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Off the Cuff:Rotator Cuff Injuryand Recovery

By

Anne Ahlman, MPT

3 clock hours will be awarded upon successful completion of this course.

Educational Planner:Amy Bernard, MS, BSN, RN-BCThe planner has disclosed that she has no significant financial or other conflicts of interest pertaining to this course book.

Copy Editor:Renee M. Ergazos

EDITORIAL BOARD

Mary K.Miller, PharmD,MD,Clinical Professor, Clinic Medical Director, OB/GYN andAmbulatory Medicine, University ofCalifornia Davis; HIV Gynecology–CARES (Center forAIDS Research, Education and Services); Sacramento, CA.

DavidA.Verhaag, MD, Family Practice Physician, Roseville, CA

Javeed Siddiqui,MD,MPH,Assistant Professor of Clinical Medicine, University of California, Davis, CA; Infectious Diseases/InternalMedicine, CARES (Center forAIDS Research Education Services) Sacramento, CA

Lilian Daughenbaugh, RNC,ALS,NRP Instructor, ECMO Specialist, Clinical Nurse Neonatal Intensive Care, Pennsylvania StateUniversity, Hershey PA, and Sutter Memorial Hospital Special Care Nursery, Sacramento, CA

WendyWulff, RN, LCSW, Private Psychotherapy Practice, Sacramento Superior Court Family Law Private Practice Mediator,Child Custody Evaluator, and Special Master, Sacramento, CA

WilliamA.Maesen, PhD, PsyD, LCPC, LCSW, Private Practice; GSC CurriculumAdvisory Board; Independent Consultant &Staff Trainer; President Community Services Council of Will County, Joliet, IL

Monty Collins, PhD, LCDC, Private Psychotherapy Practice; GSC CurriculumAdvisory Board; Tulsa, OK

Richard Ustick, RCP, CRTT, Palomar-Pomerado Health Network, La Mesa, CA

P.O. Box 1930Brockton, MA 02303800-231-7159

ii

ABOUTTHEAUTHOR

AnneAhlman, MPT, received a bachelor of sciences degree from the University of California, Davis in 1983and a master of science degree in physical therapy from the University of California, San Francisco/SanFrancisco State University in 1992. She is a practicing outpatient physical therapist at Cupertino PhysicalTherapy in San Jose, California, and has had experience as a director of rehabilitation and as a clinical instruc-tor to physical therapy students. With a background in medical research, Anne has written and presented on avariety of topics involving orthopedics, sports medicine, geriatrics, vestibular dysfunction, and hippotherapy.Anne has served as the physical therapy editor for Today in PTmagazine and is the author of Naked Elbows: APhysical Therapist’s Reflections on Patient Care, Intuition, and Healing, a medical narrative that explores per-sonal and professional stories about the joys and challenges of patient care.

Anne Ahlman has disclosed that she has no significant financial or other conflicts of interestpertaining to this course book.

ABOUTTHECONTENTEDITOR

Lee N. Marinko, PT, ScD, OCS, FAAOMPT, graduated with a bachelor of science degree in physical ther-apy from Northeastern University in 1986 and completed her ScD in rehabilitation and movement sciencefrom Boston University in 2007. She completed a 2 year fellowship in orthopedic manual physical therapy in1998 and has been a certified fellow in the American Academy of Orthopedic Manual Physical Therapy sincethat time. She has been a board certified orthopedic specialist through the American Physical TherapyAssociation since 1996. Currently she is a clinical assistant professor in the physical therapy program ofSargent College, Boston University, where she teaches on the musculoskeletal systems with the primary con-tent in the upper extremity. She also serves as the assistant to the chair in the Shoulder Special Interest Groupof the American Physical Therapy Association of Massachusetts and has published in the area of shoulderpathologies.

Lee N. Marinko has disclosed that she has no significant financial or other conflicts of interestpertaining to this course book.

iii

STOPREADTHIS PAGEBEFORE PROCEEDING.

BEFOREYOUBEGIN:

Use the COURSE EXAMINATION found at the back of this course booklet to test your existing knowl-edge of the subject matter. This will serve as an informal self-assessment. At this stage, do NOT loganswers to the exam questions on the FasTrax answer sheet included with the course. Simply circle theanswers in the course booklet, or write the answers on a separate sheet of paper.

TAKINGTHECOURSE:

Read the course in its entirety and take the COURSE EXAMINATION. Log your answers to the examquestions on the FasTrax answer sheet that has been included with your course materials. If you are com-pleting more than one course, be sure to record your answers on the FasTrax answer sheet for this course.Fill in only those numbered answer circles that correspond to the exam questions. Use blue or black inkand fill in the circles completely. The FasTrax grading system will not read pencil. If you make an error,you may use correction fluid (such as Wite- Out®) to correct it.

FasTrax answer sheets are preprinted with your name and address and the course title. If you are complet-ing more than one course, be sure to record your answers on the correct corresponding answer sheet.

You must score 75% or better in order to pass this course and receive a certificate of completion. Shouldyou fail to achieve the required score, an additional FasTrax answer sheet will be sent to you so that youmay make a second attempt to pass the course.You will be allowed three chances to pass the same coursewithout incurring additional charges.After three failed attempts, your file will be closed.

FINAL STEPS:

The COURSE EVALUATION provided on the next page of this course booklet is a critical component ofthe course and must be completed. Record responses to evaluation statements in the right-hand column ofthe FasTrax answer sheet, in the section labeled EVALUATION.

The IMPORTANT INFORMATION FORM is another way to provide additional feedback regarding thiscourse or GSC services, or to suggest new course topics. Use the space provided on the back of theFasTrax instruction sheet included with your course.

Evaluations provide GSC Home Study Courses with vital feedback regarding courses. Your feedback isimportant to us; please take a few minutes to complete the Evaluation and Important Information Form.

Return the completed Important Information form and FasTrax answer sheet to GSC Home Study Courses.

To get the most out of this GSC Home Study course, use the PSQ4R Learning Skills technique described onpages vii and viii.

GSC HOME STUDYP.O. Box 1930

Brockton, MA 02303800-231-7159

www.gscce.com

GSC HOME STUDYCOURSE EVALUATION

OFF THE CUFF: ROTATOR CUFF INJURYAND RECOVERY

INSTRUCTIONS:Using the scale below, please respond to the following evaluation statements.Allresponses should be recorded in the right-hand column of the FasTrax answer sheet, in the section marked“Evaluation.” Be sure to fill in each corresponding answer circle completely using blue or black ink. Leave anyremaining answer circles blank.

A B C DAgree Agree Disagree DisagreeStrongly Somewhat Somewhat Strongly

OBJECTIVES:After completing this course, I am able to:1. Identify the anatomical structures typically involved in a rotator cuff injury and their biomechanical interaction.2. List the components of a comprehensive physical examination for patients with a suspected rotator cuff

injury.3. Identify common clinical strategies and evidence-based treatment techniques for rotator cuff injury.4. Recognize surgical indications and complications relating to rotator cuff injuries.COURSE CONTENT5. The course materials were well-organized and clearly written.6. The course expanded my knowledge and understanding of the subject matter.7. The course was relevant to my professional practice or interests.8. The final examination was at an appropriate level for the content of the course.9. The course materials presented current developments in the field.10. As a result of this course, I have learned new skills, interventions, or concepts.CUSTOMER SERVICEThe following section addresses your experience in interacting with GSC Home Study. Use the scale below to

respond to the statements in this section.A.Yes B. No C. NotApplicable

11. GSC Home Study staff was responsive to my request for disability accommodations.12. The GSC Home Study website was informative and easy to navigate.13. The process of ordering was easy and efficient.14. GSC Home Study staff was knowledgeable and helpful in addressing my questions or problems.ATTESTATION15. By submitting the answer sheet, I certify that I have read the course materials and personally completed the

final examination based on the material presented. Mark “A” forAgree and “B” for Disagree.

Note:To provide additional feedback regarding this course, GSC services, or to suggest new course topics, use thespace provided on the Important Information form found on the back of the FasTrax instruction sheet included with your course.

v

HOWTOGETTHEMOSTOUTOFYOURGSCHOMESTUDYCOURSE

USINGTHEPSQ4RTECHNIQUE!Continuing education should provide the licensee with timely information that can be recalled for day-to-dayuse. Each GSC Home Study CE Course was planned and produced in accordance with the PSQ4R methoddescribed in the following paragraphs. GSC Home Study has found the PSQ4R method useful for retention ofnew or updated information.

PSQ4R, stands for:

P = PurposeS = SurveyQ =Question4Rs = Read Selectively, Recite, Reflect, and Review.

1. Determine your purpose for reading this course. For many of you it may be merely to obtain continuing edu-cation credit to maintain your license. But, take a moment and look beyond this reason, what is it about thisparticular course topic that interests you? How does it relate to your current practice? (Est. Time: 5 minutes)

2. Test your knowledge of the course subject matter prior to reading the course by answering the course exami-nation questions at the back of the booklet. Circle the answers in the course booklet, or write the answers ona separate sheet of paper. Do not use the FasTrax answer sheet. (Est. Time: 20 minutes)

3. Survey the course by previewing or skimming the course objectives, subject headings, illustrations, graph-ics and test questions. Pay attention to the first sentences, introductions, conclusions or summaries in thecourse. Write down any words that are unfamiliar to you. (Est. Time: 15 minutes)

4. Make up questions using the section headings as a guide. Write the questions on a blank sheet of paperand leave space for your answers (2-3 inches). For example, if the section heading states “Diagnosis ofAlzheimer’s Disease,” write the question “What are the current criteria used to diagnose Alzheimer’s dis-ease?” leaving space for the answer later on. (Est. Time: 15 minutes)

5. Read selectively to find the answers to your “section-heading” questions. Write your answers in the spaceyou provided. Be sure to write down and/or look up any words that are or were unfamiliar to you.Also, asyou continue to read don’t forget to look for ideas and information that are in alignment with your purposefor taking the course. (Est. Time: 80 minutes)

6. Recite the answers to your questions, by reading the question aloud with the answer covered up. Use your ownwords as much as possible. If you don’t recall the answers, look over that section again. (Est. Time: 5 minutes)

7. Reflect on the information in the section you’ve just read. Try to make a simple outline, table, flow dia-gram or “doodle.” (Est. Time: 5 minutes)

8. Review “section-heading” questions and answers, diagrams and outlines. (Est. Time: 15 minutes)

9. Take the Course Examination. Place your answers on the FasTrax answer sheet inserted with your coursepacket. (Est. Time: 30 minutes)

10. Complete the Course Evaluation. Place your answers under the heading “Evaluation” in the right-hand columnof the FasTrax answer sheet. (Est. Time: 5 minutes)

vii continued on next page

viii Off the Cuff: Rotator Cuff Injury and Recovery

Normal EstimatedTime to Complete this GSCHome Study CECourseActivityTest your knowledge..................................................................20 minutesRead the course ..........................................................................90 minutesTake the post-test........................................................................30 minutesRe-read the course to locate answers........................................35 minutesComplete the course evaluation ..................................................5 minutesTOTAL time ..........................................................................180 minutes

EstimatedTime to Complete this GSCHome Study CECourseActivity Using thePSQ4RMethod for ImprovingYour Reading Comprehension

Determine the Purpose for taking the course ............................5 minutesTest your knowledge..................................................................20 minutesSurvey the course ......................................................................15 minutesMake up questions ....................................................................15 minutesRead selectively..........................................................................80 minutesRecite the answers to your questions..........................................5 minutesReflect the information you just read in the course ..................5 minutesReview questions, diagrams, and outlines................................15 minutesTake the posttest ........................................................................30 minutesComplete the course evaluation ..................................................5 minutesTOTAL time using the PSQ4Rmethod .......................... 195 minutes

GSC Home Study courses are designed to provide health care professionals with the educational information they need to enhancetheir career development. The information provided within these course materials is the result of research and consultation withprominent health care authorities and is, to the best of our knowledge, current and accurate. However, the courses and course materi-als are provided with the understanding that GSC Home Study is not engaged in offering legal, medical, or other professional advice.

GSC Home Study courses and course materials are not meant to act as a substitute for seeking out professional advice or conductingindividual research. When the information provided in the courses and course materials is applied to individual circumstances, all rec-ommendations must be considered in light of the uniqueness pertaining to each situation.

GSC Home Study course materials are intended solely for your use and not for the benefit of providing advice or recommendationsto third parties. GSC Home Study divests itself of any responsibility for adverse consequences resulting from the failure to seek med-ical or other professional advice. GSC Home Study further divests itself of any responsibility for updating or revising any programsor publications presented, published, distributed, or sponsored by GSC Home Study unless otherwise agreed to as part of an individ-ual purchase contract.

Products (including brand names) mentioned or pictured in GSC Home Study courses are not endorsed by GSC Home Study, anynational accrediting organization or any state board.

CONTENTSCourse Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vFigures andTables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xiIntroduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xiii

Course Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xiiiOff the Cuff: Rotator Cuff Injury and Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Rotator Cuff Injury Defined . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Functional ShoulderAnatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

Glenohumeral and Scapulothoracic Joints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

MusculotendinousAttachments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

Biomechanics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

Etiology and Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

Stiffness versus Instability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

Diagnostic Tests and Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

Signs and Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

History and Physical Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

Observation and Palpation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

Clinical Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

Conservative Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

Injections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

Physical Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

Patient Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

Modalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

Extracorporeal Shockwave Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

Iontophoresis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

Manual Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

Exercise Concepts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

Indications and Types of Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

Conclusion and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

ix

x Off the Cuff: Rotator Cuff Injury and Recovery

ExamQuestions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37

FIGURES ANDTABLES

Figure 1:Acromion Morphology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Table 1: Prevalence of Rotator Cuff Tears inVarious Populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

Table 2: Lag Signs Effective toAid the Diagnosis of Rotator Cuff Tears . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

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I N T R O D U C T I O N

Shoulder problems are one of the most com-mon causes of musculoskeletal pain and

disability for which patients seek help each year,second only to low back and neck pain (Bilal,Duffy, Shafi, & Hafi, 2010; Roy, Dahan, Bélair,& Dahan, 2009). Ranging from acute tendonitisto chronic impingement syndrome and from partial-to full-thickness tendon tears, rotator cuffdysfunction can affect patients at virtually anyage; nonetheless, the incidence of rotator cuffpathology occurs with increased frequency afterthe age of forty (Bilal et al., 2010). When rotatorcuff problems arise, early diagnosis and treat-ment can be important to identify potentialcauses, modify aggravating factors, and educatepatients to prevent further injury and to restorefunctional mobility to the affected extremity(Goldberg, Nowinski, & Matsen, 2001).

The purpose of this course is to provide reha-bilitation professionals with a comprehensiveoverview of rotator cuff injuries and to examinemedical treatment options, physical therapy inter-ventions, and surgical approaches to the problem.This course will provide a review of relevant shoulderanatomy, examine possible causes of shoulder painranging from degenerative changes to multidirec-tional instability, describe treatment techniquescommonly used in management of the disorder,discuss areas in need of further research, and listrelative indications and complications relating torotator cuff surgery.

This course is relevant for physical therapistsand physical therapist assistants, occupational ther-apists and occupational therapy assistants, andorthopedic and rehabilitation nurses. The focus ofthis course is to explore the most recent evidence-

based research that supports rehabilitation treatmentmethods while highlighting the many areas still inneed of study. Common clinical approaches torestoring shoulder function will also be examined.

COURSE OBJECTIVESAfter completing this course, the learner will

be able to:1. Identify the anatomical structures typically

involved in a rotator cuff injury and theirbiomechanical interaction.

2. List the components of a comprehensive physi-cal examination for patients with a suspectedrotator cuff injury.

3. Identify common clinical strategies andevidence-based treatment techniques for rotatorcuff injury.

4. Recognize surgical indications and complica-tions relating to rotator cuff injuries.

xiii

OVERVIEW

Shoulder rotator cuff injuries are commonly seenin clinical practice and are thought to be one of

the leading causes of shoulder pain (Mantone,Burkhead, & Noonan, 2000). Indeed, it is estimatedthat nearly one-fifth of all individuals will experi-ence a shoulder problem at some point during theirlifetime (Hide, 2008). Although injuries to the rota-tor cuff (RTC) can affect people at virtually any age,they are most commonly seen in young athletesinvolved in throwing sports or repetitive overheadactivities, or in patients over the age of 40 experi-encing degenerative changes in the soft tissues ofthe shoulder (DeBerardino & Chang, 2010;Malanga, Visco, Andrus, & Bowen, 2009; Tuite &Sanford, 2009).

ROTATORCUFF INJURYDEFINED

The term rotator cuff injury refers to a spectrumof disorders affecting one or more of the four

main musculotendinous units of the shoulder’sRTC: the supraspinatus, infraspinatus, teres minor,and subscapularis. The injury may be acute, fol-lowing a traumatic event such as a fall, or an eventduring which the individual overloaded the tendonsby lifting improperly; alternatively, the injury maybe chronic, as the result of repeated overuse thatdamages the tendons over time (Mayo Clinic,

2010). When injured, the tendons of the RTC maybecome inflamed, partially torn, or ruptured, result-ing in pain and functional disability. Shoulderimpingement syndrome, the most common causeof RTC injury, results in compression, entrapment,or mechanical irritation of the RTC tendons, typi-cally involving the supraspinatus and infraspinatustendons (Ludewig & Reynolds, 2009). The longhead of the biceps tendon, which functionally actsas part of the RTC during arm elevation, may alsobecome involved when the RTC tendons areinjured, and there can be secondary irritation of theshoulder bursae as well (Ludewig & Reynolds,2009; Manzon & Sheetz, 2010).

Abnormalities of the shoulder joint such as anarrowed supraspinatus outlet, osteophytes on theundersurface of the acromion, joint hypermobility,or chronic bursitis may result in friction on theRTC tendons that causes acute tendonitis orimpingement of the RTC tendons with movement(Medical Disability Advisor [MDA], 2010). Thesestructural causes of injury are most commonly seenafter the age of 40 (Choi, 2009). Other commonnames for RTC injuries are impingement syn-drome, swimmer’s shoulder, pitcher’s shoulder,RTC dysfunction, RTC disease, RTC tear, andchronic supraspinatus tendonitis. Althoughsupraspinatus tendonitis is a specific type of RTCinjury affecting only the supraspinatus tendon, it ispossible to have tendon dysfunction or tears in anyof the four RTC tendons.

OFF THE CUFF:ROTATOR CUFF INJURY

AND RECOVERY

1

In general, patients younger than age 40 tend toexperience milder forms of RTC disease, such astendinopathy and impingement syndrome, thatmay be associated with shoulder instability;patients older than age 40 are more likely to experi-ence chronic or more advanced RTC disease, suchas partial- or full-thickness tendon tears, that areassociated with glenohumeral osteoarthritis oradhesive capsulitis (Fehringer, Sun, VanOeveren,Keller, & Matsen, 2008; Iannotti & Kwon, 2005;Murrell & Walton, 2001; Self, 2002).

The annual incidence of shoulder disordersaffecting the RTC is estimated to affect 1% of thepopulation in the United States, with the greatestnumber of cases occurring between the ages of 42to 46 (Bilal et al., 2010). In a Japanese study exam-ining the prevalence and risk factors of RTC tearsin a population of 683 residents of a mountain vil-lage, 20.7% of all individuals had RTC tears, withincreasing prevalence associated with age: Thepercentage of individuals with RTC tears in eachgeneration was 0% of those in their 20s, 2.5% intheir 30s, 6.7% in their 40s, 12.8% in their 50s,25.6% in their 60s, 45.8% in their 70s, and 50.0%in their 80s (Yamamoto et al., 2010). Risk factorsassociated with RTC tears included increasing age,male gender, and history of trauma or heavy labor;impaired range of motion with shoulder flexion,and reduced strength with external rotation andabduction, was also associated with RTC tears.

Symptoms may occur acutely, following aneasily remembered trauma, or they may come onmore gradually as degenerative changes in the RTCtendons progress. Half of patients experiencingdegenerative RTC changes are able to remember aspecific event or activity during which the paincame on, and the other half experience progressive,insidious onset of shoulder pain over time (Bilal etal., 2010; Roy et al., 2009). Symptomatic RTCinjuries may occur in either the dominant or non-dominant arm, and often result in a high level ofmorbidity – over 50% of patients with RTC injuries

reportedly continue to experience debilitatingsymptoms as long as 18 months after initial symp-tom onset (Bilal et al., 2010; Hide, 2008).Conversely, there is a high incidence of asympto-matic RTC tears in the general population. In a2009 Norwegian study of 420 individuals betweenthe ages of 50 and 79 without shoulder pain, 7.6%were found to have full-thickness supraspinatustendon tears as viewed on diagnostic ultrasound orMRI (Moosmayer, Smith, Tariq, & Larmo, 2009).Whether the RTC injury causes painful symptomsor is asymptomatic, the prevalence of RTC injuryincreases with age (Bilal et al., 2010; Malanga etal., 2009; Roy et al., 2009). It is not yet understoodwhy RTC pathology produces pain in somepatients, but not in others (Roy et al., 2009).

Although a symptomatic RTC injury may resultfrom an acute trauma, most cases are thought to becaused by repeated wear and tear of the RTC ten-dons against various structures within the gleno-humeral joint, either alone or in combination withprogressive age-related tendon degeneration (Roy etal., 2009). Potential mechanisms of injury include

• recurring impingement of the RTC tendonswithin the subacromial space;

• fraying of the RTC tendons in a hypermobile orunstable shoulder; and

• intrinsic tendon failure secondary to theprogressive degenerative changes of aging

(Roy et al., 2009).

FUNCTIONAL SHOULDERANATOMY

The shoulder complex is composed of severaljoints that work together to produce arm mobil-

ity (glenohumeral joint motion) based on a stableplatform (scapulothoracic stabilization) (Kibler,1998). Adjoining joints to the main shoulder com-plex that add a stabilizing component while allow-ing arm motion are the acromioclavicular and

2 Off the Cuff: Rotator Cuff Injury and Recovery

sternoclavicular joints. Although these four artic-ulations (glenohumeral joint, scapulothoracicjoint, acromioclavicular joint, and sternoclavicularjoint) normally work together to producecontrolled shoulder motion, the majority ofmovement occurs at the glenohumeral andscapulothoracic joints.

Glenohumeral and Scapulothoracic JointsThe freely moving glenohumeral joint is the

most mobile and least stable joint of the body. Theglenohumeral joint is protected from unwantedexcessive movement, subluxation, or dislocationduring motion by a set of static and dynamic stabi-lizers (Roy et al., 2009). Static stabilizers arerelatively inert structures and include the bonyjoints, cartilaginous labrum, glenohumeral liga-ments, and the joint capsule (Malanga et al., 2009).Dynamic stabilizers are the muscles of the scapulaand the RTC surrounding the shoulder joint that actto move the arm in a controlled fashion.

The glenohumeral joint consists of a bonyarticulation between the hemispherical “ball” of thehumeral head and the slightly concave “socket” ofthe glenoid cavity of the scapula that is deepened bythe cartilaginous labrum. The “roof” of the joint isthe acromial arch of the scapula, which is composedof the acromion, the coracoacromial ligament, theacromioclavicular joint, and the coracoid process(Williams, Warwick, Dyson, & Bannister, 1989).The normal resting distance between the humeralhead and the acromion (the supraspinatus outlet) isapproximately 10 mm and reduces to 3 to 5 mmwith overhead reach (Levangie & Norkin, 2011).This reduction can further narrow in the presenceof anomalies in the undersurface of the acromionor when a poorly stabilized humeral head migratessuperiorly upward (Roy et al., 2009). When thesupraspinatus outlet narrows, this can increase therisk for RTC injury due to impingement of theRTC tendons and the subacromial bursa betweenthe nearby bones and ligaments. Although a full-thickness RTC tear involves the entire depth of the

tendon, partial-thickness tears may involve eitherthe articular or bursal surfaces. Surprisingly, theunderside of the distal supraspinatus tendondirectly adjacent to the glenohumeral joint (articularsurface) is more susceptible to tearing than the top-side of the tendon located directly beneath theacromion and the subacromial bursa (bursal sur-face) (Quintana & Sinert, 2010; Zlatkin, 2003).

Despite the higher incidence of RTC tears atthe articular surface of the supraspinatus tendon,one component that has long been thought to con-tribute to an increased risk of RTC injury is theshape of the acromion, which has been classifiedinto three major forms (Figure 1) (Biglianni, 1986).

• Type I acromion: Flat, with no downwardcurve toward the humeral head.

• Type II acromion: Curved, such that theacromion has an arched shape.

• Type III acromion: Curved with an extra hookof bone at the distal acromion that curls downtoward the humeral head

(Biglianni, 1986).

Researchers have suspected that the Type IIIacromion was a precursor for RTC damage thatresults in cuff tears, but current understanding ofthe morphology of RTC tears indicates that themajority of tears occur on the articular side of the

Off the Cuff: Rotator Cuff Injury and Recovery 3

FIGURE 1: ACROMION MORPHOLOGY

Note: From Orthopedic Physical Assessment, 5th ed. (p. 336), by D.J.Magee, 2008, Philadelphia: Saunders Elsevier. Copyright (2008) bySaunders Elsevier. Reprinted with permission.

cuff tendon, not the bursal side. Researchers haverecently begun considering whether the bonychanges at the acromion are a reaction to, ratherthan a precursor for, a tendon tear (Roy et al., 2009;Quintana et al., 2010).

This theory is supported by research indicatingthat acromial curvature seems to increase naturallyas part of aging, irrespective of RTC injuries: Onestudy showed that 93% of patients over the age of70 exhibited Type II or Type III acromions(Worland, Lee, Orozco, SozaRex, & Keenan,2003). In another study evaluating the relationshipbetween acromial type and RTC status, researchersfound that 36.3% of RTC tears occurred in Type Ishoulders, 24.2% in Type II shoulders, and 39.6%in Type III shoulders (Hirano, Ide, & Takagi,2002). Although there now appears to be littlecausative relationship between the type ofacromion and the risk for RTC tears, when apatient with an acromion of greater curvaturesustains an RTC tear, the tear is more likely to be alarge one (Hirano et al., 2002). A 2009 study sup-ports the idea that acromial shape is actually notcorrelated to RTC dysfunction, nor is it inherentlyassociated with a shortened distance between theacromion and the humeral head; in other words, acurved acromion does not necessarily result indecreased subacromial space or a narrowedsupraspinatus outlet (Mayerhoefer, Breitenseher,Wurnig, & Roposch, 2009).

MusculotendinousAttachmentsFunctional mobility of the shoulder complex

requires dynamic stabilization of the glenohumeraljoint combined with mobility of the scapulo-thoracic joint in an integrated, coordinated manner.The dynamic stabilizers of the glenohumeral jointinclude the small muscles of the RTC. The largerscapular stabilizers are the teres major, rhomboids,trapezius, levator scapula, and serratus anteriormuscles. The smaller RTC muscles are thesupraspinatus, infraspinatus, teres minor, and sub-scapularis – also known by acronym as the SITS

muscles. The supraspinatus functions to abduct thearm, the infraspinatus and teres minor to externallyrotate the arm, and the subscapularis to internallyrotate the arm.

The primary function of the RTC muscles is tostabilize the glenohumeral joint by depressing andcentering the humeral head on the glenoid so thatthe larger overlying muscles, such as the deltoid,can work to elevate the arm. Without the opposingforce of the RTC muscles, the deltoid would pullthe humeral head superiorly in the glenoid fossa,making full arm elevation impossible (Malanga etal., 2009; Williams et al., 1989). In particular,supraspinatus is highly active during the first 30degrees of shoulder abduction to center and stabi-lize the glenohumeral joint in preparation for themiddle deltoid to fire and abduct the arm (Malangaet al., 2009). The other three SITS muscles work inconcert with supraspinatus by helping to center thehumeral head in the glenoid via their combinedopposing actions of external and internal rotation.

If there is weakness or muscular insufficiencyof the dynamic stabilizers, there is an increaseddemand upon the static stabilizers (joint, ligaments,joint capsule). If these demands are chronic orrepetitive, the static stabilizers may also fail, whichcan lead to joint capsule laxity and an increasedrisk of RTC impingement as the unstable humeralhead slips about within the labrum during armmotion (Malanga et al., 2009). Also, if the scapularmuscles (large dynamic stabilizers) fail, there is anincreased demand on the RTC muscles (smalldynamic stabilizers). When the scapular muscula-ture becomes weak or stretched, as occurs withpoor posture, the scapula moves forward into arelatively protracted position. This may allow ananterior shift of the humeral head relative to thelabrum, which brings the humeral head closer tothe acromion, thus increasing the risk of impinge-ment of the supraspinatus and/or the long head ofthe biceps tendons between the bones(Skolimowski et al., 2007).


Another anatomic consideration is the inherentstructure of the supraspinatus tendon. It has beensuggested that there is a region of relative hypovas-cularity located about one centimeter from thesupraspinatus tendon insertion at the greatertuberosity that corresponds with the zone where themajority of supraspinatus tendon degeneration isfound and where most RTC tears occur(Rockwood & Matsen, 2009). Also, there isthought to be a relatively smaller blood supply tothe articular surface of the RTC tendons, and less-ened blood flow may partially explain the highincidence of cuff tears on the underside of the ten-don near the joint, as opposed to its superficial sur-face that comes into direct contact with the bursaand acromion (Rockwood & Matsen, 2009; Roy etal., 2010). However, it is not clear if poor bloodsupply in the supraspinatus tendon is the cause orthe result of repeated tendon damage:Intraoperative laser Doppler flowmetry revealsdecreased blood flow at impinged RTC tendons,but is unable to locate a specific hypovascular zone(Levy et al., 2008; Luo, Hsu, Grabowski, Morrey,&An, 1998).

When an RTC tendon (usually supraspinatus)becomes injured by repetitive impingement betweenthe bones of the shoulder, it is thought to go throughthree stages before tendon failure (Neer, 1972).

• Stage I commonly affects people younger than25 and is characterized by repeated micro-trauma that results in acute inflammation,swelling, and hemorrhage of the tendon. Thisstage is normally reversible without surgicaltreatment (Neer, 1972).

• If the impingement continues, Stage II pro-duces acute tendonitis and is often associatedwith thickening of the subacromial bursa, nar-rowing of the subacromial space, and thebeginning of bone spur (osteophyte) formationon the underside of the acromion (Neer, 1972).Scar tissue, which lacks the elasticity of normaltendon fibers, begins to form on the tendon

(fibrosis) as it repeatedly attempts to heal, andleaves the tendon more vulnerable to furtherinjury. This stage usually affects peoplebetween 25 and 40 (Neer, 1972).

• Stage III commonly affects people older than40 and results in a partial- or full-thicknessRTC tear. Stage III tears often require surgeryto repair the torn supraspinatus tendon, removeosteophytes, and flatten and smooth the under-side of the acromion (acromioplasty). Duringthis stage, as the supraspinatus tendon fails andthe remaining RTC muscles become inhibitedsecondary to pain response, the humeral headbecomes less stable and glides superiorly,resulting in increased tension and loading of thelong head of the biceps tendon. Consequently,the biceps tendon may rupture in the presenceof chronic RTC insufficiency (Neer, 1972). TheStage III RTC injury is thought to be the endresult of many years of repeated episodes oftendonitis and associated fibrosis.

BiomechanicsOn average, the glenohumeral and scapulo-

thoracic joints contribute to total shoulder motion ina 2:1 ratio; that is, 120 degrees of glenohumeral jointmotion combines with 60 degrees of scapulothoracicjoint motion to make up 180 degrees of shoulderabduction (Malanga et al., 2009; Williams et al.,1989). Presently the biomechanical specifics ofscapulohumeral rhythm are being further investi-gated in the literature (Ludewig & Reynolds, 2009).

To achieve this movement, there must be coor-dinated co-contraction of specific muscles firing atspecific times to create force couples, where theforce generated by one muscle is counterbalancedby the force generated by a second muscle toachieve a resultant movement. With arm elevation,there are several major muscular force couples atwork: The coronal plane force couple involves thesupraspinatus and deltoid muscles, which co-contract with a resultant force that compresses the


humeral head into the glenoid to stabilize the inher-ently unstable, freely-moving glenohumeral joint(Parsons, Apreleva, Fu, & Woo, 2002). The trans-verse plane force couple involves subscapularis,infraspinatus, and to a lesser degree teres minor,which co-contract to center and depress thehumeral head within the glenoid during movement,counteracting the slightly upward shearing forceproduced by the coronal force couple on thehumeral head (Parsons et al., 2002). At the scapu-lothoracic joint, the trapezius and serratus anteriorforce couple acts to produce upward scapular rota-tion (Mottram, 2003).

With arm elevation, the first 30 degrees ofmotion primarily comes from the glenohumeraljoint as the combined force couples of the deltoidand SITS muscles work together to depress andstabilize the humeral head to fine tune the optimalpositioning of the glenohumeral joint (Rockwood& Matsen, 2009). During this time, the scapulaachieves stabilization against the ribcage via co-contraction of the large scapular stabilizers and thetrapezius and serratus anterior force couple (Roy etal., 2009). As the arm continues to rise, the scapularotates upward (laterally and superiorly) to enableoptimal positioning of the smaller glenoid fossa rel-ative to the larger head of the humerus, and to allowthe attached muscles to sustain an advantageouslength-tension ratio throughout the movement ofthe arm (Roy et al., 2009). Below 90 degrees ofelevation, any deficiency in the RTC muscles mayresult in improper positioning of the humeral head,which increases the risk of tendon impingementwith continued elevation. But as the arm is thenraised beyond 90 degrees of elevation, the action ofthe RTC muscles on the glenohumeral jointdecreases, leaving them vulnerable to injury whenjoint abnormalities or other muscle imbalances arepresent (Roy et al., 2009).

ETIOLOGYANDRISKFACTORS

An RTC injury may arise from acute traumaticinjury, mechanical compression from an

impingement syndrome or hypermobility problem,or intrinsic degeneration of the RTC tendon (Choi,2009). The acute RTC injury is less common thanthe chronic, degenerative type of injury, but it canresult in a partial- or full-thickness tear of any of theRTC tendons.Younger patients typically experienceimpingement pain and RTC tendinopathy caused byshoulder hypermobility or instability, whereas olderpatients generally have a structural, degenerativecause of the injury (Burbank, Stevenson, Czarnecki,& Dorfman, 2008a; Choi, 2009; Manzon & Sheetz,2010). Whether the RTC injury is due to acute ten-donitis, chronic impingement, or tendon tears, ittends to occur most frequently in the dominant arm(Choi, 2009).

Stiffness versus InstabilityAn RTC injury may be caused by a primary

impingement of the shoulder from mechanicalsqueezing of the RTC due to changes in bonyanatomy that cause the shoulder to become stiff, orby a secondary impingement from glenohumeraljoint hypermobility or instability that allows excesshumeral head movement that repeatedly traps theRTC tendons between the bones (Choi, 2009).Even without mechanical impingement, degenera-tive changes in the RTC can directly cause an RTCinjury, as progressive cuff failure allows the deltoidmuscle to dominate, leading to upward displace-ment of the humeral head, acute tendonitis, chronictendinopathy, and RTC tears (Choi, 2009).

Rotator cuff injuries are most common at thesupraspinatus tendon due to its vulnerable positionbetween the humeral head and the acromion, butRTC injuries can also involve the infraspinatus,teres minor, or subscapularis (Choi, 2009).Supraspinatus tendon damage may occur fromincreased loading of the tendon from heavy lifting,


muscle imbalance or weakness of the RTC, orrepetitive injury (Burbank et al., 2008a). Rotatorcuff injuries are commonly seen in athletes withhypermobile arms involved in throwing sports andtypically manifest as chronic tendinopathy and par-tial RTC tears secondary to the microtrauma ofongoing, subtle shoulder instability (Lintner,Noonan, & Kibler, 2008). These athletes are alsovulnerable to RTC fatigue that can result intendinopathy or RTC tears: When throwing, thelarge extrinsic muscles such as pectoralis major,latissimus dorsi, and teres major are the primemovers of shoulder internal rotation, with the sub-scapularis firing to internally rotate the cocked arm.The remaining RTC muscles fire eccentrically tocontrol and decelerate the arm during follow-through(Malanga et al., 2009).As repeated eccentric loadingoccurs, the RTC muscles fatigue and may succumbto acute tendonitis, chronic tendinopathy, tears, orimpingement. In this case, RTC fatigue can resultin the inability to center the humeral head in theglenoid, causing a secondary impingement (Choi,2009; Lintner et al., 2008).

Other people at risk of RTC injury are thosewho perform repeated overhead lifting or reaching,those with poor reaching mechanics, and thosewith poor posture (Burbank et al., 2008a; Ludewiget al., 2009). In repeatedly raising the arm over-head, especially with poor biomechanics, thesupraspinatus tendon may become frayed againstthe acromion as it rides along on the humeral head.Painters, carpenters, and those who play sportssuch as tennis, baseball, or swimming, are atincreased risk (Burbank et al., 2008a).

Poor posture in the form of a forward head,slumped, kyphotic thoracic spine and collapsedchest can result in scapular protraction, reducedserratus anterior activation, and increased uppertrapezius activation, which may contribute toaltered scapular kinematics and lead to RTCimpingement (Ludewig & Reynolds, 2009). Poorposture also promotes the elongation and weakness

of the scapular stabilizers, rendering them lesseffective and placing more of the workload directlyon the RTC muscles, which can lead to fatigue andfailure (Choi, 2009; Ludewig & Reynolds, 2009).

Another factor that increases the risk for RTCinjuries is cigarette smoking. In a recent studyexploring the correlation between shoulder painand smoking habits, patients who smoked morecigarettes and those with a long history of smokingwere more likely to have sustained an RTC tearthan those who did not smoke (Baumgarten et al.,2010). Perhaps the vasoconstrictive effect smokinghas on the microcirculation may impair the abilityof RTC tendons to heal once damaged, resulting inpainful, nonhealing tears.

Patients with a positive family history for RTCproblems also seem to have an increased predispo-sition for developing an RTC injury. Sequencevariants within certain genes seem to be associatedwith specific tendon and ligament extracellularmatrix proteins that are linked with soft tissueinjuries of the RTC (Collins & Raleigh, 2009).People with naturally hypermobile joints, such asathletes or young people with congenitally laxligaments, are also more likely to sustain tendonfriction and overload that may lead to RTC failure.In the multidirectionally unstable shoulder, thestatic shoulder stabilizers, particularly the joint cap-sule, are overstretched and become less effective incontrolling excess shoulder motion, which allowsmore strain and work to be sustained by the RTC(Lintner et al., 2008).As the throwing motion at theshoulder rapidly transitions from external to inter-nal rotation, massive shearing forces develop at theglenohumeral joint that stress the already weak-ened RTC, leading to tears of the cartilaginouslabrum as the RTC fails (Lintner et al., 2008).


DIAGNOSTICTESTSANDDIFFERENTIALDIAGNOSIS

Rotator cuff injuries typically present as a dullaching sensation in the anterolateral shoulder

that worsens with activity, particularly with reachingabove the head (Bilal et al., 2010). There is usuallypainful and limited active range of motion(AROM), muscular weakness, inability to lie orbear weight on the affected side, pain at night andwith overhead activity, and compensatory move-ment patterns of the affected upper extremity(Burbank et al., 2008a). But there are several alternateshoulder pathologies that present with similar signsand symptoms that must be ruled out, includingbursitis, biceps tendinopathy, acromioclavicular jointarthritis, adhesive capsulitis, shoulder instability,calcific tendonitis, avascular necrosis, thoracicoutlet syndrome, myocardial infarction, andreferred pain from a cervical spine dysfunction(Burbank et al., 2008a; Malanga et al., 2009;Quintana & Sinert, 2010). Virtually any of thesealternate pathologies may occur concurrentlywith an RTC injury, but an attempt must be madeto identify the exact underlying pathology of thepatient’s shoulder pain using a range of diagnos-tic and clinical tests, as appropriate.

Baseline diagnostic imaging of the shoulderusually begins with a routine series of plain X-rayfilms to examine the status of the bones. X-rays canhighlight information about the presence of osteo-phytes, arthritic changes, calcific deposits, andfractures, as well as determine the type of acromionpresent and assess the subacromial space. A sub-acromial distance of less than 7 mm between thehumeral head and acromion may indicate superiormigration of the humeral head, possibly as theresult of a chronic RTC tear (Quintana & Sinert,2010). X-rays can also reveal bony cystic changes,as well as defects in the humeral head (Hill-Sachslesions) that may be present secondary to anteriorshoulder instability.

For examination of the RTC itself, magneticresonance imaging (MRI) appears to be the mostuseful imaging tool (Quintana & Sinert, 2010;Tuite & Sanford, 2009). MRI may reveal informa-tion about the possibility of a partial- or full-thickness RTC tear, the size of the tear, and in thecase of a full-thickness tear, whether the tendon hasretracted. An MRI is an accurate way to identifyRTC tears and has an excellent correlation withsurgical findings. In a French study of 48 patientswho had an MRI before shoulder surgery, the MRIhad detected 100% of full-thickness tears and 92%of partial thickness tears accurately (Lambertet al., 2009).

Diagnostic ultrasonography is another noninva-sive imaging technique that demonstrates anaccuracy comparable to MRI for detecting RTCtears (de Jesus, Parker, Frangos, & Nazarian,2009). MRI arthrography, in which a contrastmedium is injected into the shoulder joint andviewed under MRI, seems to be more sensitivethan ultrasonography in finding small partial-thick-ness tears, but has the drawback of being invasive(de Jesus et al., 2009). In the case of a weak andpainful shoulder, electrodiagnostic studies such aselectromyography and nerve conduction testingmay help rule out cervical nerve root pathology,brachial plexus pathology, or suprascapular nerveentrapment (Malanga et al., 2009).

As always, imaging test results must be corre-lated to the patient history and physical examination,as not all RTC abnormalities captured on imagingtests cause painful symptoms. One British reviewarticle discovered that approximately 26% ofasymptomatic people have an RTC tear as seen onMRI (Reilly, Macleod, Macfarlane, Windley, &Emery, 2006) (Table 1). The researchers furtheridentified that 18.49% of studied cadavers had apartial-thickness RTC tear, and another 11.75% ofcadavers had full-thickness tears; however, it is notknown whether the tears had been asymptomatic ornot (Reilly et al., 2006).


Signs and SymptomsMany times, the patient can readily demon-

strate a painful position or range of impingementwhen reaching above 90 degrees of elevation orwhen reaching out at arm’s length (Roy et al.,2009). Half of patients with degenerative RTC dis-ease report an insidious onset of unilateral shoulderpain that aches at rest and sharply worsens witharm elevation or lifting or reaching activities, andhalf may recall a specific event of pain onset (Bilalet al., 2010; Roy et al., 2009). Patients report thatthe pain is often aggravated by donning and doffingclothing, pushing doors open, reaching forward touse the computer mouse, and by increased activityin general; aside from anterolateral shoulder pain,limited range of motion and weakness are alsocommon (Burbank et al., 2008a; Quintana &Sinert, 2010).

Patients with an acute RTC injury may reportintermittent pain with overhead activities, whereaspatients with chronic RTC inflammation or a par-tial tear may have persistent pain at rest in additionto painful reaching; often, as degenerative RTC dis-ease worsens, the pain becomes more constant andweakness sets in (Quintana et al., 2010; Roy et al.,2009). Many patients report experiencing increasedpain at night that wakes them up, and an inabilityto directly lie upon the injured shoulder. Shouldercrepitus may also be present with arm motion,which may indicate degenerative changes (tendonfibrosis) in the RTC (Roy et al., 2009).

A hallmark sign of RTC pathology is the pres-ence of a painful arc when moving the affected

extremity overhead; typically, the pain is worsebetween 60 to 120 degrees when actively movingthe arm into flexion or abduction (Johnston &Liebert, 2009).

History and Physical ExaminationA complete patient history should be recorded

including the onset of symptoms, pain patterns,diagnostic tests performed to date, activity patterns,medications or herbal supplements used, and typeof occupation. It is also important to consider pre-vious injury or shoulder trauma, age of the patient,frequency and duration of symptoms, and aggra-vating factors. The patient should be questioned asto hand dominance, work station setup, and pre-ferred hobbies or sports activities that might beexacerbating symptoms (Burbank et al., 2008a).Patients should be asked to rate their pain level on anumeric scale, both at rest and with aggravatingactivities. The diagnosis of an RTC injury is usu-ally made by a complete history and physicalexamination, clinical tests of range of motion andstrength, and provocative maneuvers; if it is sus-pected that the patient may require surgery, theresults of the physical examination should be corre-lated with imaging studies to confirm the diagnosis(Johnston et al., 2009).

Observation and PalpationThe physical examination should include a pos-

tural assessment that includes movement observa-tion, combined with hands-on palpation of theaffected shoulder. Posture must be observed in sit-ting and standing positions, and any deviations fromnormal posture that may influence the use of the

TABLE 1: PREVALENCE OF ROTATOR CUFF TEARS IN VARIOUS POPULATIONSPopulation Asymptomatic People Symptomatic Patients

MRI partial-thickness tear 15.87% 8.57%

MRI full-thickness tear 10.33% 40.81%

Ultrasound partial-thickness tear 17.2% 6.7%

Ultrasound full-thickness tear 21.7% 34.7%Adapted from “Dead men and radiologists don’t lie: A review of cadaveric and radiological studies of rotator cuff tear prevalence,” by Reilly, P., Macleod,I., Macfarlane, R., Windley, J., & Emery, R.J.H, 2006, Annals of the Royal College of Surgeons of England, 88(2), 116-121.


upper extremities, such as forward head, excessivekyphosis, slumping, or scapular winging or protrac-tion, should be noted.

Palpation of the shoulder should be combinedwith careful observation of shoulder structuresfrom all angles (Malanga et al., 2009). The thera-pist should look for symmetrical muscle bulk,possible atrophy, scapular positioning, and poten-tial asymmetry of shoulder height; any obviousasymmetries may indicate underlying pathology(Johnston & Liebert, 2009). Tenderness over theacromioclavicular joint may indicate osteoarthritis,whereas subacromial tenderness is more suggestiveof RTC dysfunction or subacromial bursitis(Burbank et al., 2008a). Palpation of shoulderstructures should focus on possible deformities,tenderness, and swelling. With RTC dysfunction,there may be tenderness, thickness, swelling, orincreased tissue density present over thesupraspinatus insertion at the greater tuberosity ofthe humerus, at the long head of the biceps tendonin the bicipital groove, or over the subacromialbursa (Malanga et al., 2009).

Muscle atrophy may be observed. Supraspinatusatrophy is often present with RTC pathology, andwhen a massive or complete RTC tear or a supra-scapular nerve entrapment has occurred, there isnoticeably decreased muscle bulk in thesupraspinatus and infraspinatus muscles (Burbanket al., 2008a; Malanga et al., 2009). Transdeltoidpalpation of the anterior shoulder, otherwise knownas the rent test, may also be performed in anattempt to identify a full-thickness tear of the RTC.With the rent test, the examiner attempts to feel arent, or soft tissue defect, in the RTC by palpatingthe anterior margin of the acromion through thedeltoid. While gently moving the patient’s passivearm into internal and external rotation during pal-pation, the patient’s arm is also moved into and outof full extension to expose the greater tuberosity ofthe humerus. Although one study determined thattransdeltoid palpation is highly sensitive and

specific for diagnosing an RTC tear with 96.3%accuracy (Wolf & Agrawal, 2001), others feel thatpalpation of RTC defects is impractical and usuallynot possible in most patients (McFarland, 2006).

Clinical TestsA thorough evaluation must include clinical

tests to rule out the cervical spine and thoracic out-let as possible shoulder pain generators (Burbank etal., 2008a; Malanga et al., 2009; Quintana &Sinert, 2010). When assessing the shoulderdirectly, both AROM and passive range of motion(PROM) of the affected arm should be recorded viagoniometric measurement and compared to theasymptomatic side. Frequently, AROM testingreveals a painful arc of movement into arm eleva-tion, such that shoulder flexion or abductionanywhere between 60 and 120 degrees is painfulwhen the RTC tendons press painfully against theacromion and the coracoacromial ligament(Johnston &Liebert, 2009; Malanga et al., 2010).The quality of active movement with elevationshould be observed from the anterior and posteriorperspectives to see whether scapulohumeralrhythm is normal and whether the patient assistsarm elevation with abnormal compensatory scapu-lar elevation; with RTC injuries, glenohumeralmotion is often decreased in conjunction with acompensatory increase in scapulothoracic move-ment (Malanga et al., 2010). Maximal upperextremity elevation may be observed in the planeof the scapula, which is located at approximately30 degrees anterior to the coronal plane(Rockwood & Matsen, 2009).

Actively moving the extremity into horizontaladduction by reaching the hand toward the oppo-site shoulder may reveal an anterior tendon pinch,and reaching the hand behind the back to test activeinternal rotation may reveal stiffness and pain, par-ticularly if the posterior glenohumeral joint capsuleis tight (Wheeless, 2010). Active external rotationshould be noted at both 0 degrees and 90 degreesof abduction to assess tightness or laxity – loss of


external rotation can result in or worsen shoulderimpingement, and conversely excessive externalrotation may indicate rupture of the subscapularismuscle (Wheeless, 2010).

When the patient is examined in supine,PROM is often unrestricted although pain may bepresent at the very end ranges of movement; this isimportant to assess as some patients may produceseemingly full AROM of the shoulder via a com-pensatory increase in scapulothoracic mobility yetactually may be restricted in their available PROM;patients found to have limitations in both AROMand PROM may have adhesive capsulitis ratherthan an RTC injury (Burbank et al., 2008a;Malanga et al., 2009).

Testing accessory joint mobility is part of thetypical orthopedic assessment because of therelationship between reduced posterior capsularmobility and RTC injury (Lin, Lim, &Yang, 2006;Seitz, McClure, Funucanee, Boradman, &Michener, 2010; Tyler, Roy, Nicholas, & Gleim,1999). Clinicians routinely assess shoulder jointmobility for the amount of excursion and quality ofthe end-feel as part of the shoulder evaluation.Mobility in the presence of an RTC injury is nor-mally pain free, but there may be decreased inferiorand anterior-posterior glide of the humeral head.Conversely, patients with impingement syndromesecondary to shoulder instability may exhibitexcessive glenohumeral joint mobility.

Manual muscle testing is used to observepotential weakness or pain in response to resistancewith comparison to the asymptomatic side. It isimportant to attempt to determine if diminishedmuscle power is secondary to pain response(increase of symptoms that inhibits the full musclecontraction during testing), or secondary to a full-thickness tear or nerve compression (no significantincrease of symptoms but weakness with testing)(Burbank et al., 2008a).

Strength tests specific for the RTC includeresisted supraspinatus testing (the “empty can” test,

also known as the Jobe test), which is performedwith the arms abducted 90 degrees in the scapularplane (30 degrees anterior to the coronal plane) andinternally rotated with the thumbs pointing down-ward – a positive sign is one in which there is painand weakness upon resistance (Burbank et al.,2008a). The “full can” test (shoulder abduction inthe scapular plane with external rotation) may alsobe of value when assessing supraspinatus function,as electromyographic testing in the test positiondemonstrates significantly greater activity of thesupraspinatus muscle as compared to other shoul-der muscles (Yasojima et al., 2008).

Strength of the posterior RTC (infraspinatusand teres minor muscles) can be tested by resistingexternal rotation while the patient’s arms are at 30degrees of abduction in the scapular plane for infra-spinatus, and 90 degrees of abduction with fullexternal rotation for teres minor, with the elbowsare bent to 90 degrees; here, the patient activelyexternally rotates against the examiner’s resistance(Burbank et al., 2008a). However, the posteriorRTC is thought to be isolated best when the patientactively externally rotates against resistance whentested in a position of 90 degrees of shoulder flex-ion combined with 90 degrees of elbow flexion(Malanga et al., 2009).

The subscapularis muscle can be tested withthe lift-off test, where the patient places the armbehind the back in a position of internal rotationwith the elbow flexed to 90 degrees and the palmfacing posteriorly – the patient then attempts to liftthe arm away from the back against the examiner’sresistance (Burbank et al., 2008a). The drop armtest also may be used to assess RTC integrity:Here, the examiner raises the patient’s passive armto full abduction within the scapular plane, andasks the patient to hold the position and then lowerit slowly; if the patient is unable to hold the posi-tion or drops the arm during lowering, this indi-cates a possible tear of the supraspinatus or deltoid(DeBerardino & Chang, 2010).


Clinical testing for lag signs are designed toexplore the integrity of the RTC, with the intentionof placing the musculotendinous units in the mostdisadvantageous positions possible in an attempt torecruit the muscles fully. In each test, the patient isseated and the examiner places the affected arm ina position of end range PROM. The patient is thenasked to try to maintain the position actively whilethe examiner releases their support; the differencebetween PROM and AROM is the estimated “lag.”A 1996 study assessed the value of lag signs tohelp diagnose RTC disorders and discovered thatthe three main tests shown in Table 2 were effec-tive, reproducible, and reliable. Those testsincluded the external rotation lag sign (ERLS), theinternal rotation lag sign (IRLS), and the drop signfor infraspinatus (not to be confused with the droparm test for supraspinatus) (Hertel, Ballmer,Lombert, & Gerber, 1996). The authors concludedthat the ERLS was more specific than the Jobesign, but was not sensitive in revealing partial tearsof the supraspinatus; the IRLS could detect partialtears of the subscapularis and was more sensitivethan and equally as specific as the Lift Off sign;and the Drop sign for infraspinatus was the leastsensitive, but was as specific as the ERLS (Hertel

et al., 1996). In the study, the magnitude of theamount of lag in the ERLS and IRLS tests wasassociated with the size of the partial RTC tear, buta more recent study found that full-thickness tearscould not conclusively be diagnosed or dismissedusing these three lag tests (Hertel et al., 1996;Miller, Forrester, & Lewis, 2008). Other studiescontinue to examine the efficacy of these clinicaltests in an attempt to validate their usefulness,specificity, and sensitivity (Hegedus et al., 2007).

Other special tests that should be included inthe physical examination are the Neer impinge-ment test and the Hawkins-Kennedy test. The Neerimpingement test is performed by passively elevat-ing the patient’s internally rotated arm into fullabduction in the scapular plane while stabilizingthe scapula, which drives the greater tuberosity andsupraspinatus tendon under the acromion(DeBerardino & Chang, 2010). The Hawkins-Kennedy test is done by rotating the arm into inter-nal rotation and horizontal adduction as it is held in90 degrees of shoulder and elbow flexion, whichalso compresses the supraspinatus tendon, this timebeneath the coracoacromial arch (DeBerardino &Chang, 2010). If either of these tests provokes apain response, it is indicative of an impingement of


TABLE 2: LAG SIGNS EFFECTIVE TOAID THE DIAGNOSIS OF ROTATOR CUFF TEARSSign Muscle(s) Tested TestMethod

External rotation Supraspinatus Arm passively elevated in scapular plane to 20 degrees andlag sign and infraspinatus held in maximal external rotation at the wrist with the elbow

flexed to 90 degrees; patient asked to hold position whileexaminer continues support of elbow but releases hold on wrist

Internal rotation Subscapularis Patient brings the hand behind the back, palm outward in fulllag sign internal rotation while the examiner holds the arm away from

the back in 20 degrees of extension; patient asked to holdposition while examiner supports patient’s elbow but releaseshold on wrist

Drop sign Infraspinatus Arm passively elevated in scapular plane to 90 degrees and fullfor infraspinatus external rotation with examiner supporting elbow and wrist;

patient asked to hold position while examiner continuessupport of elbow but releases hold on wrist

Note. A positive test is one in which the patient is unable to hold the test position. Adapted from “Lag signs in the diagnosis of rotator cuff rupture,” byHertel, R., Ballmer, F.T., Lombert, S.M., & Gerber C., 1996, Journal of Shoulder and Elbow Surgery, 5(4), 307-313.

the supraspinatus tendon and possibly of the sub-acromial bursa as well.

Tests for instability should also be performedto rule out underlying glenohumeral hypermobilitythat may be contributing to RTC dysfunction. Theapprehension test for anterior instability may beperformed with the patient supine, with the armheld in 90 degrees of abduction and neutral rotationwith the scapula stabilized. The therapist thenslowly moves the arm into external rotation whileapplying a posterior-anterior force from behindwhile palpating for anterior translation of thehumeral head. A positive test is recorded if thepatient becomes anxious over the feeling ofimpending subluxation (DeBerardino & Chang,2010). A relocation test may then be performed byapplying an anterior-posterior pressure to the ante-rior proximal humerus; a positive test is one inwhich posterior humeral translation may be pal-pated, and indicates anterior shoulder instability(DeBerardino & Chang, 2010). The sulcus signmay be tested with the patient sitting in a neutralposition with the arm at the side. The examinerapplies a downward traction force to the humerusand observes if a trough, or dimple, developsbetween the greater tuberosity of the humerus andthe acromion. A positive sulcus sign indicatespotential multidirectional instability, which canrelate to a secondary impingement (DeBerardino &Chang, 2010).

Putting several clinical special tests together,one study of 400 patients found that those whoexhibited the triad of a positive Jobe test, Hawkins-Kennedy impingement test, and external rotationresistance test, had a 98% probability of harboring apartial- or full-thickness RTC tear, and that patientsolder than 60 years of age positive for only two ofthe three tests also had a 98% probability of a cufftear (Murrell & Walton, 2001). Others have foundthat patients older than age 65 who exhibited shoul-der pain at night and who had weakness on theexternal rotation test demonstrated a 91% chance of

having either a partial- or full-thickness RTC tear(Litaker, Pioro, El Bilbeisi, & Brems, 2000). Thesefindings underscore the importance of relating thepatient history with the physical examination andthe outcome of special clinical tests.

TREATMENT

The goal of therapeutic intervention is to reduceinflammation when present, and encourage

range of motion in a way that does not increase painlevels before focusing on progressively helpingpatients regain strength, which in turn enables themto return to normal functional activities withoutexacerbating symptoms (Lin, Weintraub, &Aragaki, 2008).

ConservativeManagementFor most patients, nonsurgical management of

the RTC injury is recommended, including restfrom the aggravating activity, use of ice on theshoulder, and a short course of nonsteroidal anti-inflammatory medications (NSAIDs) to reducepain and swelling if the injury is acute (MDA,2010).Although there is no current research advisingimmobilization for a painful RTC injury, anecdo-tally most therapists report that patients arrive froma visit to the physician with instructions to movethe arm within pain-free ranges of motion.Immobilization with a sling is feared to increasethe risk of adhesive capsulitis. Even in the presenceof massive RTC tears, nonsurgical treatment has asuccess rate of 65%, an outcome that improveswhen cortisone injections are added to the treat-ment mix (Vad et al., 2002). Factors that are prog-nostic for worse outcomes with conservativetreatment include concurrent glenohumeralosteoarthritis, reduced PROM of the shoulder, poormuscle strength into external rotation and abduc-tion, and significant muscular atrophy (Vad et al.,2002).


Injections

A local injection of cortisone into the subacro-mial space can provide pain relief in patients withacute RTC tendonitis or impingement. In a study ofpatients presenting with a history of painful shoul-der symptoms for over one month, combined withpositive Hawkins-Kennedy and Neer impingementsigns, 91% experienced improved AROM andreduced pain following a cortisone injection; theremaining 9% were referred on for surgery, andwere subsequently found to have partial or com-plete RTC tears (Yu et al., 2006). However, caremust be taken to avoid repeated cortisone injec-tions, as corticosteroids will degrade tendon tissueand complications may occur in the form of a rup-tured tendon (Nichols, 2005). Aside from thepotential risk of tendon rupture, subacromial injec-tions also call for the application of strict steriletechniques to offset the rare risk of introducinginfection into the subacromial space (Gruson,Ruchelsman, & Zuckerman, 2008).

Precise indications for the common practice ofadministering corticosteroid injections are lacking,and many physicians opt for trying an injection onpatients who have had an inadequate response toinitial conservative treatment measures such asNSAIDs, ice, and physical therapy (Burbank,Stevenson, Czarnecki, & Dorfman, 2008b).Unanswered questions remain as to whether oralNSAIDs or even injections of local anesthetics inthe absence of corticosteroids are as effective asinjected corticosteroids (Gruson et al., 2008).Currently, the use of subacromial corticosteroidinjections as a form of conservative treatment forRTC injuries is supported by the AmericanAcademy of Orthopaedic Surgeons (AAOS, 2007;Self, 2002).

Physical Therapy

Physical therapy is commonly utilized as afirst-line intervention as part of the conservativetreatment approach to RTC injury, but many of thetechniques frequently used by therapists have yet to

be proven effective in clinical trials (Green,Buchbinder, & Hetrick, 2003). In fact, numerousresearch articles generally advise including physi-cal therapy for the treatment of RTC injuries, butdo not identify the exact treatment techniquesbeing recommended. In a 2010 literature reviewsifting through existing studies on rehabilitationinterventions for RTC injury, only 11 of 80 pub-lished studies were in the form of randomized clin-ical trials with validated outcome measures(Fleming, Seitz, & Ebaugh, 2010). Of the 11 stud-ies meeting the inclusion criteria, the specificrehabilitation protocols used were variable amongthe studies; however, general treatment approachesconsisting of range of motion exercises, strengthen-ing, soft tissue and joint mobilization, and variousmodalities were described (Fleming et al., 2010).

Traditionally, physical therapy treatment of anRTC injury focuses on reducing pain and inflam-mation, improving posture and normal joint mobility,teaching proper body mechanics with reaching,modifying activities to reduce loading of the ten-dons, increasing flexibility and tissue extensibility,restoring proprioception, and improving musclestrength (Burbank et al., 2008b). General recom-mendations for treatment of an RTC injury includeavoidance of painful activities, a two-week trial ofNSAIDs and ice, mobilizing the painful shoulderto promote posterior capsule stretching, and initiatingscapular strengthening and RTC exercises thatemphasize the weak external rotators (Weldon &Richardson, 2001).

Patient Education

Many therapists believe that it is essential toencourage patients to avoid aggravating activitiesthat reproduce symptoms in order to allow inflam-mation and continued microtrauma to the affectedtendon to diminish. Activity modification shouldinclude avoidance of overhead activities and heavylifting to reduce tendon strain (Litaker et al., 2000).Patients should also be cautioned against sleepingon the affected shoulder, as this position serves to


potentially approximate the glenohumeral joint anddrive the humerus and its tendinous attachmentsinto the subacromial arch, as well as inhibit circula-tion to the already injured shoulder (Werner,Ossendorf, Meyer, Blumenthal, & Gerber, 2010).

Postural deficits that may have predisposed thepatient to the RTC injury should be addressed earlyin rehabilitation. Patients should be instructed tostretch tight pectoral muscles and strengthen inter-scapular and thoracic extensor muscles to enableimproved scapular positioning: In a study of ath-letes with shoulder impingement, 47% had reducedpain with simple manual scapular repositioning toimprove retraction and posterior tilt (Tate,McClure, Kareha, & Irwin, 2008).

Anecdotally, many physical therapists find suc-cess in instructing patients to raise the arm aboveshoulder height only in a neutral or externallyrotated position (“lift with the thumb up or palmup”), as opposed to an internally rotated position;raising the arm when the shoulder is in a positionof internal rotation traps the supraspinatus tendonbetween the humeral head and the acromion. Thislatter maneuver is part of the clinical special testsused to assess whether impingement is present(Neer impingement test, Hawkins-Kennedyimpingement test), so it makes sense that such anexacerbating movement should be avoided.

ModalitiesMany therapists use modalities such as ultra-

sound and electrical stimulation with ice to addressthe inflammatory phase of an RTC injury.However, research suggests that manytendinopathies of the RTC are degenerative innature, rather than inflammatory, so anti-inflamma-tory modalities may not always be very effective(Valen & Foxworth, 2010).

Ultrasound

Therapeutic ultrasound has been historicallyused, with or without hydrocortisone cream, in anattempt to decrease inflammation and swelling of

RTC tendons and thereby improve circulatoryresponses and healing times; however, a detailed2003 review of research articles spanning from1966 to 2002 suggests that no evidence exists tosupport its use (Green et al., 2003). In a 2010review article researching the effects of variousparameters of ultrasound in treating shoulderinjuries, the results were variable and inconclusive(Alexander, Gilman, Brown, Brown, & Houghton,2010).A recent Turkish study comparing the use ofpulsed ultrasound for treatment of subacromialimpingement found that the use of ultrasound didnot enhance outcomes for patients undergoingphysical therapy treatment (Celik, Atalar,Sahinkaya, & Demirhan, 2009). Interestingly,another study examining outcomes relating tophysical therapy treatment for various disordersfound that worse outcomes were associated withtherapeutic ultrasound when it was applied topatients with shoulder disorders (Deutscher et al.,2009). A British group also found that patient out-comes were no better for patients who receivedtherapeutic ultrasound than those receiving shamultrasound as part of physical therapy treatment forshoulder pathology (Ainsworth et al., 2007).However, there does seem to be a benefit to the useof ultrasound for RTC injuries that include a com-ponent of calcific tendonitis (Green et al., 2003).

Extracorporeal Shockwave Therapy

Extracorporeal shockwave therapy, a derivativeof lithotripsy (a method of breaking up kidneystones using sound waves), uses highly concen-trated acoustic sound waves to increase circulationin a specific area. This form of treatment appears toderive similar benefits for selected patients withRTC injuries who also have a component of cal-cific tendonitis. In one study, over a course of justthree weekly treatments of constant low-energyfocused shockwave therapy administered underultrasonic navigation, 60% of tendon calciumdeposits either disappeared or altered in morphology,resulting in decreased shoulder pain (Sabeti-


Aschraf, Dorokata, Goll, & Trieb, 2005). However,in another study, 53.3% of patients who had unsuc-cessfully tried extracorporeal shockwave therapyhad to undergo arthroscopic removal of the calcificdeposits to resolve their symptoms (Lorbach,Kusma, Pape, Kohn, & Dienst, 2008). It remainsunclear why certain patients develop calcificdeposits in their RTC tendons, and why 50% ofthose patients remain asymptomatic despite the cal-cifications (Le Goff, Berthelot, Guillot, Glémarec,& Maugars, 2010). In general, extracorporealshockwave therapy is considered one option fortreating calcific tendonitis, but is not currently uti-lized for RTC injuries without tendon calcification.

Iontophoresis

Iontophoresis is another option sometimes usedfor the treatment of tendon calcification, but thereis scant evidence supporting its use for RTCinjuries, to date (Ciccone, 2003; Mouzopoulos,Stamatakos, Mouzopoulos, & Tzurbakis, 2007).Studies examining the use of iontophoresis specifi-cally for RTC disorders are few, and those that existremain inconclusive in their results (Bilal et al.,2010; Roy et al., 2009). Although the use of ion-tophoresis has not yet been proven effective forRTC injury, it does not appear to cause harm whenused for patients with RTC injuries (Perron &Malouin, 1997).

Manual Therapy

When researchers turn their attention to themore hands-on nature of physical therapy treat-ment for RTC injuries, it becomes apparent thatmanual therapy, particularly when combined withexercise therapy, is effective in helping patientsdecrease pain levels and reduce functional limita-tions (Faber, Kuiper, Burdorf, Miedema, &Verhaar, 2006; Green et al., 2003). In a case seriesof 10 patients with subacromial impingement syn-drome, a program consisting of manual stretching,shoulder mobilization, three phases of progressivestrengthening for the scapular stabilizers and RTCmuscles, patient education and activity modifica-

tion, and a home exercise program, produced goodfunctional improvement and decreased pain levelsin 80% of the patients (Tate, McClure, Young,Salvatori, & Michener, 2010). In this study, treat-ment was aimed at strengthening weak trapeziusand RTC muscles, improving stiffness with internalrotation, and mobilizing tight posterior gleno-humeral joint elements and thoracic spinal seg-ments (Tate et al., 2010).

An earlier study hypothesized that posteriorjoint capsule tightness is implicated in creatingshoulder pain by allowing increased anterosuperiormovement of the humeral head during armelevation, which can cause narrowing of thesupraspinatus interval and RTC tendon compression(Bach & Goldberg, 2006). This supports commonclinical practice in which stretching and soft tissuemobilization of tight posterior RTC tendons andmobilizing the tight posterior glenohumeral jointcapsule is considered important. Theoretically,when the RTC is injured, the muscles can nolonger properly do their job of stabilizing anddepressing the humeral head during arm elevation.Over time, the humeral head rides superiorly andsometimes anteriorly in the joint, narrowing thespace at the supraspinatus outlet and furthering therisk of tendon friction and impingement. Unless theshoulder is hypermobile with a positive sulcus signindicating excessive inferior glide, many cliniciansfeel that physical therapy treatment should includeglenohumeral joint mobilization that promotesinferior and anterior-posterior glide to help restorenormal shoulder mechanics.

In comparing a manual physical therapyapproach consisting of soft tissue and joint mobi-lization against a guided daily strengtheningprogram using elastic tubing, the mobilizationgroup experienced significantly improved pain levels;greaterAROM with flexion, abduction, and externalrotation; and faster functional return than the exer-cise group (Senbursa, Baltaci, &Atay, 2007). In thisstudy, strengthening exercises focused on the RTC


muscles and the rhomboids, levator scapulae, andserratus anterior muscles (Senbursa et al., 2007).

Exercise Concepts

Although the combination of manual therapy andstrengthening exercises appears to be an importantapproach to RTC rehabilitation, exercises to rebuilddamaged musculature are a critical component of therecovery, since most RTC injuries result in musculo-tendinous damage and muscle weakness (Bilal et al.,2010; Faber et al., 2006; Green et al., 2003; Roy et al.,2009). Consequently, the rehabilitation program for anRTC injury will normally include specific strengthen-ing exercises to help improve function anddecrease pain to optimize patient outcomes (Kuhn,2009). Exercises should begin with strengtheningthe scapular stabilizers to restore normal scapulo-humeral motion, and can include strengthening ofthe latissimus dorsi, middle and lower trapezius,rhomboids, and serratus anterior (Ludewig &Reynolds, 2009). As painful symptoms resolve,direct strengthening of the RTC and deltoid may beadded within pain-free ranges of motion, beingcareful to avoid potentially impinging exercises soas to prevent further damage to the RTC muscles(Bilal et al., 2010). New research highlights theimportance of utilizing eccentric exercise to facili-tate tendon remodeling as part of treatment forRTC injury. In a small 2010 study of 10 patientswith subacromial impingement, a 12-week dailyeccentric strengthening program of the scapularstabilizers and RTC muscles resulted in signifi-cantly increased function in 100% of the partici-pants, and a marked reduction in pain in 80% ofthe group (Bernhardsson, Hultenheim Klintberg, &Kjellby Wendt, 2010).

Strengthening of the supraspinatus muscle is ofparticular importance following an RTC injury dueto its important role as part of the coronal planeforce couple (involving both the supraspinatus anddeltoid muscles during elevation) and its frequentvulnerability to the injury itself. There currentlyexist several ways to strengthen the supraspinatus

muscle, including the “empty can” exercise (upperextremity elevation with internal rotation in thescapular plane); the “full can” exercise (upperextremity elevation with external rotation in thescapular plane); arm elevation performed whilelying prone; external rotation with the arm at theside (pendant position); and external rotation per-formed while lying prone. These latter twoexercises, although predominantly selecting forinfraspinatus and teres minor as primary externalrotators, also recruit the supraspinatus muscle,which functionally contributes to external rotationas evidenced on electromyographic testing (Dark,Ginn, & Halaki, 2007).

In a study comparing optimal exercises tostrengthen the supraspinatus muscle while mini-mizing deltoid activity, researchers found thatexercises such as external rotation in the pendantposition and external rotation while lying pronewere the most effective (Boettcher, Ginn, &Cathers, 2009).An added benefit of using exercisesthat incorporate external rotation is to promotestrength and endurance of the posterior RTC, as theinfraspinatus muscle appears more susceptible tofatigue and failure than other muscles (Stackhouse,Stapleton, Wagner, & McClure, 2010). However,some researchers report that the “full can” exerciserecruits supraspinatus with less electromyographicactivation of the deltoid as compared to the “emptycan” exercise (which selects for middle deltoid), orthe “prone full can” exercise (which selects for pos-terior deltoid) (Reinold et al., 2007). No matterwhich exercises are chosen for the individual patientby the treating therapist, activities that isolatespecific RTC muscles should be performed withcaution so as not to overload the healing tendons.

Throughout rehabilitation, therapists shouldcontinue to educate patients to use good bodymechanics, maintain proper posture, and modifyactivities to avoid further trauma or reinjury(Burbank et al., 2008b). Common clinical practiceis for therapists to encourage patients to pace activ-


ities and modify positions and use of equipment toreduce tendon loading. Patients should beinstructed to resume prior activities gradually,according to tolerance, and to build endurance withexercises using many repetitions at low resistanceto avoid reinjury. Many rehabilitation protocolsexist for shoulder RTC programs, but it is notclearly established which approach is best and evenwhether it is better to instruct patients in strength-ening exercises that use elastic resistance tubing orin exercises that use free weights (Cadoso deSouza, Trajano Jorge, Jones, Lombardi Jr., &Natour, 2009). More research in this area isneeded.

The current literature also supports the incorpo-ration of thoracic mobilization in the management ofpainful shoulder conditions (Mintkin et al., 2010).

Surgical ManagementFortunately, most orthopedic surgeons opt to

treat RTC injuries conservatively before initiatingsurgery, choosing instead to focus on oral medica-tions, corticosteroid injections, and physicaltherapy as a first line of defense (Beaudreuil,Dhénain, Coudane, & Mlika-Cabanne, 2010).However, if symptoms do not resolve and if a ten-don is found to be torn, many full-thickness tearsand some partial-thickness tears can require surgi-cal repair. Because RTC tears that do not heal tendto become larger over time, surgery is used to avoidfurther damage to the RTC (Warner, 2010).

Indications and Types of Surgery

In many cases, conservative treatment for RTCinjury yields good results, however, when shoulderpain persists, even at rest, and is combined withpoor upper extremity function despite medicalmanagement, it is recommended that the RTCshould be repaired regardless of the patient’s age,particularly if the tear is a full-thickness one(Lähteenmäki, Hiltunen, Virolainen, & Nelimarkka,2007). Many surgeons recommend repairing RTCtears that cause pain and weakness such that the

patient is unable to actively abduct the affected armover shoulder height. The optimal time period forrepair is within the first four months after symptomonset (Petersen & Murphy, 2010). However, otherresearchers indicate that an RTC repair may bedelayed longer to give conservative treatments thechance to work. It is felt that as long as the surgeryis performed before the injured musculotendinousunit becomes atrophied and infiltrated with fat, anoccurrence that typically occurs in the supraspinatuson average within three years after symptom onset,the surgery can still be successful (Melis, 2010).

Common clinical guidelines advise that sur-gery should be considered to enhance functionalrecovery in shoulders that continue to be painful,weak, or disabling after a reasonable course of con-servative treatment (Beaudreuil et al., 2010). Insuch cases, the arthroscopic approach is usuallyindicated to debride or repair a partial-thicknessRTC tear, and the choice of using arthroscopy,mini-open surgery, or an open approach for therepair of full-thickness tears, depends on imagingtest results and surgeon preference (Beaudreuil etal., 2010). An important component of RTC repairfor patients with preoperative subacromialimpingement is to adequately decompress the acro-mial arch (acromioplasty), thus opening thesupraspinatus outlet (Accousti & Flatow, 2007).Acromioplasty can be performed either arthroscop-ically or by an open approach.

Other surgical factors that may affect a suc-cessful outcome include the type of repairtechnique chosen by the surgeon: There is freshinterest in using double suture row repair tech-niques to enhance the strength of the RTC repairand more accurately restore the correct biomechanicsof the shoulder complex, as opposed to a traditionalsingle-row technique to anchor the tendon to theunderlying bone (Bell & Ahmad, 2007). Research isongoing, and data is being collected to establish out-comes and recommendations (Ghodadra,Provencher,Verma,Wilk, & Romeo, 2009).


Complications

Complications following RTC repair surgeryoccur at an overall rate of approximately 10% ofthe surgical population and include failure of thetendon to heal, stiffness, infection, reflex sympa-thetic dystrophy, and deep venous thrombosis.Only very rarely, death may occur (Brislin, Field,& Savoie, 2007). A relatively common complica-tion of RTC repair is the risk of the tendon repairfailing. Failure of the new repair to hold as thepatient returns to normal activities appears to beproblematic regardless of whether the torn tendonwas arthroscopically debrided or repaired withsutures. In one study, the reported structural failurerate was as high as 52% (Berth, Neumann,Awiszus, & Pap, 2010), but complications seem tobe associated with the skill and approach of theoperating surgeon. As another study reported, com-plete healing of the RTC tear after repair occurs in95.8% of cases (Huberty et al., 2009). In this 2009study, the incidence of postoperative stiffnessoccurred in 4.9% of patients, a complication thatwas more likely to occur in patients who had coex-isting preoperative calcific tendonitis, adhesivecapsulitis, or a labral tear (Huberty et al., 2009).

OutcomesAs the population ages and the incidence of

RTC tears rises, surgical repairs are also becomingincreasingly common. Overall, it is estimated thatthere is a 90% satisfaction rate with an initial RTCrepair, but that the repaired tendon is estimated tore-tear in up to 33% of cases when a large tear waspresent (Abrams, 2010). Positive surgical outcomeswith reduced risk for re-tearing the operated tendonare associated with younger age, and worse surgi-cal outcomes are generally associated with largertear size or a more retracted tear at the time ofsurgery (Oh, Kim, Kang, Oh, & Gong, 2010).Long-term follow-up of patients’ status post RTCrepair indicates that loss of functional mobility andincreased disability is common (O’Halleran, 2005;Feng, Guo, Nobuhara, Hashimoto, & Mimori, 2003).

When arthroscopic surgery is performed forsubacromial decompression in patients withimpingement syndrome but no RTC tear, 82% ofpatients had an intact RTC when their RTC tendonswere examined via ultrasound 15 years later(Björnsson, Norlin, Knutsson, & Adolfsson, 2010).In this study, the corresponding 18% of RTC tearssustained by the decompression group was sub-stantially lower than the expected 40% tear rate inindividuals of the same age who had not undergonesubacromial decompression (Björnsson et al.,2010). There needs to be more research on theproactive approach to RTC care to minimize riskfactors and enhance surgical outcomes, as perhapsearly decompression may be preventative for at-risk patients.

Regardless of which surgery has been per-formed to repair or enhance the function of theRTC, patients often go through physical therapy aspart of the recovery process. The goal of postopera-tive physical therapy is to restore AROM, strength,and functional mobility to the operated shoulderwhile reducing pain and preserving the integrity ofthe RTC repair (MDA, 2010). Although thisapproach is common and is often considered criti-cal to recovery, there is little evidence publishedthat indicates postoperative physical therapy short-ens recovery times (Koo & Burkhart, 2010).However, it is generally accepted that the contentof the postoperative rehabilitation approach shouldbegin with PROM and advanced toAROM exercise,and should include glenohumeral mobilization,instruction in mechanics of reaching, and tempo-rary lifestyle modifications to protect the healingrepair. Strengthening is integrated with return towork and sports activities, and progresses as toler-ated on an individualized basis (Conti et al., 2009).

It is of utmost importance that the therapist fol-lows the surgeon’s recommendations regardingpostoperative timeframes for appropriate functionaladvancement, as well as any precautions based onhow the surgery for that individual patient went


(Ghodadra et al., 2009). Keeping these restrictionsin mind, the therapist can safely advance thepatient’s shoulder range of motion (ROM) earlyduring the postoperative period and progress torestoring scapulothoracic function and strengthwithout compromising the RTC repair (Ghodadra,et al., 2009). But therapists must also be aware ofthe form in which patients perform recommendedpostoperative exercises such as the pendulum exer-cise. In a study recording electromyographic activityof the supraspinatus, infraspinatus, and deltoidmuscles during the pendulum exercise, researchersfound that when the exercise was performed incor-rectly using a larger swing (51 cm diameter circles)versus using a more restrained swing (20 cm diame-ter circles), there was more than 15% of maximumvoluntary contraction of the supraspinatus muscle(Long et al., 2010). Patients performing pendulumswith excessively large arm swings may thus inad-vertently be placing too much stress on the healingRTC repair, and must be instructed in proper tech-nique (Long et al., 2010).

Patients must also be cautioned about sleeppositions during the recovery period to enhancehealing: One study showed that subacromialpressures were significantly lower in the supineposition than in the prone or side-lying positions;this information can affect the healing ability of thefreshly repaired RTC (Werner et al., 2010).

Conclusion and RecommendationsPhysical therapy plays an important role in the

recovery of an RTC injury, whether patients arereceiving conservative management in the hopes ofavoiding surgery or are receiving postoperativecare. Physical therapy in the form of ROM exer-cises, strengthening exercises, soft tissue and jointmobilization, and manual therapy helps to promotegood patient outcomes of decreased pain andincreased function (Fleming et al., 2010; MDA,2010). Physical therapy is an integral part of recov-ery for patients receiving nonsurgical interventionfor RTC injury (Bilal et al., 2010; Lin et al., 2008;

Roy et al., 2009). After surgery, early ROM andprogressive strengthening of the RTC muscles andscapular stabilizers can enhance patient recoveryand allow for the return of function in as little as 12weeks following surgical repair (Ellenbecker,Elmore, & Bailie, 2006).

An important part of strengthening, whetherbefore or after surgery, should focus on scapularstabilizers and external rotator musculature toenhance functional return (Bernhardsson et al.,2010; Ellenbecker et al., 2006; Kuhn, 2009;Ludewig & Reynolds, 2009; Senbursa et al., 2007;Stackhouse et al., 2010; Weldon & Richardson,2001). Posture should also be addressed (Burbanket al., 2008b; Ludewig & Reynolds, 2009; Tate etal., 2008). The supraspinatus musculotendinousunit, with its direct involvement in most RTCinjuries and its indirect role in functioning as anexternal rotator as well as a shoulder abductor,deserves special attention during strengthening;however, the best way of achieving this remainsunder discussion (Boettcher et al., 2009; Dark etal., 2007; Reinold et al., 2007). Regardless of theexercise approach chosen, therapists must educatepatients not to overload the healing tendons andprovoke reinjury during recovery (Bilal et al.,2010; Burbank et al., 2008b; Litaker et al., 2000).

With shoulder mobilization, attention shouldbe paid to loosening tight posterior RTC musclesand the posterior joint capsule in order to promoteoptimal accessory joint motion and shoulder bio-mechanics (Bach & Goldberg, 2006; Tate et al.,2010). For now, studies examining the use ofmodalities such as therapeutic ultrasound and ion-tophoresis require more attention; current findingsshow no benefit in the use of these modalities intreatment of an RTC injury (Ainsworth et al., 2007;Alexander et al., 2010; Celik et al., 2009; Ciccone,2003; Green et al., 2003; Mouzopoulos et al.,2007). However, when calcific tendonitis is present,ultrasound and extracorporeal shockwave therapy


seem beneficial (Green et al., 2003; Sabeti-Aschraf, 2005).

At this time, more studies are needed to highlightthe specific approaches and outcomes associatedwith physical therapy treatment for RTC injury,both under conservative and postoperative treat-ment conditions. Until then, therapists must rely onexisting research and upon treatment techniquesdeveloped from their own patient care experiencesto build a successful, individualized treatmentapproach for the patient with an RTC injury.Although research is ongoing to develop evidence-based physical therapy treatment guidelines, muchmore study is needed to establish the effectivenessof the therapist practitioner and to provide stan-dards for optimal patient care.


1. A rotator cuff injury usually involves the

a. glenoid labrum.

b. joint capsule.

c. supraspinatus tendon.

d. humeral tuberosity.

2. A structure that functionally contributes to thefour main parts of the rotator cuff is the

a. anterior deltoid.

b. teres major.

c. joint capsule.

d. biceps tendon.

3. With a rotator cuff injury, potentialmechanisms of injury include

a. intrinsic tendon failure caused byprogressive degenerative changes of aging.

b. recurring compression of the tendonsagainst the acromioclavicular joint.

c. prolonged immobilization of the affectedextremity in the sling position.

d. repeated tensioning of the tendons fromreaching the hand behind the back.

4. One of the large scapular stabilizers that co-contracts to help provide a stable platform witharm movement is the

a. latissimus dorsi muscle.

b. posterior deltoid muscle.

c. serratus anterior muscle.

d. pectoralis minor muscle.

5. The primary function of the rotator cuffmuscles is to

a. initiate elevation of the upper extremitywhen reaching overheard.

b. allow the patient to internally andexternally rotate the shoulder joint.

c. depress and center the humeral head duringupper extremity elevation.

d. contribute to the stability of the jointcapsule to help prevent dislocation.

6. The painful arc that often occurs when apatient with a rotator cuff injury elevates thearm into abduction usually occurs between

a. 45 degrees to 90 degrees.

b. 60 degrees to 120 degrees.

c. 90 degrees to 145 degrees.

d. 120 degrees to end range.

7. Rotator cuff dysfunction may be suspectedwhen palpation reveals

a. upper trapezius tenderness.

b. acromioclavicular tenderness.

c. deltoid tuberosity tenderness.

d. subacromial tenderness.

23

Questions 1-20

Note:Choose the one option that BEST answers each question.

EXAM QUESTIONS

continued on next page

8. When a massive or complete rotator cuff tearor a suprascapular nerve entrapment hasoccurred, there is noticeably decreased musclebulk in the

a. supraspinatus and infraspinatus muscles.

b. infraspinatus and teres minor muscles.

c. supraspinatus and subscapularis muscles.

d. infraspinatus and subscapularis muscles.

9. Shoulder pain and stiffness felt when reachingthe hand behind the back may indicate

a. tearing of the supraspinatus tendon.

b. tightness in the posterior joint capsule.

c. rupture of the subscapularis muscle.

d. arthritis in the acromioclavicular joint.

10. In one study, the clinical tests found to bepredictive for a partial- or full-thickness rotatorcuff tear with 98% probability were the

a. external rotation lag sign, internal rotationlag sign, and drop sign for infraspinatus.

b. Jobe test, Hawkins-Kennedy impingementtest, and external rotation resistance test.

c. Neer impingement test, lift-off test, andapprehension test for anterior instability.

d. rent test, the drop arm test, and the emptycan test for supraspinatus testing.

11. When educating patients with a rotator cuffinjury about activity modification, they shouldbe instructed to avoid

a. sleeping in supine or prone positions.

b. using the arm in a dependent position.

c. heavy lifting and overhead activities.

d. moving the arm into external rotation.

12. Therapeutic ultrasound has been shown to beeffective for the treatment of

a. adhesive capsulitis.

b. shoulder arthritis.

c. subacromial bursitis.

d. calcific tendonitis.

13. In a research article examining the efficacy ofphysical therapy treatment for rotator cuffinjury, an additional benefit was noted whentherapeutic exercises were combined with

a. manual therapy.

b. stretching activities.

c. therapeutic ultrasound.

d. aerobic conditioning.

14. More than one research study indicates that astrengthening program for rotator cuff injuryrehabilitation should begin with exercises for the

a. scapular stabilizers.

b. pectoral muscles.

c. rotator cuff muscles.

d. thoracic extensors.

15. Research shows that one of the optimal ways tohelp strengthen the supraspinatus muscle whileminimizing deltoid activity is to perform anexercise that involves

a. scapular retraction.

b. external rotation.

c. internal rotation.

d. shoulder abduction.


16. Surgeons recommend repairing a torn rotatorcuff when the patient

a. demonstrates shoulder weakness but nopain with arm elevation.

b. has experienced a tear that has becomeinfiltrated with fat.

c. is unable to actively abduct the arm overshoulder height.

d. sustained an acute tear during an easilyremembered event.

17. An important component of rotator cuff repairsurgery for patients with preoperativeimpingement is to

a. debride the torn tendon before initiating therepair.

b. use the double suture row tendon repairtechnique.

c. adequately decompress the subacromialspace.

d. use the open surgical approach for goodvisualization.

18. Potential complications of rotator cuff repairsurgery include

a. development of shoulder arthritis.

b. poor healing of the surgical wound.

c. development of calcific tendonitis.

d. failure of the repair to hold.

19. In one study, when a subacromialdecompression surgery was performed forshoulder impingement in the absence of arotator cuff tear, what percentage of patientswere found to have torn the rotator cuff whenexamined 15 years later?

a. 8%

b. 18%

c. 48%

d. 81%

20. Proper technique of performing postoperativependulum exercises involves using a

a. small hand weight.

b. faster rhythm.

c. restrained swing.

d. protracted scapula.

This concludes the final examination.Please answer the evaluation questions found onpage v of this workbook.


AmericanAcademy of Orthopaedic Surgeonshttp://www.aaos.org

American Occupational TherapyAssociationhttp://www.aota.org

American Physical TherapyAssociationhttp://www.apta.org

National Institute ofArthritis andMusculoskeletaland Skin Diseaseshttp://www.niams.nih.gov

R E S O U R C E S

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Page reference followed by fig indicates an illustrated figure;followed by t indicates a table.

Aaccessory joint mobility testing, 11acromion morphology, 3figacromioplasty, 18active external rotation, 10–11activity modification, 14–15adhesive capsulitis, 2age differences

in annual incidence of shoulder disorders, 2rotator cuff injury (RTC) and types of, 1–2

American Academy of Orthopaedic Surgeons, 14AROM (limited active range of motion)

clinical test of, 8, 10, 11infected corticosteroids to restore, 14treatment goal of restoring, 16, 19

arthroscopic surgery, 18, 19asymptomatic RTC

description of, 2imaging tests identifying RTC tear in, 8prevalence in various populations, 9t

Bbone spur (osteophyte), 5

Ccalcific tendonitis, 16, 20–21cigarette smoking, 7clinical tests

accessory joint mobility testing, 11active external rotation, 10–11AROM testing, 8, 10, 11, 14, 16, 19electromyography, 8, 11, 17Hawkins-Kennedy test, 12, 13, 14for instability, 13Jobe test, 11, 13for lag signs, 12tmanual muscle testing, 11Neer impingement test, 12, 14PROM testing, 10, 11, 12, 19strength tests, 11

conservative managementinjections, 14patient education, 14–15rest, use of ice, and NSAIDs for, 13, 14See also physical therapy

coronal plane force couple, 5–6cortisone injections, 14

Ddiagnostic procedures

baseline diagnostic imaging, 8clinical tests, 10–13observation and palpation, 9–10patient history and physical examination, 9signs and symptoms, 8, 9

drop sign for infraspinatus, 12tdynamic stabilizers

description of, 3large and small, 4

Eelectromyography, 8, 11, 17“empty can” exercise, 17“empty can” test, 11ERLS (external rotation lag sign), 12texercise therapy, 17–18extracorporeal shockwave therapy, 15–16

Ffamily history, 7“full can” exercise, 17“full can” test, 11functional shoulder anatomy

acromion morphology, 3figbiomechanics, 5–6glenohumeral and scapulothoracic joints, 3–4, 5–6musculotendinous attachments, 4–5overview of, 2–3

Gglenohumeral joints

anatomy of, 3–4biomechanics of, 5–6

glenohumeral osteoarthritis, 2

I N D E X

37

Index—38 Off the Cuff: Rotator Cuff Injury and Recovery

HHawkins-Kennedy test, 12, 13, 14Hill-Sachs lesions, 8hydrocortisone cream, 15

Iice treatment, 13, 14impingement syndrome. See RTC impingementinjected corticosteroids, 14instability

stiffness versus, 6–7testing for, 13

iontophoresis, 16IRLS (internal rotation lag sign), 12t

JJobe test, 11, 13

Llag signs testing, 12tLift Off sign, 12lift-off test, 11

Mmanual muscle testing, 11manual scapular repositioning, 15manual therapy, 16–17mini-open surgery, 18modalities

exercise concepts, 17–18extracorporeal shockwave therapy, 15–16iontophoresis, 16manual therapy, 16–17ultrasound, 15

MRI (magnetic resonance imaging), 8muscle atrophy, 10musculotendinous attachments, 4–5

NNeer impingement test, 12, 14nerve conduction testing, 8NSAIDs (nonsteroidal anti-inflammatory medications),13, 14

Oopen approach surgery, 18osteophyte (bone spur), 5

Ppain symptoms, 8, 9palpation, 9–10patient education, 14–15patient history, 9physical examination, 9physical therapy

approaches used during, 14manual therapy component of, 16–17recommendations for, 20–21strengthening exercises, 17–18See also conservative management

pitcher’s shoulder, 1poor posture risk factor, 7, 15primary impingement, 6PROM (passive range of motion)

clinical test of, 10, 11, 12treatment goal of restoring, 19

“prone full can” exercise, 17

Rrange of motion

AROM (limited active range of motion), 8, 10, 11,14, 16, 19

PROM (passive range of motion), 10, 11, 12, 19See also rotator cuff (RTC)

relocation test, 13the rent test, 10resisted supraspinatus testing, 11rest from activity, 13ROM (range of motion), 20rotator cuff injury (RTC)

acromion morphology and risk of, 3figasymptomatic, 2, 8, 9tdefinition and types of, 1–2estimated annual incidence of, 2etiology and risk factors of, 6–7potential mechanisms of, 2stiffness versus instability of, 6–7symptomatic, 2, 8, 9t

rotator cuff (RTC)biomechanics of, 5–6glenohumeral and scapulothoracic joints of, 2, 3–4musculotendinous attachments of, 4–5stiffness versus instability of, 6–7strengthening of, 17–18, 20See also range of motion

RTC impingementcauses of, 7impingement syndrome, 1, 2primary, 6secondary, 6

RTC tendonsAROM testing of, 8, 10description of, 5effect of smoking on ability to heal, 7failure Stages I, II, III, 5PROM testing of, 10

Index—Off the Cuff: Rotator Cuff Injury and Recovery 39

Sscapulothoracic joints

anatomy of, 3–4biomechanics of, 5–6

scar tissue formation, 5secondary impingement, 6serratus anterior force couple, 6shoulder crepitus, 9sleep positions, 20Stage I RTC tendon failure, 5Stage II RTC tendon failure, 5Stage III RTC tendon failure, 5static stabilizers, 3stiffness vs. instability, 6–7strength tests, 11subacrominal injections, 14sulcus sign test, 13supraspinatus atrophy, 10supraspinatus muscle exercises, 17supraspinatus tendon

etiology and risk factors of injuries, 6–7failure of, 5

surgical managementcomplications of, 19indications and types of surgeries, 18–19

swimmer’s shoulder, 1symptomatic RTC

asymptomatic versus, 2prevalence in various populations, 9tsigns and symptoms of, 8, 9

Ttendinopathy (or RTC tears), 2, 7thoracic mobilization, 18tobacco use, 7transdeltoid palpation (the rent test), 10transverse plane force, 6trapezius anterior force couple, 6treatment

conservative management, 13–15, 20–21goal of, 13modalities, 15–18outcomes of, 19–20recommendations for recovery, 20–21surgical management, 18–19

Type I acromion, 3figType II acromion, 3fig, 4Type III acromion, 3fig–4

Uultrasonography, 8ultrasound, 15

XX-rays, 8

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