Elsevier

Manual Therapy

Volume 23, June 2016, Pages 57-68
Manual Therapy

Masterclass
Rotator cuff related shoulder pain: Assessment, management and uncertainties

https://doi.org/10.1016/j.math.2016.03.009Get rights and content

Abstract

Introduction

Rotator cuff related shoulder pain (RCRSP) is an over-arching term that encompasses a spectrum of shoulder conditions including; subacromial pain (impingement) syndrome, rotator cuff tendinopathy, and symptomatic partial and full thickness rotator cuff tears. For those diagnosed with RCRSP one aim of treatment is to achieve symptom free shoulder movement and function. Findings from published 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. However considerable deficits in our understanding of RCRSP persist. These include; (i) cause and source of symptoms, (ii) establishing a definitive diagnosis, (iii) establishing the epidemiology of symptomatic RCRSP, (iv) knowing which tissues or systems to target intervention, and (v) which interventions are most effective.

Purpose

The aim of this masterclass is to address a number of these areas of uncertainty and it will focus on; (i) RC function, (ii) symptoms, (iii) aetiology, (iv) assessment and management, (v) imaging, and (vi) uncertainties associated with surgery.

Implications

Although people experiencing RCRSP should derive considerable confidence that exercise therapy is associated with successful outcomes that are comparable to surgery, outcomes may be incomplete and associated with persisting and recurring symptoms. This underpins the need for ongoing research to; better understand the aetiology, improve methods of assessment and management, and eventually prevent these conditions.

Introduction

In most cases assessing an individual presenting with a musculoskeletal shoulder problem involves making clinical decisions in highly ambiguous situations (Lewis et al., in press). As part of the assessment process, clinicians need to determine if the symptoms are:

  • (i)

    Referred or related to another cause (e.g. from the cervical, thoracic, abdominal regions, neural and vascular tissues)?

  • (ii)

    Primarily related to a stiff shoulder (e.g. frozen shoulder, osteoarthritis, locked dislocation, neoplasm-such as osteosarcoma)?

  • (iii)

    Due to shoulder instability?

  • (iv)

    Related to the soft tissues (e.g. rotator cuff, bursa)?

  • (v)

    Due to combinations of the above?

In addition to this, clinicians need to; exclude serious pathology, consider pain mechanisms, determine the relationship and influence of other co-morbidities, and discern the contribution from often profound, obscured and interwoven psychosocial factors. The process is complicated and becomes more so with the emergence of new research information from a multitude of specialities, which is frequently incomplete, and often contradictory.

The purpose of this Masterclass is to focus on one musculoskeletal shoulder problem, rotator cuff related shoulder pain (RCRSP), and discuss; function, pain, aetiology, imaging, surgery, assessment and management.

Section snippets

Rotator cuff function

The rotator cuff (RC) muscles and tendons are commonly considered to be recruited synchronously and equally to dynamically stabilise the humeral head onto the glenoid fossa during shoulder movement. This precept has been challenged and laboratory data suggest that the supra- and infraspinatus are recruited preferentially during shoulder flexion and subscapularis is recruited at higher levels during extension. Higher supra- and infraspinatus activation during shoulder flexion may contribute to

Rotator cuff related shoulder pain

RCRSP refers to the clinical presentation of pain and impairment of shoulder movement and function usually experienced during shoulder elevation and external rotation. Although numerous factors including; genetics (Harvie et al., 2004), hormonal influences (Magnusson et al., 2007), lifestyle factors such as smoking (Baumgarten et al., 2010) alcohol consumption (Passaretti et al., 2015), comorbidities and level of education (Dunn et al., 2014), biochemical, patho-anatomical, peripheral and

Aetiology

With respect to mechanism, Neer, 1972, Neer, 1983 argued that 95% of all RC pathology occurred as a result of irritation onto the subacromial bursa and rotator cuff tendons from the under-surface of the over-lying anterior aspect of the acromion calling the condition; subacromial impingement syndrome. This hypothesis has also been embraced by physiotherapists (Grimsby and Gray, 1997). Once diagnosed, Neer (1983) recommended 12 months of non-surgical treatment for those aged over 40 years with

Relationship between imaging and symptoms

Clinical diagnoses are established through discussion with patients and clinical assessment procedures that may be supported by imaging studies and laboratory investigations (Hegedus et al., 2015, Hegedus and Lewis, 2015, Lewis et al., in Press). The reliance on imaging may be problematic, with investigations reporting substantial numbers of people without symptoms demonstrating RC structural failure (Table 1) (Milgrom et al., 1995, Sher et al., 1995, Frost et al., 1999, Girish et al., 2011).

Additional uncertainties associated with surgery

Success rates (good to excellent results) of up to 70–90% following SAD have been reported (Ellman and Kay, 1991, Spangehl et al., 2002). Following surgery there is an extended period of reduced activity and graduated return to function that might take many months. Post-operative protocols typically dictate very slow and gentle movements in the early stages of rehabilitation, with the avoidance of active shoulder movement if the RC has been repaired. Following SAD, studies from Australia and

Assessment and the Shoulder Symptom Modification Procedure

Assessment involves taking a detailed history and discussion with the patient, screening and on-going monitoring for potential red-flag presentations, functional/disability questionnaires, assessment of impairment that may include; range of movement, strength, posterior capsule extensibility, neural tests, pain behaviour, etc. Increasing and decreasing load on the muscle tendon-unit may also help to support clinical hypotheses. Orthopaedic tests and imaging may support the clinical examination.

Exercise therapy

Although a structured exercise program is unequivocally the main intervention for RCRSP (Haahr and Andersen, 2006, Ketola et al., 2013, Kukkonen et al., 2014) consensus on dosage, frequency, method of delivery, acceptable pain tolerance, inter-exercise activity levels, and specific exercise inclusion has not been achieved. Systematic reviews investigating exercise for RCRSP have produced varied findings.

Desmeules et al. (2003) reported limited evidence to support the efficacy of therapeutic

Management of rotator cuff related shoulder pain

Common to all clinical presentations is the need to engage with the individual experiencing the symptoms, allowing the person to voice their needs and concerns. Understanding and acknowledgement of the impact of the problem demonstrates empathy. In addition, patients should be given the opportunity to discuss their understanding of the cause of the symptoms, how quickly they expect to recover, the treatments they may consider to be effective, and, their thoughts on the treatment the clinician

Conclusion

Shoulder diagnosis is fraught with difficulty and assessment techniques such as the SSMP (Lewis, 2009b) may help direct management. Although no intervention can currently guarantee complete reduction in symptoms, both physiotherapists and people with RCRSP should derive confidence that an exercise based approach produces equivalent outcomes when compared to surgery for those diagnosed with subacromial impingement syndrome/RC tendinopathy, and those with atraumatic partial and full thickness

Acknowledgements

The concept for the exercises depicted in Fig. 7 originated from Marjorie Gingras, Physiotherapist, Montreal, Canada.

Many thanks to Dr Karen Beeton PhD, MPhty, BSc(Hons) FCSP, FMACP, University of Hertfordshire, United Kingdom, for help and guidance editing this manuscript.

References (119)

  • G.S. Fleisig et al.

    Kinematic and kinetic comparison of baseball pitching among various levels of development

    J Biomech

    (1999)
  • P. Frost et al.

    Is supraspinatus pathology as defined by magnetic resonance imaging associated with clinical sign of shoulder impingement?

    J Shoulder Elb Surg

    (1999)
  • T.J. Gill et al.

    The relative importance of acromial morphology and age with respect to rotator cuff pathology

    J Shoulder Elb Surg

    (2002)
  • A.J. Hahne et al.

    Do within-session changes in pain intensity and range of motion predict between-session changes in patients with low back pain?

    Aust J Physiother

    (2004)
  • C.E. Hanratty et al.

    The effectiveness of physiotherapy exercises in subacromial impingement syndrome: a systematic review and meta-analysis

    Semin Arthritis Rheum

    (2012)
  • E.J. Hegedus et al.

    Combining orthopedic special tests to improve diagnosis of shoulder pathology

    Phys Ther Sport Off J Assoc Chart Physiother Sports Med

    (2015)
  • J.E. Kuhn

    Exercise in the treatment of rotator cuff impingement: a systematic review and a synthesized evidence-based rehabilitation protocol

    J Shoulder Elb Surg

    (2009)
  • J.E. Kuhn et al.

    Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: a multicenter prospective cohort study

    J Shoulder Elb Surg

    (2013)
  • N. Mura et al.

    The effect of infraspinatus disruption on glenohumeral torque and superior migration of the humeral head: a biomechanical study

    J Shoulder Elb Surg

    (2003)
  • T. Nakajima et al.

    Histologic and biomechanical characteristics of the supraspinatus tendon: reference to rotator cuff tearing

    J Shoulder Elb Surg

    (1994)
  • P. O'Sullivan

    Diagnosis and classification of chronic low back pain disorders: maladaptive movement and motor control impairments as underlying mechanism

    Man Ther

    (2005)
  • R. Ainsworth et al.

    A prospective randomized placebo controlled clinical trial of a rehabilitation programme for patients with a diagnosis of massive rotator cuff tears of the shoulder

    Shoulder Elb

    (2009)
  • K. Akgun et al.

    Is local subacromial corticosteroid injection beneficial in subacromial impingement syndrome?

    Clin Rheumatol

    (2004)
  • C.M. Alvarez et al.

    A prospective, double-blind, randomized clinical trial comparing subacromial injection of betamethasone and xylocaine to xylocaine alone in chronic rotator cuff tendinosis

    Am J Sports Med

    (2005)
  • K.M. Baumgarten et al.

    Cigarette smoking increases the risk for rotator cuff tears

    Clin Orthop Relat Res

    (2010)
  • L.U. Bigliani et al.

    The morphology of the acromion and its relationship to rotator cuff tears

    Orthop Trans

    (1986)
  • C. Braun et al.

    Manual therapy and exercise for impingement-related shoulder pain

    Phys Ther Rev

    (2010)
  • A.J. Carr et al.

    Clinical effectiveness and cost-effectiveness of open and arthroscopic rotator cuff repair [the UK Rotator Cuff Surgery (UKUFF) randomised trial]

    Health Technol Assess

    (2015)
  • E.Y. Chang et al.

    Shoulder impingement: objective 3D shape analysis of acromial morphologic features

    Radiology

    (2006)
  • C.P. Charalambous et al.

    Return to work and driving following arthroscopic subacromial decompression and acromio-clavicular joint excision

    Shoulder Elb

    (2010)
  • J. Clark et al.

    The relationship of the glenohumeral joint capsule to the rotator cuff

    Clin Orthop Relat Res

    (1990)
  • J.M. Clark et al.

    Tendons, ligaments, and capsule of the rotator cuff. Gross and microscopic anatomy

    J Bone Jt Surg

    (1992)
  • E. Codman

    The Shoulder: rupture of the supraspinatus tendon and other lesions in or about the subacromial bursa

    (1934)
  • A.C. Colvin et al.

    National trends in rotator cuff repair

    J Bone Jt Surg

    (2012)
  • P.M. Connor et al.

    Magnetic resonance imaging of the asymptomatic shoulder of overhead athletes: a 5-year follow-up study

    Am J Sports Med

    (2003)
  • C. Cook et al.

    Is there preliminary value to a within- and/or between-session change for determining short-term outcomes of manual therapy on mechanical neck pain?

    J Man Manip Ther

    (2014)
  • J. Cook et al.

    Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy

    Br J Sports Med

    (2009)
  • J.L. Cook et al.

    Managing tendinopathies

  • D.P. Crawshaw et al.

    Exercise therapy after corticosteroid injection for moderate to severe shoulder pain: large pragmatic randomised trial

    BMJ

    (2010)
  • A.A. Daghir et al.

    Dynamic ultrasound of the subacromial-subdeltoid bursa in patients with shoulder impingement: a comparison with normal volunteers

    Skelet Radiol

    (2012)
  • B.J. Dean et al.

    Glucocorticoids induce specific ion-channel-mediated toxicity in human rotator cuff tendon: a mechanism underpinning the ultimately deleterious effect of steroid injection in tendinopathy?

    Br J Sports Med

    (2014)
  • E. Dean et al.

    Lifestyle factors and musculoskeletal pain

  • F. Desmeules et al.

    Therapeutic exercise and orthopedic manual therapy for impingement syndrome: a systematic review

    Clin J Sport Med Off J Can Acad Sport Med

    (2003)
  • C.J. Dillman et al.

    Biomechanics of pitching with emphasis upon shoulder kinematics

    J Orthop Sports Phys Ther

    (1993)
  • H. Dollings et al.

    Shoulder strength testing: the intra-and inter-tester reliability of routine clinical tests, using the PowerTrack II Commander

    Shoulder Elb

    (2012)
  • W.R. Dunn et al.

    Symptoms of pain do not correlate with rotator cuff tear severity: a cross-sectional study of 393 patients with a symptomatic atraumatic full-thickness rotator cuff tear

    J Bone Jt Surg

    (2014)
  • J.G. Edelson et al.

    Anatomy of the coraco-acromial arch. Relation to degeneration of the acromion

    J Bone Jt Surg

    (1992)
  • H. Ellman

    Diagnosis and treatment of incomplete rotator cuff tears

    Clin Orthop Relat Res

    (1990)
  • H. Ellman et al.

    Arthroscopic subacromial decompression for chronic impingement. Two- to five-year results

    J Bone Jt Surg

    (1991)
  • J. Feltner MaD

    Dynamic of the shoulder and elbow joints of the throwing arm during the baseball pitch

    Int J of Sports Biomech

    (1986)
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