Rotator Cuff Related Shoulder pain

Anju Jaggi

Consultant Physiotherapist

RNOHT Shoulder & Elbow Service

How big is the Problem?

• Prevalence of Shoulder pain in the UK – 14%

• 1-2% adults present to the GP with pain

• 70% of shoulder pain is due to RC insufficiency

• Growing problem with aging population?

Mitchell, C., Adebajo, A., Hay, E., Carr, A., Shoulder pain: diagnosis and management in primary care, BMJ, 2005. 331: p. 1124-1128.

The Problem!

• Current classifications unreliable

– RC tendinitis/tendinosis

– Bursitis

• Diagnostic labels unhelpful

• Soft tissue damage does not correlate with symptoms– Unruh et al 2014, Miniaci et al 2002, Frost et al

1999, Milgrom et al 1995, Sher et al 1995>50% of partial tears > 60yrs

Asymptommatic!

Current Tests

• Impingement tests

– High Sensitivity

– Poor Specificity

• Current Impingement tests –specificity of <50%– Park et al (2005) JBJS

• Manual Muscle tests

– Unable to test specific muscles

Tell you it hurts but not the reason why!

What does the evidence base say?

What tests to use?

• Research on special tests for shoulder pathology generally poor quality.

• Sensitivity and Specificity vary greatly.

• A way to improve the clinical diagnostic process is to cluster Orthopaedic Special Tests (OSTs).

• These clusters can then be used to either rule in or out different pathologies.

Cluster tests for RC tear

Litaker et al. (2000)

• Age > 65

• Weak ER

• Night pain

LR + 9.84

LR - 0.54

Park et al. (2005)

• Age > 60

• + Painful arc test

• + Drop arm test

• + Infraspinatus test

LR + 28.0

LR – 0.09

Hegedus et al. (2015)

Painful arc

• Painful arc on active abduction or eccentric lowering.

Drop arm test

• Patients arm is passively abducted and then released.

• Test is positive if the patient is unable to hold their arm in the abducted position i.e. It drops down.

Infraspinatus Test

ER should be tested

both in

• Neutral and in

• 90 degrees of abduction

BESS/BOA Guidelines

• Patient Hx and simple shoulder tests for diagnosis

• Imaging not recommended in primary care

– Poor correlation structure vs symptoms

Kulkarni R et al (2015) BESS/BOA Patient Care Pathway Subacromial Shoulder pain.Shoulder & Elbow Vol. 7(2) 135-143.

Beard et al. Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial. The

Lancet 2017

• Multi-centred randomised pragmatic, parallel grp, placebo controlled, 3 grp study

• 51 surgeons, 32 hospitals, 313 pts randomised

• 3 Groups

– Arthroscopy only

– Arthroscopy + surgical intervention

– No treatment, one f/u 3/12 by a shoulder specialist, no intervention

Surgical groups had better outcomes for shoulder pain and function compared with no treatment but this difference was not clinically important. Additionally, surgical decompression appeared to offer no extra benefit over arthroscopy only. The difference between the surgical groups and no treatment might be the result of, for instance, a placebo effect or postoperative physiotherapy.

Subacromial decompression surgery for adults with shoulder pain: a clinical practice guideline

Getting it Right: Addressing Shoulder Pain (GRASP)

GRASP team:Chief Investigators: Sallie Lamb / Sally Hopewell

Co-investigators: Andrew Carr, Alastair Gray, William Hamilton, Chris Littlewood, Karen Barker, Susan Dutton, Melina Dritsaki, David Keene, Anju Jaggi, Zara Hansen, Iveta Simere

Clinical and cost effectiveness of progressive exercise compared to best practice advice,

with or without corticosteroid injection, for the treatment of rotator cuff disorders: a 2x2 factorial randomised controlled trial

Trial Intervention

• Electrotherapy, acupuncture, soft tissue mobilisation and manipulation not included – decrease efficacy

• Stretching was not a priority

• Isolated exercises to correct posture omitted

• Exercise with some pain mild-moderate settle within a few hours

• Best Practice session

• 6 sessions of physio over 16 weeks

(Keene et al, 2019 Physiotherapy)

Trial Exercise Intervention

• Level 1 – Simple Shoulder Exs

– Reduce fear, encourage movement, improve mobility, increase confidence

• Level 2 – Progressive Resisted Strengthening

– Focused to the posterior RC

– 5days a week with 2 non-consecutive recovery days

• Level 3 – Patient specific functional restoration

(Keene et al, 2019 Physiotherapy)

Key Principles of rehab

• Restore cuff & Scapula balance

• Rest & modify in an acute reactive phase

• Appropriately challenge the muscles

• Apply knowledge of functional anatomy

• Manage as a long term condition

• Understand it from the patient perspective

Motor Control at the ShoulderWattanaprakornkul et al (2011) “A comprehensive analysis of muscle recruitment patterns during shoulder flexion – an EMG study.” Clin Anatomy

Wattanaprakornkul et al (2011) “The rotator cuff muscles have a direction specific recruitment pattern during shoulder flexion and extension exercises.” J Sc Med Sport

Reed et al (2013) ‘Does supraspinatus initiate abduction?’ J Electromyogr Kinesiol 23:425-9

Tardo et (20130) “Rotator cuff muscles perform distinctly different roles during shoulder rotation exercises”. Clin Anat 26:236-43

0

20

40

60

80

100

120

supraspinatus infraspinatus subscapularis upper trapezius lower trapezius serrautsanterior

deltoid latissimus dorsi pectoralismajor

Avera

ge E

MG

(%

MV

C)

flextion 70%

flextion 50%

flextion 20%

extension 70%

extension 50%

extension 20%

MUSCLES

Wattanaprakornkul et al (2011) “The rotator cuff muscles have a direction specific recruitment pattern during shoulder flexion and extension exercises.” J Sc Med Sport

Abduction 90Internal Rot.

o

Flexion 90o Flexion 0 o Abduction 0oExtension

Exercise

20

40

60

80

100

120

Mu

scle

Act

iva

tion

(%M

VC

)

supraspinatus

infraspinatus

upper subscapularis

lower subscapularis

Abduction 90External Rot.

o

Does dynamic stability require RC co-contraction?

isometric tasks

Does dynamic stability require RC co-contraction?

Conclusions▪ during maximum isometric abduction

▪ anterior RC (subscapularis) and posterior RC (supraspinatus, infraspinatus) co-contract

▪ globally compressing shoulder joint articular surfaces▪ counter-balancing the superior translation of the humeral head cause by

deltoid

▪ during isometric and dynamic flexion and extension▪ RC muscle(s) do not co-contract at similar levels

▪ RC on the opposite side of shoulder joint to the muscles producing torque are activated at significantly higher levels

▪ subscapularis are significantly more active during extension ▪ infraspinatus & supraspinatus are significantly more active during flexion

▪ employing a more specific joint stabilizing strategy than gross global compression

▪ not acting as barriers to humeral head translation

counterbalancing the antero-posterior translation of the humeral head caused by flexion-extension torque producing muscles respectively

Normal rotator cuff muscle functionbased on research evidence

▪ rotate the humerus▪ infraspinatus, teres minor & supraspinatus = external rotators▪ subscapularis = internal rotator

▪ abduct the humerus▪ supraspinatus initiates abduction

▪ stabilise the shoulder joint▪ take up slack in shoulder joint capsule

▪ co-contract to:▪ globally compress the humeral head to provide dynamic stability▪ depress the humeral head to prevent it gliding superiorly

▪ block humeral head translation ▪ anteriorly – subscapularis▪ posteriorly - infraspinatuscounterbalance potential translation of humeral head

by muscles producing movements of humerus

NO

NO!

NOT during rotation, flexion, extension & adduction

Shoulder joint stability model

humeral head

extensors lat dorsi

teres majorpost deltoid

flexorspec major ant deltoid

abductordeltoid

all RCsubscapularissupraspinatusinfraspinatusteres minor

X

anterior RCsubscapularisX

posterior RCinfraspinatussupraspinatus

teres minor

X

balanced muscle forces

Scapulohumeral rhythm

▪ = co-ordination between humeral and scapular movements

▪ requires significant muscle co-ordination

▪ kinematics of scapulohumeral rhythm▪ example: during abduction

▪ humerus abducts and externally rotates▪ scapula laterally (upwardly) rotates ▪ 0º to 30º abduction

▪ mainly humerus movement▪ variable scapular movement

▪ 30º to 180º abduction▪ approximately 1.5 times as much humeral movement as scapula movement

▪ example: during hand-behind-back▪ humerus extends, adducts and internally rotates▪ scapula medially (downwardly) rotates

Axioscapular muscle functionupward rotation mover role

27

upper trapezius

lower trapezius

serratus anterior

• accurately position the glenoid fossa

• “re-align” scapulohumeral muscles

Axioscapular muscle functionstabiliser role

28

scapulohumeral musclesdeltoid

rotator cuffteres major

Axioscapular muscle functionstabiliser role

29

rhomboids

upper trapezius

lower trapezius

middle trapezius scapulohumeral musclesdeltoid

rotator cuffteres major

Scapular stability model

30

upper trapezius

lower trapezius

rhomboids

serratus anterior

middle trapezius scapulohumeral musclesdeltoid

rotator cuffteres major

Scapular stability modeldynamic shoulder rotation at 90ᵒ abduction

31

Tardo et al (2013) “Rotator cuff muscles perform distinctly different roles during shoulder rotation exercises”. Clin Anat 26:236-43

concentric eccentric

Physiotherapists’ recommendations for examination & treatment of RCRSP: A consensus exercise

• Consensus reached– Diagnosis

– Imaging

– Injections

– Exercise mainstay

• Lack of consensus– Exercise into pain/no pain

– Standard vs individualised

– Dose (reps/frequency)

– Wait and see?

C Littlewood et al Physiotherapy Practice & Research 40 (2019) 87–94

SUBACROMIAL SHOULDER PAIN

This section is for GP’s and their patients and provides information and exercise videos for the most common cause of shoulder pain.

These booklets and videos have been prepared by BESS surgeons and BESS physiotherapists with the support of the NHS Getting it Right First Time Programme (GIRFT).

Below you can download these booklets for use at home on your device or print in different formats. The content of the booklet also appears on this web page along with our videos. The videos are now also available in a playlist via the BESS YouTube Channel.

https://www.youtube.com/channel/UC09T_cXrnSFu-irWGcfEifg

Prognostic factors

• Patient expectation of recovery

• Pain self efficacy

• Number of co-morbidities

• Anxiety or Depression

• Higher baseline pain and disability

• Higher resting pain

• Duration of symptoms• Current employment status• Leisure time physical activity• Active shoulder flexion or

abduction• Active and passive abduction• Symptom modification on

facilitation of elevation

• Patients expectations and beliefs were most consistently associated with outcome

• Clinical examination findings were not consistently associated with outcome

• Recommendation: Re-balance assessment between psychological and clinical variables

- High levels of pain and disability at baseline are associated with high levels of pain and disability at 6-month follow-up.

- ‘ Predicted’ poor outcome is modified to a predicted better outcome if the patient has highpain self-efficacy and a greater expectation of treatment.

- Low levels of baseline pain and disability are associated with low levels of follow-up pain and disability. This predicted better outcome is modified to a predicted poor outcome if the patient has low pain self-efficacy.

- RECOMMENDATIONS: pain self-efficacy and patient expectation of outcome as a result of physiotherapy treatment should be formally assessed and discussed at the first physiotherapy appointment.

Chester R, Khondoker M, Shepstone L, et alSelf-efficacy and risk of persistent shoulder pain: results of a

Classification and Regression Tree (CART) analysisBr J Sports Med Published Online First: 09 January 2019. doi:

10.1136/bjsports-2018-099450

• Poor agreement between the therapist’s and the patient’s expectation of recovery

• Therapist expectation of recovery is a POOR predictor.

• Do we need to use questionnaires?

Eg Orebro Musculoskeletal Pain Screening Questionnaire, Modified STarT back

Listen to our patients

Re-framing our approach topersistent MSK pain

• The majority of persistent non-traumatic musculoskeletal pain disorders do not have a pathoanatomical diagnosis that adequately explains the individual’s pain experience and disability.

• Structural changes observed on imaging that are highly prevalent in pain free populations, such as rotator cuff tears, intervertebral disc degeneration & labral tears, are ascribed to individuals as a diagnosis for their condition.

• Interventions such as manual therapy, pharmacology and injections, when provided, should be seen as an adjunct, and their risks and benefits must be considered and honestly communicated.

Re-framing our approach to persistent MSK pain

By aligning the management of such conditions with the principles underpinning the management of other chronic conditions:

• Strong clinical alliance• Education,• Exercise and lifestyle (sleep hygiene, smoking cessation, stress

management, etc)

in order to build the individual’s self-efficacy to take control and ultimately be responsible for their health.