So after a very busy start to 2016, we are kicking off the New Year of clinical education with the “all-too-well-known” Rotator Cuff of the shoulder.
The rotator cuff is one of the most commonly talked about, treated, operated on, shoulder structures in our community. But a lot of people don’t really understand what it is, what it does, and why it comes to surgery so often.
You probably know someone who has undergone a rotator cuff repair. The population over the age of 50 has more common contact with this sort of issue. And if you’ve ever seen someone wandering around with a big blue or black shoulder sling on, there’s a good chance they have had a rotator cuff repair.
I have been working with pre-operative and post-operative rotator cuff repairs for over a decade and have also helped people avoid the need for surgery. Yes, it’s possible to get away without surgery!
Let’s take a look at the anatomy;
The rotator cuff is made up of 4 muscles in fact
- Supraspinatus (Latin for “above the spine of the scapula”)
- Infraspinatus (Latin for “beneath the spine of the scapula”)
- Subscapularis (Latin for “under the scapula”)
- Teres Minor (my Latin fails me as to who Terry is)
The rotator cuff muscles play a few different roles. They are not all particularly large muscles, but they are very influential around the shoulder joint and the shoulder blade (scapula). The primary roles include;
- Movement of the shoulder joint. Rotation is an important feature of this, hence the name, however each muscle plays a role in other directions of movement
- Stability of the Shoulder joint. As the shoulder joint itself is inherently unstable in it’s bony structure, the rotator cuff plays an important role in providing extrinsic stability in conjunction with the ligament and capsule structure around the shoulder joint
So, how does the Rotator Cuff get injured?
There are multiple ways in which a rotator cuff injury can occur. Typically, a forceful trauma or short term irritation or long standing degenerative wear are three of the more common reasons.
- If the shoulder is forced into an unnatural position, naturally things can be torn or ruptured. In high impact sports, activities or vehicle accidents, large forces can be absorbed by the shoulder and can result in damage to multiple structures, including any of the four rotator cuff muscles. Accidents like falls or reaching forcefully for objects can also cause injury.
- Repeated load and irritation can lead to Tendinopathy of the rotator cuff tendons. The supraspinatus is most commonly affected by this, but technically, any of the four muscles can be affected. Overhead work and sports can be a common cause of this.
- Long term degenerative wear or impingement are also commonly associated with rotator cuff injury. Take a look at my previous post on shoulder impingement (http://inclinicphysio.com/2015/08/04/shoulder-impingement-whats-it-all-about/) . Here, the supraspinatus tendon is the most commonly affected. Physical compression can result in tendinopathy and ultimately tears and ruptures.
Beware the MRI!
I’m always a bit apprehensive getting scans done on shoulders. There are many occasions were clinically it is very important to have these investigations done, and so I do so. However, there is a wealth of clinical evidence available now (similarly to lower backs) that show us that a large portion of the population will have rotator cuff tears without any pain or evident weakness.
So, what that means is we need to make a clear decision about whether or not what we see on MRI is actually responsible for the pain or dysfunction, because it often isn’t, and surgery may not be necessary.
What Do We Do With Them?
The treatment pathway is entirely dependent on the extent of deficit (pain, weakness, loss of movement, effect on daily life). Often times we can have great success using Physiotherapy and conservative management, including;
- Soft tissue therapy
- Postural training
- Spinal mobilization to assist with posture and mobility
- Specific and appropriate strength and exercise rehabilitation
- Activity modification
The extent of each of these measures is entirely dependent on how things look in the clinic. Specific diagnosis is key to employing the right conservative (non-surgical) management
What About Surgery?
It is the case with some patients that surgery is required to repair the damaged portion of the rotator cuff. The vast majority of the time now, this is done arthroscopically with minimal invasion. Our local surgeons here are incredible and all do a wonderful job.
Some injuries require open surgery, whereby the entry incision is larger than the arthroscope incision, but the surgery is similar in it’s effect.
I have included a nice little vid here for your viewing pleasure!
Typically, 6 weeks will be required in a sling after the surgery, then the Physio fun can really begin. A little can be useful to keep things comfortable whilst in the sling, but the real action happens after this period. Graded rehabilitation in line with the best evidence and the surgeon’s guidelines will see most patients feeling like normal again by about 6 months.
Naturally, there is a spectrum of recovery. I normally say that full recovery will be experienced in the 12-18 month range after surgery. There will normally be good lifestyle function, including some sports by 6 months.
For further, more specific guidelines about your injury, email me firstname.lastname@example.org, or speak with your trusted health professional.