Muscle Re-education for Rotator Cuff Syndrome

Rotator Cuff Syndrome usually refers to pathology involving the supraspinatus tendon but may involve the infraspinatus, teres minor or subscapularis tendons. These tendons are particularly vulnerable to overload and degenerative changes due to their small muscle tendon cross sectional complex, high level activation, relatively poor vascularity and high stress location.

Role of physiotherapy

Physiotherapists have the clinical skills to assess and treat posture and muscle imbalances, and overuse injuries of the rotator cuff muscles. The physiotherapist will develop a strengthening program to restore normal function of the shoulder and prevent recurrence of Rotator Cuff Syndrome.

An underlying instability may lead to internal impingement of the posterio-superior corner of the supraspinatus tendon against the humeral head and labrum. Physiotherapists can accurately assess the underlying instability and design and implement a specific strengthening program.


Benefits of physiotherapy

The usual pathology for young athletes presenting with rotator cuff pain is supraspinatus tendonitis where there is an inflammatory overload reaction in the tendon structure. The older patient usually presents with supraspinatus tendonitis where there is degenerative structural breakdown in the tendon and a secondary inflammatory reaction in the surrounding tissues (predominantly the sub-acromial bursa or the glenohumeral joint capsule itself). Both scenarios result in the patient presenting with supraspinatus impingement pain where physiotherapy intervention can provide relief.

In the young athlete, the impingement pain is usually caused by muscle imbalance around the shoulder girdle or by an underlying anterior instability.

Scapula function/positioning influences rotator cuff function and its vulnerability to developing sub-acromial impingement. In turn, scapula function is affected by:
bullet Spinal dysfunction e.g. postural changes. Physiotherapists use mobilisation, postural education and exercise programs to treat spinal dysfunction.
bullet Muscle tightness e.g. pectoralis minor leading to scapula protraction. Physiotherapists use massage and stretching techniques to treat muscle tightness.
bullet Scapula stabiliser weakness e.g. poor lower trapezius control. Physiotherapists can help to retrain and strengthen this area by prescribing specific exercises.
The usual pattern of muscle imbalance is a protracted scapula, weak and lengthened lower trapezius, weak external rotator, and tight and overactive internal rotators and levator scapulae.

This will result in an anteriorly placed humeral head and propagate sub-coracoid or subacromial impingement (Kibler 1991). Because of the alteration in humeral head position, local muscle imbalances and aberrant firing of the rotator cuff will occur.

In the older patient it is well documented that local forms of capsulitis can result in response to the degenerative changes seen in the supraspinatus tendon.

Capsulitis responds very well to a combination of appropriate anti-inflammatory treatment and specific local physiotherapy techniques such as massage, mobilisation and capsular stretches.

Recent work by Burkhart (1994) and Warner (1990) has also pointed to the importance of developing adequate external rotation strength in rotator cuff pathology as it is the strength present in the inferior force couple of the rotator cuff that enables the supraspinatus to function adequately.

Wuelker (1992) has demonstrated that while subacromial decompression may decrease the pressure in the subacromial space by 5%, adequate strength in the inferior force couple may decrease the pressure by 61%. This demonstrates the significant role physiotherapists play in the management of rotator cuff syndrome and the development of muscle strength.

References

Kibler BW (1991): The role of the scapula in the overload throwing motion. Contemporary Orthopaedics. 22 (5): 525-532.

Burkhart S. (1994): Reconciling the paradox or rotator cuff repair versus debridement: a unified biomechanical rationale for the treatment of rotator cuff tears. Arthroscopy 10 (1): 4-19.

Burkhead WZ and Rockwood CA 1992: Treatment of instability of the shoulder with an exercise program. The Journal of Bone and Joint surgery 74A (6): 890-896.

Warner J, Michaeli L, Arslanian L, Kennedy J and Kennedy R (1990): Patterns of flexibility, laxity and strength in normal shoulders and shoulders with instability and impingement. The American Journal of Sports Medicine, 18 (4): 366-375.

Wuelker N, Roetman B and Roessig S (1995): Coracoacromial pressure recordings in a cadaveric model. The Journal of Shoulder and Elbow Surgery, Vol. 4, (6): 462-467.

Finding a physiotherapist

Would you like the names of physiotherapists who have a special interest in Muscle Re-education for Rotator Cuff Syndrome?  This falls under the category of musculolskeletal.  Call us on (03) 9527 7532 or contact us here.
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By courtesy of the Australian Physiotherapy Association