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Nonoperative Care of Rotator Cuff Disorders: Physical Therapy, Modalities, and Injectables
Introduction
Rotator cuff lesions are among the most common causes of shoulder pain and upper quarter disability seen in orthopedics and physical therapy. Surprisingly, a lack of data exists on the natural history of patients with rotator cuff disease, but in general the frequency of rotator cuff tears increases with age, and full-thickness tears are uncommon in patients younger than 40. Once thought to be predominately a function of disuse, rotator cuff tears are in fact a pathology more closely associated with active patients and athletes. Rotator cuff pathology spans a broad spectrum of severity from mild impingement to progressive failure, developing ultimately to full-thickness tears of one or more rotator cuff tendons. A large incidence of rotator cuff tears is present in both symptomatic and asymptomatic shoulders across the population. Conservatively, it has been estimated that 5.7 million Americans older than 65 years of age have full-thickness rotator cuff tears. In the United States, approximately 275,000 rotator cuff surgeries are performed annually. Therefore fewer than 5% of people with rotator cuff tears undergo surgery each year.
Rotator cuff failure is usually a gradual, progressive process. The tendons of the rotator cuff are weakened by a combination of factors, including age, repeated microtrauma attrition, repeated steroid injections, impingement hypovascularity, poor oxygen uptake of tendons, and major trauma. Investigators have shown that there is no direct relationship between patients suffering from atraumatic full-thickness tears of the rotator cuff and numerous factors, including pain and severity of the tear, duration of symptoms, or even activity level.
Nonoperative rehabilitation has been shown to be an effective mainstay in the management of rotator cuff pathology. The success of nonoperative treatment has been shown to be similar to results for surgical intervention of rotator cuff tears in randomized trial comparisons. These comparisons documented success rates for nonoperative rehabilitation of rotator cuff tears to be 76% and 92%. A physical therapy program for atraumatic full-thickness rotator cuff tears was found to be effective in more than 80% of patients with at least a 2-year follow-up.
This chapter outlines the critical keys to the successful rehabilitation of nonoperative rotator cuff pathology. It presents an organized multiphased approach to the process, which offers a unique combination of exercise techniques designed to bridge the gap between rehabilitation and the restoration of upper extremity function providing for a higher degree of humeral head control via kinetic linking of the body’s musculature, which is a critical component necessary to return patients with rotator cuff pathology to unrestricted symptom-free activity.
Key Rehabilitation Principles
The keys to the successful nonoperative rehabilitation of rotator cuff lesions lie in the ability to adequately ascertain and appropriately address functional characteristics and underlying pathologies inherent to the shoulder with rotator cuff pathology. These include the intrinsic soft tissue and osseous adaptations evident during physical examination, as well as the extrinsic elements that comprise factors such as age, activity level, and overhead functional demand. These keys include the importance of patient expectations, proper shoulder mobility, the need for a functional scapular base of support, and the critical role that dynamic stability and neuromuscular control play in the rehabilitation of the shoulder with rotator cuff pathology.
Patient Motivation and Expectations
The most important predictor for successful nonoperative treatment has been shown to be patient expectation. In other words, patients who believe that physical therapy will work are much more likely to have a successful result with nonoperative rehabilitation. This fact underlines the need for extensive patient education and positive motivation directed toward influencing a positive mental approach when patients undertake a program of nonoperative rotator cuff rehabilitation. Constructive patient education regarding the fact that nonoperative management even in the presence of a “tear” is the best course of action and framing their expectations in a positive mental framework provides for the best possible outcome when coupled with an appropriate nonoperative rehabilitation program.
Normalizing Shoulder Mobility
Normalizing pain-free shoulder motion and accessory mobility is essential for the successful rehabilitation of the patient with rotator cuff pathology. Attention should be given to restoring physiologic shoulder elevation, internal rotation (IR), and external rotation (ER). Patients with rotator cuff disease present with inferior, posterior-inferior and possibly posterior capsular tightness that needs to be addressed. This asymmetrical capsular tightness has been referred to as a reverse capsular pattern and is managed with joint mobilization techniques, physiologic stretching, and proprioceptive neuromuscular facilitation stretching maneuvers.
Functional Scapular Base
The scapula provides proximal stability to the shoulder joint, enabling distal segment mobility. Scapular stability is crucial for normal asymptomatic arm function, especially in the presence of rotator cuff pathology. Several authors have emphasized the importance of scapular muscle strength and neuromuscular control in contributing to normal shoulder function. The force couples of the upper trapezius, serratus anterior, and lower trapezius play an integral role in arm elevation by posteriorly tilting, elevating, and upwardly rotating the scapula, thereby placing it in a functionally appropriate position for successful activity away from the body.
Patients with rotator cuff pathology frequently exhibit rounded shoulders and forward head posture. This postural positioning is associated with muscle weakness of the scapular retractors due to prolonged elongation and altered length tension relationships between synergistic muscle groups that elevate, posteriorly tip, abduct, and protract the scapula during active arm elevation. In addition, the scapula on the involved side may often appear protracted, depressed, and anteriorly tilted in relation to the contralateral scapula. An anteriorly tilted scapula has been shown to contribute to a loss of glenohumeral joint IR. It is our experience that this abnormal scapular positioning is associated with pectoralis minor muscle tightness, coracoid pain, lower trapezius muscle weakness, and a forward head posture. The lower trapezius muscle is an important muscle in arm function because of its controlling effect on scapular elevation and protraction. Weakness of the lower trapezius muscle may result in improper arm elevation mechanics or a greater propensity toward developing shoulder symptoms during functional activities. Careful assessment of scapular position, mobility, and strength in the patient with rotator cuff pathology is essential to ensure symptom-free use of the arm.
Neuromuscular Control and Dynamic Stability
Neuromuscular control plays a critical role in the generation of dynamic shoulder stability. Neuromuscular control refers to the continuous interplay of afferent input and efferent output in an individual’s awareness of proprioceptive joint position and the ability to produce a voluntary muscular contraction to stabilize the glenohumeral joint, preventing excessive humeral head translation.
The primary stabilizers of the glenohumeral complex produce a combined muscular contraction that enhances humeral head stability during active arm movements. The combined effect of the rotator cuff musculature is a synergistic action that creates humeral head compression within the glenoid and counterbalances the shearing forces generated by the deltoid. These muscles act together in an agonist/antagonist relationship to both effect movement of the arm and at the same time stabilize the glenohumeral joint.
Additionally, active glenohumeral joint stability is provided through blending of the rotator cuff tendons in the shoulder capsule, which produces tension with the capsular ligaments. This tension serves to actively tighten the glenohumeral capsular complex and thereby accentuates centering of the humeral head within the glenoid fossa.
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