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
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).
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).
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).
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.
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.
To relieve pain
To restore normal range of motion – active and passive
To improve functional strength of the rotator cuff muscles
To restore the ability of the rotator cuff to dynamically stabilise the humeral head during active movements
Task-specific rehabilitation exercises
Facilitate integration of the kinetic chain
Four factors have been identified with successful outcome following conservative management (Tanaka et al., 2010). They are
- Preserved active range of motion in external rotation ( more than 52 degrees)
- Negative impingement signs
- Little or no atrophy of the supra-spinatus muscle
- 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).
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.
- Demographics ( Younger age and male gender)
- Clinical factors ( Absence of diabetes mellitus and obesity, higher level of sporting activity, greater pre-operative range of motion of shoulder)
- Factors related to cuff integrity ( Smaller sagittal size of cuff lesion, less retraction, less fatty infiltration, no multiple tendon involvement)
- Surgical factors ( No concomitant biceps or AC joint procedures).
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.
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