Rotator cuff disease - all you need to know. Part2
My name is Gavin Jennings. I am a consultant orthopaedic surgeon specialising in shoulder problems.
This presentation is the second of three parts providing an in-depth overview of rotator cuff disease. This part deals with the symptoms, examination and non-operative treatment of patients with rotator cuff problems
In the diagnosis of rotator cuff disease, we need to consider the onset, site and timing of the pain as well as aggravating factors. If we exclude significant one off traumatic injury, a typical presentation would be of a gradual onset pain, often spontaneous or perhaps after some unaccustomed activity and sometimes after what initially felt like a small muscle ‘pull’. The pain is usually felt in the region of the deltoid, but not beyond the elbow.
The pain is made worse by lifting the arm up from the side, reaching out in front or when lying on that side at night. The arm usually feels fine when down by the side.
Examination of the shoulder specifically for rotator cuff problems, still starts with an assessment of the neck looking to eliminate cervical nerve root compression as a cause of the shoulder pain. I find Spurling’s test useful for this. With pure cuff disease passive range of motion should be well maintained, particularly external rotation, though FF and abduction may be limited due to the pain generated (as opposed to actual stiffness). Attention should be paid to core stability, posture, scapular control and any dyskinesis. Impingement tests such as Neer’s, Jobe’s, Hawkins-Kennedy etc, if positive will produce deltoid pattern pain. Finally examination for possible primary causes such as instability (particularly in a younger patient) should be considered.
Subacromial steroid and local anaesthetic injections can be useful both diagnostically and therapeutically.
Subacromial injections can be given by either a posterior or lateral route.
Following an injection the patient should then be re-examined after a few minutes, repeating the previously positive provocative tests, which should then be less painful. if they are not, two possibilities are that the injection was incorrectly placed or that the diagnosis of cuff disease was incorrect.
If we consider the role of physical therapy in the treatment of rotator cuff problems, it is worth recalling the statement from Part 1 of this presentation. “Younger patients are more likely to have rotator cuff dysfunction because of overuse, subtle instability, or muscle imbalance”
It is certainly worth addressing any such problems in a patient of any age with these issues.
The other principles of rehabilitation include addressing any issues with core stability or scapulothoracic control, stretching out tight structures, restoring rotator cuff balance, especially eccentrically and posture re-education.
Finally, I would like to consider some of the other potential non-operative treatments for cuff disease. Ultrasound therapy has been shown to be of short term benefit in calcific tendonitis. Extracorporeal shock wave therapy (which uses sound waves) has been shown to effective in calcific tendinopathy, but not tendonitis without calcium deposition. Suprascapular nerve blockade or ablation has been demonstrated to be of use in long term pain relief. We will shortly be submitting our experience of this treatment for publication. There is little evidence for the use of the other modalities listed here.
Many thanks for listening to part 2 of an overview of rotator cuff disease. Part 3 will deal with the role of surgery. If you would like any further information, please feel free to contact me.