Physical therapy management of Rotator cuff tear

A rotator cuff tear is an injury of one or more of the tendons or muscles of

the rotator cuff of the shoulder. Symptoms may include shoulder pain,
which is often worse with movement, or weakness.

Types of rotator cuff tears:

 Partial thickness tear

 Full-thickness tears
 Acute tears
 Chronic tears
 Traumatic tears
 Degenerative tears

Classification:

(According to American Arthroscopic Orthopedics)

 Small Tear (<1cm)

 Medium Tear : Size of the tear ranges between 1cm to 3 cm
 Large Tear: Size of the tear ranges between 3cm to 5cm

Etiology:

The causes for rotator cuff tears, partial or full, are as follows:

 Age > 40 years.

 Occupations requiring repetitive and excessive overhead movements.
 Overhead sports and athletes like throwers, swimmers, tennis players,
etc.
 Degenerative etiology is the major cause.
 Dislocation of shoulder joint in 40-60 years of age.
 About 2/3rd cases are seen in male population.

Clinical Presentation:

All patients with impingement syndrome have similar clinical features like:

 Pain
 Swelling
  Limitation of shoulder movements
 Muscle atrophy (supraspinatus and infraspinatus)
 Tenderness over the greater tuberosity, etc.

The following grades are described in anterior impingement syndrome.

Grade I: This is common in young adults and athletes in the age group of
18-30 years. Due to overstress and repeated overhead activity,
impingement occurs and supraspinatus is inflamed.

Grade II: This is seen in age group of 40-45 years and may be due to
supraspinatus tendinitis or subacromial bursitis. The cause could be either
overuse or degeneration and osteophyte formation.

Grade III: It is seen in patients over 45 years of age and may be due to
occupational overuse, fall, and sudden increase in activity, atrophic
degenerative changes in the cuff and rarely due to acute tear of the rotator
cuff.

Diagnosis:

 The pain is most pronounced when the painful tear is exposed to

compression. The following signs can be elicited for diagnosis:
 Neer’s (1972) Impingement Sign: This sign is elicited by passively
fully abducting the arm overhead which causes pain by
compressing the inflamed subacromial bursa and rotator cuff
against a prominent anterior acromion.
 Hawkins Sign (Hawkins & Hobeika, 1983): Hawkins sign, also
called impingement reinforcement sign, is performed with the
arm in 90 degrees of elevation in the scapular plane. The humerus
is internally rotated so that the greater tuberosity passes under
the coracoacromial arch. This causes pain in cases of impingement
syndrome.
 Investigation To diagnose rotator cuff tear
 X-rays of the shoulder: This helps to detect bony avulsions, spurs,
calcific deposits, sclerotic areas, etc
 Arthrogram: Single contrast arthrogram is considered as the gold
standard in diagnosing rotator cuff tears.
 Ultrasonography: This is highly reliable in diagnosing rotator cuff
pathology with a sensitivity of 98 percent.
  MRI: This is also very accurate (81%) but expensive.

TREATMENT

 Medical management:
 NSAID’s
 Local infilteration of hydrocortisone
 Sub acromial Steriod Injections

 Surgical Management:

Indications for Surgery

The primary indications for surgical management of a rotator cuff tear

confirmed by imaging are pain and impaired function as the result of the
following.

 Partial-thickness or full-thickness tears of the rotator cuff tendons

resulting from repetitive microtrauma and chronic impingement,
which lead to irreversible degenerative changes in soft tissues. Some
patients with stage II lesions and most with stage III lesions (Neer
classification) who continue to be symptomatic and have functional
limitations after a trial of nonoperative treatment are candidates for
surgery.
 Acute, traumatic rupture (frank, full-thickness tear) of the rotator
cuff tendons often combined with avulsion of the greater tuberosity,
labral damage, or acute dislocation of the GH joint in individuals with
no known history of cuff injury. Full-thickness, traumatic tears occur
most often in young, active adults.

Types of surgical treatments to repair rotator cuff tears.

1. Open repair

A traditional open surgical incision is often required for large or

complex tears.

2. Arthroscopic Repair

An optical scope and small instruments are inserted through small

puncture wounds instead of through a larger incision. The operation
can be carried out under visual control via a video display.
 3. Mini-Open Repair

New techniques and instruments allow surgeons to perform a

complete recovery of the rotator cuff through a small incision of
generally 4 to 6 cm.

The operative treatment is done mostly arthroscopically which is less

invasive than open/mini-open surgery and leaves only a few small scars.
The rehabilitation can start faster and the patient has less pain during
recovery.

 Physiotherapy Management:

Conservative management

The basic aims and objectives of physiotherapy are as follows:

1. Preventive measures: To avoid its occurrence:

(a) Avoid sudden lifting of heavy weight. When the weight exceeds the
tensile strength of the tendon, it invariably ruptures the tendon.

(b) Avoid repeated compression and nipping of the tendon, e.g., professions
involving repeated movement of strenuous abduction and flexion.

(c) People in age group prone for degenerative changes need to take extra
cautions while attempting these movements with weights.

(d) Strengthening of the rotator cuff muscles by PRE. It should be planned

on an individual basis specifically to strengthen all the three components of
the rotator cuff, namely, abductor, internal rotator and external rotator
muscle groups.

(e) Avoid sports involving repetitive movements of elevation without

specific conditioning and strengthening programme.

2. Prevention of further damage

(a) Positioning during standing: Guidance to use support of good arm

should be taught or an arm sling with proper and secured support to the
shoulder and elbow may even be considered.
(b) Positioning during exercise: In the presence of a rupture, the patient
should be taught the correct positions and actions so that the ruptured
tendon is not exposed to any further stretch and damage.

(c) Passive full ROM to avoid adhesive capsulitis is to be kept in mind and
taught to the patient as self-assisted movements in supine lying position
and not in standing or sitting positions.

3. Restoration of function: During the early phase of an

acute episode:

(a) Rest with proper support in a sling,

(b) Movements of elbow, forearm, wrist and hand,

(c) Cryotherapy, transcutaneous electrical nerve stimulation (TENS),

ultrasonics.

After acute symptoms are abated, isometric contractions should be given to

all the three muscle groups with special emphasis on abductors and flexors
with self-built-up pain- free controlled contractions.

Transverse friction massage just below the acromion is useful.

Deep heating modality like short-wave diathermy could given provided the
patient does not complain of increased pain during the exposure.

Exercise programme:
1. Relaxed passive movements: Relaxed passive full range movements
with the patient in supine lying position for abductors and side lying
for flexors should be started at the earliest.
2. Active or active-assisted exercises: This programme is of vital
importance in the return of function. With the patient in supine
position, the arm is held in neutral position of rotation with the
elbow in flexion. Stabilization is given just above the glenohumeral
joint over the shoulder girdle. The patient is then asked to the abduct
the arm. If the patient can perform this, the lever arm is lengthened
by extending the elbow joint. The patient should be taught to perform
movements without elevating the shoulder girdle. If both these
movements are not possible, assisted abduction should be initiated
with the physiotherapist totally supporting the weight of the arm.
 3. Resisted exercises: Finally, manual resistance or resistance with
dumbbells starting with minimal weight could be added. The
shoulder needs to be compared with the normal side to assess the
progress. Properly controlled resisted exercise programme for
rotator cuff muscles and self- generated tension are important
because the scapular muscles are the ‘power house’ of the shoulder
movements, whereas the muscles of the humerus are primarily
oriented to provide greater range of movement.

Post Operative management

After surgical repair of a torn rotator cuff tendon, there are many factors
that influence decisions about the position and duration of immobilization,
the selection and application of exercises, and the rate of progression of
each patient’s postoperative rehabilitation program.
Despite variations among postoperative programs, they share three
common elements: (1) immediate or early post operative motion of the
GH joint; (2) control of the rotator cuff for dynamic stability; and (3)
gradual restoration of strength and muscular endurance.

 Immobilization

Size of tear Types & duration of immobilization

Small (≤ 1 cm) Sling for 1–2 weeks; removal for exercise the day of
surgery or 1 day postop
Medium to large ( 5 Sling or abduction orthosis/pillow for 3–6 weeks; removal
cm) for exercise 1–2 days postop
Massive ( 5 cm) Sling or abduction orthosis/pillow for 4–8 weeks; removal
for exercise 1–3 days postop

 Exercise
The emphasis of a therapist’s interaction with a patient must be placed on
patient education for an effective and safe home-based exercise program.

Exercise: Maximum Protection Phase

The maximum protection phase extends for as little as 3 to 4 weeks after a
fully arthroscopic or mini-open repair of small or medium tears or as long
as 6 to 8 weeks after repair of large or massive tears.

Goals & intervention

 Control pain and inflammation.

 Periodic use of ice.
 Arm support for comfort.
 Cervical spine ROM and shoulder relaxation exercises.
 Grade I oscillations of the GH joint.

 Prevent loss of mobility of peripheral joints.

 Assisted ROM of the elbow.
 Active ROM of the wrist and hand.

 Prevent shoulder stiffness/restore shoulder mobility.

 Pendulum exercises typically the first postoperative day or
when the immobilizer may be removed for exercise.
 Passive ROM of the shoulder within safe and pain-free ranges.
 Self-assisted ROM using the opposite hand or a wand.
 Active control of the shoulder with assistance as needed from
therapist or family member.
 Prevent or correct postural deviations.
 Posture training and exercises to prevent excessive thoracic
kyphosis
 Develop control of scapulothoracic stabilizers.
 Active movements of the scapula.
 Submaximal isometrics to isolated scapular muscles.

Exercise: Moderate Protection Phase

The focus of the second phase of rehabilitation is to begin to develop
strength, endurance, and neuromuscular control of the shoulder while
continuing to attain full or nearly full, pain-free shoulder motion.
For a patient with a repair of a small or medium tear, this phase begins
around 4 to 6 weeks postoperatively and extends an additional 6 weeks.

Goals & intervention

  Restore nearly complete or full, nonpainful, passive mobility of the
shoulder.
 Self-assisted ROM with an end-range hold by means of wand or
pulley exercises, in single plane and combined (diagonal)
patterns.
 Mobilization of the incision site if well healed to pre vent
adherence of the scar.
 Increase strength and endurance and re-establish dynamic
stability of the shoulder musculature.
 Active ROM of the shoulder continued or begun through
gradually increasing but pain-free ranges.
 Isometric and dynamic strengthening to key scapulo thoracic
stabilizers.
 Submaximal multiple-angle isometrics of the rotator cuff and
other GH musculature against gradually increasing resistance.
 Upper extremity ergometry at or just below shoulder level
against light resistance to increase muscular endurance.
 Use of the involved upper extremity for light (no-load or low-
load) functional activities.

Exercise: Minimum Protection/ Return to Function Phase

i. This final (advanced) phase usually begins no earlier than 12 to 16
weeks postoperatively for patients with strong repairs or at 16
weeks or later for a tenuous repair.
ii. If full ROM still has not been restored with assisted and active
exercises, passive stretching of the GH musculature and joint
mobilization is now initiated.
iii. Patients generally are not allowed to return to high demand activities
for 6 months or possibly 1 year postoperatively depending on the
patient’s level of comfort, strength, and flexibility as well as the
demands of the desired activities.