Physiotherapy in Action

Physiotherapy in action: Rotator Cuff Tears

by: - October 18, 2016
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Dr Lucia Corriette

Dr Lucia Corriette

By: Dr Lucia Corriette

Rotator Cuff Tears

Background

The rotator cuff is made up of four muscles located around the shoulder joint. These muscles help to provide stability for the shoulder, which is a very flexible joint. They provide the support needed to keep your arm in the shoulder socket. They come together to form a common tendon around the head of the arm bone or humerus.

Shoulder joint

shoulder-joint shoulder-joint2

Tears of the rotator cuff are relatively common and their prevalence tends to increase with age. Symptomatic tears are more common in the dominant shoulder (for instance the right shoulder in right handed people) and tears in both shoulders occur in 36% of patients. Tears of the rotator cuff occur mainly in the supraspinatus muscle and begin with fraying of the tendon due to friction as it rubs against bone.

rotator-cuff rotator-cuff-tear

Causes
• Due either to injury or wear and tear of the tendon.
• Tears due to injury can occur from lifting a heavy item or sudden sharp movements of the shoulder.
• Tears due to wear and tear are the result of aging.
• Overuse injuries occur because of repeating the same action many times. This can occur as part of your job, normal tasks at home or during exercise/weight lifting.
• Bone spurs may also cause fraying of the tendon as it rubs against the spurs repeatedly.

Signs and Symptoms
• Pain at rest and at night, particularly if lying on the affected shoulder
• Pain when lifting and lowering your arm or with specific movements
• Weakness when lifting or rotating your arm
• A crackling sensation when moving your shoulder in certain positions
• Sudden, severe pain and weakness of your arm (in tears due to injury)

Medical Management

Your physician may refer you for x-rays, computed tomography (CT) scan, ultrasound or (magnetic resonance imaging) MRI. X-rays will show any bony spurs that may be present. They will not show a tear in the tendon. Ultrasound, CT scans and MRI can be used to show the tear and help determine its size or severity.

Conservative or Non-Surgical Management
This includes physiotherapy, rest, and the use of medications such as non-steroidal anti-inflammatory drugs like ibuprofen, naproxen and diclofenac. A steroid injection may be suggested by your physician if other medication and physiotherapy are not helpful in relieving the pain.

Physiotherapy Management
Many patients are referred to physiotherapy for rotator cuff tears. This is often done to avoid the option of surgery. Recent studies have suggested that patients opting for physical therapy have demonstrated high satisfaction, an improvement in function, and success in avoiding surgery.

Physiotherapy management of rotator cuff tears involves the use of pain relieving modalities such as ultrasound; friction massage over the torn tendon; and exercises. Kinesio taping may also be used to relieve pain. The purpose of therapy is pain relief, improved range of motion and improved strength.

Friction massage

Friction massage

Exercise

Exercise

Kinesio tape

Kinesio tape

Surgical Intervention
There are different options for repairing rotator cuff tears but the goal remains the same: Getting the tendon to heal. The type of surgery done depends on several factors, including your surgeon’s experience and familiarity with a particular procedure, the size of your tear, your anatomy, and the quality of the tendon tissue and bone.

Your surgery may be done as an outpatient procedure, in which case you would not have to stay overnight in the hospital. If there are other shoulder problems, such as osteoarthritis, bone spurs, or other soft tissue tears, those may also be dealt with during the operation.

The three techniques most commonly used for rotator cuff repair are traditional open repair, arthroscopic repair, and mini-open repair. Open repair means that an incision (that may be several centimeters long) will be made over the shoulder joint. This may be necessary if the tear is large or complex. Arthroscopy involves the insertion of a small camera into the shoulder joint. The surgeon uses the images shown to guide miniature surgical instruments and repair the tear. The mini-open repair uses newer technology and instruments to perform a repair through a small incision. The incision is typically 3 to 5 cm long.

Following surgery, you will be referred to a physiotherapist for rehabilitation. This physiotherapy programme will progress in stages and is likely to take several months. The treatment will involve a series of exercises that are geared towards improving your ability to move the shoulder joint. Strengthening exercises will begin once the tissues are healed and will progress over several weeks.

Ultimately, physiotherapy is a large part of the management of rotator cuff tears. Most patients are referred to a physiotherapist as part of the conservative or non-surgical treatment. Should surgery be required, the patient will need extensive physiotherapy following surgery in order to regain movement and strength. The rehabilitation of rotator cuff tears occurs over several weeks and even months. Patient commitment to therapy is thus a very important factor as this will have a significant effect on the eventual outcome.

References
1. American Academy of Orthopedic Surgeons. Rotator Cuff Tears. http://orthoinfo.aaos.org/topic.cfm?topic=A00064
2. WebMD. Pain management guide. http://www.webmd.boots.com/pain-management/guide/shoulder-pain
3. Mount Sinai. The Rundown on the Rotator Cuff. http://blog.mountsinai.org/blog/rotator-cuff-injury-prevention/
4. Oliva F, Piccirilli E, Bossa M, et al. I.S.Mu.L.T – Rotator Cuff Tears Guidelines. Muscles, Ligaments and Tendons Journal. 2015;5(4):227-263. doi:10.11138/mltj/2015.5.4.227
5. Edwards P, Ebert J, Joss B, Bhabra G, Ackland T, Wang A. Exercise rehabilitation in the non-operative management of rotator cuff tears: A review of the literature. International Journal of Sports Physical Therapy. 2016;11(2):279-301.
6. Matthewson G, Beach CJ, Nelson AA, et al. Partial Thickness Rotator Cuff Tears: Current Concepts. Advances in Orthopedics. 2015;2015:458786. doi:10.1155/2015/458786.
7. The Moon Shoulder Group, Kuhn JE, Dunn WR, et al. Effectiveness of Physical Therapy in Treating Atraumatic Full Thickness Rotator Cuff Tears. A Multicenter Prospective Cohort Study. Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons . [et al]. 2013;22(10):1371-1379. doi:10.1016/j.jse.2013.01.026.