Rotator Cuff Injuries & Physiotherapy
Rotator Cuff Anatomy 101
The shoulder is a ball and socket joint designed primarily for mobility, this in turn can lead to problems with stability. Stability of the shoulder is provided by a combination of ligaments, a fibrous labrum, the joint capsule and the surrounding rotator cuff muscles (Jones, O, 2018). The head of the arm bone is much bigger than the socket of the shoulder blade that it sits into, which makes the shoulder more vulnerable to episodes of instability. This can cause injury to the structures listed above that provide stability. One the structures most commonly affected is the rotator cuff.
The rotator cuff is made up of four muscles supraspinatus, infraspinatus, teres minor and subscapularis (SITS) and its associated tendons. These tendons form a cuff around the head of the arm bone, they work in unity to provide control and stability of the shoulder when you move your arm. Due to the high loads and repetitive movements of the shoulder. Injuries to the rotator cuff can vary from a mild strain, to a tendinopathy, to a full thickness tear (New Zealand Guidelines Group [NZGG], 2004). Some injuries can cause severe pain while others will have no symptoms. They can be injured individually or in combination depending on the mechanism of injury.
Who is at Risk?
Tendinopathies and tears to the rotator cuff can be caused by a specific injury or attributed to a degenerative process. Most are likely caused by some combination of some intrinsic (shoulder anatomy, lack of blood flow) and extrinsic (force/trauma to arm, repetitive activities) factors. Due to high loading of the shoulder, the rotator cuff is exposed to wear and tear, which also explains why tearing of the tendons increases with age (Jones, O, 2018).
There are certain factors that contribute to rotator cuff injury such as history of trauma, limb dominance, being a smoker, having high cholesterol, family history, posture, and certain heavy occupations (Sambandam et al, 2015). Overall, prevalence of rotator cuff abnormalities ranges from 9.7% in patients younger than 20 years of age and increased to 62% in patients aged 80 years or older, regardless of symptoms (Sambandam et al, 2015).
What Goes Wrong When It Goes wrong?
Rotator cuff tears are a common cause of shoulder pain and dysfunction. A rotator cuff tear frequently occurs after seemingly minor trauma to the musculotendinous unit of the shoulder. However, in most cases, the pathologic process responsible for the tear has been a long time in the making and is the result of ongoing tendinitis.
Injuries to the rotator cuff muscles usually happen at the tendon. Tendons are structures that attach muscle to bone, and they are fundamental when transferring load during movements of the joint. There are varying degrees of tears and tendinopathies which are classified using special tests and correlated with appropriate imaging. Tears are usually classified as partial or full thickness tears, which are managed differently depending on your age and levels of physical activity.
Tendinopathies and tendon tears result in pain, decreased exercise tolerance and decreased function. Tendons can go through different stages of change which can include reactive tendinopathy, tendon dysrepair and degenerative tendinopathy (Cook and Purdam, 2009). Again, depending at what stage your tendinopathy is at, will determine how the tendinopathy is managed.
Which Rotator Cuff Tendons are at Risk of Injury:
Rotator Cuff Tendinosis is a process involving failure of collagen fibres to heal (degeneration) frequently due to aging, micro trauma, or blood flow compromise (NZGG, 2004). The supraspinatus and infraspinatus muscle tendons within the shoulder are particularly susceptible to the development of tendinitis and this is associated with various reasons (Waldman, 2018). These are firstly subjected to many repetitive motions and activities above shoulder height; additionally the space in which the musculotendinous unit function is reduced by shoulder bony structures and as mentioned previously poor blood flow to tendons which makes microtrauma in these tendons difficult to heal (Waldman, 2018). As a result, tendinitis to one or more of these tendons for prolonged periods can lead to calcium deposits around the tendon may occur causing constant irritation and secondary complications such as bursitis or neck pain.
Understanding Tendinopathies? What are the Stages of Tendinopathy?
Tendinopathies are viewed as part of a continuum and diagnosis falls into different categories (Cook and Purdam, 2009).
Reactive Tendinopathy: non-inflammatory usually as a result of acute tensile or compression overload. Usually starts after a burst of unaccustomed activity or following a direct blow to the tendon.
Dysrepair Tendinopathy: usually where tendon has attempted to heal but unsuccessfully. Primarily presents in people with chronically overloaded tendons with a variation in age ranges and loading.
Degenerative Tendinopathy: usually found in the older person or the young who are chronically overloaded. There can be focul nodules on the tendon. There is little capacity for reversibility of the degeneration.
What are the Classifications of Rotator Cuff Tears? Classification of Rotator Cuff tears based on NZGG, 2004 Guidelines:
Partial Rotator Cuff Tears occur through a small portion of the muscle or tendon but does not extend through the entire muscle tendon.
Full Thickness Rotator Cuff Tears involve a complete disruption of the tendon and there can be some muscle retraction associated with this.
Massive Rotator Cuff Tears are considered to present when the tear present is greater than 5cm or there are multiple rotator cuff muscles torn.
What else is causing my shoulder pain, differential diagnosis? Other structures that may contribute to shoulder symptoms:
Bursa There are synovial bursae's that sit between tendons and joint which can sometimes become inflamed when there is injury to some of the rotator cuff muscles. This is known as bursitis and can often contribute to some of the pain experienced with a rotator cuff injury. It is usually a sign of impingement (pinching).
Acromioclavicular (AC) joint Structural compromise such as having a hooked acromion can contribute to some symptoms and make your shoulder pain worse.
Tendons such as the long head of biceps. Can cause pain due to tendinosis and calcific tendinosis.
What are the Common Symptoms Related to Rotator Cuff Injury?
Vary largely depending which structure is involved. Most patients report pain with activity and noticeable pain at night especially when lying on the effected shoulder (BMJ, 2018). Majority of the rotator cuff muscles refer pain to outer aspect of shoulder. As this is where the tendons attach to and can cause pain over the side of the shoulder which can refer down into arm/elbow. Partial tears tend to produce more pain compared with full thickness tears as they still have innervated fibres intact and these can produce pain.
Discomfort can also be caused by some of the surrounding muscles compensating for rotator cuff weakness. Patients will often notice a loss in active range of movement of the shoulder joint. You may also notice some weakness around the shoulder especially when lifting away from the body.
Can My Physiotherapist Help with my Rotator Cuff Injury?
Your physiotherapist can provide a thorough assessment of the shoulder joint and local soft tissue. The following processes will be included:
We will conduct a subjective assessment to understand how you did to injure yourself. The onset of your symptoms and movements directly after your injury will give us a good idea of the type and severity of injury.
We will then complete range of motion and local muscle strength testing.
We then will complete specific special tests which help us determine which structures are specifically involved in your injury.
We also look at some of your functional movements especially those associates with work or sports. This allows us to provide specific treatment to your needs.
Lastly, we will assess the neck and mid back to rule out any structures that may contribute to your pain.
Your Physiotherapist can refer you for imaging as required.
Following a thorough examination, your physiotherapist may refer you for an Ultrasound to classify the type of injury you have experienced. Ultrasound has been shown to be a valid tool to assess the rotator cuff. It is a dynamic form of imaging which allows the scanner to move the shoulder joint as they scan to get an accurate diagnosis. Ultrasound has been shown to be as accurate as MRI imaging when assessing the rotator cuff (Singh, JP, 2012).
If deemed appropriate you may also require an x-ray depending on your presenting symptoms to rule out associated fractures that sometimes occur with a large thickness tear.
Should you require further imaging we can refer you to a specialist for more advanced imaging such as MRI or MRA.
How are Rotator Cuff injuries treated? Can Physiotherapist Help?
There is a debate within the scientific literature as to whether rotator cuff tears require surgical intervention or whether a well-structured rehabilitation program can resolve symptoms effectively. There is insufficient evidence to support one option over the other. It usually comes down to the level of damage, to the patient’s symptoms and levels of daily activity which determine what the best course of management is.
Analgesics: Simple analgesic relief such as paracetamol can provide adequate pain relief and has less potential for serious consequences like non-steroidal anti-inflammatories which can in some cases lead to gut bleeding, alterations in renal function and bronchospasm of the lung(NZGG, 2004).
Activity Modification: Unloading the shoulder and allowing the symptoms to settle by taking time away from the activities that aggravate your pain can be beneficial. As symptoms start to settle you can gradually increase the load on the shoulder and work back towards your normal activities (Cook and Purdam, 2009).
Physiotherapy Guided Shoulder Exercises: have been shown to affect the tendon structure and reduce pain. Graded exercises are tailored to your symptoms and stage of injury, which may include passive or assisted movements, static to eccentric loading and strength and conditioning exercises. Eccentric exercises, exercises which strengthen while they lengthen, have been shown to increase collagen production and improve tendon structure in the short and longer term (Cook and Purdam, 2009). Your physiotherapist can complete a supervised exercises program that can be beneficial and help to improve symptoms and function (NZGG, 2004).
Physio Manual Therapy: Research has shown that Mulligans Mobilisations can help to improve range of motion, pain and function of the rotator cuff (Menek et al, 2019). It has also been shown when this is combined with acupuncture it can give further benefit that mobilisations on their own (Wang et al, 2018)
Corticosteroid injection Referral: ACC advisory group note that these should be used with caution. They provide short term relief but the long-term effects have not been established (NZGG, 2004).
Specialist Referral: it is important to refer individuals with larger rotator cuff tears, especially in the younger patient population. If symptoms fail to improve with partial thickness tears after 6 weeks of treatment, a referral to a specialist is advised.
Surgical Treatment as indicated by your Shoulder Specialist: Research has shown that patients who wish to return to higher levels of activity or those with an acute tear have better functional outcomes than those who take the non-operative route (BMJ, 2018). A study published in 2018, followed up patients 10 years post a massive rotator cuff repair and it was noted that the majority of patients maintained considerable improvements functionally and also on imaging after the 10 years (Colin P et al, 2018). 11% experienced complications which included post-operative stiffness and infection. They noted up to 34% of the candidates initially operated on suffered a re-tear of the rotator cuff (Colin P et al, 2018). The decision whether to proceed with surgery is one that is carefully considered based on several factors such as your age, occupation and sporting interests. If your physiotherapist feels your injury warrants a specialist review this can be arranged through the clinic.
References:
Jones, O (2018). Teach Me Series: The shoulder joint. Retrieved from: https://teachmeanatomy.info/upper-limb/joints/shoulder/
Sambandam, S.N. Khanna, V. Gul, A. Mounasamy, V. (2015). Rotator Cuff Tear: An evidence based approach. World Journal Orthopedics: 6 (11): 902-918. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4686437/
New Zealand Guidelines Group [NZGG] (2004). The Diagnosis and Management of soft tissue shoulder injuries and related disorders: Best Practice Evidence Based Guideline. Retrieved from: https://cdn.ymaws.com/www.alaskachiropracticsociety.com/resource/resmgr/imported/shoulder.pdf
Cook JL, Purdam CR Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy British Journal of Sports Medicine 2009;43:409-416. Retrieved from: https://bjsm.bmj.com/content/43/6/409?ijkey=b4717abfe851bb2f74b50df348fba6d411e3d88f&keytype2=tf_ipsecsha
Singh J.P (2012). Shoulder Ultrasound: What you need to know. Indian Journal of Radiology and Imaging. 2(4): 284-292. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3698891/
Colin P, Colmar M, Thomazeau H, Mansat P, Boileau P, Valenti P, Saffarini M, Nover L, and Kempf JF (2018). Clinical and MRI outcomes 10 years after repair of massive posterosuperior rotator cuff teats. Journal of bone and joint surgery: American Volume. 7:100(21):1854-1863. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/30399080
British Medical Journal (2018). Best Practice: Rotator Cuff Injury. Retrieved from: https://bestpractice.bmj.com/topics/en-us/586
Menek B, Tarakci P, Algun Z.C. (2019). The effect of Mulligans Mobilisations on pain and quality of life of patients with rotator cuff syndrome: A randomized control trial. Journal of back and musculoskeletal rehab. 32(1): 171-178. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/30248039
Waldman, S. (2018). Atlas of Common Pain Syndromes. https://books.google.co.nz/books?id=_61SDwAAQBAJ&printsec=frontcover&dq=The+atlas+of+common+pain+syndromes&hl=en&sa=X&ved=0ahUKEwin0o7-yv_oAhWPb30KHeiYBh8Q6AEIKDAA#v=onepage&q=The%20atlas%20of%20common%20pain%20syndromes&f=false
Wang Y, Wang C, Che H, Ye X (2018). Shoulder joint pain of rotator cuff injury treated with electroacupuncture and mulligans mobilisation: A randomized control trial.Journal of Chinese Acupuncture and Moxibution. 12: 38 (1): 17-21. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/29354931
Written by:
Aoife Hennely, Physiotherapist
M.R.S Physiotherapy
Editted by:
Jenny Chen, Physiotherapist.
M.R.S Physiotherapy
Last updated: April 24, 2020