The rotator cuff muscles, used for example in throwing motions, are commonly injured as a result of chronic overuse. This usually occurs when the athlete is weak and throws forcefully or incorrectly. A stretch or tear of the muscle or a swelling and impingement of the tendon is the result. Rotator cuff injuries are common in swimming and throwing sports because of the frequency of overhead arm movements.

Anatomical Details

• There are four muscles that make up the "rotator cuff" – supraspinatus, infraspinatus, teres minor, and subscapularis. These muscles stabilize the shoulder and are responsible for helping the shoulder rotate and abducting the arm.
• There are two types of rotator cuff injuries – a rotator cuff tear (which is fairly uncommon) and an impingement syndrome (most common).
• A tear usually involves the supraspinatus muscle and causes the athlete to have difficulty abducting or externally rotating the arm.
• Impingement occurs when the supraspinatus muscle, long head of the biceps and/or the subacromial bursa is squeezed between the ligaments and bones in the shoulder. This results in inflammation, swelling and further impingement and can lead to permanent thickening of the rotator cuff and the development of scar tissue.

Signs and Symptoms

• Pain with throwing, spiking, and serving motions. The pain may become worse at night especially when you lie on the uninvolved shoulder. Pain may actually decrease when you lie on the involved shoulder. 
• Inability to throw, spike, or serve with a normal pattern of arm motion.
• Tenderness over the front edge of the clavicle, greater tuberosity of the humerus (supraspinatus), or along the shoulder blade.
• Pain when abducting the shoulder, worsening at 90 degrees. If it is a strain rather than an impingement, there will be less or no pain with passive abduction.

On-Site Management

P.R.I.C.E. PROTECT. The offending activity must be decreased or completely stopped (REST) until normal strength and flexibility is regained. This will prevent the injury from progressively getting worse. ICING the shoulder after workouts can be very beneficial to reduce inflammation. Heat may be beneficial before a workout, but should not be applied after. COMPRESSION (tensor wrap) can help move inflammation away from teh area. ELEVATION is not necessary.

Referral. Physicians may prescribe anti-inflammatory medication. Physiotherapists can apply Ultrasound and other electrical modalities to help the healing process. In severe cases, surgery may be required to remove the scar tissue or ossification of bone that has built up and is causing the impingement.

Rehabilitation. It is important that the athlete realizes that the muscles of the rotator cuff are small and used to control the shoulder blade (not throw the ball). The motions for rehabilitation are very small and controlled and focus on protraction, retraction, and depression of the shoulder blades. Postural training/taping helps to decrease inflammation and encourage endurance in these muscles.

Return to Activity. Have the athlete gradually begin throwing, starting with slow speed and short distance throws, and gradually increasing the speed and distance. This should take 1 to 2 weeks. The athlete can return to activity when the shoulder regains full range of motion and strength and is pain free.

Prevention

• Pre-season strengthening, particularly the external and internal rotators, and slow stretching of the shoulder girdle.
• A gradual warm-up before any activity.

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