Conservative Management of Rotator Cuff Pathology Dustin Maracle, PT, DPT, MS, SCS, COMT, CSCS APTA Board Certified Sports Specialist Clinical Director/Co-Owner: Lattimore Physical Therapy
Presentation Overview: Introduction Brief Anatomy of the Shoulder and Rotator Cuff. Physical Therapist Examination and Diagnosis of the Injured Shoulder. Rehabilitation Considerations for Conservative Treatment of RC: Tendinitis Tendinosis Impingement Partial Tears Role of the Scapula Dyskinesia and Cervical Spine. When to Consider Referral for Surgical Treatment.
Shoulder and Rotator Cuff Anatomy Rotator Cuff (4): Origins/Insertions Innervation Function: Individual Grouped Concavity Compression
Differentiate and Diagnose Proper Patient History regarding Injury (Acute vs Chronic) Posture and observable muscle imbalances Length of Injury/Impairment Onset: Mechanism of Injury or Insidious in its onset Work Environment (Repetition/Overuse) Type of Athlete (Overhead athletes, swimmers, etc.) Previous injuries and PMHx. Note: Cyriax/Maitland: A thorough patient history should provide us with a potential diagnosis before we even begin our physical exam.
Shoulder Physical Examination ALWAYS Rule out the Cervical Spine First! Assess AROM/PROM/Passive Accessory Mobility of Shoulder. Perform Manual Muscle Testing when appropriate. Perform Neurological Screens when appropriate. Assess for Rotator Cuff Tendinopathy vs. Tear vs. Labrum Shoulder Clustering Special Tests: (QUADAS Scores 0-14) Tendinopathy/Impingement (Q = 10) Hawkins-Kennedy Test Infraspinatus Test Painful Arc sign
Shoulder Physical Examination Rotator Cuff Tears (Q = 8): External Rotation Lag Sign The Dropping Sign The Hornblower s Sign Internal Rotation Lag Sign SLAP Lesions (Q = 11): Biceps Load I Biceps Load II Bankart Lesion and/or Anterior Labral Tear (Q = 11): IR MMT < ER MMT Apprehension Test Anterior Release Test ( Surprise Test )
Overall Objectives for Rehabilitation of all Rotator Cuff Injuries: Establish an understanding of the injury and condition. Assess and reduce the patients comparable sign. Restore structural and functional mobility Strengthen dynamic stabilizers of gleno-humeral and scapula-thoracic joints of shoulder Address kinetic chain deficits to reduce overall loading onto the injured shoulder (pillar/core exercise)
Shoulders: None are the same The role of physical therapists has evolved to help other orthopedic specialists treat and diagnose these conditions, and therefore it is our professional responsibility to always: Respect the individuality of all patients, Understand their goals and limitations, Match protocols to each individual patient, and always Monitor their treatments for improved efficiency throughout rehab.
Rotator Cuff Tendinopathies Tendinitis: Acute condition where tendon or tendons become inflamed. Usually seen in the younger patient/athlete, and due to repetitive activities/overuse. Tendinosis: Chronic condition where the tendon or tendons break down as a result of overuse/repetition, usually seen > 40 y/o. Supraspinatus tendon becomes mechanically and biologically disadvantaged. Poor blood supply in supraspinatus tendon, poor ability to heal itself. Analogous to polypropylene rope left out in sun Partial Tears: An incomplete tear of one or more of the rotator cuff muscles of the shoulder. Can be acute traumatic, degenerative. Symptoms can be similar to tendonitis/tendinosis, depending on the injury/reason for tear, and the current state the cuff tendon may be in.
Rotator Cuff Impingement Syndrome Impingement Syndrome: Tendons of the rotator cuff complex become irritated and inflamed as they pass through the sub-acromial space. Primary Impingement: Abnormal bony arch, or Acromion Secondary Impingement: Degenerative Tendinosis, causing thickening of rotator cuff/bursa which are then pinched against otherwise normal acromion. Internal Impingement: Decreased space between rotator cuff and posterior-superior glenoid. Usually seen in OH athletes, where ER/ABD are stressed to their maximum end ranges, placed stress on the contractile, soft tissue. Subcoracoid Impingement: Stress on the subscapularis between the coracoid and lesser tuberosity. Max Hor ADD/IR/Flexion stresses most (e.g. catching a baseball)
Physical Therapy in the Conservative Management of RC Tendinopathies Phase I: Early Injury Protection Phase II: PROM AAROM AROM Phase III: Restore Scapular Control Phase IV: Restore Normal Neck-Scapulo-Thoracic-Shoulder Function Phase V: Restore Rotator Cuff Strength/Stability/Function Phase VI: Restore High Speed, Power, Proprioception Phase VII: Return the Patient to Sport or Work
Conservative Management Phase I: Early Injury Protection: Pain relief, Anti-inflammatory tips, Patient Education. REST: Activity modification, hold on sport causing pain. ICE: 10-30 minutes Compression: Sling or Taping if needed for protection. NSAID s: Contact physician regarding tolerance/interactions. Manual Therapy: Joint mobilizations (Grades I and II for pain relief) Soft Tissue Massage (STM) and Self Myofascial Release (SMR) Modalities: US and TENS may be used in office for Acute pain relief.
Conservative Management Phase II: Address Range of Motion Deficits PROM AAROM AROM as patient can tolerate pain free. May take 6 weeks for new tissue to heal. Scar tissue forms, less pliable than before. Remold tissue to prevent restrictions. Assess and range developed joint capsule tightness that may develop. *Improving ROM most effective with combination of evidence based manual therapy AND patient centered exercise program.
Conservative Management Phase III: Scapular Control Assess for Proper Scapulo-Humeral Rhythm (120/60) Scapular Dyskinesis: The SICK Scapula Scapular Inferior Coracoid Dyskinesia Dyskinesia can be defined as winging or aberrant movements. Type I: Inferior Border Prominence Type II: Medial Border Prominence Type III: Superior Border Prominence Treatment should ALWAYS focus on assessing/correcting the imbalances!
Conservative Management Phase IV: Restore Normal Cervical-Thoracic-Scapulo-Glenohumeral Function Initial Examination should already have ruled out more sinister spine pathology Cervical Radiculopathy/Myelopathy (ULTT/Cervical Rotation < 60/Distraction and Spurling +). Assess for Hypo or Hyper mobility in Cervical and Thoracic Spine Conservative Treatment Focusses on their ability to move and function together properly. Manual therapy including joint mobilizations and manipulations (prn). Isolated and Functional exercises to move into restrictions and out of developed behaviors and postures.
Conservative Management Phase V: Restore Rotator Cuff Function Exercises should focus on control and stability of the cuff muscles, and should be individual and specific. Current Concepts in the Scientific and Clinical Rationale Behind Exercises for Glenohumeral and Scapulothoracic Musculature: JOSPT (Reinold,M., et al.)
Conservative Management Phase VI: Restore Speed, Power, Agility, Strength, Proprioception
Conservative Management Phase VII: Return to Sport or Work Respect the Specificity of the Sport/Activity.
Surgical Treatment for Rotator Cuff When Do We consider a referral for Surgery? Evidence for Conservative Treatment: Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: a multicenter prospective cohort study. 75% of individuals avoided surgery after 2 years despite full-thickness tears. Treatment of non-traumatic rotator cuff tears: A randomised controlled trial with one-year clinical results. One year follow up indicated no difference in surgery vs. conservative treatment of non-traumatic supraspinatus tears. Keep it Simple!! Patient Centered Treatments Progression in reduction in intensity and frequency of symptoms each week. Physical Therapy should NOT continue greater than 4 weeks with no change in patient condition or presentation. Red flags = Immediate referral to specialist. Always keep an open line of communication with other specialists Patients ultimately benefit.
References 1. Reinold, MM, Escamilla R, and Wilk KE. Current Concepts in the Scientific and Clinical Rationale Behind Exercises for Glenohumeral and Scapulothoracic Musculature. J of Orthopaedic and Sports Physical Therapy. 2009;39: 105-117. 2. Whiting P, Rutjes AWS, Reitsma JB, Bossuyt PM, Kleijnen J: The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews. BMC Medical Research Methodology. 2003, 3: 25-10.1186/1471-2288- 3-25. 3. Bagg SD, Forrest WJ. Electromyographic study of the scapular rotators during arm abduction in the scapular plane. Am J Phys Med. 1986; 65: 111-124. 4. Kuhn JE, Dunn WR, et al. Effectiveness of Physical Therapy in Treating Atraumatic Full Thickness Rotator Cuff Tears. A Multicenter Prospective Cohort Study. J Shoulder Elbow Surg. 2013 Oct; 22(10): 1371 1379. 5. Kukkonen J., Joukainen A., et al. Treatment of non-traumatic rotator cuff tears: A randomised controlled trial with one-year clinical results. Bone Joint J. 2014 Jan;96-B(1):75-81. 6. Konrad GG, Jolly JT, et al. Thoracohumeral muscle activity alters glenohumeral joint biomechanics during active abduction. J Orthop Res. 2006; 24: 748-756.