Rotator Cuff Related Shoulder Pain
Rotator cuff related shoulder pain (RCRSP) assessment and management, a recently published article by Jeremy Lewis, a leading shoulder pain researcher.
RSRSP is related to shoulder pain and dysfunction typically during shoulder elevation and outward rotation. Shoulder pain is common and associated with high levels of morbidity. While there is a range of influences that can create RSRSP, the major influence appears to be excessive and maladaptive load exerted on the shoulder soft-tissues, particularly tendon. Similar to other musculoskeletal conditions, such as low back pain, a definite structural diagnosis for RSRSP may be elusive. There is ongoing debate as to the cause of RSRSP with;
1) The mechanisms of pain uncertain
2) Poor correlation between symptoms and structural failure often observed in rotator cuff tendons, substantial numbers of people without shoulder pain demonstrate structural rotator cuff changes on imaging.
3) The role of tendon inflammation is controversial and there has been a lack of inflammatory cells found in pathological tendons.
4) Acromial shape was reported in a study of 523 people who had shoulder surgery and there was no association with rotator cuff pathology (Gill, 2002). The researchers argued that a type III (hooked) acromion represented a degenerative process and that the relationship between cuff tears and degeneration should be seen as one of association rather than the acromion being the cause.
5) Special orthopaedic tests for the shoulder often provoke pain, however associating the test to a structure is difficult and therefore results must be interpreted with caution.
Consequently the term RSRSP or subacromial pain may be an appropriate term to use clinically. The clinical diagnosis is established following questioning and examining a patient and this may be supported by imaging investigation.
The primary management for RCRSP should primarily be a structured exercise program and activity (load) modification. Usually, a period of relative rest is required, often using static exercises to assist pain management. Following this is a period of gradually increasing load via exercises and activity. As in all clinical presentations, it is important to understand the individual needs of the patient and provide information to assist understanding on the cause of the symptoms, expectations for recovery and appropriate management strategies. Threatening language such as ‘wear and tear to the tendon’ is often not helpful as even with structural changes the shoulder remains a robust structure.
A number of studies do not show added benefit of surgery over non-surgical care. The literature proposes that ‘surgery should only be offered after an appropriate period (3-6months) of non-surgical care’. Surgery involves an extended period of reduced activity with a graduated return to activity that can take many months. A recent study (Heuberer 2017) using MRI at 2 years after rotator cuff tendon repair surgery reported 42% of patients showed a full-thickness re-rupture, 25% had a partial re-rupture and 33% of tendons remained intact. At 10 years the percentages respectively were 50%, 25% and 25%. Interestingly long term (10 year) clinical outcomes were reasonable with poor correlation to the structure of the repaired tendon. It was proposed as a mechanism for improvement following surgery may be the enforced rest and rehabilitation.
While some of this information may be contentious, it is clear that conservative management has a significant role to play in the treatment of shoulder pain. The references below are highly recommended for further information. This document has a strong recommendation for exercise and activity modification in the management of rotator cuff syndrome.
At Central Bassendean Physiotherapy our physiotherapists have a comprehensive understanding of the role of exercise in shoulder and tendon rehabilitation. For optimal outcomes, we spend time with our patients providing individualized care. Call today to book an appointment 9279 7411 or Book Online
Lewis, J. Rotator cuff related shoulder pain: Assessment, management and uncertainties. Manual Therapy. 2016.
Gill et al. The relative importance of acromial morphology and age with respect to rotator cuff pathology. J Shoulder Elbow Surg, 2002.
Heuberer et al. Longitudinal long-term MRI and clinical follow-up after single-row arthroscopic rotator cuff repair. AJSM, 2017
Leading shoulder researcher Jeremy Lewis discussing shoulder pain
Comparison of management of shoulder pain in comparison with best evidence. The clinical vignettes in appendix are a very useful learning tool. http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0061243
Curtin University WA 2002
Cumberland College of Health Sciences NSW 1988
Rob Waller is a Musculoskeletal Physiotherapist, with over 25 years experience. He is passionate about restoring function following injury and for people with complex musculoskeletal presentations, particularly spinal and shoulder pain. He is also a lecturer at Curtin University teaching on the Postgraduate Clinical Masters program and is currently completing a PhD investigating pain characteristics in young adults using data from the Raine Study Birth Cohort. (http://www.rainestudy.org.au). Other research interests include spinal pain and translation of evidence to practice.
Low Back Pain (LBP) and Cognitive Functional Therapy (CFT)
WHAT IS COGNITIVE FUNCTIONAL THERAPY (CFT)?
CFT provides a patient centered targeted approach to management of LBP based on a thorough examination. This classification based management approach for LBP considers many domains including: lower back movement and postures, psychological factors, social factors, workplace factors, comorbidities (e.g. diabetes, obesity), pain processing mechanisms: influenced by genetics and life experiences, sleep and lifestyle factors and their relative contributions to an individual’s LBP. CFT challenges thoughts and behaviours in a functionally specific and graduated manner.
It differs from Cognitive Behavioural Therapy (CBT) as changes in beliefs, thoughts and emotions can be realized by the patient when they experience an improvement in symptoms as they move which may challenge previous beliefs, experiences and knowledge about their condition. In a recent study CFT when compared with a manual therapy and exercise group showed clinically and statistically significant large effect sizes across multiple dimensions. The group receiving CFT was 3x less likely to take time off work in the 12 months following treatment1.
As physiotherapists, in a practical sense, it means we are considering both mechanical and non-mechanical aspects of a person’s disorder. By managing patients in this way we are helping them better understand their pain and to move and function in a way that does not perpetuate their pain. By involving the patients in the problem solving and goal setting the longer term prognosis is improved. Essentially this puts patients back in the “driving seat” for directing the course of their rehabilitation and Sarah and I are both excited about the results we are seeing implementing our improved skills so far….
Low back pain (LBP) is very common and is currently the leading cause of disability worldwide3. Only a very small proportion of people with LBP have serious pathology, such as vertebral fracture, cancer, infection or underlying inflammatory disorder, causing their pain2. Unfortunately using a scan to help diagnose LBP is not reliable because MRI abnormalities are as common in those with LBP as in those without. A common recommendation across all high quality LBP guidelines is routine imaging is discouraged unless serious pathology or specific disease is suspected e.g. if surgery is being considered or there has been a limited response to conservative care. There is no evidence that routine imaging improves LBP outcomes. Over time there has been a significant increase in LBP expenditure without any change in associated levels of disability.
Key positive messages supported by current best evidence regarding LBP include:
- The causes of LBP are rarely serious
- LBP has a good prognosis
- Stay active and resume normal activity as soon as reasonable
- Bed rest is specifically not advised
- The back is a strong structure
- Pain does not equal harm
Key management principles for LBP include:
- Diagnosing LBP via thorough questioning and physical examination
- Limited use of imaging
- Advice about what’s contributing to LBP and an understanding of what’s contributing to the pain experience
- Strategies to self-manage pain including physical activity
- Treatment and exercise specific to the problem
- Medication when required but not as the primary management
The key message here is the clear majority of people with LBP, including leg pain (sciatica), will have a good outcome with evidence based, non-surgical care. Cognitive Functional Therapy is an emerging approach to deliver high quality care considering the complexity of factors that can be relevant to a patient’s lower back condition. At Central Bassendean Physiotherapy we pride ourselves on our accurate diagnosis and evidence based, contemporary management of LBP. We are happy to have a further discussion on the material presented here.
You can BOOK HERE or Call us to make an appointment at 9279 7411
- Vibe Fersum, K, O’Sullivan P, Skouen J, et al. Efficacy of classification based cognitive functional therapy in patients with non-specific chronic low back pain- A randomised control trial. Eur J Pain 2013;17;916-28
- Almeda M, Saragiotto B, Richards B, et al. Primary care management of non-specific low back pain: key messages from recent clinical guidelines. Med J Aust 2018;208(6):272-275.
- Clark S, Horton R. Low back pain: a major global challenge. The Lancet 2018;391(10137):2302.