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Rotator Cuff, Part 3 – Physical Therapy Treatment for Rotator Cuff Tendinopathy and Degenerative Tears

The blog, Rotator Cuff Part 1 detailed some of the factors that contribute to rotator cuff tendinopathy and Rotator Cuff Part 2 discussed a research study that concluded that physical therapy should be the primary treatment for degenerative rotator cuff tears, not surgery. The physical therapy treatment for both conditions is similar. It should be noted that treatment is individually determined based on the results of the physical examination and the factors thought to be contributing to the rotator cuff problem.

Some of the common treatments include:

  1. Manual therapy or hands on treatment aimed at improving the range of motion of the ball and socket joint of the shoulder. The joint capsule of the shoulder joint might be tight on one side (more commonly the posterior side) causing the ball to not sit properly in the socket. Hands on treatment would be used to mobilize the joint capsule, allowing the ball to sit more congruently in the socket.

  2. Manual therapy to improve the mobility of the shoulder blade (scapula). A stiff or mal-positioned shoulder blade affects the position of the socket and the movement of the socket during movement. If this is the case, hands-on treatment is aimed to loosen tight muscles and mobilize the shoulder blade.

  3. Treatment to improve posture is important as the mechanics of the shoulder are influenced by posture. A slouched posture is associated with an abnormal positioning of the shoulder blade and therefore also the socket of the shoulder joint. When the socket is mal-positioned, there is decreased flexibility in flexion (reaching arm up) and decreased flexion strength. Also the rounded posture (kyphosis) results in a reduced space under the coracoacromial arch (the rotator cuff tendon occupies this space – so a smaller space means an increased chance of the tendons being impinged or pinched). Treatment would then aim to loosen and stretch the tight muscles and thoracic joints to reduce the rounded mid-back posture (kyphosis).

  4. Therapeutic exercise – The ball of the shoulder joint sits in a shallow socket. Shoulder movements require proper timing and coordination of a lot of muscles that control the shoulder blade as well as the shoulder joint (called scapulohumeral rhythm). This coordinated action requires strength of the scapular stabilizer muscles and the shoulder muscles, but a key to treatment is re-teaching the muscles how to control the timing of this scapulohumeral rhythm to create pain-free shoulder movement. As well, the manual therapy addressed in points 1-3 above is followed by stretches to continue to improve these areas of tightness/stiffness. The next article Rotator Cuff Part 4 will detail some of these exercises.

  5. Education – an important part of healing is removing the aggravating factors (relative rest) and using ice or modalities if there is inflammation and pain.


References:

1. Kuhn JE, Dunn WR, Sanders R, An Q, Baumgarten KM, Bishop JY et al. Effectiveness of physical therapy in treating atraumatic full thickness rotator cuff tears. A multicenter prospective cohort study. J Shoulder Elbow Surg. 2013; 22(10): 1371-1379.

2. Tate AR, McClure PW, Young IA, Salvatori R, Michener LA. Comprehensive impairment–based exercise and manual therapy intervention for patients with subacromial impingement syndrome: A case series. J Orthop Sports Phys Ther 2010; 40(8): 474-493.

3. Kuhn JE. Exercise in the treatment of rotator cuff impingement : A systematic review and a synthesized evidence-based rehabilitation protocol. J Shoulder Elbow Surg 2009; 18: 138-160.

4. Ludewig PA, Reynolds JF. The association of scapular kinematics and glenohumeral joint pathologies. J Orthop Sports Phys Ther 2009;39(2): 90-104.

Matt Seltzer