Evaluation of the risk factors and training techniques used for prehabilitation of a Rotator Cuff Tendinopathy
Word count: 1843
Rehabilitation in Sports & Exercise
It is recoded that 1 in 3 people will have a shoulder injury in their life’s and injuries to the Rotator Cuff (RC) muscles are recorded to be the most common when it comes to shoulder injuries. RC tendinopathy is an umbrella term for a wide range of injuries related to the tendons found underneath the sub acromial space and these conditions have a high prevalence in athletes that require repetitive overhead moments, such as baseball and swimming. The symptoms associated to RC tendinopathy are pain and weakness in shoulder movements i.e., external rotation and elevation (Lewis, McCreesh, Roy & Ginn, 2015). The RC muscles consist of 4 muscles, The supraspinatus, infraspinatus, subscapularis and the teres minor and these muscles originate at the scapular and insert on to the humeral head creating a cuff like structure, which helps to create movements of the shoulder and stabilize the humeral head within the glenoid humeral joint(“Rotator cuff injury – Symptoms and causes”, 2020).Tendons connect muscle to bone and have a proximal and distal end, they come in all different shapes and sizes dependent on the amount of physical stress required. They are predominately made of type 1 collagen; however, they also consist of type 3 and V. The type 1 collagen creates the strength of the tendon and allows it to withstand high forces and poteoglycan within the tendon creates the elastic qualities. Their fibro elastic composition allows them to transmit significant forces created from the muscle to the bone, which in turn, creates movement(“Tendon Anatomy”, 2020). Shoulder tendinopathies are caused by two factors, extrinsic and intrinsic and sometimes a combination of the two. Extrinsic factors can involve the injury of the tendon from the coracoacromialarch located above, the causes of this can be from tightness and weakness in the RC muscles, the shape of the acromion, posture and an elevated humeral head. Intrinsic factors are those that have an effect on the tendon’s health, these include aging and excessive loading of the tendon (Lewis, McCreesh, Roy & Ginn, 2015). There are two ways that a tendon reacts to repetitive overload, these are with inflammation and or with degeneration. A damaged tendon requires time to repair and if left without proper rehab then the tendon will decrease in strength and this could lead to a rupture (SHARMA & MAFFULLI, 2005).A RC tendinopathy can take up to 6 months or longer to heal and therefore the injury has the potential to make an athlete take time out of their sport, or a physical worker to take time off work (“Tendinopathy”, 2020). Shoulder injuries can be challenging to fix, and it is reported that around 40% of RC tendinopathy’s fail to heal from conservative treatment. Therefore, prevention is seen to be the more beneficial route than the treatment once injured (Leong et al., 2019).In this I will evaluate the risk factors and training techniques used for pre-habilitation of RC tendinopathies.
Risk factors and Training techniques
The main risk factors associated with RC tendinopathies are age, over training, weakness and stiffness in muscles, previous and existing medical condition i.e. arthritis and repetitive over use of certain shoulder movements.With age comes Sarcopenia and a reduction in muscle strength, RC injuries can have a direct effect on a person’s life, especially on the elderly and they these injuries have increased in prevalence from 25.6% to 50.0% for adults in the ages of sixty to eighty. RC injuries can restrict an elderly person in their normal everyday activities and tasks, from cleaning themselves to driving vehicles (Vidt et al., 2016). Age was reported to be the greatest risk factor of obtaining RC Syndrome with jobs requiring the abduction of the shoulder as the highest’s in work related cases, furthermore a lack of social support was a key predictor in mainly cases in males (Bodin et al., 2012).People with arthritis in the shoulder have a higher risk of an RC tendinopathy/ injury. Arthritis is a condition that causes an increased inflammation within a joint and creates pain, it can affect people of all ages, genders and activity levels, however arthritis is more common in the elderly. It is recorded that over 10 million people suffer from the condition in the UK (“Arthritis”, 2020). Over training increases the risk of RC injuries, a sudden increase of activity level can cause a RC tendinopathy. When a load exceeds the tendons compacity, then injury to the tendon can occur. The compacity of a tendon will vary on person to person and the specific tendon, for example a patella tendon of a high level sprinter, is more likely to have a higher compacity and would be able to withstand higher load forces than that of an inactive elderly individual (“Tendon Load and Capacity”, 2020). Because of the increased in inflammation with arthritis within the shoulder, in and around the glenoid humeral joint, people with this condition are more likely to obtain an RC injury and treatment can be more difficult(Thankam, Boosani, Dilisio & Agrawal, 2017).
A study by Edouard, Beguin, Farizon & Calmels, (2011)tested whether there is a link between the strength of the RC and shoulder instability. They tested the strength of the RC by using external and internal rotation movements of the shoulder. The study showed that there was a link between weaknesses in the RC muscles and shoulder instability, which could increase the likeness of impingement. Shoulder stability and RC exercises can reduce the patients pain and strengthen up the RC tendons to help to prevent injury (“Shoulder instability and rotator cuff issues | Functional Resistance Training”, 2020). Muscles that help stabilise the scapular include serratus anterior, rhomboid, levator scapulaeand the trapezius. It is important to strengthen all of the muscles that help the movement of the scapular because weakness, will have an impact of the scapular function and therefore could lead to nerve impingements, strains and tears(“11 Scapular Stabilization Exercises for Injury Prevention & Strength”, 2020). One isometric exercise for scapular stabilisation is the Inferior Glide, to perform this exercise the client sits down and places their arm on a table to the side of them, the client then applies pressure in a downwards motion towards the table in an adduction movement. This exercise focuses on both the depression of the humeral head and also scapular retraction. It has shown a high Electromyography (EMG) in the serratus anterior and the lower trapezius muscles (Physio tutors, 2020).
Mistakes can be made when preforming RC strengthening exercises. A common mistake can be made when performing the external and internal rotation of the shoulder. When performing these exercises without a towel between the elbow and the side of the body, the client tends to bring their elbow in a outwards position, which stops the movement isolating the RC muscles and incorporates the deltoid into the movement which increases the elevation of the humeral head, resulting in the impingement of the RC tendons. Another mistake comes with the position when performing the same exercises, protrusion of the shoulders when performing this movement will decrease the ROM and the subacromial space. The ideal position is to stand with the shoulder blades pulled backwards and down, with the head in a neutral position looking forward. The third mistake is a lack of strengthening of the serratus anterior and the lower trap muscles. By training these muscles, it will enforce the scapular into the proper position (Athleanx, 2020).A study by Leong, Hug & Fu, (2016)showed that having stiffness in the upper trapezius (UT) muscle can contribute to RC tendinitis. Stiffness in this muscle can affect the persons shoulder function, in movements that can cause an impingement on the RC tendons and therefore, ensuring reduced tension in the UT can decrease the chance of obtaining a RC injury. Exercises such as the overhead shrugs and upper rotation shrug, using the cable machine and standard lateral raises, which have a high level of activation of the UT, should be used to strengthen the UT muscle. Although training a muscle makes that muscle tighter, this is only true for the short time following. Resistance training can have the opposite effect on a muscle and help to increase the flexibility and range of motion (ROM). Resistance training can also reduce the chance of injury and eccentric exercises can increase muscle strength, reduce inflammation and increase the adaptation of the muscle (Physiotutors, 2020).Eccentric training is when a muscle lengthens under contraction, this method of strengthening is widely used for prehabilitaion and rehabilitation of tendinopathy conditions, including RC, achilles tendon and the patella tendon. Three things that eccentric training does to a tendon is lengthen, gradually load and increase the contraction speed. By lengthening the tendon, it is believed that the tendon will not be overstretched in the full ROM of the muscle. The pathology of the majority or tendinopathies are that of overuse and overloading, therefore using progressive loading will reduce the risk of injury and can induce the remodelling phase of the tendon healing. Eccentric exercises are seen to put the tendon under more stress than that of a concentric contraction, this can create more strength in the muscle and tendon (Camargo, 2014).
RC Tendinopathies are increasing in prevalence and this condition can be have a massive impact on an individual’s life. It can stop individuals from being able to live independently and affect their everyday tasks. Because of the cost, duration and frequency of this injury, prevention can be seen as extremely beneficial. To prevent an injury, the potential risk factor needs to be known. The main identified risk factors of RC tendinopathies are predominantly age, arthritis, improper function of the scapula, weakness in the RC muscles and over training. Although we cannot change the aging process, we can put in place certain strengthening exercise/ programmes to help strengthen the tendons. Smoking, diet and physical activity all have an effect of a tendons healing. Weaknesses of the RC muscles can cause an improper function of the humeral head and a lack of stabilisation. Using exercises that utilises all functional movements of the shoulder including external and internal rotation can help increase the strength, especially when combined with eccentric movements, which are seen as the more beneficial approach to strengthening up a tendon and this type of contraction can be used to help improve a individuals ROM. There is a link to bad posture and rotator cuff tendinopathies and therefore it could prove beneficial to incorporate certain posture exercises in everyday life and individuals wanting to decrease the likeness of a RC tendinopathy should ensure that they are performing specific strengthening and stabilization exercises with proper form to ensure to not aggregate the condition. More research needs to be done into the risk factors of RC tendinopathies and the use of preventive measure to reduce the amount of the population affected.
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