff tendons (particularly in the over 40 crowd of recreational athletes), results in degenerative rotator cuff tears.

Younger athletes with cuff tears are generally those who do an inordinate amount of overhead activities like pitching. Overuse and irregular pitching/overhead mechanics can also play a role in predisposing these players to injury.

Another cause of rotator cuff tears is outright trauma, such as in a dislocation. A traumatic tear of the cuff is also the likely outcome for the person who holds onto a banister for dear life while falling down a flight of stairs. Though without dislocation, Roethlisberger’s injury may have been of the traumatic variety. However, now that he has the tear, experiences pain and may have weakness in the involved muscle, Roethlisberger’s joint mechanics may be altered sufficiently to contribute to further wear and tear.

Loss of mobility in the shoulder joint, whether from inflammation, scar tissue that forms in response to inflammation, immobilization, or disuse can make impingement more likely. If diminished, mobility must be restored to provide normal joint function, lessen the risk of injury and ensure the success of surgery (if it becomes necessary).

Adequate strength of the muscles that stabilize the scapula (the rhomboids, middle and lower trapezeii and serratus) facilitates good joint mechanics with overhead movement. This is also crucial to preventing or rehabilitating impingement and avoiding degenerative rotator cuff tears or the progression of existing small partial thickness tears.

Roethlisberger’s Tear is Partial; if it Tears More – Then What?

Most degenerative tears of rotator tendons are partial thickness – they don’t extend through the entire structure – as when you just begin to cut a piece of beef. Other tears are full thickness, as though the beef is cut from top to bottom but remains attached to the rest of the piece. In the case of a complete tear, or rupture, total detachment occurs, separating one end of the tendon from the other. These result in complete loss of use of the involved muscle/tendon unit – it cannot be rehabilitated or strengthened without surgical repair.

Repairs are also performed on partial and full thickness tears that are not complete tears. The choice to have surgery generally depends on the extent of a tear, the age of the individual, the demands of the individual’s activities as well as the mobility and overall health

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and function of the shoulder joint. Oftentimes surgery is for more than one condition rather than an isolated cuff repair. This is because issues such as impingement must also be addressed in order to have a favorable outcome.

Roethlisberger is a tough competitor – he rarely lets an injury get in his way. We’ll have to see how this one plays out. There is no doubt though that he is more vulnerable.

Follow Abby on Twitter @abcsims

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Ben Roethisberger's Rotator Cuff

Took a look at the current NFL injury report and had to mention that (including a few due to suspensions) it is 80 men deep – as of August 1st!

Not on the list is Steelers’ quarterback, Ben Roethlesberger, who yesterday just happened to mention that he has been playing with some shoulder pain due to a partial rotator cuff tear since sustaining the injury in a loss to Baltimore on November 6th, 2011.  As with many of his prior injuries, Roethlisberger evidently has no intention of sitting this one out and is simply limiting his throwing in practice. I saw no mention of any medical treatment in the media. Though he reportedly laughed off the possibility of the tear worsening, that outcome wouldn’t be shocking.

The rotator cuff muscles are important to the overall function of the shoulder girdle, and particularly so for a throwing or overhead athlete.

What is the Rotator Cuff?

Four muscles that originate on the shoulder blade (scapula) all essentially converge into a common tendon to attach at the front, top and back of the head of the humerus (the bone of the upper arm). Collectively, they constitute the rotator cuff. You may recall that tendons connect muscle to bone. Those of the rotator cuff are no different.

The muscles that contribute to this tendon are responsible for different actions. The Subscapularis tendon is the foremost. Its muscle belly is on the undersurface of the scapula and the tendon wraps around the front of the humeral head. The action of the muscle is to internally (inwardly) rotate the humerus By virtue of its location, the subscapularis tendon also helps to protect the front of the shoulder. The Supraspinatus, insertion is the uppermost of the cuff tendons. When it contracts, the supraspinatus raises the arm out to the side (abducts). Infraspinatus & Teres Minor, the next two in order of attachment, are the primary external rotators of the shoulder. These tendons come around the back of the head of the humerus, thereby providing the leverage to rotate the bone outwardly.

Why is the Cuff so Important and how is it Injured?

In addition to enabling the shoulder to move in the directions described, the muscles of the rotator cuff help to foster normal mechanics of the joint. Weakness and strength imbalances of the cuff lead to abnormal mechanics, which then result in injury. This is particularly so when combined with the increased demand of sports or other repetitive overhead activities.

When they have rotator cuff problems, younger people tend to suffer from tendinitis, which is simply an inflammation of a tendon. The cuff tendon most likely to be involved is the supraspinatus tendon because of its uppermost position immediately below the hood of the shoulder, known as the acromion.

The narrow space below the acromion (the “subacromial” space) can be narrowed even further by poor posture (forward head, forwardly tilted shoulder blade/rounded shoulders), by variations in the shape of the acromion itself, and by the presence of bone spurs. This space also becomes smaller when the outward rotators are weak and do not adequately control the position of the head of the humerus when the arm is elevated overhead. The end result is impingement of the cuff tendons.

“Impingement” is as it implies – a pinching of the structures involved. At first the tendons just become inflamed. The swelling that accompanies this inflammation can further diminish the subacromial space” and create a vicious cycle. Over time, the wear and tear from impingement leads to degenerative changes of the tissue, and that is called tendinosis. Tendinosis can be likened to gliding a rope back and forth over a rock until the rope begins to fray. Give it a little more time and overuse, and the fraying of the cuff tendons (particularly in the over 40 crowd of recreational athletes), results in degenerative rotator cuff tears.

Younger athletes with cuff tears are generally those who do an inordinate amount of overhead activities like pitching. Overuse and irregular pitching/overhead mechanics can also play a role in predisposing these players to injury.

Another cause of rotator cuff tears is outright trauma, such as in a dislocation. A traumatic tear of the cuff is also the likely outcome for the person who holds onto a banister for dear life while falling down a flight of stairs. Though without dislocation, Roethlisberger’s injury may have been of the traumatic variety. However, now that he has the tear, experiences pain and may have weakness in the involved muscle, Roethlisberger’s joint mechanics may be altered sufficiently to contribute to further wear and tear.

Loss of mobility in the shoulder joint, whether from inflammation, scar tissue that forms in response to inflammation, immobilization, or disuse can make impingement more likely. If diminished, mobility must be restored to provide normal joint function, lessen the risk of injury and ensure the success of surgery (if it becomes necessary).

Adequate strength of the muscles that stabilize the scapula (the rhomboids, middle and lower trapezeii and serratus) facilitates good joint mechanics with overhead movement. This is also crucial to preventing or rehabilitating impingement and avoiding degenerative rotator cuff tears or the progression of existing small partial thickness tears.

Roethlisberger’s Tear is Partial; if it Tears More – Then What?

Most degenerative tears of rotator tendons are partial thickness – they don’t extend through the entire structure – as when you just begin to cut a piece of beef. Other tears are full thickness, as though the beef is cut from top to bottom but remains attached to the rest of the piece. In the case of a complete tear, or rupture, total detachment occurs, separating one end of the tendon from the other. These result in complete loss of use of the involved muscle/tendon unit – it cannot be rehabilitated or strengthened without surgical repair.

Repairs are also performed on partial and full thickness tears that are not complete tears. The choice to have surgery generally depends on the extent of a tear, the age of the individual, the demands of the individual’s activities as well as the mobility and overall health and function of the shoulder joint. Oftentimes surgery is for more than one condition rather than an isolated cuff repair. This is because issues such as impingement must also be addressed in order to have a favorable outcome.

Roethlisberger is a tough competitor – he rarely lets an injury get in his way. We’ll have to see how this one plays out. There is no doubt though that he is more vulnerable.

Follow Abby on Twitter @abcsims

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