Rotator cuff management series (1/5)

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Recent studies have suggested that patients opting for physical therapy have demonstrated high satisfaction, an improvement in function, and success in avoiding surgery. It has been observed in patients whose repairs fail after surgical repair, that reported satisfaction levels and clinical outcome scores are similar to those with intact repairs.

The authors of this study suggest that the reason for these findings is that because most of the patients in these studies engaged in some form of structured post-operative physical therapy, that it is possible that the post-operative rehabilitation is more responsible for the improvements in outcome.

Rotator Cuff Injury Management CLINICAL PRESENTATION: It can vary by type of injury and mechanism of onset. In addition, superoposterior tears show a loss of active range of motion and weakness in external rotation with a positive lag sign.

Dysfunction of scapulohumeral rhythm and a compensatory shoulder shrug may be observed during active abduction and elevation. Finally, patients with long-standing rotator cuff tears may present with obvious atrophy, with muscular wasting in the supraspinatus also commonly associated with a concomitant infraspinatus tear.

Examination of the athlete should include: History including, palpation. Knowledge of the natural history of rotator cuff tears is important when making treatment decisions to achieve best outcomes for patients.
Glenohumeral stability : Athletes will often demonstrate a painful arc of active motion. . overhead athletes with rotator cuff pathology may present with GIRD; (excessive passive external rotation and limited internal rotation at 90 degrees of glenohumeral abduction (>20º vs. normal side)

IMAGINE INCLUDE:

X rays – rule out bony injury & assess for pre-existing degenerative changes .

MRI scan – gold standard to assess integrity of the rotator cuff tendon, musculature, labrum and articular cartilage. .

Diagnostic ultrasound – Dynamic assessment of rotator cuff injury.

REHABILITATION:

Conservative management should include a comprehensive program. .

A recent review by Edwards et al. (2016), provided an evidence-based 4-phase exercise protocol for the conservative management of rotator cuff injury.

Including:
1. Range of motion
2. Flexibility
3. Strengthening
4. Advanced strengthening/proprioception. .

Focused on:

  1. Eliminating initial pain
  2. Improving mobility
  3. Addressing stability, strength, power, and neuromuscular control
  4. Correcting identifiable issues along the kinematic chain. .

OUR VIEWS ON THIS STUDY :

  • Patients with chronic rotator cuff tears may develop symptoms when they are more active, or that a higher activity level contributes to the development of rotator cuff lesions.
  • Shoulder activity level is correlated with age and gender in patients with symptomatic or atraumatic rotator cuff tears, it does not correlate with the size or severity of the tear. It may be possible that increased activity which helps patients to develop compensatory kinematics and strength, which may prevent or minimize symptoms.
  • If rotator cuff tears spreading into the posterior cuff then it gradually disrupt the balance of muscular forces whihc  impacting GHJ stability and affecting optimal function. Restricted range of motion in external rotation and tears extending from the supraspinatus to the infraspinatus tendon negatively affect the outcome following conservative treatment.
  • Depending on the size and duration of injury conservative trteatment should be consider.
  • Better understanding of who will or who will not respond well to conservative treatment prior to deciding and starting conservative is of utmost important.

The influence of tear size on the success of conservative management is not known.

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Next Up:
2. Early Rehabilitation
3. Intermediate Phase
4. Advanced/Late Stage Rehabilitation
5. Future Directions and Conclusions

Referance:

  1. weiss et al. 2018. Management of Rotator Cuff Injuries in the Elite Athlete. Cur Rev Musc Med.
  2. Edwards et al. 2016. Exercise rehabilitation in the non-operative management of rotator cuff tears