a practical guide to rotator cuff rehab
Post on 08-Jan-2017
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A Practical Guide to Rotator Cuff Rehabilitation
Julia Walton Specialist Shoulder Physiotherapist
Manchester Shoulder Clinic &
Wrightington Hospital
Its been a journey………
● Joined The Nottingham Shoulder Unit 2002
● Picked up lots of ideas on the way…
● Isolated rotator cuff work
● Kinetic chain
● No recipe….
● BUT there are key ingredients………
●Controls humeral head ●Push/shoulder flexion
●Supraspinatus, infraspinatus. deltoid, trapezius and serratus anterior higher activation
●Pull/shoulder extension ●Subscapularis & Lat dorsi higher activation (Wattanaprakornkul et al 2011)
●In combined ER/Abduction Supraspinatus main stabiliser. Deltoid has a role too ● Subscap less (Tardo et al 2013)
What does the rotator cuff do? Stabilisers
●Infraspinatus -‐ Torque producer in 90 degrees abd for IR/ER (Tardo et al 2013)
The cuff has different roles in different positions
BUT all works synergistically
What does the rotator cuff do? Torque Producer
Where do we begin?
● Improvement testing is the way in ● Positive predictor of physio success
● Scapula assist ● ER/IR recruitment ● Kinetic chain ●Grip ● Reinforce afferent input
● visual ●manual ● audible ● tactile
improvement test!
What does the rotator cuff need?
● Intact/functional
● Comfortable as possible
● Functional range of movement
● Good mechanical position throughout
●With support from proximal control
● AND tap into the kinetic chain to generate functional power
All of these LEAD to happier rotator cuff
What goes wrong?
● Ageing/Damage/injury ● Stiffness ● Disuse ● Pain inhibition ● Poor timing ● Poor control
● Doesn’t switch on
● Poor centralisation of HH
● Can’t cope with load
● Fatigues
How do we rehab the rotator cuff? What and Where do we need to train?
● So is it all about strength?
● Control ● Proprioception ● Timing -‐ presetting ● Load ● Endurance -‐ can it cope?
How do we rehab the rotator cuff? What and Where do we need to train?
● So is it all about strength?
● Control ● Proprioception ● Timing -‐ presetting ● Load ● Endurance -‐ can it cope?
● Through range
●What is functional to them?
● So is it all about strength?
● Control ● Proprioception ● Timing -‐ presetting ● Load ● Endurance -‐ can it cope?
● Through range
●What is functional to them?
How do we rehab the rotator cuff? What and Where do we need to train?
How do we rehab the rotator cuff? What and Where do we need to train?
● So is it all about strength?
● Control ● Proprioception ● Timing -‐ presetting ● Load ● Endurance -‐ can it cope?
● Through range
●What is functional to them?
Key components for RC exercises
● Proprioception
● Kinetic chain
● Rotational control & loading through range
Which exercises? Consider their value
Key components: Proprioception
● Vital for RC function
● Reflex arc from capsule to shoulder musculature
● Mechano-‐receptors influence muscle recruitment
● Enhancing gleno-‐humeral control
● Stretch
● Compression
● Hand grip
● Isometrics
● Reinforce with afferent input
Key components: Kinetic chain
●What is the rotator cuff attached too?
●Mobility vs stability
●Where does the functional power come from? ● 50% lower limb ● 30% thoracic ● 20% arm
Key components: Kinetic chain
• A step increases scapulothoracic recruitment by 10%
• Rotator cuff strength improves by 24% when scapula is retracted/stabilised
Kibler et al 2006 Tate et al 2008
STOP THE PRESS!
Key components:Kinetic Chain
● All these exercise are functional patterns we can recognise for a reason
● Textbook ways to move
● We become lazy or adapt to pain and injury
● TROUBLE!
Key components:Rotator cuff rotational control and loading
● Sometimes rotator cuff with kinetic chain is not enough…
● RC constantly switches its roles depending on position and gravitation pull (eccentric/concentric, mover/stabiliser)
● Large ROM -‐ EOR often neglected
● Proprioceptively deficient -‐ appears stiff!
● Complements Kinetic chain
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