Editing Rotator cuff

{{short description|Group of muscles}}
{{Use dmy dates|date=September 2020}}
{{Infobox anatomy
| Name        = Rotator cuff
| Latin       =musculi cuffiae musculotendineae 
| Precursor   = 
| System      = 
| Artery      =[[Suprascapular artery]], [[circumflex scapular artery]]<ref>{{cite journal|url=https://scielo.conicyt.cl/pdf/ijmorphol/v32n1/art23.pdf|title=Arterial Supply to the Rotator Cuff Muscles |last1=Naidoo |first1=N. |last2=Lazarus |first2=L. |last3=De Gama |first3=B. Z. |last4=Ajayi |first4=N. O. |last5=Satyapal |first5=K. S|journal=International Journal of Morphology|year=2014|issue=1|pages=136–140|access-date=30 September 2019|archive-date=29 September 2020|archive-url=https://web.archive.org/web/20200929022513/https://scielo.conicyt.cl/pdf/ijmorphol/v32n1/art23.pdf|url-status=live}}</ref> 
| Vein        = 
| Nerve       =[[Subscapular nerve]], [[suprascapular nerve]], [[axillary nerve]] 
| Lymph       =[[Axillary lymph nodes]] 
|acronym=SITS muscle}}
[[File:Shoulder joint bf.svg|thumb|400px|Right shoulder joint. Posterior view at left. Anterior view at right. 1. [[Clavicle]], 2. [[Scapula]] (with 3. [[Scapular spine]], 4. [[Coracoid process]], 5.[[Acromion]]), 6. [[Humerus]]; Joints: 7. [[Acromioclavicular joint|Acromioclavicular (AC)]], 8. [[Glenohumeral joint|Glenohumeral]]; 9: [[Synovial bursa|Bursa]]; '''10. Rotator cuff (with 11. [[Supraspinatus muscle|Supraspinatus]], 12. [[Subscapularis muscle|Subscapularis]], 13. [[Infraspinatus muscle|Infraspinatus]], 14. [[Teres minor muscle|Teres minor]])''', 15. [[Biceps muscle]]]]

The '''rotator cuff (SITS muscles)''' is a group of [[muscle]]s and their [[tendon]]s that act to stabilize the human [[shoulder]] and allow for its extensive [[range of motion]]. Of the seven [[scapulohumeral muscles]], four make up the rotator cuff. The four muscles are:
* [[supraspinatus muscle]]
* [[infraspinatus muscle]]
* [[teres minor muscle]]
* [[subscapularis muscle]].

==Structure==

===Muscles composing rotator cuff===
{| class="wikitable"
! Muscle
! Origin on scapula
! Attachment on humerus
! Function
! Innervation
 |-
 | ''[[Supraspinatus muscle]]''  || [[supraspinous fossa]] || superior<ref>Grays Anatomy 40th</ref> facet of the [[greater tubercle]] || [[Abduction (kinesiology)|abducts]] the [[humerus]] || [[Suprascapular nerve]]
([[Cervical spinal nerve 5|C5]])
 |-
 | ''[[Infraspinatus muscle]]'' || [[infraspinous fossa]] || middle facet of the [[greater tubercle]]|| [[external rotation|externally rotates]] the humerus || [[Suprascapular nerve]]
([[Cervical spinal nerve 5|C5]]–[[Cervical spinal nerve 6|C6]])
 |-
 | ''[[Teres minor muscle]]''  || middle half of [[lateral border]] || inferior facet of the [[greater tubercle]] || externally rotates the humerus || [[Axillary nerve]]
([[Cervical spinal nerve 5|C5]])
 |-
 | ''[[Subscapularis muscle]]''  || [[subscapular fossa]] || [[lesser tubercle]] || [[internal rotation|internally rotates]] the [[humerus]] || [[Upper subscapular nerve|Upper]] and [[Lower subscapular nerves|Lower]] subscapular nerve
([[Cervical spinal nerve 5|C5]]–[[Cervical spinal nerve 6|C6]])
|}

The supraspinatus muscle spreads out in a horizontal band to insert on the superior facet of the [[greater tubercle]] of the [[humerus]].  The greater tubercle projects as the most [[Lateral (anatomy)|lateral]] structure of the [[humeral head]]. [[Medial (anatomy)|Medial]] to this, in turn, is the [[lesser tubercle]] of the humeral head. The subscapularis muscle [[Origin (anatomy)|origin]] is divided from the remainder of the rotator cuff origins as it is deep to the [[scapula]].

The four [[tendon]]s of these muscles converge to form the rotator cuff tendon.  These tendinous [[Insertion (anatomy)|insertions]] along with the [[articular capsule]], the [[coracohumeral ligament]], and the [[glenohumeral ligament]] complex, blend into a confluent sheet before insertion into the humeral tuberosities (i.e. greater and lesser tubercle).<ref name="matava">{{cite journal |vauthors=Matava MJ, Purcell DB, Rudzki JR |title=Partial-thickness rotator cuff tears |journal=Am J Sports Med |volume=33 |issue=9 |pages=1405–17 |year=2005 |pmid=16127127 |doi=10.1177/0363546505280213 |s2cid=29959313 }}</ref> The infraspinatus and teres minor fuse near their [[musculotendinous junction]]s, while the supraspinatus and subscapularis tendons join as a sheath that surrounds the [[biceps]] tendon at the entrance of the [[bicipital groove]].<ref name="matava"/> The supraspinatus is most commonly involved in a [[rotator cuff tear]].

==Function==
The rotator cuff muscles are important in shoulder movements and in maintaining [[glenohumeral joint]] (shoulder joint) stability.<ref name=Morag2006>{{cite journal |vauthors=Morag Y, Jacobson JA, Miller B, De Maeseneer M, Girish G, Jamadar D |title=MR imaging of rotator cuff injury: what the clinician needs to know |journal=Radiographics |volume=26 |issue=4 |pages=1045–65 |year=2006 |pmid=16844931 |doi=10.1148/rg.264055087|doi-access=free }}</ref> These muscles arise from the [[scapula]] and connect to the head of the [[humerus]], forming a cuff at the shoulder joint (hence the name rotator cuff). They hold the head of the humerus in the small and shallow [[glenoid cavity|glenoid fossa]] of the scapula. The glenohumeral joint has been analogously described as a [[golf ball]] (head of the humerus) sitting on a [[golf tee]] (glenoid fossa).<ref>{{cite journal |vauthors=Khazzam M, Kane SM, Smith MJ |title=Open shoulder stabilization procedure using bone block technique for treatment of chronic glenohumeral instability associated with bony glenoid deficiency |journal=Am. J. Orthop. |volume=38 |issue=7 |pages=329–35 |year=2009 |pmid=19714273 |url=http://www.amjorthopedics.com/pdfs/038070329.pdf }}</ref>

The rotator cuff compresses the glenohumeral joint during abduction of the arm, an action known as concavity compression, in order to allow the large [[deltoid muscle]] to further elevate the arm.  In other words, without the rotator cuff, the humeral head would ride up partially out of the glenoid fossa, lessening the efficiency of the deltoid muscle.  The anterior and posterior directions of the glenoid fossa are more susceptible to [[shear force]] perturbations, as the glenoid fossa is not as deep relative to the superior and inferior directions. The rotator cuff's contributions to concavity compression and stability vary according to their stiffness and the direction of the force they apply upon the joint.

In addition to stabilizing the glenohumeral joint and controlling humeral head translation, the rotator cuff muscles also perform multiple functions, including abduction, [[internal rotation]], and [[external rotation]] of the shoulder. The infraspinatus and subscapularis have significant roles in scapular plane shoulder abduction ([[scaption]]), generating forces that are two to three times greater than the force produced by the supraspinatus muscle.<ref name=Escamilla09>{{cite journal |vauthors=Escamilla RF, Yamashiro K, Paulos L, Andrews JR |title=Shoulder muscle activity and function in common shoulder rehabilitation exercises |journal=Sports Med |volume=39 |issue=8 |pages=663–85 |year=2009 |pmid=19769415 |doi=10.2165/00007256-200939080-00004 |s2cid=20017596 }}</ref> However, the supraspinatus is more effective for general shoulder abduction because of its [[moment arm]].<ref>{{cite book |last=Arend |first=C.F. |chapter=01.1 Rotator Cuff: Anatomy and Function |chapter-url=http://www.shoulderus.com/ultrasound-of-the-shoulder/rotator-cuff-anatomy-and-function/ |title=Ultrasound of the Shoulder |publisher=Master Medical Books |year=2013 |url=http://www.shoulderus.com/ |access-date=5 September 2013 |archive-date=14 October 2013 |archive-url=https://web.archive.org/web/20131014020541/http://www.shoulderus.com/ |url-status=live }} ShoulderUS.com]</ref> The anterior portion of the supraspinatus tendon is submitted to a significantly greater load and stress, and performs its main functional role.<ref>{{cite journal |vauthors=Itoi E, Berglund LJ, Grabowski JJ, Schultz FM, Growney ES, Morrey BF, An KN |title=Tensile properties of the supraspinatus tendon |journal=J. Orthop. Res. |volume=13 |issue=4 |pages=578–84 |year=1995 |pmid=7674074 |doi=10.1002/jor.1100130413 |s2cid=22224279 }}</ref>

==Clinical significance==

===Tear===
{{Main|Rotator cuff tear}}
The tendons at the ends of the rotator cuff muscles can become torn, leading to [[pain]] and restricted movement of the arm.  A torn rotator cuff can occur following trauma to the shoulder or it can occur through the "wear and tear" on tendons, most commonly the supraspinatus tendon found under the [[acromion]].

Rotator cuff injuries are commonly associated with motions that require repeated overhead motions or forceful pulling motions. Such injuries are frequently sustained by athletes whose actions include making repetitive throws, athletes such as [[Handball|handball players]], [[baseball]] [[pitcher]]s, [[softball]] [[pitchers]], [[American football]] players (especially [[quarterback]]s), [[firefighter]]s, [[cheerleaders]], weightlifters (especially [[powerlifters]] due to extreme weights used in the [[bench press]]), [[Rugby football|rugby]] players, [[volleyball]] players (due to their swinging motions),{{citation needed|date=June 2012}} [[water polo]] players, rodeo [[team roping|team ropers]], [[shot put]] throwers, [[swimmers]], [[Boxer (boxing)|boxer]]s, [[kayaker]]s, [[martial arts|martial artists]], [[Fast bowling|fast bowlers]] in cricket, [[tennis]] players (due to their service motion){{citation needed|date=June 2012}} and [[Tenpin Bowling|tenpin bowlers]] due to the repetitive swinging motion of the arm with the weight of a [[bowling ball]]. This type of injury also commonly affects [[orchestra conductor]]s, [[choral conductor]]s, and [[drummer]]s (due, again, to swinging motions).

As progression increases after 4–6 weeks, active exercises are now implemented into the rehabilitation process. Active exercises allow an increase in strength and further range of motion by permitting the movement of the shoulder joint without the support of a physical therapist.<ref name="Jobe, F.M. 1992">{{cite journal |vauthors=Jobe FW, Moynes DR |title=Delineation of diagnostic criteria and a rehabilitation program for rotator cuff injuries |journal=Am J Sports Med |volume=10 |issue=6 |pages=336–9 |year=1982 |pmid=7180952 |doi=10.1177/036354658201000602|s2cid=41784933 }}</ref> Active exercises include the Pendulum exercise, which is used to strengthen the Supraspinatus, Infraspinatus, and Subscapularis.<ref name="Jobe, F.M. 1992" /> External rotation of the shoulder with the arm at a 90-degree angle is an additional exercise done to increase control and range of motion of the Infraspinatus and Teres minor muscles. Various active exercises are done for an additional 3–6 weeks as progress is based on an individual case-by-case basis.<ref name="Jobe, F.M. 1992" /> At 8–12 weeks, [[strength training]] intensity will increase as free-weights and resistance bands will be implemented within the exercise prescription.<ref name="Escamilla09" />

===Impingement===
{{Main|Impingement syndrome}}
The accuracy of the physical examination is low.<ref name="pmid17720798">{{cite journal  |vauthors=Hegedus EJ, Goode A, Campbell S, etal |title=Physical examination tests of the shoulder: a systematic review with meta-analysis of individual tests |journal=British Journal of Sports Medicine |volume=42 |issue=2 |pages=80–92 |date=February 2008 |pmid=17720798 |doi=10.1136/bjsm.2007.038406|doi-access=free }}</ref> The [[Hawkins-Kennedy test]]<ref>{{cite web |url=http://www.shoulderdoc.co.uk/education/article.asp?article=580 |author1=ShoulderDoc.co.uk Shoulder |author2=Elbow Surgery |name-list-style=amp |title=Hawkins-Kennedy Test |access-date=2007-09-12 |url-status=dead |archive-url=https://web.archive.org/web/20071015085708/http://shoulderdoc.co.uk/education/article.asp?article=580 |archive-date=15 October 2007}} (video)</ref><ref name="Brukner14">{{cite web |url=http://www.clinicalsportsmedicine.com/chapters/14d.htm |title=Chapter 14: Shoulder Pain |access-date=2007-08-30 |vauthors=Brukner P, Khan K, Kibler WB |url-status=dead |archive-url=https://web.archive.org/web/20070810165243/http://www.clinicalsportsmedicine.com/chapters/14d.htm |archive-date=10 August 2007}}</ref> has a [[sensitivity (tests)|sensitivity]] of approximately 80% to 90% for detecting impingement. The infraspinatus and supraspinatus<ref>{{cite web |url=http://www.shoulderdoc.co.uk/education/article.asp?article=582 |title=Empty Can/Full Can Test |author1=ShoulderDoc.co.uk Shoulder |author2=Elbow Surgery |name-list-style=amp |access-date=2007-09-12 |url-status=dead |archive-url=https://web.archive.org/web/20071015085715/http://shoulderdoc.co.uk/education/article.asp?article=582 |archive-date=15 October 2007}} (video)</ref> tests have a [[specificity (tests)|specificity]] of 80% to 90%.<ref name="pmid17720798"/>

A common cause of shoulder pain in rotator cuff impingement syndrome is [[tendinosis]], which is an age-related and most often [[Self-limiting (biology)|self-limiting]] condition.<ref>{{Cite journal|last1=Mohamadi|first1=Amin|last2=Chan|first2=Jimmy J.|last3=Claessen|first3=Femke M. A. P.|last4=Ring|first4=David|last5=Chen|first5=Neal C.|date=January 2017|title=Corticosteroid Injections Give Small and Transient Pain Relief in Rotator Cuff Tendinosis: A Meta-analysis|journal=Clinical Orthopaedics and Related Research|volume=475|issue=1|pages=232–243|doi=10.1007/s11999-016-5002-1|issn=1528-1132|pmc=5174041|pmid=27469590}}</ref>

Studies show that there is moderate evidence that hypothermia (cold therapy) and exercise therapy used together are more effective than simply waiting for surgery and they suggest the best outcome for non-surgical treatment of subacromial impingement syndrome. The group of patients who participated in the exercise group were found to use significantly lower amounts of non-steroidal anti-inflammatory drugs (NSAIDS) and analgesics than the control group with no intervention. <ref>{{Cite journal|last1=Gebremariam|first1=Lukas|last2=Hay|first2=Elaine M.|last3=Sande|first3=Renske van der|last4=Rinkel|first4=Willem D.|last5=Koes|first5=Bart W.|last6=Huisstede|first6=Bionka M. A.|date=2014-08-01|title=Subacromial impingement syndrome—effectiveness of physiotherapy and manual therapy|url=https://bjsm.bmj.com/content/48/16/1202|journal=British Journal of Sports Medicine|language=en|volume=48|issue=16|pages=1202–1208|doi=10.1136/bjsports-2012-091802|issn=0306-3674|pmid=24217037|s2cid=27383041 |access-date=9 March 2021|archive-date=19 April 2021|archive-url=https://web.archive.org/web/20210419025001/https://bjsm.bmj.com/content/48/16/1202|url-status=live|url-access=subscription}}</ref>

===Inflammation and fibrosis===
The rotator interval is a triangular space in the shoulder that is functionally reinforced externally by the [[coracohumeral ligament]] and internally by the [[glenohumeral ligament|superior glenohumeral ligament]], and traversed by the intra-articular [[biceps tendon]]. On imaging, it is defined by the coracoid process at its base, the supraspinatus tendon superiorly and the subscapularis tendon inferiorly. Changes of [[adhesive capsulitis]] can be seen at this interval as [[edema]] and [[fibrosis]]. Pathology at the interval is also associated with glenohumeral and biceps instability.<ref>{{cite journal|last1=Petchprapa|first1=CN|last2=Beltran|first2=LS|last3=Jazrawi|first3=LM|last4=Kwon|first4=YW|last5=Babb|first5=JS|last6=Recht|first6=MP|title=The rotator interval: a review of anatomy, function, and normal and abnormal MRI appearance.|journal=AJR. American Journal of Roentgenology|date=September 2010|volume=195|issue=3|pages=567–76|pmid=20729432|doi=10.2214/ajr.10.4406}}</ref> Adhesive capsulitis or "frozen shoulder" is often secondary to rotator cuff injury due to post-surgical immobilization. Available treatment options include intra-articular corticosteroid injections to relieve pain in the short-term and electrotherapy, mobilizations, and home exercise programs for long-term pain relief. <ref>Challoumas D, Biddle M, McLean M, Millar NL. Comparison of Treatments for Frozen Shoulder: A Systematic Review and Meta-analysis. JAMA Netw Open. 2020;3(12):e2029581. Published 2020 Dec 1. [http://doi:10.1001/jamanetworkopen.2020.29581 doi:10.1001/jamanetworkopen.2020.29581]{{Dead link|date=February 2023 |bot=InternetArchiveBot |fix-attempted=yes }}</ref>

== Pain management ==
Treatment for a rotator cuff tear can include rest, ice, physical therapy, and/or surgery.<ref>{{Cite news|url=http://www.mayoclinic.org/diseases-conditions/rotator-cuff-injury/diagnosis-treatment/treatment/txc-20128411|title=Rotator cuff injury - Treatment|work=Mayo Clinic|access-date=2017-09-10|archive-date=19 September 2017|archive-url=https://web.archive.org/web/20170919015612/http://www.mayoclinic.org/diseases-conditions/rotator-cuff-injury/diagnosis-treatment/treatment/txc-20128411|url-status=live}}</ref> A review of manual therapy and exercise treatments found inconclusive evidence as to whether these treatments were any better than placebo, however "High quality evidence from one <abbr>trial</abbr> suggested that manual <abbr>therapy</abbr> and exercise improved function only slightly more than <abbr>placebo</abbr> at 22 weeks, was little or no different to <abbr>placebo</abbr> in terms of other patient-important outcomes (e.g. overall pain), and was associated with relatively more frequent but mild adverse events."<ref>{{Cite journal | title = Manual therapy and exercise for rotator cuff disease {{!}} Cochrane | url = http://www.cochrane.org/CD012224/MUSKEL_manual-therapy-and-exercise-rotator-cuff-disease | doi = 10.1002/14651858.CD012224 | pmid = 27283590 | year = 2016 | journal = Cochrane Database of Systematic Reviews | issue = 6 | pages = CD012224 | last1 = Page | first1 = Matthew J | last2 = Green | first2 = Sally | last3 = McBain | first3 = Brodwen | last4 = Surace | first4 = Stephen J | last5 = Deitch | first5 = Jessica | last6 = Lyttle | first6 = Nicolette | last7 = Mrocki | first7 = Marshall A | author-link8 = Rachelle Buchbinder | last8 = Buchbinder | first8 = Rachelle | volume = 2016 | pmc = 8570640 | access-date = 10 September 2017 | archive-date = 10 September 2017 | archive-url = https://web.archive.org/web/20170910220459/http://www.cochrane.org/CD012224/MUSKEL_manual-therapy-and-exercise-rotator-cuff-disease | url-status = live }}</ref>

The rotator cuff includes muscles such as the supraspinatus muscle, the [[infraspinatus]] muscle, the [[teres minor muscle]] and the [[subscapularis muscle]]. The upper arm consists of the [[deltoids]], [[biceps]], as well as the [[triceps]]. Steps must be taken and precautions need to be made in order for the rotator cuffs to heal properly following surgery while still maintaining function to prevent any deteriorating effects on the muscles. In the immediate postoperative period (within one week following surgery), pain can be treated with a standard ice wrap. There are also commercial devices available which not only cool the shoulder but also exert pressure on the shoulder ("compressive cryotherapy"). However, one study has shown no significant difference in postoperative pain when comparing these devices to a standard ice wrap.<ref>{{cite journal|last1=Kraeutler|first1=MJ|last2=Reynolds|first2=KA|last3=Long|first3=C|last4=McCarty|first4=EC|title=Compressive cryotherapy versus ice-a prospective, randomized study on postoperative pain in patients undergoing arthroscopic rotator cuff repair or subacromial decompression|journal=Journal of Shoulder and Elbow Surgery|date=Jun 2015|volume=24|issue=6|pages=854–859|pmid=25825138|doi=10.1016/j.jse.2015.02.004}}</ref>

=== Continuous passive motion ===
[[Physiotherapy]] can help manage the pain, but utilizing a program that involves continuous passive motion will reduce the pain even further. [[Continuous passive motion|Assisted passive motion]] at a low intensity allows the tissues to be stretched slightly without damaging them<ref name="Plessis, M 2011">Plessis, M. Du, E. Eksteen, A. Jenneker, E. Kriel, C. Mentoor, T. Stucky, D. Van Staden, and L. Morris. "The Effectiveness of Continuous Passive Motion on Range of Motion, Pain and Muscle Strength following Rotator Cuff Repair: A Systematic Review." Clinical Rehabilitation (2011): 291-302</ref> [[Continuous passive motion]] improves the shoulder range and enables the subject to expand their range of motion without experiencing additional pain. Easing into the motions will allow the person to continue working those muscles to keep them from undergoing atrophy, while also still maintaining that minimum level of function where daily function is allowed. Doing these exercises will also prevent tears in the muscles that will impair daily function further.<ref name="Plessis, M 2011"/>

=== Manual therapy ===
A systematic review and [[meta-analysis]] study shows [[manual therapy]] may help to reduce pain for patient with Rotator cuff [[Tendinopathy|tendiopathy]], based on low- to moderate-quality evidence. However, there is not strong evidence for improving function also.<ref>{{Cite journal|last1=Desjardins-Charbonneau|first1=Ariel|last2=Roy|first2=Jean-Sébastien|last3=Dionne|first3=Clermont E.|last4=Frémont|first4=Pierre|last5=MacDermid|first5=Joy C.|last6=Desmeules|first6=François|date=May 2015|title=The Efficacy of Manual Therapy for Rotator Cuff Tendinopathy: A Systematic Review and Meta-analysis|journal=Journal of Orthopaedic & Sports Physical Therapy|volume=45|issue=5|pages=330–350|doi=10.2519/jospt.2015.5455|pmid=25808530|issn=0190-6011|doi-access=free}}</ref>

=== Surgery ===
Surgical approaches include [[acromioplasty]] (a part of the bone is removed to decrease pressure placed on the rotator cuff tendons), removal of a bursa that is inflamed or swollen, and [[subacromial decompression]] (the removal of tissue or bone that is damaged in order to allow more space for the tendons).<ref name=":0">{{Cite journal|last1=Karjalainen|first1=Teemu V.|last2=Jain|first2=Nitin B.|last3=Page|first3=Cristina M.|last4=Lähdeoja|first4=Tuomas A.|last5=Johnston|first5=Renea V.|last6=Salamh|first6=Paul|last7=Kavaja|first7=Lauri|last8=Ardern|first8=Clare L.|last9=Agarwal|first9=Arnav|last10=Vandvik|first10=Per O.|last11=Buchbinder|first11=Rachelle|year=2019|title=Subacromial decompression surgery for rotator cuff disease|journal=The Cochrane Database of Systematic Reviews|volume=1|issue=1 |pages=CD005619|doi=10.1002/14651858.CD005619.pub3|issn=1469-493X|pmc=6357907|pmid=30707445}}</ref>

Surgery may be recommended for patients with an acute, traumatic rotator cuff tear resulting in substantial weakness.{{Citation needed|date=April 2020}} Surgery can be performed open or arthroscopically, although the arthroscopic approach has become much more popular.<ref name=":0" /> If a surgical option is selected, the rehabilitation of the rotator cuff is necessary in order to regain maximum strength and range of motion within the shoulder joint.<ref name="Brewster93">{{cite journal |vauthors=Brewster C, Schwab DR |title=Rehabilitation of the shoulder following rotator cuff injury or surgery |journal=J Orthop Sports Phys Ther |volume=18 |issue=2 |pages=422–6 |year=1993 |pmid=8364597 |doi=10.2519/jospt.1993.18.2.422 }}</ref> [[Physical therapy]] progresses through four stages, increasing movement throughout each phase. The tempo and intensity of the stages are solely reliant on the extent of the injury and the patient's activity necessities.<ref>{{cite journal |author=Kuhn JE |title=Exercise in the treatment of rotator cuff impingement: a systematic review and a synthesized evidence-based rehabilitation protocol |journal=J Shoulder Elbow Surg |volume=18 |issue=1 |pages=138–60 |year=2009 |pmid=18835532 |doi=10.1016/j.jse.2008.06.004 }}</ref> The first stage requires [[immobilization (pathology)|immobilization]] of the [[shoulder joint]]. The shoulder that is injured is placed in a sling and shoulder flexion or abduction of the arm is avoided for 4 to 6 weeks after surgery (Brewster, 1993). Avoiding movement of the shoulder joint allows the torn tendon to fully heal.<ref name="Brewster93" /> Once the [[tendon]] is entirely recovered, passive exercises can be implemented. Passive exercises of the shoulder are movements in which a physical therapist maintains the arm in a particular position, manipulating the rotator cuff without any effort by the patient.<ref name="Waltrip03">{{cite journal |vauthors=Waltrip RL, Zheng N, Dugas JR, Andrews JR |title=Rotator cuff repair. A biomechanical comparison of three techniques |journal=Am J Sports Med |volume=31 |issue=4 |pages=493–7 |year=2003 |pmid=12860534 |doi=10.1177/03635465030310040301 |s2cid=24737981 }}</ref> These exercises are used to increase stability, strength and range of motion of the subscapularis, supraspinatus, infraspinatus, and teres minor muscles within the rotator cuff.<ref name="Waltrip03" /> Passive exercises include internal and external rotation of the shoulder joint, as well as flexion and extension of the shoulder.<ref name="Waltrip03" />

A 2019 Cochrane Systematic Review found with a high degree of certainty that subacromial decompression surgery does not improve pain, function, or quality of life compared with a placebo surgery.<ref name=":0" />

=== Orthotherapy exercises ===
Patients that suffer from pain in the rotator cuff may consider utilizing [[Rotator cuff tear|orthotherapy]] into their daily lives. Orthotherapy is an exercise program that aims to restore the motion and strength of the shoulder muscles.<ref name="Wirth, Michael A. 1997">Wirth, Michael A., Carl Basamania, and Charles A. Rockwood. "Nonoperative Management of Full-Thickness Tears of the Rotator Cuff." Orthopedic Clinics of North America (1997): 59-67</ref> Patients can go through the three phases of orthotherapy to help manage pain and also recover their full range of motion in the rotator cuff. The first phase involves gentle stretches and passive all around movements, and people are advised not to go above 70 degrees of elevation to prevent any kind of further pain.<ref name="Wirth, Michael A. 1997"/> The second phase of this regimen requires patients to implement exercises to strengthen the muscles that are surrounding the rotator cuff muscles, combined with the passive exercises done in the first phase to keep on stretching the tissues without overexerting them. Exercises include [[Push-up|pushups]] and shoulder shrugs, and after a couple of weeks of this, daily activities are gradually added to the patient's routine. This program does not require any sort of medication or surgery and can serve as a good alternative.
The rotator cuff and the upper muscles are responsible for many daily tasks that people do in their lives. A proper recovery needs to be maintained and achieved to prevent limiting movement, and can be done through simple movements.

==Additional images==
<gallery mode="nolines">
File:Shoulder joint.svg|Human shoulder joint, front view
File:Shoulder joint back-en.svg|Human shoulder joint, back view
File:Gray412.png|Muscles on the dorsum of the scapula, and the triceps brachii
File:Gray521.png|The scapular and circumflex arteries (posterior view)
File:Gray810.png|Suprascapular and axillary nerves of right side, seen from behind
File:Gray818.png|The suprascapular, axillary, and radial nerves
</gallery>

==See also==
[[Adhesive capsulitis of shoulder|Frozen shoulder]]

==References==
{{Anatomy-terms}}
{{Reflist|30em}}

{{Muscles of upper limb}}

{{DEFAULTSORT:Rotator cuff}}
[[Category:Rotator cuff| ]]
[[Category:Shoulder]]
[[Category:Upper limb anatomy]]

[[de:Oberarm#Rotatorenmanschette]]