Clinically we cannot really differentiate between a rotator cuff tendinopathy, partial tear or impingement syndrome therefore the use of a term such as rotator cuff related pain is often more appropriate. This is an umbrella term which describes a range of these conditions and as such, we will look into each individually.
In relation to impingement syndrome this is more of a description of the mechanism of irritating the subacromial structures – today we will look into subacromial bursitis.
Looking at the 4 tendons of the rotator cuff coming in from a lateral view, we are predominantly looking at the distal insertions. Superiorly we have supraspinatus coming from above the spine of the scapular and passing under the acromion. Next to the posterior we have infraspinatus from below the spine of scap. Then next is teres minor and finally subscapularis on the anterior aspect of the Glenoid.
Rotator Cuff Tendinopathy
Rotator cuff tendinopathy is caused by excessive load on the RC joint. This is often caused by repetitive movements in awkward positions and overhead positions, so for athletes, this is often seen in swimmers and overhead shots in racquet sports, as well as throwing etc.
Clinical presentation
- Dull pain in the areas of RC tendons exacerbated by the overhead activity
- Likely to also report that they are getting weaker and ultimately can loose active range of motion and have pain at EOR passive movement.
Subacromial Bursitis
Mechanism of Injury:
- Acute trauma
- Fall or knock
- Acute overload
- Sudden increase in certain activities such as overhead lifting
- Chronic Overload
Individuals will commonly present with a painful arc of movement between 60-120 degrees.
The above findings are important when interpreting the results of imaging, noting that changes in the subacromial bursa may be incidental findings and not necessarily the root cause of shoulder problems. Imaging makes up a part of the clinical picture.
Rotator Cuff Tears
Acute tears can have fairly obvious physical signs such as bruising, swelling, and a marked loss of active movement particularly for large RC tears. For example, you may be able to passively externally rotate the upper arm but when released the patient is unable to maintain this position.
Chronic tears likely to have more adaptive strengthening and postures. Similar to the subacromial bursa, studies have shown that a high percentage of population have non symptomatic tears, so again, a tear seen on imaging needs to be correlated with the clinical presentation.
Clinical Presentation
Clinical assessment starts with observation and palpation. Marked atrophy is a strong indicator of a rotator cuff tear. Atrophy and fatty deposits in the musculature of the rotator cuff may also show up on an ultrasound. If active range of motion is impaired in comparison with passive, it can be indicative of a muscle or tendon issue.
Impingement tests such as hawkins kennedy or manual resistance testing, although very sensitive for rotator cuff related pain generally, cannot isolate individual muscles as all of the rotator cuff fires together and insertion of the tendons is so interconnected. These tests cannot be used to accurately diagnose a specific tendon problem.
Conservative Management
The acute phase of a traumatic tear would revolve around reducing inflammation and maintaining pain-free movements. The subacute to chronic phase is looking into restoring full ROM, restoring scapulohumeral rhythm and strength.
Medical Management
Medical management can consist of corticosteroid injection – remembering that the injection is only removing the inflammation. If the underlying cause of the inflammation is not addressed then inflammation may just recur at a later date.
Surgical interventions – depending on the age of the individual, the extent of the tear, and the extent of their limitations and symptoms, surgical repair may be required. A younger individual with a full thickness tear may be an excellent candidate for this. For an older individual, a trial of conservative treatment is often recommended.
If you are suffering from Rotator Cuff pain and would like it examined by one of our fully qualified therapists, please call us at Melbourne Hand Therapy today (03) 9899 8490 or leave an enquiry and we will get back to you as soon as possible.
