Physio Penrith Rotator Cuff Shoulder Pain Treatments
Treatment of Rotator Cuff Related Shoulder Pain at Sydney Muscle & Joint Physio Penrith
What is rotator cuff related shoulder pain?
Rotator cuff related shoulder pain is an over-arching term that encompasses a spectrum of shoulder conditions including; subacromial pain (impingement) syndrome, rotator cuff tendinopathy, and symptomatic partial and full thickness rotator cuff tears. For those diagnosed with rotator cuff related shoulder pain one aim of treatment is to achieve symptom free shoulder movement and function. These injuries to the tendon result in a weak and painful shoulder, most commonly experienced with movements of shoulder external rotation and elevation. These injuries are often described as a lack of tolerance or capacity to absorb load and generally are a consequence of excessive load on the rotator cuff tissues.
At Sydney Muscle & Joint Physio Penrith our treatment approach is in line with evidence-based practice and our physiotherapists use techniques proven to work for rotator cuff related shoulder pain. Findings from published high quality research investigations suggest that a graduated and well-constructed exercise approach confers at least equivalent benefit as that derived from surgery. Our physiotherapy approach includes passive modalities to help settle high pain and irritability, as well as concurrent use of loading exercises- isometrics, heavy slow resistance and possible plyometrics if warranted.
What are the symptoms of rotator cuff related shoulder pain?
Rotator cuff related shoulder pain will present with pain and impairment of shoulder movement and function usually experienced during shoulder elevation and external rotation. Pain over the shoulder girdle, especially down the area over the deltoid and weakness are the most common symptoms. Assessment of impairments related to the rotator cuff need to be thorough as much of the treatment will focus on these, they may include range of movement, strength, posterior capsule extensibility, neural tests, pain behaviour and testing increasing and decreasing load on the muscle tendon-unit.
Treatment of a highly irritable rotator cuff related shoulder pain
This may occur in acute and chronic presentations and is commonly characterised by easily aggravated and prolonged (sometimes constant) shoulder pain once provoked, together with night pain. As with all presentations load management (relative rest) is important and the aim is to identify a level of activity that reduces the amount of pain experienced.
Anecdotal evidence suggests that isometric exercises, with the arm supported, performed in the direction of pain may help to control pain, at Sydney Muscle & Joint Physio Penrith our physiotherapists use low load isometrics such as shoulder abduction, external rotation or flexion to moderate pain and initiate the first phase of load. Exercise in the form of gentle loading, such as short lever flexion exercises may be well tolerated, as may shoulder flexion supported on a ball, which may be progressed as the patient is able. This and other examples of motor control exercises should not increase irritability and when appropriate should incorporate lower limb weight transfer. Additional anecdotal evidence suggests that the application of ice wraps may also be helpful in controlling pain.
Pharmacological management may include topical or oral NSAIDs and certain injection therapies. There is some research that have compared analgesic only injections to corticosteroid, with analgesic injections reportedly having comparable outcomes up to 6 months. Both glucocorticoids and local anaesthetics appear to be able to reduce tenocyte numbers, with increased proliferation of tenocytes being associated with tendinopathy. One theory is that this type of injection therapy may contribute to restoration of tendon cellular homeostasis by reducing tenocyte numbers. This hypothesis requires appropriate scrutiny. Nevertheless, injection therapy may help reduce pain to permit exercise therapy to continue more effectively. At Sydney Muscle & Joint Physio Penrith our physiotherapists, when clinically relevant, encourage the use of these injections to be used adjunctive to a graded loading program.
Treatment of a non-irritable rotator cuff related shoulder pain
This presentation is characterised by pain (that may range from mild to severe) that increases with movement and has none or minimal irritability- often assessed by how the shoulder feels 1hr after and the next morning after aggravation. Pain and weakness is most commonly experienced in the direction of external rotation and elevation and may benefit from a graduated shoulder flexion program, starting initially in short lever (i.e. elbow bent) shoulder flexion progressing to long lever and higher levels of elevation, then with increasing weights and resistances. In addition to shoulder flexion, a concurrent graduated shoulder external rotation program should be introduced.
Exercise treatment programs need to include strengthening and endurance exercises and training in a range of postures and arm positions (even within one training session) to introduce variability in loading.
Some research studies suggest that patients with rotator cuff related shoulder pain managed with exercise therapy should expect equivalent outcomes to surgery. It is possible that the addition of whole body exercises, manual therapy, life style management, screening of potential postural factors as identified during assessment procedures such as the shoulder symptom modification procedure, and staged rehabilitation relevant to the patient's clinical presentation may further enhance outcomes.
A clinical pearl to remember when treating rotator cuff related shoulder pain
Providing a local shoulder based treatment in isolation is an ineffective management strategy when treating rottator cuff related shoulder pain and typically outcomes are not favourable. Physiotherapists and patients need to appreciate that many upper limb activities require that energy is transferred from the lower to upper limbs through the trunk and the inability to transfer energy from the lower limbs may result in increased demands on the shoulder joint and shoulder muscles. This can lead lead to local overload and therefore local rotator cuff symptoms. This be easy to appreciate by reflecting how a ball would be thrown, how a tennis serve takes place and how something might be pushed or pulled into place.
Rehabilitation of weak rotator cuff needs to take into account rotational strength through the trunk and stiffness through the hips. Our physiotherapists at Sydney Muscle & Joint Clinic Penrith utilise specific exercises that focus on these specific requirements.