Rotator Cuff Disease. A Guest Blog by Benoy Mathew

I'm pleased to give you another great guest blog on 'The Sports Physio' on a subject close to my heart, the shoulder! Ben who is a ESP physio in the NHS and can be found on twitter at @function2fitnes has done an academical review of common issues with the rotator cuff. Now despite being a very informative article I unfortunately do not agree with the term 'Rotator Cuff Disease' that Ben has used, in fact I loathe it, despite it often being used in the literature. In my opinion calling the rotator cuff diseased implies it's sick, infected, contaminated, rotten etc which it's just not, it's often tendinopathic, torn or painful and these I feel are much more accurate descriptions to use, and an even better term is simply Sub Acromial Pain until a firm diagnosis of any specific structure can be made, anyway Ben will now take us though Rotator Cuff Disease Sub Acromial Pain

Introduction

This narrative review will explore current understanding in relation to pathology, treatment and prognosis of (rotator cuff disease) sub acromial pain with reference to literature specifically relating to degenerative rotator cuff tears. (Rotator cuff disease) Sub Acromial Pain is the most commonly diagnosed shoulder disorder in primary care, accounting for nearly half of all shoulder complaints. It is an umbrella term which encompasses a spectrum of diseases that includes rotator cuff tendinopathy, subacromial bursitis, partial thickness and full thickness rotator cuff tears (Hermans et al., 2013). There are low recovery rates for degenerative rotator cuff tears, even three years after onset with considerable effect on health and basic activities of daily living (Winters, 1999). Degenerative rotator cuff tears tend to occur in older patients (over 50 years old) and commonly present with progressive shoulder pain with no obvious history of trauma (Clement, Nie & McBirnie, 2012).

Patho-physiology

The rotator cuff (RC) is responsible for dynamic stabilisation of the shoulder and opposes superior translation of the humeral head during elevation. The RC tendons are not isolated structures and cadaveric evidence has shown that the tendons of supraspinatus, infraspinatus and subscapularis interdigitate to form a common and continuous insertion on the humerus (Clark & Harryman, 1992).

It is probable that the cause of degenerative tendon pathology is multi-factorial and various models have been proposed. There is a linear relationship with age since nearly 50% of asymptomatic patients over the age of 60 have RC tears on imaging (Sher, Uribe, Posada, Murphy, & Zlatkin, 1995). Histological evidence have shown that the pre-existing degenerative changes in the middle and deep fibres of the rotator cuff tendons in association with micro-trauma as the primary cause of degenerative cuff tears (Hashimoto, Nobuhara, & Hamada, 2003). There is bio-chemical evidence that an inflamed and thickened su-acromial bursa (SAB) is the primary pain generator in rotator cuff disorders (Blaine et al., 2005). Although external factors may play a role in the progression of RCD, genetic , vascular and age- related processes have been implied in the development of degenerative rotator cuff tears (Yamaguchi et al., 2006).

Clinical Examination

The utility of physical provocation examination tests to enable the clinician to arrive at a structurally specific diagnosis has been challenged (Lewis, 2009). Since the rotator cuff tendons are not isolated structures, it is extremely unlikely that an individual test can isolate a specific tendon during physical examination. Further, the highly innervated sub-acromial bursa is closely linked with the tendons during movements. In primary care, a positive painful arc test result and a positive external rotation resistance test result were the most accurate findings for detecting (RCD) SAP whereas the presence of a positive lag test (external or internal rotation) result was most accurate for diagnosis of a full-thickness rotator cuff tear (Hermans et al., 2013).

Imaging

An ultrasound scan offers dynamic assessment of the rotator cuff and is cost-effective, relative to a MRI scan. However, it is operator dependent. A MRI scan also evaluate tear size and retraction, but in addition the rotator cuff muscles can be assessed for fatty atrophy which predicts surgical outcomes after tendon repair.

Management

Conservative management of partial thickness rotator cuff tears has been recommended by many authors prior to surgical treatment (Ainsworth & Lewis, 2007; Pegreffi et al., 2011). There is considerable evidence for the effectiveness of exercises therapy to improve clinical outcomes in patients with rotator cuff disorders (Kuhn, 2009). It is superior to wait-and-see approach or placebo treatment in primary care (Lombardi, Magri, Fleury, Da Silva & Natour, 2008). A recent multi-centre randomised trial has shown that nearly 75% of patients improved clinically and avoided surgical repair by performing rotator cuff strengthening, soft tissue mobilisation and joint mobilisation despite having full thickness tears (Kuhn et al., 2013). A three phase rehabilitation programme has been recommended in the management of degenerative rotator cuff tear (Pegreffi, 2011) – see table below.

Stage One

Goals

Phase One

1.

To relieve pain

2.

To restore normal range of motion – active and passive

Phase Two

1.

To improve functional strength of the rotator cuff muscles

2.

To restore the ability of the rotator cuff to dynamically stabilise the humeral head during active movements

Phase Three

1.

Task-specific rehabilitation exercises

2.

Facilitate integration of the kinetic chain


Four factors have been identified with successful outcome following conservative management (Tanaka et al., 2010). They are

  1. Preserved active range of motion in external rotation ( more than 52 degrees)
  2. Negative impingement signs
  3. Little or no atrophy of the supra-spinatus muscle
  4. Preserved intramuscular tendon of the supra-spinatus tendon

There was no additional benefits with inclusion of manual therapy with exercises from the findings of a systematic review (Ho, Sole, & Munn, 2009). There was only minor effect on pain intensity after 5 weeks. Steroid injections remain a popular choice despite the potential deleterious effects such as tendon atrophy and decreased tissue quality (Pegreffi, Paladini, Campi, & Porcellini, 2011).

Surgery

Active 20 to 50 year old patients with an acute traumatic tear and severe functional deficit from a specific event are best treated with early surgery (Clement et al., 2012). Further, patients who do not respond to structured conservative management might benefit from surgical review. Prolonged conservative management in symptomatic rotator cuff patients can lead to increased difficulty of surgical repair secondary to muscle atrophy with fatty infiltration and retraction of tendon (Oh, Wolf, Hall, Levy, & Marx, 2007). Complete restoration of muscle strength after surgery can take more than one year postoperatively.

Based on a recent systematic review, twelve prognostic factors, which could be divided into four categories, were identified as being associated with better recovery (Fermont, 2014). Knowledge and understanding of these prognostic factors can be useful for the decision-making process concerning surgical referral.

They are

  1. Demographics ( Younger age and male gender)
  2. Clinical factors ( Absence of diabetes mellitus and obesity, higher level of sporting activity, greater pre-operative range of motion of shoulder)
  3. Factors related to cuff integrity ( Smaller sagittal size of cuff lesion, less retraction, less fatty infiltration, no multiple tendon involvement)
  4. Surgical factors ( No concomitant biceps or AC joint procedures).

Conclusion

There is no consensus in the literature regarding the exact patho-mechanics involved in the development of degenerative rotator cuff tears. One could argue that it is part of the ageing process. However, it is unclear why some rotator cuff tears become painful whereas a significant number of patients with large full thickness tear are asymptomatic. There is strong evidence for the effectiveness of exercise therapy in the management of RC tears. Given the multi-dimensional nature of the condition, a comprehensive multi-axial approach may be used in the management of this chronic condition.

References:

Ainsworth, R. & Lewis, J.S. (2007). Exercise therapy for the conservative management of full thickness tears of the rotator cuff: a systematic review. British Journal of Sports Medicine, 41(4), 200–210.

Blaine, T. A., Kim, Y.S., Voloshin, I., Chen, D., Murakami, K., Chang, S., et al. (2005). The molecular pathophysiology of subacromial bursitis in rotator cuff disease. Journal of Shoulder and Elbow Surgery, 14(1), 84–89.

Clark, J. & Harryman, D. (1992). Tendons, ligaments and capsule of the rotator cuff. Gross and microscopic anatomy. The Journal of Bone & Joint Surgery, 74(5), 713–725.

Clement, N. D., Nie, Y. X. & McBirnie, J. M. (2012). Management of degenerative rotator cuff tears: a review and treatment strategy. Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology, 4(1), 48.

Hashimoto, T., Nobuhara, K. & Hamada, T. (2003). Pathologic evidence of degeneration as a primary cause of rotator cuff tear. Clinical Orthopaedics and Related Research, 415, 111–120.

Hermans, J., Luime, J. J., Meuffels, D. E., Reijman, M., Simel, D. L. & Bierma-Zeinstra, S. M. (2013). Does this patient with shoulder pain have rotator cuff disease?: The rational clinical examination systematic review. The Journal of the American Medical Association, 310(8), 837–847.

Ho, C., Sole, G. & Munn, J. (2009). The effectiveness of manual therapy in the management of musculoskeletal disorders of the shoulder: a systematic review. Manual Therapy, 14(5), 463–474.

Fermont et al., (2014). Prognostic Factors for successful recovery after arthroscopic rotator cuff repair: A Systematic Review. JOSPT, 44(3), 153- 162.

Kuhn, J. E. (2009). Exercise in the treatment of rotator cuff impingement: a systematic review and a synthesized evidence-based rehabilitation protocol. Journal of Shoulder and Elbow Surgery,18(1), 138–60.

Kuhn, J. E., Dunn, W. R., Sanders, R., An, Q., Baumgarten, K. M., Bishop, J. Y., et al. (2013). Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: a multicenter prospective cohort study. Journal of Shoulder and Elbow Surgery, 22(10), 1371–1379.

Lewis, J.S. (2009). Rotator cuff tendinopathy. British Journal of Sports Medicine, 43(4), 236–241.

Lombardi, I., Magri, A. G., Fleury, A. M., Da Silva, A. C. & Natour, J. (2008). Progressive resistance training in patients with shoulder impingement syndrome: a randomized controlled trial. Arthritis and Rheumatism, 59(5), 615–622.

Oh, L. S., Wolf, B. R., Hall, M. P., Levy, B. A. & Marx, R. G. (2007). Indications for rotator cuff repair: a systematic review. Clinical Orthopaedics and Related Research, 455, 52–63.

Pegreffi, F., Paladini, P., Campi, F. & Porcellini, G. (2011). Conservative management of rotator cuff tear. Sports Medicine and Arthroscopy Review, 19(4), 348–353.

Sher, J., Uribe, J., Posada, A., Murphy, B. & Zlatkin, M. (1995). Abnormal findings on magnetic resonance images of asymptomatic shoulders. The Journal of Bone & Joint Surgery, 77(1), 10–15.

Tanaka, M., Itoi, E., Sato, K., Hamada, J., Hitachi, S., & Tabata, S. (2010). Factors related to successful outcome of conservative treatment for rotator cuff tears. Upsala Journal of Medical Sciences, 115(3), 193–200.

Winters, J. (1999). The long-term course of shoulder complaints: a prospective study in general practice. Rheumatology, 38(2), 160–163.

Yamaguchi, K., Ditsios, K., Middleton, W. D., Hildebolt, C. F., Galatz, L. M., & Teefey, S. A. (2006). The demographic and morphological features of rotator cuff disease. A comparison of asymptomatic and symptomatic shoulders. The Journal of Bone and Joint Surgery. American Volume, 88(8), 1699–704.

 

 

2 thoughts on “Rotator Cuff Disease. A Guest Blog by Benoy Mathew

  1. “Disorder” is more aptly used to designate the same kind of affliction denoted by the word “disease” by this British author. “Disorder” is preferred in American literature and is certainly less linked to the notions of infection conveyed by the word “disease”.

    I welcomed the reminder that the three major tendons of the rotator cuff are not easily distinguished by physical examination as they “interdigitate to form a common and continuous insertion on the humerus”.

    Some doctors prefer ultrasound images to RMI as being more precise, but they are aware that their quality depends very much on the skill of the operator, so that getting both images seems to be the solution.

    The conclusion of this article tends to incriminate ageing and degeneration of rotator cuff muscle fibers as the major cause of “rotator cuff disorder” or “sub-acromial pain”, often resulting in partial or total tear.

    And so, for us aging members of the 3F club (physical fitness fanatics), the advice is to maintain strength and function of shoulder joints by remaining faithful to a regular routine of shoulder exercises.
    I try to do some myself nearly every day, or every second day, while watching opera on YouTube.

    I can attest that in my case, over a period of 6-7 months the improvement of sub-acromial pain (due to osteophytes forming under the subsurface of the acromion and rubbing on the tendon of the supraspinatus) has been noticeable. As a consequence I have refused any injection of cortisone and prefer to depend on regular physical therapy exercises with applications of heat whenever needed.

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