In the next year, 20 percent of the American population will complain of pain in their shoulder that emanates from the rotator cuff, according to the World Health Organization. Over a lifespan, that number will grow to 50 percent. As one of the most common orthopedic conditions on a physical therapist's caseload, rotator cuff tears prove a challenge for the recovering patient.
A person may first notice that routine daily tasks such as tucking a shirt into the back of their pants, hair drying, lifting objects heavier than 5 pounds and elevating the arm above shoulder level have become exceptionally difficult.
The rotator cuff is comprised of a group of muscles and tendons that stabilize the ball of the shoulder in the socket as the arm moves throughout space. Injury to this system is hallmarked by intense pain, poor range-of-motion (ROM) and distinct weakness of the shoulder joint that can dramatically limit daily activities. The causes of rotator cuff dysfunction vary broadly from trauma to chronic degeneration, and present themselves differently in each person.
The diagnosis of a rotator cuff tear is established through both clinical evaluation and imaging studies — most often an MRI. Although each case is unique, patients typically present with some combination of the previously mentioned symptoms.
Of course, there are multiple degrees of tearing. While the larger, more complex tears are thought to cause more problems in daily life, I frequently find that even small tears can bring profound pain. Trauma can bring with it a constellation of damage to the surrounding tendons, making the diagnosis of a tear relatively straightforward. Patients without a history of injury can be more difficult to evaluate, and a definitive diagnosis may not be reached until a few weeks into the process.
Non-operative management involves a host of interventions, with specific focus on manual restoration of ROM and functional strengthening. As a course of rehab progresses, these interventions will increase in difficulty and will focus on full restoration of functional activities. While I cannot firmly comment on the number of patients who go on to seek operative care, overwhelming evidence suggests that patients with small partial tears (most cuff tears are partial) are highly satisfied with their pain and function after a full conservative course of therapy.
For those patients who do not respond to conservative management, surgery is the intervention of choice. Surgery is preferable in patients who have sustained large or massive tears, or multiple-tendon tears. Without repair, the nature of these tears is to progress to the point of tendon failure or rupture.
The advent of arthroscopic surgery (minimally invasive surgery) has revolutionized the treatment and recovery of rotator cuff repair. Rehab after arthroscopic surgery has three distinct phases. After surgery, Phase 1 is the most critical in setting the stage for recovery. Its focus is purely on restoration of passive ROM. At my institution, the use of the arm sling is discontinued after four weeks, allowing for expedited motion recovery. Patients undergo extensive stretching and joint mobilization in anticipation of Phase 2 — active motion and gentle strengthening.
In Phase 2, we begin laying the framework for full restoration of all activities in a gradual, progressive fashion. Phase 3 incorporates specific functional activities such as lifting heavy objects, sporting activity and labor retraining. From the first day after the repair, the total elapsed rehabilitation time is between three and six months — the longer rehab bouts being reserved for patients with difficult, physical jobs.
As a clinician, I feel the most successful cases are the ones where a partnership between the patient and physical therapist is established early on in the course of rehab. Additionally, I make it a top priority to impress upon my patients the importance of taking their rehab as seriously as I do. With the right dedication to a course of physical therapy, patients can expect good return of their shoulder function shortly after the initiation of treatment.
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Joe DiVincenzo of Beverly is a clinical specialist at the outpatient division of Beverly Hospital. He writes "On the Mend" weekly for the Salem News' Health North section.
