TABLE 8.1 A. Goals: 1. Relieve pain and inflammation 2. Normalize range of motion (ROM) 3. Reestablish muscular balance 4. Patient education and improve posture B. Avoidance: The elimination of any activity that causes an increase in symptoms C. ROM: • L-bar: flexion, elevation in scapular plane • External rotation (ER) and internal rotation (IR) in scapular plane at 45 degrees abduction, progressing to 90 degrees of abduction • Horizontal abduction/adduction • Pendulum exercises • Active assisted range of motion (AAROM): limited symptom-free available range of motion • Rope and pulley: flexion D. Joint mobilizations: emphasize inferior and posterior glides in scapular plane; goal is to establish balance in the glenohumeral joint capsule E. Modalities: cryotherapy, iontophoresis F. Strengthening exercises: rhythmic stabilization exercises for ER/IR; rhythmic stabilization drills, flexion/extension; ER strengthening; if painful isometrics (ER, IR, abduction), scapular strengthening, retractors, depressors. Protractors: patient education: educate patient regarding activity level, activities. Pathology and avoidance of overhead activity, reaching, and lifting activity: correct seating posture (consider lumbar roll), seated posture with shoulder retraction G. Guideline for progression: 1. Decreased pain and/or symptoms 2. Normal ROM 3. Elimination of painful arc 4. Muscular balance Goals: 1. Reestablish nonpainful ROM 2. Normalize arthrokinematics of shoulder complex 3. Normalize muscular strength 4. Maintain reduced inflammation and pain ROM: • L-bar • Flexion • ER at 90 degrees of abduction • IR at 90 degrees of abduction • Horizontal abduction/adduction at 90 degrees Rope and pulley: • Flexion • Abduction (symptom-free motion) Joint mobilization: • Continue joint mobilization techniques to the tight aspect of the shoulder (especially inferior) • Initiate self-capsular stretching • Grade II/III/IV • Inferior, anterior, and posterior glides • Combined glides as required Modalities: (as needed) • Cryotherapy • Ultrasound/phonophoresis • Iontophoresis Strengthening exercises: • Progress to complete shoulder exercise program • Emphasize rotator cuff and scapular muscular training • ER tubing • Side-lying ER • Full can • Shoulder abduction • Prone horizontal abduction • Prone rowing • Prone horizontal abduction ER • Biceps/triceps • Standing lower trapezius muscular strengthening Functional activities: • Gradually allow an increase in functional activities • No prolonged overhead activities • No lifting activities overhead Goals: 1. Improve muscular strength and endurance 2. Maintain flexibility and ROM 3. Gradual increase in functional activity level Flexibility and stretching: • Continue all stretching and ROM exercises • L-bar ER/IR at 90 degrees abduction • Continue capsular stretch • Maintain/increase posterior/inferior flexibility Strengthening exercises: • Establish patient on the fundamental shoulder exercises (see Table 8.2) • Tubing ER/IR • Lateral raises to 90 degree dumbbell • Full can dumbbell • Side-lying ER • Prone horizontal abduction • Prone extension • Push-ups • Biceps/triceps Guideline for progression to phase IV: 1. Full nonpainful ROM 2. No pain or tenderness 3. Strength test fulfills criteria 4. Satisfactory clinical examination Return to activity phase Goals: unrestricted symptom-free activity Initiate interval sport program: • Throwing • Tennis • Golf Maintenance exercise program: Flexibility exercises • L-bar: • Flexion • ER and IR at 90-degree abduction • Self-capsular stretches Isotonic exercises: • Fundamental shoulder exercises • Perform 3 times a week TABLE 8.2 L-bar: • Elevation in the scapular plane • External rotation (ER) in scapular plane Self internal rotation (IR) sleeper stretch Tubing: • IR 0 degrees • ER 0 degrees • Row
Nonoperative Care of Rotator Cuff Disorders
Physical Therapy, Modalities, and Injectables
Introduction
Key Rehabilitation Principles
Patient Motivation and Expectations
Normalizing Shoulder Mobility
Functional Scapular Base
Neuromuscular Control and Dynamic Stability
Multiphased Rehabilitation Program
Phase 1: Acute Phase
I. Maximal Protection: Acute Phase
II. Intermediate Phase
III. Advanced Strengthening Phase
Phase 2: Intermediate Phase
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Nonoperative Care of Rotator Cuff Disorders: Physical Therapy, Modalities, and Injectables
Chapter 8
Kevin E. Wilk, Christopher A. Arrigo, Ricardo Colberg, and Jeffrey R. Dugas
Rotator cuff lesions are among the most common causes of shoulder pain and upper quarter disability seen in orthopedics and physical therapy. Surprisingly, a lack of data exists on the natural history of patients with rotator cuff disease, but in general the frequency of rotator cuff tears increases with age, and full-thickness tears are uncommon in patients younger than 40. Once thought to be predominately a function of disuse, rotator cuff tears are in fact a pathology more closely associated with active patients and athletes. Rotator cuff pathology spans a broad spectrum of severity from mild impingement to progressive failure, developing ultimately to full-thickness tears of one or more rotator cuff tendons. A large incidence of rotator cuff tears is present in both symptomatic and asymptomatic shoulders across the population. Conservatively, it has been estimated that 5.7 million Americans older than 65 years of age have full-thickness rotator cuff tears. In the United States, approximately 275,000 rotator cuff surgeries are performed annually. Therefore fewer than 5% of people with rotator cuff tears undergo surgery each year.
Rotator cuff failure is usually a gradual, progressive process. The tendons of the rotator cuff are weakened by a combination of factors, including age, repeated microtrauma attrition, repeated steroid injections, impingement hypovascularity, poor oxygen uptake of tendons, and major trauma. Investigators have shown that there is no direct relationship between patients suffering from atraumatic full-thickness tears of the rotator cuff and numerous factors, including pain and severity of the tear, duration of symptoms, or even activity level.
Nonoperative rehabilitation has been shown to be an effective mainstay in the management of rotator cuff pathology. The success of nonoperative treatment has been shown to be similar to results for surgical intervention of rotator cuff tears in randomized trial comparisons. These comparisons documented success rates for nonoperative rehabilitation of rotator cuff tears to be 76% and 92%. A physical therapy program for atraumatic full-thickness rotator cuff tears was found to be effective in more than 80% of patients with at least a 2-year follow-up.
This chapter outlines the critical keys to the successful rehabilitation of nonoperative rotator cuff pathology. It presents an organized multiphased approach to the process, which offers a unique combination of exercise techniques designed to bridge the gap between rehabilitation and the restoration of upper extremity function providing for a higher degree of humeral head control via kinetic linking of the body’s musculature, which is a critical component necessary to return patients with rotator cuff pathology to unrestricted symptom-free activity.
The keys to the successful nonoperative rehabilitation of rotator cuff lesions lie in the ability to adequately ascertain and appropriately address functional characteristics and underlying pathologies inherent to the shoulder with rotator cuff pathology. These include the intrinsic soft tissue and osseous adaptations evident during physical examination, as well as the extrinsic elements that comprise factors such as age, activity level, and overhead functional demand. These keys include the importance of patient expectations, proper shoulder mobility, the need for a functional scapular base of support, and the critical role that dynamic stability and neuromuscular control play in the rehabilitation of the shoulder with rotator cuff pathology.
The most important predictor for successful nonoperative treatment has been shown to be patient expectation. In other words, patients who believe that physical therapy will work are much more likely to have a successful result with nonoperative rehabilitation. This fact underlines the need for extensive patient education and positive motivation directed toward influencing a positive mental approach when patients undertake a program of nonoperative rotator cuff rehabilitation. Constructive patient education regarding the fact that nonoperative management even in the presence of a “tear” is the best course of action and framing their expectations in a positive mental framework provides for the best possible outcome when coupled with an appropriate nonoperative rehabilitation program.
Normalizing pain-free shoulder motion and accessory mobility is essential for the successful rehabilitation of the patient with rotator cuff pathology. Attention should be given to restoring physiologic shoulder elevation, internal rotation (IR), and external rotation (ER). Patients with rotator cuff disease present with inferior, posterior-inferior and possibly posterior capsular tightness that needs to be addressed. This asymmetrical capsular tightness has been referred to as a reverse capsular pattern and is managed with joint mobilization techniques, physiologic stretching, and proprioceptive neuromuscular facilitation stretching maneuvers.
The scapula provides proximal stability to the shoulder joint, enabling distal segment mobility. Scapular stability is crucial for normal asymptomatic arm function, especially in the presence of rotator cuff pathology. Several authors have emphasized the importance of scapular muscle strength and neuromuscular control in contributing to normal shoulder function. The force couples of the upper trapezius, serratus anterior, and lower trapezius play an integral role in arm elevation by posteriorly tilting, elevating, and upwardly rotating the scapula, thereby placing it in a functionally appropriate position for successful activity away from the body.
Patients with rotator cuff pathology frequently exhibit rounded shoulders and forward head posture. This postural positioning is associated with muscle weakness of the scapular retractors due to prolonged elongation and altered length tension relationships between synergistic muscle groups that elevate, posteriorly tip, abduct, and protract the scapula during active arm elevation. In addition, the scapula on the involved side may often appear protracted, depressed, and anteriorly tilted in relation to the contralateral scapula. An anteriorly tilted scapula has been shown to contribute to a loss of glenohumeral joint IR. It is our experience that this abnormal scapular positioning is associated with pectoralis minor muscle tightness, coracoid pain, lower trapezius muscle weakness, and a forward head posture. The lower trapezius muscle is an important muscle in arm function because of its controlling effect on scapular elevation and protraction. Weakness of the lower trapezius muscle may result in improper arm elevation mechanics or a greater propensity toward developing shoulder symptoms during functional activities. Careful assessment of scapular position, mobility, and strength in the patient with rotator cuff pathology is essential to ensure symptom-free use of the arm.
Neuromuscular control plays a critical role in the generation of dynamic shoulder stability. Neuromuscular control refers to the continuous interplay of afferent input and efferent output in an individual’s awareness of proprioceptive joint position and the ability to produce a voluntary muscular contraction to stabilize the glenohumeral joint, preventing excessive humeral head translation.
The primary stabilizers of the glenohumeral complex produce a combined muscular contraction that enhances humeral head stability during active arm movements. The combined effect of the rotator cuff musculature is a synergistic action that creates humeral head compression within the glenoid and counterbalances the shearing forces generated by the deltoid. These muscles act together in an agonist/antagonist relationship to both effect movement of the arm and at the same time stabilize the glenohumeral joint.
Additionally, active glenohumeral joint stability is provided through blending of the rotator cuff tendons in the shoulder capsule, which produces tension with the capsular ligaments. This tension serves to actively tighten the glenohumeral capsular complex and thereby accentuates centering of the humeral head within the glenoid fossa.
The optimal rehabilitation program for the patient with nonoperative rotator cuff pathology involves a progressive, sequential, multiphased approach that is based on findings identified during the physical examination with regard to the specific structures involved and root cause of the condition. The four rehabilitative phases for nonoperative rotator cuff lesions are presented in Table 8.1. This approach should be paired with the therapist’s knowledge of the sequential, progressive implementation of principles related to the restoration of strength, dynamic stability, and neuromuscular control in the patient with rotator cuff pathology. Each phase represents a progression where exercises become more progressive and demanding, and the stresses applied to the shoulder complex gradually intensify.
The primary goals of the initial rehabilitation phase are to diminish inflammation, control pain, improve flexibility, reestablish baseline dynamic stability, normalize muscle balance, and restore proprioception. Diminishing the patient’s pain and inflammation is accomplished using local therapeutic modalities such as ice, iontophoresis, nonsteroidal antiinflammatory drugs (NSAIDs), and/or injections. Clinically, the use of iontophoresis for glenohumeral soft-tissue inflammation is most frequently the most effective local modality. Modifications to the patient’s activities including repetitive arm use and exercise activities must be addressed to emphasize pain-free range of motion (ROM) and control the stresses placed on healing tissue.
Restoration of ROM is initially focused on improving elevation, ER, and IR to improve the overall flexibility of the shoulder complex. Normalizing glenohumeral elevation is typically accomplished via the use of supine active assistive ROM using an L-bar controlling movement and gentle overpressure with the uninvolved arm. Initially, the therapist may need to provide assistance or support as the patient lowers the arm from 80 to 30 degrees of elevation or the patient will have pain secondary to their inability to eccentrically control the arm while lowering it secondary to their underlying rotator cuff pathology. Increasing the flexibility of the posterior musculature is achieved via a combination of gentle patient self-stretching and manual therapist stretching. The sleeper stretch (Fig. 8.1) is used to stretch the posterior musculature of the glenohumeral joint. Manually, a supine horizontal adduction with IR stretch should also be incorporated (Fig. 8.2). Mobilization of the posterior-inferior capsule is recommended when that portion of the capsule is shown to be excessively hypomobile on clinical examination. If the posterior joint capsule is hypomobile, then posterior-lateral joint mobilization glides are performed to effectively create increased mobility of the posterior capsule (Fig. 8.3).
Additional goals of the first phase are to restore muscle strength, reestablish baseline dynamic stability, and restore proprioception. In the early phase of rehabilitation, the goal is to reestablish muscle balance. Therefore the focus is placed on improving the strength of all weak musculature, such as the shoulder external rotators and the scapular muscles, as well as the muscles of the lumbopelvic region, and even the lower extremities.
If the patient is extremely sore or painful, submaximal isometric exercises should be employed for the shoulder and all other exercise activities modified to accommodate shoulder symptoms. Conversely, if the patient exhibits minimal soreness, then lightweight band and/or isotonic exercises may be safely initiated to facilitate strengthening of the shoulder complex and the remaining rotator cuff musculature. Additionally, during this phase we use rehabilitation exercise drills that are designed to restore the neurosensory properties of the shoulder capsule (stimulation of afferent mechanoreceptors) that have experienced microtrauma.
Specific exercises that restore neuromuscular control during this initial phase are rhythmic stabilization exercises for the internal/external rotator muscles of the shoulders. Additionally, proprioceptive neuromuscular facilitation patterns are used with rhythmic stabilization and slow reversal holds to reestablish proprioception and dynamic stabilization of the upper quarter. The purpose of these exercises is to facilitate agonist/antagonist muscle coactivation. Efficient coactivation assists in restoring balance to force couples of the shoulder joint even in the presence of a full-thickness rotator cuff lesion, thus enhancing joint congruency and compression. Uhl et al. reported improved proprioception after specific neuromuscular training that challenged the glenohumeral musculature.
Other exercises commonly used during this first rehabilitation phase include joint repositioning tasks and axial loading exercises (upper extremity weight-bearing exercises). Active joint compression stimulates the articular receptors. Thus axial loading exercises such as weight shifts, weight shifting on a ball, wall push-ups, and quadruped positioning drills are beneficial in restoring proprioception to the rotator cuff impaired shoulder.
In phase 2 of the rehabilitation program, the primary goals are to progress the strengthening program, continue to improve flexibility, and facilitate neuromuscular control of the shoulder. During this phase, isotonic strengthening activities are progressed with emphasis on the restoration of muscle balance. Selective muscle activation is also implemented to restore muscle control and symmetry. In the patient with rotator cuff pathology, the shoulder external rotator muscles and scapular retractor, protractor, and depressor muscles are frequently isolated because of weakness. We have established a fundamental exercise program for the nonoperative patient with rotator cuff pathology that specifically addresses the vital movements and muscles involved when rotator cuff pathology is present (Table 8.2). This exercise program was developed based on the collective information derived from electromyographic (EMG) research of numerous investigators. Incorporation of exercises including side-lying ER and rowing into ER to address ER muscle weakness are critical as both have been shown to elicit the highest amount of muscular activity of the posterior cuff muscles during EMG investigation.
Rehabilitation progressions should also emphasize isotonic periscapular strengthening and neuromuscular control drills. Wilk et al. developed specific exercise drills to enhance neuromuscular control of the scapulothoracic joint. These exercise drills are designed to maximally challenge the scapulothoracic muscle force couples and to simulate the proprioceptive and kinesthetic awareness of the scapula (Fig. 8.4). In addition to the restoration of glenohumeral motion, the resting position and mobility of the scapula as well as scapular muscle strength should be carefully assessed. It is routine for patients to require pectoralis minor muscle stretching and strengthening of the lower trapezius muscle in addition to their scapular retractors beginning early in this second phase. Furthermore, a scapular brace in the form of a postural shirt may be utilized to assist in postural correction and proprioceptive feedback for the shoulder girdle in active patients when needed.