MasterclassRotator cuff related shoulder pain: Assessment, management and uncertainties
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.
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