clinical review

Rotator Cuff Injuries

Indexing Metadata/Description
 Title/condition: Rotator Cuff Injuries  Synonyms: Rotator cuff tear; injuries, rotator cuff  Anatomical location/body part affected: Glenohumeral joint, rotator cuff musculature (supraspinatus, infraspinatus, teres minor, subscapularis), subacromial space, acromion, coracoid process, acromioclavicular joint  ICD-9 codes 726.10 disorders of bursae and tendons in shoulder region, unspecified; rotator cuff syndrome NOS; supraspinatus syndrome NOS 726.61 complete rupture of rotator cuff 840.4 rotator cuff (capsule) sprain  ICD-10 codes M75.1 rotator cuff syndrome; rotator cuff or supraspinatus tear or rupture (complete) (incomplete), not specified as traumatic supraspinatus syndrome S43.4 sprain and strain of shoulder joint; coracohumeral (ligament); rotator cuff capsule S46.0 injury of tendon of rotator cuff of the shoulder  Reimbursement: No specific issues or information regarding reimbursement have been identified  Presentation/signs and symptoms: Depending on severity of injury (impingement with partial tearing vs. full rotator cuff tear), signs/symptoms may vary(1) With an acute traumatic injury full thickness cuff tears may be associated with sudden weakness in the ability to elevate the arm, while patients with chronic degeneration may have a gradual onset of shoulder weakness with pain and crepitus Overall, anterolateral or posterolateral shoulder pain is often described Pain is worse with elevation, abduction, and overhead activity.(1) The patient may also have pain reaching behind his or her back. Pain may disturb sleep(1) In patients with significant, chronic rotator cuff tears reduced shoulder strength may be more pronounced than shoulder pain(1) Patient may also note significant functional deficits secondary to pain or secondary to range of motion (ROM)/strength limitations(1) Many patients are asymptomatic even with full-thickness rotator cuff tears Symptoms may develop over time. Asymptomatic rotator cuff tears seen on ultrasound became symptomatic in 23.1% of patients over a mean of 2.8 years(2)

Causes, Pathogenesis, & Risk Factors

Authors
Amy Lombara, PT, BS Ellenore Palmer, BScPT, MSc

Reviewers
Diane Matlick, PT Cinahl Information Systems Glendale, California Rehabilitation Operations Council Glendale Adventist Medical Center Glendale, California

Editor
Sharon Richman, MSPT Cinahl Information Systems

May 25, 2012

 Causes Acute cases Falls Shoulder dislocation coupled with rotator cuff tear(3) Direct trauma(3, 4) Lifting/pulling Chronic cases: degeneration of rotator cuff (chronic impingement syndrome)(3, 4)  Pathogenesis Acute: Direct trauma or lifting/pulling injury may result in partial or full-thickness tear of the rotator cuff. Direct trauma may also result in compression of the rotator cuff tendons by the humeral head, resulting in inflammation (tendonitis)(5, 6) Chronic: Repetitive overhead activities result in recurrent compression of the rotator cuff tendons, resulting in inflammation.(5, 6) Continued microtrauma can result in progression from tendonitis to tendinosis, with fibrotic scarring of the rotator cuff tendons. Loss of tensile strength over time can ultimately result in a partial or fullthickness rotator cuff tear. Narrowing of the subacromial space can also contribute to inflammation or rotator cuff tears; this can be caused by sloped/hooked acromion or thickened coracoacromial ligaments or by functional narrowing due to increased superior translation of the humeral head.(5, 6) This results in an impingement of the rotator cuff tendons, with a progression similar to the onset described for repetitive activity

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 Risk factors Several factors have been identified that predispose an individual to rotator cuff tendonitis or rotator cuff tears Aging: Normal wear and tear can contribute to impingement syndrome and rotator cuff tears. Prevalence of full thickness tears increases with age(2) Increasing age correlates with increasing severity of rotator cuff damage: 39% of all persons over age 60 experience full rotator cuff tears(7) Atypical bony anatomy (e.g., acromial hooking/sloping, acromioclavicular spurs)(1) Occupational activities associated with repetitive upper extremity use, especially overhead or lifting Sports that involve repetitive overhead activity (e.g., baseball)(4) Poor posture: Slouching decreases space in subacromial region, potentially leading to rotator cuff impingement during overhead tasks(8) Deficient biological health of soft tissue, impeding the healing process following an injury(1)

Overall Contraindications/Precautions
 Avoidance of exacerbating activities, especially overhead activities, is recommended for patients with rotator cuff tendonitis/tendinosis. Proper throwing/ lifting techniques should be employed to prevent progression of rotator cuff disease. For patients with partial or full rotator cuff tears that are nonsurgical, the same precautions apply. Occupational and leisure activities, as well as therapeutic activities, should be limited to a pain-free range. Avoid strengthening exercises for 2 weeks after corticosteroid injection; evidence has shown tendon weakness for 14 days after injection(7)  See specific Contraindications/precautions under Assessment/Plan of Care

Examination
 History History of present illness/injury Mechanism of injury: Patients may report insidious onset of shoulder pain, progressing over time (chronic). Others may report a specific injury or trauma, resulting in sudden onset of shoulder pain (acute) Course of treatment Medical management: Conservative management may include physical therapy, activity modification, intraarticular injections, and/or medication. Surgical options for rotator cuff repair include:(9) Open repair frequently used in patients with large/massive tears; procedure includes takedown of the deltoid where the deltoid is surgically separated from the acromion (followed by reattachment prior to close) Mini-open repair majority of repair is completed arthroscopically with goal of reducing trauma to deltoid (as compared to trauma sustained to deltoid during open repair) Arthroscopic repair tissue is not retracted during this procedure; instead small incisions are made for placement of cannulas There has been a significant increase in rates of rotator cuff repairs. National trends in the decade from 1996-2006 showed a 141% increase in all rotator cuff repairs, with arthroscopic procedures increasing by 600% while open repairs increased by only 34%(10) Medications for current illness/injury: Determine what medications clinician has prescribed, if any; are they being taken? Does the patient feel they are effectively controlling symptoms? Nonsteroidal anti-inflammatory drugs (NSAIDs) and analgesics are commonly used and generally effective for symptomatic relief.(5, 6) Cortisone injections may be helpful, reducing inflammation and pain and resulting in increased tolerance and performance in physical therapy(5, 6) Diagnostic tests completed: X-ray may identify hooking of the acromion or the presence of bone spurs. MRI may determine the presence and severity of injury to the rotator cuff. MRI with contrast may provide increased sensitivity to rotator cuff pathology. Ultrasound has been reported to be accurate for diagnosing rotator cuff tears, in particular full thickness tears, based on a meta-analysis of 62 studies that included 6066 shoulders(11) Home remedies/alternative therapies: Document any use of home remedies (e.g., ice or heating pack) or alternative therapies (e.g., acupuncture) and whether or not they help Previous therapy: Document whether patient has had occupational or physical therapy for this or other conditions and what specific treatments were helpful or not helpful Aggravating/easing factors (and length of time each item is performed before the symptoms come on or are eased): Typically aggravated by overhead activities Body chart: Use body chart to document location and nature of symptoms, including any referred pain. Rotator cuff myofascial pain syndrome may result in trigger points that refer pain to the anterior shoulder over the biceps brachii area to the antecubital fossa.(12) Tendinopathy of the long head of biceps commonly occurs in patients with rotator cuff tears, and the inflammation in one head tends to lead to inflammation in the other(13) Nature of symptoms: Document nature of symptoms (constant vs. intermittent, sharp, dull, aching, burning, numbness, tingling). What symptoms is the patient experiencing? Any clicking, catching, crepitus? How/when did symptoms begin? Have symptoms worsened or improved over time? Has the patient noticed a loss of strength or ROM? Rating of symptoms: Use a visual analog scale (VAS) or 0-10 scale to assess symptoms at their best, at their worst, and at the moment (specifically address if pain is present now and how much) Pattern of symptoms: Document changes in symptoms throughout the day and night, if any (A.M., mid-day, P.M., night); also document changes in symptoms due to weather or other external variables Sleep disturbance: Nocturnal pain is commonly described and may disturb sleep.(1) Document number of wakings/night, if any. Does patient experience pain in any lying position or only if he/she rolls onto the affected arm? Has patient tried sleeping in semi-reclined position? Other symptoms: Document other symptoms patient may be experiencing that could be indicative of a need to refer to physician

 Barriers to learning
Are there any barriers to learning? Yes No

Medical history Past medical history

If Yes, describe _______________________

Previous history of same/similar diagnosis:

Is there a history of

 Trauma to the shoulder?  Previous shoulder injury/pain/surgery?  Contralateral shoulder injury?  Cervical dysfunction? Comorbid diagnoses: Ask patient about other problems, including diabetes, cancer, heart disease, pregnancy, psychiatric disorders, orthopedic

disorders, etc. Medications previously prescribed: Obtain a comprehensive list of medications prescribed and/or being taken (including over-the-counter drugs) Other symptoms: Ask patient about other symptoms he/she may be experiencing Social/occupational history Patients goals: Document what the patient hopes to accomplish with therapy and in general Vocation/avocation and associated repetitive behaviors, if any: Does the patient participate in overhead sports or other recreational activities? Does the patient do any occupational tasks that require overhead activities and/or repetitive use of the affected upper extremity? Functional limitations/assistance with ADLs/adaptive equipment: Is there any functional limitation noted? Is the patient able to wash his or her hair or under his or her arms? Living environment: Stairs, number of floors in home, with whom does patient live, caregivers, etc. Identify if there are barriers to independence in the home; any modifications necessary?  Relevant tests and measures: (While tests and measures are listed in alphabetical order, sequencing should be appropriate to patient medical condition, functional status, and setting) Assistive and adaptive devices: Document use of any assistive/adaptive devices Balance: Evaluate as indicated by patient history and signs/symptoms Cardiorespiratory function and endurance: Evaluate as indicated Circulation: Distal pulses should be normal Ergonomics/body mechanics: Inquire if patient performs excessive overhead or repetitive motions. Is patients workstation setup contributing to symptoms? Determine if modifications are possible or appropriate Functional mobility (including transfers, etc.): Evaluate as indicated Gait/locomotion: Evaluate as indicated Joint integrity and mobility: Assess for possibility of instability or labral tear in addition to rotator cuff injury. There are several tests for labral tears that may be used. For more information please see Clinical Review...Labrum Lesions, Shoulder: Conservative Management. Accession Number 5000007756. Defects associated with instability of the joint occur in the anterior, superior and posterior directions. If the coracoacromial arch is compromised the humeral head can dislocate anteriorly and superiorly during elevation of the arm, resulting in an unstable situation known as anterosuperior escape. Assess for appropriate scapulohumeral rhythm. Screen cervical spine to rule out cervical pathology with radicular symptoms to the shoulder.(14) Assess glenohumeral joint accessory motion and the posterior and inferior capsule for tightness. Assess scapular mobility Observation: Examine the shoulder for signs of muscle atrophy of the deltoid, supraspinatus, infraspinatus or a mixture Muscle strength: Assess strength of rotator cuff and periscapular musculature using manual muscle testing or dynamometry. Compare to contralateral side. Also, screen remainder of upper extremity for weakness. Pseudoparalysis of the arm occurs when the humeral head is destabilized in the glenoid concavity causing contraction of the deltoid muscle to be ineffective in abducting the arm away from the side Pain: Assess for pain at rest, with active ROM, and with resisted motion of the shoulder. Pain with resisted motion may indicate rotator cuff involvement, but varies depending on muscle involved. Pain felt during isometric resisted external rotation suggests involvement of the infraspinatus; pain felt during internal rotation suggests involvement of subscapularis and during elevation suggests involvement of supraspinatus. Pain radiating down the upper arm to the elbow is common Palpation: Assess for tenderness of the rotator cuff tendons, particularly the supraspinatus (most commonly affected). Palpate and inspect for rotator cuff atrophy. Assess for involvement or abnormality of the acromioclavicular joint. Crepitus may be palpated below the acromion as the arm is rotated, indicating changes from the edges of the torn cuff Posture Assess the neck, clavicles, scapulae, and shoulders and thoracic spine for bilateral symmetry and general posture. Inspect for abnormalities, including rounded shoulders, depressed or elevated humeral head, internally rotated shoulders, kyphosis, forward head posturing, scoliosis, and scapular rotation or winging Note presence of muscular atrophy, which may be evident in the supraspinatus and infraspinatus fossae(3) Range of motion: Determine active and passive ROM of the shoulder. Compare to contralateral shoulder. In partial thickness rotator cuff injuries limitation of internal rotation and abduction is common. Assess for appropriate scapular mobility with shoulder motion Self-care/activities of daily living (objective testing): Evaluate as indicated Sensory testing: The dermatome scan should be normal

 Special tests specific to diagnosis Empty can test (supraspinatus or Jobe test): Patient is seated. Arm is abducted to 90 with neutral shoulder rotation; resistance to abduction is provided
by the examiner. Arm is then internally rotated 30 so that the thumb is pointing downwards. Resistance in abduction is again provided. Weakness or pain is a positive finding for tear of the supraspinatus tendon or muscle(15) Drop-arm test (Codmans test): Examiner abducts shoulder to 90, then asks patient to slowly lower the arm in the same arc. If the patient is unable to return the arm to the side slowly, or if severe pain is present when arm return is attempted, it is considered a positive finding, indicative of a tear of the rotator cuff(15) Neer impingement test: With patient seated, the examiner fully and passively flexes the affected shoulder in the scapular plane with the arm in an internally rotated position. If patients facial expression is consistent with pain, it is a positive finding for overuse injury of the supraspinatus(15) OBriens test: To rule out superior labrum anterior to posterior (SLAP) tear. With patient seated, position shoulder at 90 of flexion and 15 of horizontal abduction; the humerus is in full internal rotation and forearm is pronated. The patient resists examiners downward force placed over the patients distal forearm. Repeat the test with humerus externally rotated and forearm supinated. Pain in the glenohumeral joint with the humerus internally rotated that decreases during external rotation may indicate a labral tear. If there is pain in the acromioclavicular (AC) joint, suspect AC joint pathology Hawkins-Kennedy impingement test: With the patient standing, the examiner forward flexes the patients arm to 90, then forcibly internally rotates the shoulder. Pain with this maneuver is an indication of rotator cuff tendinosis or secondary impingement(15) The majority of clinical tests designed to detect injury of the rotator cuff may be inaccurate(16) Based on a systematic review comprised of 13 studies investigating 14 clinical tests There were 89 different assessments of diagnostic accuracy and the vast majority of the assessments had positive or negative likelihood ratios that were not significant The authors of the review propose that positive results on the following tests may be useful for increasing confidence regarding the presence of a rotator cuff injury Positive palpation Combined Hawkins-Kennedy/painful arc/infraspinatus test Napoleon test: Patients hand is placed flat on abdomen with the hand, wrist and elbow in a straight line. The patient is unable to move the elbow anteriorly Lift-off test: Patient places hand behind back at the lumbar level and attempts to lift it away from the back Belly-press test: With hand placed flat on abdomen and hand, wrist and elbow in a straight line, the patient is instructed to press down on the abdomen. Test is positive if 90 degrees wrist flexion is required Drop-arm test: Examiner passively abducts shoulder to 160 degrees, patient attempts to slowly adduct arm to side. Test is positive if arm drops quickly to side The authors of the review propose that negative results on the following tests may be useful for increasing confidence in the absence of a rotator cuff injury Negative palpation Empty can test Hawkins-Kennedy test Note: The belly-press, Napoleon, and lift-off tests are all designed to assess the integrity of the subscapularis and incorporate shoulder internal rotation and flexion during the maneuvers Disabilities of the Arm Shoulder and Hand (DASH) questionnaire

Assessment/Plan of Care
 Contraindications/precautions Only those contraindications/precautions applicable to this diagnosis are mentioned below, including with regard to modalities. Rehabilitation professionals should always use their professional judgment Postoperative treatment may include a prolonged period of immobilization.(17) Clinicians should follow the guidelines of their clinic/hospital and what is ordered by the patients physician. The treatment summary presented below is meant to serve as a guide, not to replace orders from a physician or a clinics specific protocols Cryotherapy contraindications include:(18) Raynauds syndrome Medical instability Cryoglobulinemia Cold urticaria Paroxysmal cold hemoglobinuria Avoid applying cold over superficial nerves, areas of diminished sensation, poor circulation or slow-healing wounds Cryotherapy precautions include:(18) Use caution with patients who are hypertensive as cold can cause a transient increase in blood pressure; discontinue treatment if there is an elevation in blood pressure Use caution with patients who are hypersensitive to cold Avoid aggressive treatment with cold modalities over an acute wound Use of cryotherapy with patients who have an aversion to cold may be counterproductive if being used to promote muscle relaxation and decrease pain

 Superficial heat is contraindicated with:(19) Decreased circulation Decreased sensation Presence of DVT Acute/subacute traumatic and inflammatory conditions Impaired cognition Malignant tumors Tendency for hemorrhage or edema Very young or old individuals
 Diagnosis/need for treatment: Pain in the anterolateral or posterolateral shoulder that may increase with overhead activity and may disturb sleep. Physical therapy is indicated as a conservative treatment to improve ROM, strength, posture, shoulder mechanics, and functional deficits as well as decrease pain; physical therapy should be attempted prior to surgical intervention in most cases A study to determine which atraumatic tears will progress and/or become symptomatic and/or require surgery identified patient factors associated with pain and loss of function as measured by the Western Ontario Rotator Cuff Index (WORC) and the American Shoulder and Elbow Surgeons (ASES) score(2) Age, tear retraction, duration of symptoms and humeral head migration were not statistically significant Nonsurgically modifiable factors such as scapulothoracic dyskinesia, active abduction and strength in forward elevation and abduction were associated with lower WORC and ASES scores. Physical therapy was identified as treatment that could target these modifiable factors associated with pain and loss of function Physical therapy should be considered the first option in the treatment of irreparable rotator cuff tears(20) Based on a treatment algorithm developed from a literature review of the indications and expected outcomes of interventions for irreparable rotator cuff repair Patients without anterosuperior escape should initially be treated with physical therapy for anterior deltoid training  Rule out(21) Glenoid labral tear Muscle strain Subacromial bursitis Bicipital tendonitis Myofascial pain Fracture Acromioclavicular sprain Tumor Myofascial/vascular thoracic outlet syndrome Cervical radiculopathy Traumatic or atraumatic brachial plexus pathology Suprascapular neuropathy Thoracic outlet syndrome Cardiac pathology  Prognosis In patients with rotator cuff injuries, rehabilitation is most effective when implemented early(22) In one study of 53 patients with full-thickness rotator cuff tears, 74% had no or slight pain following conservative care (follow-up time averaged 7.6 years)(23) Other studies have reported improvement in 33-85% of patients undergoing conservative care, but the selection of patients and the methods used in many of these studies are unclear(7) Patients most likely to opt for surgery following conservative care are those with ongoing pain or sleep disturbance and those who are unable to resume occupational or other functional activities Functional recovery period after arthroscopic rotator cuff repair was reported to be within 6 months for 72% of patients in a retrospective study(24) Functional recovery period was defined as the time required to achieve a score of greater than 80% in each component of the Japanese Orthopedic Association scoring system Younger patients without shoulder stiffness and with smaller rotator cuff tears had shorter functional recovery periods There is moderate evidence that Workers Compensation status correlates with a less favorable outcome of rotator cuff surgery(25, 26) Massive rotator cuff tears (greater than 5 cm in diameter, with at least 2 tendons involved) are associated with a high retear rate after repair(17)  Referral to other disciplines: Refer to orthopedic surgeon for lack of progress with physical therapy, as the injury may require surgical intervention. Also refer to orthopedic surgeon if cortisone injection may be warranted  Other considerations Rotator cuff tears can occur in adolescent athletes, and clinicians should monitor for symptoms potentially indicative of injury to the rotator cuff among skeletally immature patients(27)  Treatment summary: Treatment will vary according to patient presentation (patient presenting postoperatively vs. patient presenting for conservative management) and unique characteristics (e.g., age, history of high activity level vs. sedentary lifestyle). Clinicians should modify treatment plan as indicated by patient needs and physician orders

 Several recent systematic reviews indicate that more research is needed to provide evidence for the effectiveness of interventions to treat rotator

cuff injuries(28, 29, 30) Surgery does not appear to be more effective than active nonsurgical treatment in patients with impingement syndrome(31) Based on Cochrane systematic review The systematic review included 14 randomized or quasi-randomized trials evaluating surgical interventions in 829 patients with rotator cuff disease 11 trials evaluated patients with impingement 2 trials evaluated patients with rotator cuff tears 1 trial evaluated patients with calcific tendinitis All trials included had some methodological limitations No significant differences in outcomes were noted when comparing open or arthroscopic subacromial decompression to active nonsurgical treatment (exercise program, physical therapy regimen of exercise and education, or graded physical therapy strengthening program) in 3 trials with 257 patients (with impingement syndrome) Surgery is more effective than physical therapy for improving pain and function at 1 year in patients with small- and medium-sized rotator cuff tears(32) Based on a randomized trial 103 patients aged 44-75 years with symptomatic small or medium-sized (< 1 cm to 3 cm) rotator cuff tears were randomized to surgery vs. physical therapy Surgery was offered to patients in physical therapy group after 15 physical therapy sessions if no improvement was observed Surgery was open or mini-open repair Patients in physical therapy group completed 9-55 training sessions (mean 24 sessions) 9 patients in physical therapy group had surgery after failing physical therapy 93 patients were followed up at 12 months Changes from baseline to 12 months comparing surgery vs. physical therapy Mean change in Constant score 41.4 vs. 28.4 (statistically significant) Mean change in American Shoulder and Elbow Surgeons score 47.1 vs. 31 (statistically significant) Mean change in pain-free abduction 83 vs. 54.2 (statistically significant) Mean change in pain score (10 cm VAS) -5 cm vs. -3.2 cm (statistically significant) There is limited overall evidence to guide physical therapy treatment of shoulder pain(33) Based on a Cochrane systematic review In patients with rotator cuff disease, exercise was shown to be effective. There was an additional observed benefit when combined with mobilization There was some evidence presented that corticosteroid injections may be more effective than physical therapy for rotator cuff disease There was no evidence found demonstrating the benefit of laser therapy or ultrasound for rotator cuff tendinitis; however, ultrasound and pulsed electromagnetic field therapy was found to be beneficial when compared to placebo in patients with calcific tendinitis Physical therapy and steroid injections appear to have similar outcomes for patients with unilateral shoulder pain(34) Based on a randomized trial The study included 207 patients presenting in primary care facilities with a new episode of unilateral shoulder pain. Patients were randomized to corticosteroid injection vs. physical therapy No statistically significant differences were found when comparing steroid treatment to physical therapy Average improvements in disability scores were 3.03 vs. 2.56 at 6 weeks Average improvements in disability scores were 4.55 vs. 5.97 at 6 months No adverse effects from a progressive rehabilitation program following rotator cuff repair were reported in small randomized trial(35) Based on a small randomized trial 18 patients having rotator cuff repair were randomized to progressive rehabilitation vs. traditional rehabilitation and were followed for 24 months Progressive rehabilitation The day after surgical repair passive ROM and exercises targeting the rotator cuff were initiated Following 4 weeks of immobilization, progressive loading to the rotator cuff began Traditional rehabilitation Immobilization occurred for 6 weeks Passive ROM was initiated the day after surgical correction No exercises targeting the rotator cuff were implemented during the 6 weeks, and loading was avoided 14 patients completed the study Comparing progressive rehabilitation to traditional rehabilitation at 24-month follow-up Progressive group had significantly greater median pain reduction during activity Progressive group had significantly greater median pain reduction at rest Note: Progressive group had higher median preoperative pain scores Compared to baseline Both groups had significant improvement in the Functional Index of the Shoulder score The Constant scores (on modified 75-point scale) were 71 for the progressive group (35 points at baseline) and 73 for the traditional group (45 points at baseline) No adverse outcomes were reported in either group

 Combined aquatic and land-based therapy program appears as effective as land-based therapy alone for passive ROM and quality of life outcomes in

patients having rotator cuff repair(36) Based on a prospective cohort study 18 patients (mean age 55 years) having rotator cuff repair were assigned to combined aquatic and land-based therapy (n = 12) or land-based therapy alone (n = 6) for 12 weeks At 3 and 6 weeks, the patients in the combined program had significantly greater passive shoulder forward flexion ROM when compared with landbased group At 12 weeks, all patients had significant improvement in passive ROM and Western Ontario Rotator Cuff Index scores compared to baseline; there were no significant between-group differences Continuous passive motion (CPM) has been reported safe to use with physiotherapy treatment following rotator cuff repair surgery(37) Based on a systematic review. Three studies with a total of 113 participants ranging in age from 30 to 80 were included It may help prevent secondary complications post operatively CPM in conjunction with physiotherapy significantly improved shoulder range of motion and reduced pain in the short term compared the control group of physiotherapy alone There was no significant reduction in pain at mid or long term

Problem
Pain and inflammation of the rotator cuff tendon(s)

Goal
Eliminate/decrease pain and inflammation

Intervention
Physical agents/mechanical modalities Ice packs to reduce inflammation and pain High- Extracorporeal shock-wave therapy (ESWT) is effective to treat the pain of noncalcific rotator cuff tendinosis based on a systematic review of 17 RCTs(38) Manual therapy Grade I & II mobilizations for pain Patient education and activity modification Rest and avoidance of aggravating factors, posture education, and gentle posture exercises to begin improving shoulder girdle alignment and promoting proper mechanics N/A

Expected Progression

Home Program
Recommend a home program for pain management as indicated and appropriate for each unique patient

Problem
Reduced shoulder ROM Atypical scapulohumeral rhythm Rotator cuff weakness or atrophy; weakness of other shoulder/scapular muscles

Goal
Improve mobility and shoulder ROM Restore appropriate scapulohumeral rhythm Increase strength of rotator cuff and other weak muscles

Intervention
Therapeutic exercises In the acute/sub-acute phase, treatment may consist of gentle ROM exercises, Codmans (pendulum exercises), active-assistive ROM (pulley, wall ladder), and posterior and/or inferior capsule stretching as indicated and appropriate. Use care to avoid any active movement in the painful arc(21) Shoulder endurance activities (upper body ergometer) can be used early in the treatment program to facilitate improved muscular endurance Care should be taken to avoid aggravating activities such as overhead exercises, especially early in the treatment program(21) Patient should be monitored carefully to ensure proper technique: avoid substitution, increased muscle fatigue, poor scapulohumeral rhythm, and increased humeral translation Once ROM is full and pain-free, begin progressive resistive strengthening exercises for rotator cuff musculature, anterior deltoid, and scapular stabilizers (latissimus dorsi, rhomboids, serratus anterior, and middle and lower trapezius) Lastly, there is a gradual progression to dynamic stability, plyometric, and return to work or sport/activity-specific training exercises(21) Physical agents/mechanical modalities Moist heat pack to increase tissue elasticity prior to manual therapy and stretching exercises Ultrasound does not provide additional benefit over exercise alone(33) Manual therapy To resolve restricted scapular and/or shoulder joint arthrokinematics. Particular attention should be paid to posterior joint capsule mobility; appropriate mobilization may be applied, as needed, to prevent anterior translation of the humeral head, which can result in further rotator cuff impingement(39) Exercise with the addition of mobilization results in greater improvement of pain and disability(33, 40)

Expected Progression
Progress patient as indicated

Home Program
Home exercise program may consist of Stretching and strengthening exercises for the rotator cuff and shoulder; use of ice pack to reduce inflammation

Problem
Functional/occupational limitations Poor posture

Goal
Return to prior level of function Correct postural abnormalities

Intervention
Functional training Functional strengthening and scapular stabilization exercises for upper-extremity movements in daily activities Taping may be used to improve posture Patient education For correct postural alignment at rest and during activity

Expected Progression
Progress patient as indicated

Home Program
Implement a home program as indicated to address postural deviations and foster functional strengthening

At risk for reinjury or progression of rotator cuff disease

Patient education for prevention of reinjury and independent home exercise program

Patient education For pain management (ice pack/heat pack), independent exercise program, and avoidance of exacerbating or aggravating activities

N/A

N/A

Desired Outcomes/Outcome Measures

 Desired outcomes Eliminated/decreased pain and inflammation Improved mobility and shoulder ROM Restored appropriate scapulohumeral rhythm Increased strength of rotator cuff and other weak muscles Return to prior level of function Corrected postural abnormalities Independent home exercise program  Outcome measures SF-36 ROM Strength VAS for pain Posture reassessment Flexibility reassessment WORC Index ASES DASH questionnaire

Maintenance or Prevention
 Lifestyle or activity modifications may be warranted for patients with rotator cuff injuries. Functional training to ensure proper athletic or occupational technique is also beneficial. An independent home exercise program with comprehensive stretching and rotator cuff strengthening is imperative

Patient Education
 Mayo Clinic, http://www.mayoclinic.com/health/rotator-cuff-injury/DS00192

Coding Matrix
References in this Clinical Review are rated using the following codes, listed in order of strength: M Published meta-analysis SR Published systematic or integrative literature review R Published research (not randomized controlled trial) C Case histories, case studies G Published guidelines RCT Published research (randomized controlled trial) RV Published review of the literature RU Published research utilization report QI Published quality improvement report L Legislation PP Policies, procedures, protocols X Practice exemplars, stories, opinions GI General or background information/texts/reports U Unpublished research, reviews, poster presentations or other CP Conference proceedings, abstracts, presentations

PGR Published government report PFR Published funded report

such materials

References
1. Alford JW. Taking a closer look at rotator cuff disorders. J Musculoskel Med. 2008;25:481-488. (RV) 2. Harris JD, Pedroza A, Jones GL; MOON (Multicenter Orthopedic Outcomes Network) Shoulder Group. Predictors of pain and function in patients with symptomatic, atraumatic full-thickness rotator cuff tears: a time-zero analysis of a prospective patient cohort enrolled in a structured physical therapy program. Am J Sports Med. 2012;40(2):359-366. (R)

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