Physical Therapy For Rotator Cuff Disorders: a review of the literature

Fouad Fayad, MD, PhDRheumatology Department- Hotel-Dieu de France Hospital

Saint-Joseph University

Anatomy of Rotator Cuff

• Four muscles fuse to form a tendon that encompasses the humeral head.

• RC contributes to GH movement and functions as a dynamic stabiliser of the joint, supporting the capsule.

Subacromial Space Clearance

• Role of the forces generated by the RC– Abduct the shoulder

– Stabilize the joint

– Neutralize the superior directed force generated by the deltoids at lower abduction angles

Escamilla, Sports Med, 2009

Subacromial Space Clearance

• Role of the scapula

– Scapular protraction and anterior tilt

• Decrease subacromial space width

• Increase impingement risk

Fayad et al, ClinBiomeh, 2006

Ludewig, J Orthop Sports Phys Ther, 2009

Aetiology of Rotator Cuff Disease

• Disorders of the rotator cuff, are considered to be the most common among the shoulder pathologies.

• Multiple hypothesis: – Extrinsic mechanisms:

• acromion, coracoid process, superior aspect of the glenoid fossa

– Intrinsic degeneration– Postural abnormalities– Glenohumeral instability– Dietary insufficiencies

• Few randomized trials have compared the effectiveness of different approaches to the management of RCL, and none have directly compared surgical with nonsurgical intervention.

• Cochrane review 2004: insufficient data to support or refute any treatment

• Many limitations: control group, follow-up duration, …

• Therefore, approach is largely based on clinical experience, an understanding of the anatomy, and the management of tendon failure at other sites.

Treatment of Rotator Cuff Lesions

Rotator Cuff Impingement

• Systematic review on role of exercise therapy:– 11 randomised controlled trials

• Findings:– Exercise therapy is effective for the reduction of pain

– Home exercise may be as effective as supervised exercise

– The effect of exercise may be augmented with manual therapy

– Acromioplasty with postoperative exercise also produces improvements in symptoms

– There may be a role for bracing but need of further studies

Kuhn, J Shoulder Elbow Surg, 2009

Acute Complete Tears

• Best repaired as soon as possible, ideallywithin 6 weeks after injury.

• Prolonged observation and nonsurgical management allow:– the detached tendon to retract and resorb– the muscle atrophies.

Safran, JBJS Am, 2000; Gerber, JBJS Am, 2000; Coleman, JBJS Am, 2003; Gerber, JBJS, Am, 2004; Gladstone, Am J sports Med, 2007

Partial-Thickness Rotator-Cuff Tendon Defects

• Acute or chronic partial-thickness often improve with nonsurgical management– program of range-of-motion exercises

• Patients refractory to this stretching program– debridement of the lesion – smoothing of the humero-scapular motion interface– curettage of the deep surface of the tendon

attachment

Budoff, JBJS Am, 1998; Matsen, 2004

Chronic, Full-Thickness, Degenerative Tendon Defects

• Most cases, best managed without surgery:– NSAID– Acetaminophen– Activity modification– Gentle stretching and

strengthening of intact muscles

Ainsworth, Br J Sports Med, 2007; Matsen, NEJM, 2008

Chronic, Full-Thickness, Degenerative Tendon Defects

• Systematic review on exercise therapy:– No randomised controlled trials

– Evaluation based on 10 observational studies

– Type of exercises• Strengthening and stretching exercises• Scapular exercises• Humeral head depressor exercises

(pectoralis major and latissimus dorsi).

Ainsworth, Br J Sports Med, 2007;

Chronic, Full-Thickness, Degenerative Tendon Defects

• Systematic review on exercise therapy:Findings:

• Exercise therapy, either in isolation or as part of a nonoperative package of care for full thickness tears of the rotator cuff, has some benefit.

However,• No definitive guidance as to when to start the

program, what to include in the program and when to refer for a surgical opinion.

Ainsworth, Br J Sports Med, 2007;

• Subacromial corticosteroid injection:– Benefit uncertain

– Effects slight and non sustained

– Repeated use discouraged except in cases in which: • surgery is not considered an option• the response to other nonsurgical interventions is inadequate• there is a perceived improvement in symptoms with injection

Chronic, Full-Thickness, Degenerative Tendon Defects

Buchbinder, Cochrane, 2003

Ejnisman, Cochrane, 2004

• Other approaches:– Electrotherapy– Therapeutic ultrasonography– Acupuncture– Injection of hyaluronic acid– Shock-wave therapy

Have also been used in patients with rotator-cuff failure, but:– These methods have not been rigorously studied– The indications and benefits are unclear

Chronic, Full-Thickness, Degenerative Tendon Defects

Ejnisman, Cochrane, 2004

Matsen, NEJM, 2008

• Surgery:– Symptoms persist in spite of nonsurgical measures

1- The clinical evaluation suggests that the cuff is reparable: Repair the rotator cuff

2- The rotator cuff is irreparable: Debridement and preserve the integrity of the coracoacromial arch Tenotomy or tenodesis of the long head of the biceps tendon

3- There is a degenerative arthritis of the GH joint: Shoulder joint replacement

Chronic, Full-Thickness, Degenerative Tendon Defects

Ejnisman, Cochrane, 2004

Matsen, NEJM, 2008

• Rotator cuff disorders are common

• Physical therapy is efficient in impingement syndrome and partial tears and may help in full thickness tears

• There is little consensus as to the optimum management of rotator cuff disorders

• This review highlights the paucity of published evidence concerning the use of specific exercises in the management of rotator cuff tears

• There is a need for a quality trials to develop the evidence base as to the optimum exercise program.

Conclusion