Overview of the shoulder
The shoulder is the most mobile joint in our body. Whilst this beneficially allows for multidirectional use, it also means that the shoulder is the least stable of all joints in the human body. Due to the lax nature of the shoulder joint, it becomes more reliant on the surrounding structures to provide stability, namely the muscles, ligaments and tendons.
The Rotator Cuff Muscles
There are four rotator cuff muscles that surround the shoulder joint. The primary purpose of these muscles is to stabilise the shoulder, keeping the ball of your humerus in the shoulder socket. Each muscle of the rotator cuff contributes largely to the multidimensional movement of the shoulder.
The supraspinatus, infraspinatus and teres minor muscles all attach to the back of your shoulder. This is where they are involved in outwards rotational movements and moving the arm away from the body. The subscapularis muscle is the largest of the four rotator cuff muscles. It attaches to the front of the shoulder blade and is important for inwards rotational movements.
There is a lot of evidence that highlights how dysfunction of the rotator cuff can result in reduced ability to use shoulder in functional tasks. This includes shoulder pain and impaired quality of life. If you do end up with shoulder pain or reduced shoulder movements, it is important to get this assessed by a Physiotherapist. They are the best person to determine the type of injury and the best treatment plan.
What is a Rotator Cuff Tear?
One of the most frequent injuries that occur in the shoulder is a rotator cuff tear. It is important to determine whether the tear is partial or a full-thickness tear. Symptoms that can identify a rotator cuff tear include shoulder pain, difficulty using the arm for functional tasks, reduced strength in the shoulder, increased stiffness in the shoulder, pain that worsens at night, or an audible sound when moving the arm that sounds like cracking or popping. It is important to recognise that pain is not always present. A study conducted by Itor (2013) highlighted how only one-third of individuals have pain with a rotator cuff tear.
The size of the rotator cuff tear is important to consider when determining whether to have surgery on your shoulder or not. Partial and even full-thickness tears are often
managed conservatively. Intrinsic and extrinsic factors such as the patient’s age, their medical history and their current shoulder pain, movement and strength are all important to consider when calculating the best treatment approach (Edwards et al., 2016).
Some rotator cuff injuries are most suitable for surgical management. There are three surgical techniques that are most common.
Open Rotator Cuff Repair:
This technique is the most invasive. It involves a large incision (usually several centimetres long) conducted to separate and reattach a larger shoulder muscle (the deltoid) to repair the tear. This surgical approach is primarily used for individuals who have complicated rotator cuff injuries.
Arthroscopic Rotator Cuff Repair
This technique is the least invasive of the three procedures. They are generally conducted on individuals with smaller tears (equal or less than 3 centimetres). People who undergo arthroscopic surgery generally have less pain and a shorter recovery time period.
Mini-Open Rotator Cuff Repair
This is a newer surgical technique that involves an keyhole (arthroscopic) incision to evaluate the rotator cuff tear and remove loose cartilage. A further incision (around 4 to 6 centimetres) is then conducted to repair the injury.
In nearly all cases, all three surgical approaches require a period of time in a sling. The open rotator cuff repair often requires individuals to have their shoulder immobile in a sling for more than a month. Whilst unlikely, some surgical cases can take up to 2 years to properly rehabilitate. Thus it is crucial to see a physiotherapist as soon as appropriate to prevent stiffness, regain movement, improve strength, improve quality of life and recover movement automatism.
Most rotator cuff injuries are recommended to undergo conservative treatment. Physiotherapy will be aimed at increasing strength and movement of the shoulder, improving the quality of life and reducing pain. Physiotherapy will also be involved in realigning the shoulder structures and recovering movement automatism. A physiotherapist will involve a combination of manual therapy techniques and exercise to maximise these outcomes.
Other forms of conservative management include rest, thermotherapy (use of heat or cold) and NSAIDs (non-steroidal anti-inflammatory drugs). Corticosteroid injections are also a common practice, however caution should be taken if you are considering this management route.
Recent studies have highlighted how conservative treatment has a high likelihood of improving functional use and reducing pain. It is important to have your shoulder assessed by a physiotherapist and orthopaedic surgeon before deciding on taking the surgical route.
If you have had recent shoulder pain or a recent shoulder operation make an appointment below at one of our clinics at Total Physiocare Heidelberg, Reservoir, Footscray and Kew.
Blog by Evan Yang (Physiotherapist)