Rotator Cuff Related Shoulder Pain

• Step 1 - Consider the Person:

  • what does the person do for leisure activities or their occupation - are there a lot of overhead movements, repetitive movements
  • look for the MOI to start form the hypothesis

  
• Step 2 - Triage:

  • try to identify possible red flags
  • if they dont have any red flags and you deem this pt appropriate for physiotherapy, you can start with a subjective and objective evaluation

  
• Step 3- Stage & SIN:

  • rotator cuff injuries usually fall into 2 categories:
  • acute
  • shoulder pain follows a specific activity or
  • usually seen with a younger age group
  • chronic
  • seem more in an older population
  • pain can come and go, may disturb sleep
  • may be associated with degenerative changes
  • can be seen with a loss of capacity/lower levels of functional capacity

  
• Step 4 - Dominant Pain Mechanism:

  • pain mechanism for rotator cuff injuries are almost always nociceptive
  • the bursa is highly innervated and sensitive
  • the tendons can be in an acute phase and will be vulnerable to inflammatory changes
  • when its more chronic you can see nociplastic changes which may be more of a challenge to rehabilitate

  
• Step 4 - Structural Diagnosis pt1:

  • you can suspect which tissues are involved, but all the tissues of the shoulder bend and work together, so it is difficult to identify a single structure at fault even with diagnostic imaging
  • there can be a dominance of pain, so pain can be present on a consistent basis with rotator cuff injuries, which is related to the loss of function with specific activities such as overhead activities, lying on the shoulders (e.g. sleeping) and with repetitive movement

  
• Step 4 - Structural Diagnosis pt2:

  • if this has been going on for a long time you can consider a loss of function e.g. can anticipate seeing weakness, loss of range and decrease neuromuscular control of the shoulder complex, including the scapula
  • summary:
  • pain dominates, but not usually constant
  • capacity impairment - weakness associated with fear
  • functional impairment - cant perform overhead activity or lie on shoulder
  • almost always a combination of all of the above

  
• Step 5 - Hypothesis:

  • when thinking about rotator cuff injuries, the main hypothesis will most likely be a tendon disease, +/- the implication of the bursa and the surrounding ligaments
  • prognosis depends on factors such as age - the younger population will most likely heal quicker, the older population may have rehabilitation challenges without additional help (e.g. injections)

  
• Subjective questions for a suspected rotator cuff injury:

  • stiffness in the shoulder
  • weakness in the shoulder - also ask about dominance
  • feel the shoulder joint shifting a lot e.g. does it pop or crack
  • what activities or movements are difficult to do
  • how did you hurt yourself - any trauma to the shoulder or other areas
  • aches/pain in other joints
  • neck pain
  • numbness or tingling
  • pain during sports/job
  • medication - does it influence pain
  • treatments for this before
  • other health problems/injuries
  • history of cancer, heart problems or breathing problems
  • general health
• DO THIS LECTURES CASE STUDY WHEN REVISING
• RCRSP considerations - take home messages:

  • Tissue differentiation impossible
  • Inflammatory / degenerative tendon / inflammatory bursa
  • Tissue disease often found in absence of pain
  • Multifactorial influences affecting onset / prognosis
  • Current interchangeable definitions
  • You may hear “impingement” terminology still used… but you know better
  • You are not treating an image (x-ray / MRI / CT scan), you are treating the functional limitations of a person
• Take home messages for management:

  • Dyskinesia exists in asymptomatic (you will see this with each other!)
  • Assessment of dyskinesia is possible (sensitivity)
  • Assessment of actual faults is difficult (specificity)
  • Is it relevant to the person and the management?
  • Focus on the rotator cuff may be appropriate for most
  • Functional recovery in later stages advisable
  • What is important to the person?