Rotator Cuff Tendonopathy
The rotator cuff includes four tendons: the supraspinatus, infraspinatus, teres minor and subscapularis as they insert into the capsule of the glenohumeral (ball and socket) joint. Collectively, the primary function of the rotator cuff is to stabilize the shoulder while the larger muscles move it. The supraspinatus muscle is also called upon to eccentrically decelerate an athlete’s arm after ball release, tennis serve, etc.
Rotator cuff injury is the most common problem to affect the shoulder, accounting for 4.5 million physician office visits per year (1). Injuries range from a mild strain of a single tendon to complete rupture of multiple tendons. Strains of the rotator cuff can occur abruptly from a single insult (falling, pushing, pulling, throwing or lifting) but more commonly ( over 90 percent) develop from multiple factors-including repetitive injury and age-related changes (2,3,4,31,33). Damage often begins and progresses from a partial to a full thickness tear (54,56,57). A “full thickness tear” is sometimes termed a “complete tear” and is not a rupture, but rather a hole or a slit in the tendon much like what would be created by running a knife lengthwise down the center of a rope. Most tears begin in the supraspinatus but may progress to involve the infraspinatus and subscapularis (3).
The rotator cuff is predisposed to damage by a multitude of factors including obesity, high cholesterol, genetics or a history of corticosteroid injections (5-10). Impingement may produce recurring damage and impair the cuff’s ability to recover. Shoulder abduction (lifting arm above your head) is thought to impede blood flow by compressing or “wringing out” the critical zone. As we age, the natural vascularity of our tissue decreases while degenerative spurring increases, thereby advancing the age-related progression of degenerative cuff tendon failure (11). Smoking diminishes blood flow and is another known risk factor for the development of rotator cuff pathology. Research suggests that 95% of chronic rotator cuff tears are associated with impingement syndrome(32). Repetitive overhead activity predisposes a patient to impingement related injury- particularly sports like baseball, swimming, volleyball, tennis, rowing, weightlifting and archery and jobs including carpentry, painting, wallpaper hanging, cleaning windows and washing/ waxing cars. The unilateral nature of these tasks makes rotator cuff injury more common in the dominant arm (12). Patients with scapular dyskinesis or upper crossed syndrome are highly predisposed to rotator cuff damage from repetitive impingement.
Like tendinopathies affecting other areas of the body, the etiology of rotator cuff maladies is now considered more “degenerative” than “inflammatory”. It is a failed healing response (58-65).
Symptoms of rotator cuff injuries:
The clinical presentation for rotator cuff injury differs significantly between acute and chronic tears.
Acute injuries, resulting from falls, throws or other powerful movements, begin as a “tearing” or “snapping” feeling accompanied by severe pain and weakness, particularly shoulder abduction.
Chronic or degenerative tears usually begin silently with widely variable symptoms, becoming more evident as the tear progresses (13). Patients often report gradual onset pain and weakness accompanied by clicking or noises in their shoulders. Pain may be localized to the anterolateral aspect of the shoulder but can radiate down the arm. Early symptoms are provoked by overhead activity and may progress to the point that the patient has difficulty raising their arm overhead. Pain is often worse at night, particularly when lying on the affected shoulder (36).
Signs of rotator cuff injury:
Shoulder range of motion testing will likely demonstrate limited passive internal rotation and decreased active elevation and abduction. (14-16) Slightly diminished internal rotation ROM on the patient’s dominant shoulder is common. Your doctor will also perform some orthopedic tests to determine if the rotator cuff is injured or aggravated.
The importance of proper scapulohumeral rhythm cannot be overstated. The scapula serves as a functional platform for proper glenohumeral mechanics, and alterations in normal mechanics may lead to pathology. Scapular dyskinesis and upper crossed syndrome are two of the most significant contributors to rotator cuff pathology. Glenohumeral to scapulothoracic motion is a 2:1 ratio. Scapular winging may be noted on the affected side. Evaluation of the remainder of the kinetic chain may demonstrate a need to address deficits in hip mobility and core stability as these problems are associated with shoulder injury in throwers (18,19).
Is imaging necessary for rotator cuff injuries?
The decisoin to image the shoulder (and all other imaging) should rely on whether the outcome of the study will affect treatment. Acute injury in a young patient suspected of having a rupture may warrant immediate advanced imaging, whereas an 80-year old patient with slow onset shoulder pain and weakness may not.
In cases where surgery is contemplated, both ultrasound and MRI are highly accurate (90%) in detecting complete rotator cuff tears (21,23, 79-82). MRI arthrography has long been considered the most sensitive test, particularly for detecting partial tears (34), however, it is not routinely recommended for diagnosing rotator cuff tears as it has a marginal benefit over plain MRI or Ultrasound (79). The likelihood of finding a rotator cuff tear on advanced imaging is relatively proportionate to the patient’s age. Researchers have shown that asymptomatic rotator cuff defects are present in 10% of those under the age of 20, 50% of people over 70 years of age, and 50-80% of people over 80 years of age (24,74,76,88). Not all tears are the source of the symptoms.
Treatment and management of rotator cuff injuries:
Although there is no consensus on the most appropriate management for rotator cuff injuries, current research suggests that conservative care should be the first choice for most non-traumatic tears (25, 45,75,76). The decision to initiate conservative versus surgical management should be based on acuity, tear size, age and loss of function (5). Data suggests that conservative management of partial thickness and chronic full-thickness tears yields good outcomes (5,28,29). Success rates for conservative care vary between 33-92%, and the prognosis seems to be based on the patient’s history, tear size and duration of symptoms (25). Findings from high-quality research investigations “suggest that a graduated and well-constructed exercise approach confers at least equivalent benefit as that derived from surgery for; subacromial pain (impingement) syndrome, rotator cuff tendinopathy, partial thickness rotator cuff (RC) tears and atraumatic full-thickness rotator cuff tears” (75).
*Long-term non-operative outcomes compare to surgical repairs (91).*
The conservative management of rotator cuff injuries should include activity modification, stretching, strengthening, manual therapy, and restoration of scapular mechanics (86). Patients should avoid painful overhead activity, carrying heavy objects and sleeping on the affected side, especially with the arm stretched overhead. Patients may benefit by sleeping on the unaffected side with a pillow between their affected arm and trunk. Smokers should consider a cessation program. Overweight patients would benefit from a diet and aerobic exercise regimen.
Early interventions should minimize stressful loading of the injured tissues. Stretching and myofascial release techniques may be appropriate for the pectoral muscles, infraspinatus, teres minor, subscapularis, trapezius, levator and posterior capsule.
Transverse friction massage or IASTM may be implemented judiciously to enhance remodeling of scar tissue.
Low-level laser therapy may be helpful (86)
The use of elastic therapeutic tape may help to facilitate or inhibit muscular function.
Joint mobilization and manipulation are appropriate for restrictions in the scapulothoracic, glenohumeral joint, and cervicothoracic spine (30).
There is evidence to suggest that cervicothoracic and thoracic spine manipulation may help decrease shoulder pain while improving mobility and function (41-44,73).
Rotator cuff rehab should begin with moderate effort and low repetitions. Response to tensile loading may be assessed by the patient’s change in night pain. Increases in night pain indicate the current rehab load is excessive. Progression advances when the patient tolerates a given level of tensile load. (89).
Gentle range of motion exercises can begin with Codman pendulum exercises, wall walking and stick or towel exercises.
Stretching exercises should focus on restoring adduction, internal rotation, and external rotation. This may be accomplished by a cross body stretch and sleeper stretch.
Progressive resistance exercises can be implemented as tolerated for the rotator cuff and periscapular musculature, particularly the external rotators, serratus anterior and lower trapezius. Clinicians should correct deficits of hip mobility or trunk stability in throwers. Other treatment options:
The use of NSAIDs should be limited as these drugs inhibit collagen synthesis and may interfere with natural healing (71,72,79,83,84,85).
Although PRP injections have been shown promote tendon healing (68,69), existing literature does not support their use for rotator cuff tendinopathy. (56,70,71).
Patients who fail conservative therapy may have an orthopedic consultation.
Rotator cuff surgery patients who undergo concurrent biceps tendon repair demonstrate lower effectiveness. (87)
Arthroscopy patients demonstrate improved functional scores when a post-surgical sling is not utilized (92).
At Creekside Performance Center, we are highly trained to treat this condition. We are the only inter-disciplinary clinic in Sheboygan county that provides chiropractic, myofascial release, ART (Active Release Technique), massage therapy, acupuncture, physiotherapy, rehabilitative exercise, nutritional counseling, personal training, and golf performance training under one roof. Utilizing these different services, we can help patients and clients reach the best outcomes and the best versions of themselves.
Evidence Based-Patient Centered-Outcome Focused
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