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Rotator Cuff Injury

Questions

What is Rotator Cuff Injury?

The rotator cuff is a group of muscles and tendons that surround the shoulder joint, keeping the head of your upper arm bone firmly within the shallow socket of the shoulder. A rotator cuff injury can cause a dull ache in the shoulder, which often worsens when you try to sleep on the involved side.

Rotator cuff tears are the leading cause of shoulder pain and shoulder-related disability.

The severity is expressed by the number of tendons which are torn, sometimes on the size of the tear.

Symptoms of Rotator Cuff Injury

Individuals with rotator cuff tear may suffer from:-

·         severe pain at time of injury

·         pain at night

·         pain with overhead activities

·         positive painful arc sign

·         weakness of involved muscle

·         shoulder stiffness.

Causes of Rotator Cuff Injury

Rotator cuff tears can be caused by:

·         degenerative changes

·         repetitive micro traumas

·         traumatic injuries

Ø  falling on an outstretched hand

Ø  Unexpected force when pushing or pulling

Ø  During shoulder dislocation

·         Atraumatic injuries

Ø  Excessive repetitive motions

Ø  Age – related muscle deterioration

·         Intrinsic factors

Ø  Poor vascularity

Ø  Alterations in material proportions

Ø  Alterations in matrix composition

·         Extrinsic factors

Ø  Subacromial and internal impingement

Ø  Tensile overload

Ø  Repetitive stress

Smoking and inflammation of the joint capsule (frozen shoulder) can also lead to a higher risk for a rotator cuff tear. Also, thyroid pathologies could play a role in rotator cuff tear pathology.

Diagnosis of Rotator Cuff Injury

Diagnosis is based on:
1. History:
The therapist should check for yellow flags for shoulder injuries:

·         Passive coping tendencies

·         Depression

·         Fear Avoidance Beliefs

·         Pain Syndromes

·         Concurrent Psychological Illness

·         Worker’s Compensation

·         Lack of family/community Support

2. Clinical examination - The physical examination should include inspection and palpation, range of motion testing, strength testing and special tests.

Active and passive range of motions that the clinician needs to test are: forward flexion, abduction and internal/external rotation at 0° and 90°. Rotator cuff tears lead to loss of active range of motion, passive range of motion is often preserved.

Strength can be tested using a portable hand-held dynamometer. Each motion is predominantly exerted by a specific muscle. We test the external rotation force for the infraspinatus muscle, abduction for the supraspinatus and internal rotation for the subscapularis muscle. Rotator cuff tears often present with shoulder weakness. 

There are many special tests described for examination of the rotator cuff. A few are presented here. 

Tests for Subscapularis

·         Lift-off test and Passive Lift Off Test

·         Belly Press

·         Belly-off sign

·         Bear Hug Test


Tests for Supraspinatus and Infraspinatus

·         External rotation lag sign: 0° and 90°

·         Jobe's test

·         Drop arm test

·         Neer test

Test for Teres minor:

·         Hornblower's sign

3. X-rays (to exclude sclerosis and osteophyte formation on the acromion)
4. 
MRI and ultrasound
5. IMPT (isokinetic muscle performance test): to estimate the functional status of the rotator cuff muscles

Treatment of Rotator Cuff Injury

Medical management:

Conservative treatments-such as rest, ice and physical therapy —sometimes are all that's needed to recover from a rotator cuff injury. If your injury is severe and involves a complete tear of the muscle or tendon, you might need surgery.

Injections- If conservative treatments haven't reduced your pain, your doctor might recommend a steroid injection into your shoulder joint, especially if the pain is interfering with your sleep, daily activities or exercise. While such shots are often temporarily helpful, they should be used judiciously, as they can contribute to weakening of the tendon.

Surgery - Many different types of surgeries are available for rotator cuff injuries, including:

·         Arthroscopic tendon repair. In this procedure, surgeons insert a tiny camera (arthroscope) and tools through small incisions to reattach the torn tendon to the bone.

·         Open tendon repair. In some situations, an open tendon repair may be a better option. In these types of surgeries, your surgeon works through a larger incision to reattach the damaged tendon to the bone. Compared to arthroscopic procedures, open tendon repairs typically heal in the same length of time but recovery may be more uncomfortable.

·         Tendon transfer. If the torn tendon is too damaged to be reattached to the arm bone, surgeons may decide to use a nearby tendon as a replacement.

·         Shoulder replacement. Massive rotator cuff injuries may require shoulder replacement surgery. To improve the artificial joint's stability, an innovative procedure (reverse shoulder arthroplasty) installs the ball part of the artificial joint onto the shoulder blade and the socket part onto the arm bone.

Physical therapy management:

Goals to be achieved with physical therapy:

·         Reducing pain and muscle tension in the scapular and neck area in order to promote the motility of the scapula.

·         Improving the wrong humeral head position in order to restore scapulo-humeral mobility.

·         Strengthen the muscles that stabilize and move the shoulder, the upper part of the M.

·        Serratus anterior and the intact rotator cuff muscles.

·        Regain proprioception and movement automatism by neuromotor rehabilitation

·        Both nonoperative rehabilitation and postoperative rehabilitation of the rotator cuff involves the following principles.

·        Reduction of overload and total arm rehabilitation

·       There should be no compensatory actions in the upper extremity.

·       It is advised to quickly use the elbow, forearm and wrist in order to strengthen them, especially during long immobilization.

·       Mobilization of the scapulothoracic joint and submaximal strengthening of the scapular stabilizers are indicated. The injured tissues should not be inappropriately stressed or loaded.

·         A technique which is used early in the rehabilitation phase is the scapular protraction and retraction resistance exercise. It involves a side-lying position and specific hand placement to resist scapular protraction and retraction without stress applied on the glenohumeral joint.

·       This exercise begins at low resistance. The glenohumeral joint must be in slight abduction and forward flexion during scapular motion.

·       Restoration of normal joint arthrokinematics

·       Posterior capsular mobilization and stretching techniques are often indicated and applied to improve internal rotation ROM.

·       Promotion of muscular strength balance and local muscular endurance