Jin-Young PARK (ed.)Sports Injuries to the Shoulder and Elbow10.1007/978-3-642-41795-5_6

6. Rotator Cuff Tears in Athletes: Part II. Conservative Management – American Mind

Simon A. Euler^{1, 2}, Dirk Kokmeyer³ and Peter J. Millett^{4, 5}

(1)

Center for Outcomes based Orthopaedic Research, Steadman Philippon Research Institute, 181 W. Meadow Drive Suite 1000, Vail, CO 81657, USA

(2)

Department of Trauma Surgery and Sports Traumatology, Medical University Innsbruck, Anichstr. 35, Innsbruck, 6020, Austria

(3)

Department of Howard Head Physical Therapy, The Steadman Clinic, 181 W. Meadow Drive Suite 400, Vail, CO 81657, USA

(4)

The Steadman Clinic, 181 W. Meadow Drive Suite 400, Vail, CO 81657, USA

(5)

Steadman Philippon Research Institute, 181 W. Meadow Drive Suite 1000, Vail, CO 81657, USA

Peter J. Millett

Email: drmillett@thesteadmanclinic.com

6.1 Introduction

Rotator cuff tears are common injuries in athletes and may occur as a result of acute trauma (such as a fall onto an outstretched arm) or, more commonly, as a result of chronic overuse with repetitive overhead activity. While traumatic conditions are generally treated surgically, chronic overuse injuries are more often treated using a conservative approach.

Overuse injuries of the shoulder are commonly related to microtrauma due to repetitive overhead activities, especially in throwing sports such as baseball or javelin. As these athletes progress to higher levels of competition, greater demands are placed on the glenohumeral joint with increased throwing velocities. Throwing velocity is maximized by increases in shoulder abduction and external rotation range of motion, which leads to anatomic bony and soft tissue adaptations that facilitate hyperabduction and external rotation over time. These anatomic changes can lead to contracture of the posterior capsule with subsequent posterosuperior humeral head migration [1]. This is known as glenohumeral internal rotation deficit (GIRD), which in addition to restricted internal rotation can lead to tearing of the superior labrum (SLAP) via the “peel-back” mechanism [1]. GIRD may also lead to posterosuperior glenoid impingement – an entity characterized by posterosuperior rotator cuff and/or labral tearing as a result of osseous impingement between the greater tuberosity and the glenoid rim in positions of abduction and external rotation (internal impingement). Additionally, muscle imbalances can produce scapular dyskinesis, which may decrease the space available for the rotator cuff tendons to pass beneath the acromion, thus leading to fraying and partial-thickness tearing. The majority of throwing athletes have articular-sided, partial-thickness rotator cuff tears, most of which occur near the interval between the supraspinatus and infraspinatus tendons, presumably due to internal impingement [1].

Athletes who undergo surgery in the midst of a season are commonly excluded from play for the majority of the season. Even off-season surgical treatment may limit return to play or a return to the preinjury level. For efficient and successful treatment with physical therapy, it is important to keep in mind some basic considerations and to follow the basic principles of rehabilitation described below.

Although the pathomechanisms surrounding rotator cuff tears in overhead athletes are still heavily debated, conservative management remains a mainstay of treatment [2]. Therefore, the purpose of this chapter is to review the basic principles of conservative management for rotator cuff tears in athletes with a focus on the overhead athlete.

6.2 Basic Considerations

In the overhead athlete with a rotator cuff tear, the primary goal of nonsurgical management is to achieve a return to full competitive sport while also preventing further injury. This is underscored by specific rehabilitation goals such as decreasing pain and inflammation, strengthening surrounding musculature to promote proper joint kinematics, and promoting proper throwing mechanics that maintain a normal scapulohumeral angle. It is unlikely that conservative treatment induces healing of a torn rotator cuff. However, when overhead athletes present with pain as their major symptom, they can often be treated nonoperative with the goal to improve their range of motion and return them to prior competitive levels.

6.3 Basic Principles: Phases of Rehabilitation

6.3.1 Phase 1

In the overhead athlete with a rotator cuff tear not qualifying for initial surgery, phase 1 of rehabilitation should focus primarily on methods to decrease pain and inflammation, which facilitates range of motion while decreasing pain arthrogenic inhibition, so that more advanced exercises may be implemented. In addition to rest, activity modification, cryotherapy, and anti-inflammatory medications, there are several other therapeutic options that may help to decrease pain and inflammation associated with rotator cuff tears. These may include transcutaneous electrical nerve stimulation (TENS), massage therapy, and laser and heat therapy. However, there is a paucity of evidence to support their use specific to shoulder injuries in the overhead athlete. Nevertheless, since these modalities are typically inexpensive and present minimal risk to the patient, subjective and objective improvements as a result of these interventions may warrant their use.

Subacromial and/or intra-articular injections can also be used to decrease pain and inflammation in patients with rotator cuff tears. Injections may include hyaluronic acid [3], corticosteroids [4, 5], platelet-rich plasma [6], or local anesthetic preparations [7]. While local anesthetics and corticosteroids have been shown to be effective at decreasing pain and inflammation in those with rotator cuff tears, the efficacies of hyaluronic acid and platelet-rich plasma injections are still debated.

In addition to decreasing pain and inflammation, it is critical to ensure that throwing athletes maintain appropriate glenohumeral range of motion. Although the throwing shoulder is often found to have increased external rotation and decreased internal rotation, the total arc of motion should be almost equal to that of the non-throwing shoulder [8]. When physical examination reveals a loss of internal rotation with an associated decrease in the total arc of motion (i.e., glenohumeral internal rotation deficit [GIRD]), specific stretching exercises should be implemented to relieve contractures of the posterior structures, pectoralis minor, and short head of the biceps tendon [8, 9]. Cross-body stretching, the sleeper stretch, and the unilateral corner stretch have been found to significantly increase internal rotation capacity in overhead athletes with GIRD [9, 10]. If an athlete returns to throwing activities before achieving their normal arc of motion, symptoms may recur even after completion of a full rehabilitation program [11]. Therefore, active and passive glenohumeral range of motion should be maintained and emphasized throughout all phases of the rehabilitation process to ensure a successful return to throwing sports.

6.3.2 Phase 2

The athlete may progress to the second phase of rehabilitation following the relief of pain and inflammation. In phase 2, strengthening of surrounding musculature (including that of the hand, wrist, and elbow) is initiated while maintaining pain-free active and passive range of motion. Although the specific strengthening program should be individualized according to the needs of each patient, some have shown that specific emphasis on scapular retractors and glenohumeral external rotators may be beneficial during rehabilitation of the overhead athlete [12].

The concepts of neuromuscular control and dynamic stability center around the coordination of agonist/antagonist muscle groups which work together to produce force couples that center the humeral head within the glenoid fossa at all levels of humeral elevation and rotation. Techniques that focus on neuromuscular control, such as plyometrics, perturbation training, proprioceptive neuromuscular facilitation (PNF) exercises, and closed kinetic chain exercises, should be implemented into the rehabilitation program of any overhead athlete to prevent future injury [13].

6.3.3 Phase 3

Progression to phase 3 requires that the athlete demonstrates optimal upper extremity strength, normalization of range of motion deficits, advanced neuromuscular control, a lack of symptoms, and a lack of significant physical examination findings. In phase 3, intensive upper and lower extremity strength and endurance training is initiated along with an introduction to plyometric exercises that are designed to optimize neuromuscular control. Furthermore, core stability has to be strengthened to ensure proper throwing motion to generate efficient forces within the shoulder joint motion, counteracting distractive and compressive work in a synchronous and coordinated fashion. Any mismatch occurring in this kinematic chain may lead to pathological shear stress in the shoulder joint and to injuries [11]. Therefore, to successfully treat any rotator cuff tear with physical therapy, potentially underlying deficits in the athlete’s throwing mechanics have to be detected and incorporated. The athlete should be taught to work on a balanced distribution of training exercise for the agonist and antagonist muscles of the upper and lower extremities and the trunk to optimize core stability [14, 15]. To prepare for phase 4, light endurance-like roadwork and cycling as well as throwing activities should be started at this point to help transition the athlete back into overhead activity.

6.3.4 Phase 4

During phase 4, the athlete is gradually returned to sport. A structured interval throwing program should be implemented to ensure a graduate progress because there is an elevated risk of rotator cuff re-injury within this stage [11]. Criteria for return to play should be adequate strength tested with handheld dynamometry [16, 17]; achievement of sufficient thresholds in functional outcome scores, such as the Kerlan-Jobe Orthopaedic Clinic (KJOC) questionnaire [18]; controlled pain; and appropriate ROM and scapulohumeral rhythm before an athlete may be considered “cleared” for full activities. Furthermore, increases in pain during overhead activity should be addressed with rest and activity modification. When indicated, pain-free stretching should be continued after rehabilitation to prevent loss of internal rotation and recurrent symptoms [8]. However, the strength training program should be altered gradually to avoid an overuse injury [19].

Only gold members can continue reading. Log In or Register to continue