Understanding the Dynamics of Rotator Cuff Muscles

1. The four rotator cuff muscles that are attached to the upper part of the humerus at different points are mentioned from top to bottom:

Supraspinatus originates from the supraspinous fossa and supports medial or internal rotation of the shoulder away from the body and produces 15-degree rotation of the first motion after which the trapezius and the deltoid muscle take over the action (Eovaldi and Varacallo, 2018).

Infraspinatus originates from infraspinous fossa and supports abduction of the arm away from the body centre and it is located at the back of the shoulder blade close to the bond and deep inside the skin (Williams et al., 2020).

Teres minor develops from the lateral scapula border and supports lateral rotation of the arm at the external edge (Gereli et al., 2020).

Subscapularis originates from subscapular fossa and is the strongest of the four cuff muscles and it supports arm rotation towards the midline of the body that is the medial rotation (Aguirre et al., 2021).

The rotator cuff muscles work together by initially flexing and then abducting the arm followed by causing internal and external rotation of the arm. The muscular action leads to the keep the head of the humerus above the glenoid fossa of the scapulary bone for supporting enlargement of the range of motion in the joint and avoiding any form of mechanical obstruction (Kim et al., 2018).

The excessive shoulder girdle protraction adversely affects the rotator cuff muscles by causing damage to the tendons that support its movement and present in a tight space. This is because it causes the rotator cuff tendon to rub against each other against the acromion and initiate inflammation of the tendon. The other way rotator cuff muscles are negatively affected is excessive pressure from the shoulder girdle protraction cause the inflammation may reach to the fluid pockets that lubricate the tendons causes bursitis and at times causes tear of the tendon out of the inflammation (Diaz et al., 2018).

In lifting a book from the table, initially, stabilisation of the humerus head of the shoulder joint is required to support enhanced grip. It is supported with collaborative action from the supraspinatus followed by infraspinatus, teres minor and subscapularis muscles. The lowering of the arm to the side to grip the book on the table include the action of pectoralis major and lastissimus dorsi on the front and back and supraspinatus along with other fibres of the deltoid to be used. The raising of the arms to keep the book on the high shelf involves the action of pectoralis major accompanied by anterior fibres of deltoid muscles to be contracted in supporting the action. Thereafter, to return the arm to the lower position from the extended state, the teres major and latissimus dorsi acts to contract in making the action (Motabar and Nimbarte, 2021; Simon et al., 2017).

2. In the consultation process for remedial massage and soft tissue therapy, the subjective assessment of the patient is done to gather key information regarding their pain, health condition and general health history to understand the problem faced and factors that may be responsible for causing health issues such as pain (Hosseini et al., 2020). In the assessment, the clinician gathers information on the quality, location, severity, behaviour and irritability of the expressed symptoms to understand the level of complication faced by the patients and in which position of the body. The information is assimilated by the physician to be used as diagnosis resource in deciding the probable physical therapy to the delivered to them (Cosyn et al., 2017).

The objective assessment in the remedial massage and soft tissue therapy includes discovering the pathophysiology and clinical signs of the problem rather than only the symptoms. It informs the clinicians regarding the range of movement and current strength of the major tissues and muscles in the body. The information is assimilated by the clinician to understand the internal physiological cause of the problem and it is used to decide the way the psychical therapy is to be provided to the patients so that it helps in effectively resolving the pain with enhanced improvement of the damaged muscles or tissues (Thoma et al., 2018).

3. Phosphagen system: The system is a nature of anaerobic metabolism which generates Adenosine Tri-phosphate (ATP) used in providing energy to all body purpose through creation of creatine phosphate. In the process, very little amount of ATP is generated which provides maximum power required for short amount of activity (Cooke and Wu, 2020). It is significant in sports as it supports enough last-minute increased burst of energy required by the splinter when they explode the sprinter out from the blocks.

Anaerobic system: The system is also known as the lactic acid system in which the body quickly creates energy as ATP and the process is fuelled by glucose as the primary element. The energy allows the muscles to the powered anywhere in the body from 10-30 sec for making any intense effort (Kostrzewa-Nowak et al., 2020). In sports, the anaerobic system is used by the weight lifter in creating quick energy to lift the weight in the last moment above the head.

Aerobic system: The system allows low to medium intensity production of energy in making any activity that last for 2 minutes to few hours (Kostrzewa-Nowak et al., 2020). In football, the Aerobic system is used which is significant as higher the player’s aerobic power, the quicker is their ability in recovering from high-intensity energy burst to continue playing effectively (Gabrys et al., 2020).

The fast and low twitch fibres are two types of skeletal muscle fibres. The slow-twitch fibres are developed for supporting endurance of activities that needs long-term as well as repeated contractions which they accomplish by creating improved supply of oxygen-rich blood in the body for supporting the continuous need for energy (Lysenko et al., 2020). It is important in sports as it helps the sportsman to move or stay still longer such as runners who require stable energy for long-distance running (Lysenko et al., 2020). In contrast, the fast-twitch fibres are those that support short, yet powerful energy burst required for the sudden burst of energy in overcoming fatigue in sports and making swift movement (Plotkin et al., 2021). It is significant in sports activities such as basketball in which increased burst of energy is required for jumps in moving the ball to the goal (Plotkin et al., 2021).

4. Soft tissues therapy assist in enhanced performance of athletes by creating flexibility of the muscles to be stretched. This is because the therapy focuses to loosen and stretch the fascia muscles that stores fat as well as water and acts as passage for the blood vessels, nerves and lymph to the muscles along with acts to reduce friction of the muscular force. Thus, its stretching causes restriction of the muscles to be limited and supports enhanced flexibility required for making extensive free movement during sports or dancing (Kim et al., 2017). The soft tissue muscles help an athlete to perform well by reducing their pain stimulation. This is because the muscle spasms causing pain in athletes are resolved through the soft tissue therapy that lowers the spams by creating increased flow of blood through the muscles, re-aligning the hindered fibres and density of the muscle tissues (Rhyu et al., 2018). In sports and dancing, soft tissue muscles limits injury as it causes improves the blood flow to the issues and raises the tissue temperature along with metabolic rate which enhanced elasticity of the muscle collagen and possible prevention of injury (Nazari et al., 2019).

5. Sprain: The symptoms of sprain include bruising, swelling, limited ability to move, hearing or feeling of pop in the joint where the injury has occurred. The cause of sprain includes walking or exercising in uneven surface, pivoting during athletics, landing on ground with outstretched hands and overextension of muscles (Nathan et al., 2018). The healing time usually includes 2-4 weeks in minor to moderate sprain injuries (Nathan et al., 2018).

Strain: The symptoms of strain include soreness, bruising, swelling, soreness, muscle spasms, stiffness and limited movement. The causes include muscle overextension and fatigue, poor flexibility, hindered conditioning and not warning up prior to execution of any physical action. In case of mild strains, the healing time is 3-6 weeks and in major strain the healing time could take months (Aicale et al., 2018).

Stress fracture: The symptoms of stress fracture include initiation of pain that worsen overtime along with tenderness in the specific sport which reduces with rest. It is caused by increased repetitive force and overuse of muscular action such as repeated jumping, running long distance and others. The healing time is roughly between 6-8 weeks (Young et al., 2020).

Tendonitis: The symptoms of Tendonitis include pain that is dull ace, mild swelling and tenderness. It is caused mainly due to any sudden jury that is caused by repetition of any certain movement overtime. It takes roughly 2-3 weeks for healing (Silbernagel et al., 2020).

Osteoarthritis: The symptoms of osteoarthritis include pain, stiffness of the joint, hindered joint flexibility, tenderness, bone spurs, swelling and grating sensation. It is caused due to the loss of cushion at the ends of the bones in the joints leading increased fraction between the bones to cause depletion of the bone with time. It cannot be healed but the symptoms diminish with rest (Jacquet et al., 2020).

6. The process of breathing includes inhaling air into the lungs to support the absorption of the oxygen from the air through the alveoli into the blood and at the same time absorption of carbon dioxide from the blood to be released out from the lungs in the exhalation process (Cedar, 2018).

The diaphragm is the key muscle involved in supporting respiration as it is present below the rib cage and in the abdominal area which contracts and stretches while inhaling and exhaling during breathing. The accessory muscles that are involved in supporting breathing are sternocleidomastoid, scalene, trapezius, intercostal muscles and pectoralis major muscle (Fogarty et al., 2018).

The presence of stress makes the person face hardship and increased breathing. This is because the condition causes the release of stress hormones that raises the overall blood pressure making the heart to beat faster and blood vessels delivering blood to the organs to be narrowed. It creates chest tightness and the need for increased distribution of the oxygen-rich blood to the organs which raises the breathing as it is the way more oxygen can be included in the blood to be delivered in meeting the need (Zhu et al., 2017). In this condition, the soft tissue therapy helps in avoiding the development of tension in the body responsible in creating stress which in turn helps in improving respiration (Kim et al., 2019).

7. The pain mechanism is classified into three types that are nociceptive, peripheral and central pain mechanisms (Apkarian and Reckziegel, 2019). The nociceptive pain mechanism involves rise of painful feeling due to noxious chemical or ischemic stimuli that cause activation of peripheral reception terminals of primary afferent neuron to support pain perception. The objective symptoms include localised pain perception, cardinal signs of inflammation, maladaptive behaviour due to pain and others. The subjective symptoms include pain related to trauma, absence of any neurological symptoms, rapid resolving of pain, response to NSAIDs or analgesic and others (Clauw et al., 2019).

In the peripheral neuropathic pain mechanism, the pain is initiated as a result of any dysfunction or presence of primary lesion in the peripheral nervous system. The mechanism includes chemical, thermal and mechanical sensitivity along with abnormal and hyperexcitability impulse of pain generation. The objective assessment of the mechanism reveals presence of hyperplasia, latent pain perception, autonomic dysfunction and others. The subjective assessment reveals the mechanism include high pain sensitivity, spontaneous pain which worsen at night and others (Chang, 2018).

The dysfunction or presence of any primary lesion in the central nervous system is the mechanism involved with central pain. The subjective assessment reveals the pain include unremitting pain, disturbed sleep, skin discolouration, irritability due to pain and others. The objective assessment mentions the pain mechanism include symptoms such as the absence of injury, antalgic posture, disuse of the muscle atrophy and others (Clark et al., 2017).

8. Post Isometric Relaxation (PIR): PIR is referred to the technique that causes the decrease of the muscle tone in a single muscle group after the same muscles face brief time of submaximal isometric contraction. The PIR technique initiates by creating position in which the muscle is stretched. Thereafter, isometric contraction is exerted with the help of minimal resistance on the muscle which causes gradual relaxation that is developed with stretching of the muscles as it gradually releases from the contraction (El Laithy and Fouda, 2018). The PIR is used in resolving muscle tension and dysfunction of the joint in myofascial pain syndrome. This is because it works on muscle energy technique according to which it helps in restoring the biomechanism of the muscle which enhances its mobility and the technique supports enhanced blood circulation along with lymphatic drainage which assist in pain improvement (Fahmy et al., 2021).

Reciprocal Inhibition (RI): RI is the process of relaxing muscles of one side pf the joint for accommodating the contraction of another side. RI works by initially making the muscle affected be in a mid-range position while leading the patient to push against barriers whereas the therapist tries to create isometric effects and allows isotonic movement. In this condition, the central nervous system provides message to the muscle making the movement to contract and the tension in the muscles which are causing opposing to the movement to the inhibited with the help from impulse from the motor neuron and later simultaneously relaxing (Hirabayashi et al., 2020). It is further followed by relaxation of the patient along with supporting the individual to exhale while the therapist initiates to apply passive stretch to new barrier. The action is to be used in helping individuals recovering from muscle pain in executing stretched exercise such as running, gymnastics and others. This is because it helps in avoiding muscle tear and assist in making coordinated along with improved movements (Seif et al., 2021).

The combination of PIR and RI would involve autogenic inhibition and reciprocal inhibition. When autogenic inhibition occurs, the submaximal contraction of the muscle would follow stretching of the same muscles whereas in reciprocal inhibition, the submaximal muscle would followed by the experiencing stretching of the opposite muscle. The combination of the therapy is used in supporting enhanced movement among gymnasts. This is because the combined process causes relaxation as well as lengthening of the muscle that assist them to access greater stretch of legs along with their range of making motion of joint movement is faced which assist them in making more effective bending movements (Sathe et al., 2020).

9. Trigger point therapy is referred to neuromuscular therapy which is designed for improving recovery in a speedy way by correcting muscle imbalances and injury which assist in releasing pain. According to Paul St. John Method, the neuromuscular effect of the trigger point is initiated when the trigger points in the muscle are released with the help of external pressure on the affected muscle. It causes increased release of acetylcholine that assist in sustained depolarisation of the affected muscles to be remodelled into contracted muscle fibres and the process assist in overcoming muscle dysfunction and pain (Finn, 2020).

Trigger point therapy is applied in condition when there is the presence of muscle tightness or injury. This is to be applied by making the part of the muscle affected be placed in a relaxed point and the trigger points in the area to be released through external pressure from the therapist. It assists in reprograming the affected neuromuscular system to their normal state and helps in lowering inflammation and promotes healing along with pain reduction (Galasso et al., 2020).

10. The protonation of the ankle is referred to natural ankle movement that occurs with the landing of the foot while walking or running. One of the muscles which act during protonation of the ankle are anterior tibialis that is lengthened by the increased force surpassing the resting muscle force of the ankle showing eccentric contractions. It is followed by extensor digitorum longus to be extended and finally the external hallucis longus that helps in extending the big toe along with helps dorsiflexion of the foot at the site of the ankle (Saki et al., 2021).

The supination of foot is opposite to protonation which occurs during foot impacting the ground and there is not enough space for an inward roll in making foot motions. One of the muscles involved in supination of the foot is tibialis posterior that assist in stabilising the lower leg as well as it contracts to support inversion of the foot along with foot planner flexion at the ankle. The other muscle involved in flexor digitorum longus that assist in inverting the foot and supporting planar flexing of the foot (Domínguez-Morales et al., 2019).

In gait cycle for walking, when protonation happens, the weight of the body is found on inner side of the foot whereas in supination the weight remains on the outside of the foot. In the wing phase, the supination occurs and in this condition the foot is shortened that assist in clearing the ground (Northeast et al., 2018).

11. The myofascial network includes the entire connective tissues of the body extending from the cartilage to bones, ligaments, tendons, muscles, adipose tissues, joint capsules and blood vessels. The network is responsible for controlling body position and posture along with allows efficiency in making smooth body movement (Al‐Moraissi et al., 2020).

In making movement, the role of the myofascial network is to collectively cover the tissues to shape them into different groups and connect them with each other so that responses flow from one another to support required movement. Moreover, the role of the network in movement is to avoid friction of the tissues by wrapping them in surface muscles which avoid pain and inflammation while movement. It helps in creating a triple-layer construction for making muscular movement and it helps in providing greater power throughput the body in making free movement with balance (Wilke et al., 2017).

12. The positional release technique works through neurological action in which a signal is send to the brain through the technique in supporting reduced contraction of muscles. This is executed to assist in resolving chronic muscle spams which cannot be improved through other therapeutic techniques (Kothawale and Rao, 2018).

The positional release technique is to be used in case of acute injuries like whiplash for treating the pain and spams of the muscles. It is to be applied by initially placing the patient in a comfortable position mostly making them lay down. Thereafter, the affected area is to be palpated while instructing the patient to relax. The body part palpated is to be passively moved in the process to release the tension while maintaining light connection over the tender point in response monitoring of the patient. The position is to be managed for 90 seconds and thereafter the patient is asked to be relaxed (Sailor et al., 2018). The positional release is to be applied because it helps in overcoming chronic pain as well as sub-acute ,muscle spams that are related to making the patient feel pain and be disabled since other therapies has failed to resolve the condition (Sailor et al., 2018).

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