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Rotate

Derived from Latin rota, which translates to “wheel,” “rotate” as a verb means to move in a circle around a central point, to change which crops are planted in a field, to provide equal opportunities to several people in a group, or switch the location of automobile tires.
For aviators, abbreviated to “r” and preceded by “V” it means to apply yoke back pressure, thereby raising the nose. Doing it properly decreases the distance required to transition to the joy of flight. Doing it improperly can mess up your tail. 

When working properly applied to your shoulder, rotation allows one to play tennis, cast a fly at the noble trout, check the overhead circuit breakers in your cockpit or even wash your hair. If you still have some. When not working properly, these tasks become almost impossible as blinding pain limits movement due to damage to the rotator cuff.

The shoulder is a pretty remarkable piece of engineering. The most mobile joint in the body, it consists of the smoothly surfaced head of the upper arm bone, (humerus), moving hither and thither within a depression (glenoid) in the shoulder blade (scapula) surrounded by a lip (labrum) of rubbery cartilage and fibrous tissue that acts as a shock absorber. 

A series of strong, white, fibrous bands (ligaments) with really cool $100 names tie the humerus to the scapula; once you understand the naming system it is not quite so daunting. For instance, the glenohumeral ligament – yes, you guessed it, joins the humerus and glenoid. In fact, the ligaments surround the bony junction of humerus and scapula and help create a watertight bag around the joint. These ligaments guarantee a lot of the joint stability that we rely on to be able to swing a golf club or reach for the top shelf.

Shoulder movements are a function of various muscles that span the joint and pull the arm up and down, allowing it to rotate in and out and move away from (abduct) and toward (adduct) the side of the chest. Some emanate from the back, chest, and side, as well as from above. There are four muscles that constitute a “cuff” that facilitate rotation:

Supraspinatus – participates in lifting the arm and twisting or rotating inwards 
Infraspinatus – contracting this muscle rotates the arm outwards
Teres minor – assists arm rotation
Subscapularis – when contracting pulls the arm away from the body

These muscles have tendons, white, fibrous tissue that attaches the muscle to bone. There are a number of fluid-filled sacs called bursas that act as buffers between the various structures and which, in the case of problems like rotator cuff injuries, can become inflamed, causing bursitis.

With increasing age, many human tissues deteriorate; being sedentary or overweight hastens this decline. Poor blood supply from smoking, diabetes or the damage done to blood vessels by hypertension also plays a role and this can manifest in the shoulder as a tear to the cuff, one or more of the muscles and tendons that make up this structure, either partial or total. Sometimes, a specific action can induce a tear such as a sudden, violent movement especially while lifting a weight or pulling on something. Like an airplane. This results in point pain, usually in front of the shoulder, tender to touch and rest on at night, and worsened when trying to raise the arm away from your body. There is often weakness as well, especially if the tear is complete, although some weakness may, in fact, be due to limitations in movement due to pain.

It is pretty straightforward to diagnose this problem with a medical history and physical exam, which will include an evaluation of how many degrees the arm can be moved at the shoulder in several directions. A simple X-ray can be used to exclude other causes such as fracture or deposit of malignant cells from the prostate or elsewhere, and if the tear has become chronic, one may see an opacity above the shoulder due to deposition of calcium in the supraspinatus tendon. An MRI scan may help characterize the severity of the tear and help plan treatment.

This is a very common condition, affecting one in five adults, and many can be managed by taking anti-inflammatory medications such as ibuprofen, application of intermittent heat and ice, and physical therapy exercises to strengthen the non-damaged muscles and stimulate better blood supply to induce healing. Exercises include standing facing a wall and “walking” your hands slowly upwards, trying each time to go just a little bit further. Alternatively, using latex bands of increasing resistance can also strengthen the tissues over time. On some occasions, injecting cortisone into the afflicted area may help, but doing this repetitively can lead to tissue degradation and is not recommended.

Although many patients may see symptoms improve with the above modalities, in some cases surgical repair is recommended; this is usually done as a day case under arthroscopic guidance (keyhole surgery). The torn tendon is stitched or stapled back in place, and in order to enhance the time to heal, strength of repair and reduce the risk of a further tear, a variety of regenerative medicine techniques are used, so if you are contemplating surgery, please ask your surgeon about these methods. With hundreds of thousands surgical repairs every year in the US, this is a safe procedure, but recurrence does sadly occur in a significant number, some possibly due to patients not following recommended post-operative rehab regimes.
From a flying perspective, if you are in pain from a new rotator cuff injury, self-ground until you are recovered as you should not be flying if in pain or medicated with prescription drugs. Likewise, in the case of surgery wait until fully recovered and ensure you can provide your AME with copies of the clinical and operative notes and reports of X-rays and MRI procedures.

In helicopters, autorotation is a condition of flight where the rotor is driven by air moving upwards, most commonly used to land when the engine has decided to quit. To enjoy all activities of daily living, including flying, one needs pain-free rotation, autorotation if you will. If you are having issues, see a doctor and explore the options.

You can send your questions and comments to Dr. Sackier via email: [email protected] and listen to his weekly podcasts at:
https://www.emg-health.com/omnipresent/?category=podcasts&therapeutic_area=healthcare

Jonathan Sackier

Dr. Jonathan Sackier is an expert in aviation medical concerns and helps members with their needs through AOPA Pilot Protection Services.

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