The rotator cuff assists with the movement of the shoulder joint however due to the degree of movement they also have a significant role in stabilising the shoulder joint. The rotator cuff by definition is comprised of 4 major muscles:
These muscles act as a force-coupling unit to maintain the head of the arm in the centre of the ‘socket’ (glenoid) during movement of your arm and shoulder. Deficiencies in these muscles will affect how the arm moves within the shoulder and associated injuries may occur.
Rotator cuff pathologies make up approximately 80% of all shoulder complaints. However, this figure varies depending on the age, occupation, sport/activity levels of an individual as the demand placed on the muscles varies with different tasks.
Rotator cuff tears are not as common in young athletes but are typically seen as a consequence of degeneration or following an acute incident in a middle aged or older athlete/person. Tears can be classified as partial or full thickness in relation to the severity of the tear, with pain typically located at the front, back or tip of the shoulder. Individuals with a rotator cuff tear can also have difficulty when moving their arm overhead and can experience pain that makes sleep difficult at night.
The presence of pain and difficulty moving the arm overhead may not always be indicative of a rotator cuff tear. Individuals/athletes who spend a lot of time with their arm overhead, or are performing tasks overhead including tennis, throwing, painting etc. are vulnerable to developing another extremely common rotator cuff injury. Rotator cuff tendinopathy may arise when there has been a change in load placed on a particular muscle (group) that is not conditioned to tolerate it, or when the tendon itself is experiencing compression. A tendinopathy is an irritation of the muscles’ tendon (the link between the muscle and bone) that can often become thicker than when it is not injured. Therefore, due to the increase in size, the tendon is at risk of compression, causing pain and consequently inhibiting function of the rotator cuff muscle group. This compression is often reported as impingement, notwithstanding that there are other examples of shoulder impingement.
The management of a rotator cuff tear is largely dependent upon the degree of tear. For example, if there has been a particular incident leading to an acute onset of sharp localised pain in the shoulder and an overall loss of global strength and function of the affected shoulder/arm, it is likely you may have experienced a new larger tear. If a full thickness tear is confirmed with imaging, this would usually indicate surgical intervention followed by physiotherapy encompassing a gradual and progressive exercise rehabilitation program.
However, if a similar incident has occurred with the diagnosis of a partial thickness tear (whereby a portion of the rotator cuff muscle fibres remain intact) with only mildly reduced muscle strength and shoulder function, then although a surgical opinion is often obtained, there may be more scope for trialling a physiotherapy-guided exercise rehabilitation program.
Lastly, if a partial or full thickness tear has occurred over time and is degenerative in nature i.e. there has not been an acute mechanism or moment in time that the injury occurred, and there is reasonable strength remaining, then you are likely to benefit from a structured and progressive rehabilitative program. This program should target not only the rotator cuff muscles, but also the other muscles that influence the shoulder complex as a whole. The duration of a rehabilitative program varies between people depending on the magnitude of injury/deficits, patient adherence to the program, and natural healing properties of each individual.
Like tendinopathies in other areas of the body, the most effective way to combat this injury is through correct loading principles and parameters, to activate the muscle and allow for the tendon to remodel and resemble its normal properties. Therefore, the primary approach to treating rotator cuff tendinopathy is through exercise. Depending on the irritability of your shoulder, general advice surrounding lifestyle modifications will also form a large portion of treatment. On top of this, selection of appropriate exercises that will not exacerbate pain but load the cuff in a way to achieve the desired outcome (an overall improvement in function and reduction of pain), will also form a major part of the treatment plan. Recent studies have shown that people experiencing rotator cuff tendinopathies that have accurately been assessed, diagnosed and managed can expect equivalent outcomes to surgical interventions in both short and long term follow up periods.
Diagnosis of shoulder pain or injury requires a thorough assessment with an understanding of the lifestyle factors that may be contributing to the cause of pain. If you are experiencing shoulder pain and want to get to the bottom of it, our team of physiotherapists at CSSM can help find the cause of the pain and work with you to develop a plan to get you back to your meaningful life. Whether that be on the tennis court, in the swimming pool, or simply out in the garden, our physiotherapists will equip you with the strategies to empower you to take an active approach to your recovery to give you the best chance of obtaining an optimal outcome.
Content for this page on rotator cuff injuries was prepared by Camberwell Sports and Spinal Medicine Physiotherapist, Peter Stath. Peter has a clinical interest in shoulder injury and rehabilitation, particularly injuries involving the rotator cuff.
The decision to pursue the surgical pathway vs the conservative option is always a hotly debated topic no matter the region of injury. Ultimately, the decision comes down to numerous factors, and best practice recommends the decision is collaborative between the health practitioner and the patient.
However, there are some key factors that will determine the likelihood of success/failure of conservative management that must be taken into consideration. These factors include, but are not limited to; age, mechanism of injury and subsequent loss of function, the presence of night pain, duration of symptoms and magnitude of injury.
Therefore, depending on the type of injury, how it has been sustained and how it is affecting daily life, the decision for surgical repair should be made in the best interest of the patient that will allow them to achieve their most desired outcome. Furthermore, if the decision for surgery is agreed upon, the importance of a pre-operative physiotherapy program cannot be understated as it can facilitate better outcomes post-operatively.
Imaging can play an important role in providing further information to the clinical presentation of each shoulder injury. However, it is important to note that certain findings may not be the cause of pain at that specific point in time and can often be a subsequent finding. A scan essentially is a photo of what is going on within the joint, therefore it is important to denote which findings are clinically relevant and which provide valuable information that will guide management.
Depending on your suspected injury, the type of scan you may need will vary as certain structures become vulnerable in different types of injuries as well as different mechanisms of injury. An x-ray will provide valuable information of bony pathologies that may be associated with falls that can lead to fractures, and are gold standard following a shoulder dislocation. MRIs and ultrasound will provide further information about soft tissue structures such as rotator cuff tendons.
As physiotherapists we will always advocate to our patients to maintain their activity levels where they can, and often to push through low levels of discomfort during their exercise rehabilitation program. Regarding shoulder injuries however, caution must be taken as to not aggravate an already sensitive structure.
The rotator cuff muscles play a vital role in the stability of the shoulder joint. If there is a large amount of pain, we typically see the rotator cuff reduce its ability to perform its function, known as inhibition. Therefore, if the rotator cuff is not performing its role adequately, there will be uncontrolled movement of the shoulder joint itself. If this is not regulated through structured, pain free exercise rehab, the rotator cuff can begin to waste away; known as atrophy, further exacerbating this downward spiral.
Therefore, it is important to continue to exercise and stay physically fit and active, however, we would often recommend performing movements and exercises that are pain free to avoid further aggravating your injury and delaying your recovery. Our physiotherapists are skilled in modifying your current activity loads and exercises to help you train around pain.
An often overlooked component of recovery regarding both performance and rehabilitation. Sleep can often become more challenging in the presence of shoulder pain. Particularly if you’re a side sleeper, your affected shoulder may be painful to lie on, keeping you up at night as well as being very sore and stiff in the morning. Similar to that of exercising, if we are constantly putting pressure on an already painful region, it may only exacerbate our symptoms and delay our recovery. In the case of shoulder injuries, particularly with tendon pathology, compressing the tendon by lying on the affected side may be preventing your progress in rehab. However, it is also worth noting that sleeping on your unaffected side can also become painful as your affected shoulder may want to roll inwards and compress sensitive structures in this manner. Note that positions of comfort may range between individuals and between different shoulder pathologies. Although there is no sure-fire way to guarantee comfort, we recommend adopting a position of comfort that will limit direct compression on your shoulder, enabling you to get a good restful sleep.
Should your night pain persist, and it is increasingly difficult to get a goodnight’s sleep, perhaps a visit to your local GP may be necessary to enquire about appropriate pain medication to assist.
The use of anti-inflammatories is increasingly becoming debated. Our body’s natural healing properties use inflammation to facilitate recovery and the reliance on anti-inflammatory medication can be seen to interrupt this valuable healing property. In the case of rotator cuff injuries, it depends on the situation of your injury. There is a grey area in the research regarding the effectiveness of anti-inflammatories on muscle and tendon injuries, and whether it may slightly impede recovery. However, if there is persistent swelling or osteoarthritic changes/pain within the joint itself, anti-inflammatories may provide relief for these conditions given the constant irritation of local nerves in the area.
As physiotherapists it is important to note that we are not experts in the prescription of medication. Any information given is advice that should be followed up with your GP if you have any further questions or concerns.
To make an appointment for treatment of your shoulder injury you do not need a referral.
Appointments can be made with any of our team by calling the clinic directly. Alternatively you can make an appointment via our online portal at our website – www.cssm.com.au
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