A Modern Take on Rotator Cuff Injuries

A Modern Take on Rotator Cuff Injuries

by Cindy Dehan, MS PT 

The shoulder is considered to be one of the most intricate joint systems in the entire human body, with interactions between the upper arm (the humerus), the scapula, and the thoracic spine, in addition to the complex neurovascular system. The rotator cuff plays a vital role in proper shoulder function. Specifically, the rotation cuff system consists of the interaction of four major muscles: the supraspinatus, the subscapularis, the teres minor and the infraspinatus. The primary roll of the rotator cuff is to center the shoulder joint and allow for proper joint motion.

Identifying the reasons for shoulder pain can be just as complex as the shoulder system itself. Similar to the spine, it is difficult to determine a true pathoanatomical “culprit” for shoulder pain, and it may be more beneficial to conceptualize issues found in the shoulder with regards to functional limitations. The American Physical Therapy Association recently published a clinical guideline article regarding the shoulder and outlined three separate types of classifications that shoulder issues may fall into. Shoulder pain and mobility deficits/adhesive capsulitis (frozen shoulder), shoulder stability and movement coordination impairments/dislocation of the shoulder joint, and shoulder pain and muscle power deficits/rotator cuff syndrome. Any of these conditions can impact the rotator cuff, but for the purposes of this article, we will focus on the muscle power deficits/rotator cuff syndrome (RCS) classification.

Traditionally, pathology of the rotator cuff was thought to be almost always be related to issues with impingement, where compression and high levels of friction were associated with the pain and dysfunction often reported by patients. More recent evidence suggests that mechanical loading of the tissue may cause changes to the tendon quality and contribute to the sensitivity of the tissue. Overhead movements such as throwing, can increase tensile load. Reaching overhead can increase the compressive forces in part of the shoulder complex. It is not uncommon to find pain while catching at midrange when lifting the arm. In fact, pain and weakness are common when performing movements that place any stress onto the rotatory cuff system.

Very few things in life have a specific protocol that you can follow from start to finish without having to adjust a little. Managing rotator cuff issues is no different. Given the fact that underlying cause of shoulder pain and dysfunction can be multifactorial the interventions should be selected to treat the impairments, not necessarily the diagnosis. Specific exercises which address the scapula and rotator cuff, in conjunction with manual therapy, has been shown to be beneficial for patients with RCS. It is also of benefit to look at the mechanics and relationship of the thoracic spine to the shoulder, as treatment to the thoracic spine may improve certain shoulder impairments. Core/midline stabilization can also contribute to issues seen in the shoulder based upon the specific activities someone participates in.

In an ideal world, we could develop a series of movements, exercises or hands on treatment that could fix everyone just the same. But the challenge is that we all are very unique and while we might share a common complaint of shoulder pain, the underlying cause is very different from person to person. That is why it is important to have a thorough, comprehensive exam so that the individual characteristics associated with your shoulder can be addressed and a detailed, personalized approach can be implemented.

Sham surgery may be better than Menisectomy for Knee Pain

A partial menisectomy has been one of the most commonly recommended surgeries for people suffering from knee pain. A meniscus tear is likely when there is medial or lateral pain along the joint line, there is pain with twisting, and the knee locks up, gives way or buckles when walking. In December of 2013 a double blinded study from Finland was released in the New England Journal of Medicine that compared a group who had the typical surgery to a group that had a fake surgery where they were arthroscopically probed but the torn meniscus was left as it was. The participants that had the meniscus cleaned up and smoothed out had better results early on, but by 12 months there were no differences between the two groups.

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This suggests that maybe you should give a second thought to whether you go under the knife to fix your knee pain. An earlier study by a different group compared physical therapy to arthroscopic surgery and found no difference at 6 and 12 months between the two groups. These two research studies may be pointing more patients towards physical therapy to deal with their knee injuries. It is more cost effective than the $3,000 to $6,000 sticker price for the menisectomy, and also less traumatic to the body. Of course, surgery will always have its place, especially in cases where the meniscus is flapping over on top of itself or ligaments are also torn.

Physical therapy can reduce swelling and pain, strengthen the muscles around the knee and help you to correct any biomechanical faults that may have been the cause of the damage to the meniscus. This is one of the main reasons that the research studies are finding surgery coming up short: it may clean up the injured tissues for a moment, but more damage is likely to occur if one continues to use their knee in the same way.