Rotator Cuff tear and Physiotherapy Management

While working at home, the number of cases of the rotator cuff and other like muscle tear and joint effusion is a common problem. There isn’t an exact definition of a massive rotator cuff tear. Sometimes the severity is expressed by the number of tendons that are torn, sometimes on the size of the tear.

These rotator cuff tears can be further divided into 5 categories (according to Collin et al.)

• Type A: supraspinatus & superior subscapularis tears
• Type B: supraspinatus and entire subscapularis tears
• Type C: supraspinatus, superior subscapularis & infraspinatus tears
• Type D: supraspinatus & infraspinatus tears
• Type E: supraspinatus, infraspinatus & teres minor tear

There are a number of classification systems that are used to describe the size, location and shape of rotator cuff tears. Most commonly tears are described as partial- or full-thickness. A commonly cited classification system for full-thickness rotator cuff tears was developed by Cofield (1982). The classification system is:

• 1. Small tear: less than 1 cm
• 2. Medium tear: 1–3 cm
• 3. Large tear: 3–5 cm
• 4. Massive tear: greater than 5 cm.

Characteristics / Clinical Presentation

The location of the tear has an important influence on the possible dysfunctions.

Individuals with a rotator cuff tear may suffer from:

• severe pain at the time of injury
• pain at night
• pain with overhead activities
• positive painful arc sign
• the weakness of involved muscle
• shoulder stiffness.
• Individuals with a tear of the supraspinatus may complain of tenderness over the greater tuberosity, pain located in the anterior shoulder, and symptoms radiating down the arm.

Medical Management of Rotator Cuff Tear

There are three types of surgical treatments to repair rotator cuff tears.

• Open repair: A traditional open surgical incision is often required for large or complex tears.

• Arthroscopic Repair: An optical scope and small instruments are inserted through small puncture wounds instead of through a larger incision. The operation can be carried out under visual control via a video display.

• Mini-Open Repair: New techniques and instruments allow surgeons to perform a complete recovery of the rotator cuff through a small incision of generally 4 to 6 cm.

The operative treatment is done mostly arthroscopically which is less invasive than open/mini-open surgery and leaves only a few small scars. The rehabilitation can start faster and the patient has less pain during recovery.

Physical Therapy Management Of Rotator Cuff tear

Conservative management is warranted in most rotator cuff injuries. In addition to physical therapy, non-surgical treatment may include non-steroidal anti-inflammatory drugs and steroid injections, time, local rest, application of cold or heat and massage. The judicious use of no more than three to four injections of steroids into the subacromial space or around the biceps tendon can be helpful in the early phase.

During examination and rehabilitation, it is important to isolate the individual rotator cuff muscles as much as possible. This because the rotator cuff muscles can become fatigued, injured, or atrophied individually[17]. Physical therapy has a beneficial effect when it’s part of a treatment program. 

Goals to be achieved with physical therapy

• Reducing pain and muscle tension in the scapular and neck area in order to promote the motility of the scapula. This to ensure the correct position of the glenoid. The muscles targeted are the M. pectoralis minor, upper trapezius, and M. levator scapulae.
• Improving the wrong humeral head position in order to restore scapulohumeral mobility.
• Strengthen the muscles that stabilize and move the shoulder, the upper part of the M. serratus anterior, and the intact rotator cuff muscles.
• Regain proprioception and movement automatism by neuromotor rehabilitation

Both nonoperative rehabilitation and postoperative rehabilitation of the rotator cuff involves the following principles.

Reduction of overload and total arm rehabilitation

- There should be no compensatory actions in the upper extremity.

- It is advised to quickly use the elbow, forearm, and wrist in order to strengthen them. Especially during long immobilization.

- Mobilization of the scapulothoracic joint and submaximal strengthening of the scapular stabilizers are indicated. The injured tissues should not be inappropriately stressed or loaded.

A technique that is used early in the rehabilitation phase is the scapular protraction and retraction resistance exercise. It involves a side-lying position and specific hand placement to resist scapular protraction and retraction without stress applied to the glenohumeral joint. This exercise begins at low resistance. The glenohumeral joint must be in slight abduction and forward flexion during scapular motion.

Scapular resistance exercise

Restoration of normal joint arthrokinematics

- Posterior capsular mobilization and stretching techniques are often indicated and applied to improve internal rotation ROM.

Promotion of muscular strength balance and local muscular endurance

EXAMPLES OF OPEN CHAIN EXERCISES 

• Side-lying external rotation: Lie on uninvolved side, with a small pillow between involved arm and body. Keep the elbow of involved arm bent and fixed to the side, raise the arm into external rotation. Slowly lower to starting position and repeat.

• External rotation

• Shoulder extension: Lie in the prone position on a table. The involved arm is hanging straight to the floor. With the thumb pointed outward, raise the arm straight back toward your hip. Slowly lower the arm and repeat.

• Shoulder extension

• Prone horizontal abduction: Lie in the prone position on a table. The involved arm is hanging straight to the floor. With the thumb pointed outward, raise the arm out to the side, parallel to the floor. Slowly lower your arm and repeat.

• horizontal abduction
• 90/90 external rotation: Lie in the prone position on a table. The shoulder is abducted to 90° and the arm is supported on the table. The elbow is bent at 90°. Keep the shoulder and elbow fixed and rotate the arm into external rotation. Slowly lower to starting position and repeat.

• External rotation

EXAMPLE CLOSED CHAIN EXERCISE

The therapist applies rhythmic stabilization or perturbation stresses with the patient’s shoulder placed in the scapular plane and 90° of elevation.

Rhythmic stabilization

Late stages of rehabilitation of rotator cuff injury include progressive resistive strengthening, proprioception training, and sport-specific exercises. Thrust and non-thrust manipulation (TSTM) of the cervicothoracic spine and/or ribs may lead to significant improvement in pain and disability in patients with a primary complaint of shoulder pain. The use of TSTM with shoulder patients can be described as the relationship of restoring mobility between adjacent vertebrae. This can be recognized as a reflexogenic mechanism.TSTM can not only be used to improve shoulder mobility but also the overall functional performance.