The Rotator Cuff Series: Part III

February 9, 2017

In part one and two of this series we discuss the structure, function and common injuries to the rotator cuff. If you missed either, click here: Rotator Cuff Series: Part I; Rotator Cuff Series: Part II. Part three will discuss how our therapist at Portland Physical Therapy treats these common injuries, as well as some ways to protect the rotator cuff in daily activities.

Treatment of Rotator Cuff Tendonitis

As discussed in part II, rotator cuff tendonitis is microtrauma to the tendon with acute inflammation. This usually leads to pain, weakness and decreased range of motion. Our first goal is to decrease the pain and inflammation in the tendon. Rest, ice, activity modification, and the use of NSAID’s (as prescribed by your physician) are the first steps in reducing the inflammation of the tendon. Once in physical therapy, we address the impairments found using manual therapy techniques, specific exercises to target the appropriate muscles and neuromuscular reeducation to change the biomechanics of the shoulder complex to reduce the likelihood of repeat injuries.

Treatment of Rotator Cuff Tendinosis

Part II of this series discussed the differences of tendonitis and tendinosis. The major difference is the absence of acute inflammation and the changes to the tendon(s) on the molecular level. Because these changes are usually secondary to repetitive trauma to the tendon(s) that develop over a period of time, it will take longer to see improvements in symptoms. We use various manual therapy techniques to address the changes in the muscles around the shoulder, as well as targeted exercises to repair and strengthen the damaged tendon(s). We take a critical look at our patient’s daily activities and teach them better ways to move and use their body to reduce stress to the shoulder. It is also very important that we change the biomechanics of the shoulder joint and shoulder blade (scapula) to allow for proper movement of the entire shoulder complex when using the arm. After all, it was likely impaired biomechanics coupled with repetitive movements that damaged the tendon(s) to begin with.

Treatment of Rotator Cuff Tear (Non-surgical)

A rotator cuff tear that is being treated non-surgically, often responds well to physical therapy interventions. A study performed by Kuhn et al.¹ found that physical therapy was successful in treating 75% of the over four hundred patients in the study for full thickness tears of the rotator cuff. The other 25% in the study elected to have surgery.

Much like a tendonitis or tendinosis, we employ various techniques to reduce the pain and possible inflammation around the tendon. Once we have reduced these symptoms, we work to reestablish the proper biomechanics and strength within the shoulder complex. We also discuss daily activities and teach activity modification to reduce stress to the area.

Treatment of Rotator Cuff Tear (Post-Surgical)

Post-surgical rehabilitation of a rotator cuff tear is very different than the previous diagnoses. Immediately following surgery our ultimate goal is to protect the repaired tendon, while trying to maintain passive range of motion. This requires the therapist to move/manipulate the shoulder in various directions. By having the therapist move the shoulder, it prevents activation of the rotator cuff, which if over-activated could lead to re-tearing. At the appropriate time, we start to introduce activation of shoulder and parascapular musculature. This eventually leads to activation of the rotator cuff muscles and return to normal activity.

Activity Modification

Activity modification is a key component to improving shoulder pain from rotator cuff issues. I often use this example with my patients, “If we continue to bang our head against the wall, it would stand to reason that we would continue to have a headache. So, it will not matter that we exercise or take pain medicine, as long as we continue to bang our head, we will continue to have pain.” The same holds true with the rotator cuff and our shoulder. If we do not change and reduce the aggravating factors throughout our day, our shoulder will continue to be in a pain cycle. Listed below are some activity modifications to consider throughout your day to prevent exacerbation of shoulder pain.

When reaching, reach in front of the body, with the thumb up. Avoid reaching out to the side by turning to face what you are intending to lift.
If repetitive reaching overhead is required, use a step stool to reduce flexion in shoulder.
Place commonly used items in convenient places (i.e. bring phone/keyboard/mouse on desk close to body so you do not have to reach as far for them).
When dressing, put your shirt or jacket on the painful side first.
Try to avoid sleeping on the affected arm.

We hope this series has been educational and given some insight into the shoulder complex. This context is not intended to diagnosis or treat anyone’s condition. There are many other structures in the shoulder, and if you are having shoulder pain, we recommend seeking consultation from an appropriate practitioner. Portland Physical Therapy is located in Portland, ME and treats a wide variety of orthopaedic conditions. We are happy to answer questions, and can be contacted at info@pptmaine.com or 207-828-4455.

Work Cited

1) Kuhn J, Dunn W, Sanders R, et al. Effectiveness of Physical Therapy in Treating Full Thickness Atraumatic Rotator Cuff Tears. A Multicenter Prospective Cohort Study. J Shoulder Elbow Surg. 2013; 22(10): 1371-1379.