Posts in Arm Injuries
Physical Therapy Accelerates Recovery From Rotator Cuff Tears
shoulder pain-rotator cuff tear-physical therapy-treatment

Rotator cuff tears are a common finding among middle aged adults with shoulder pain, but are also found among their peers without shoulder pain. Many of us will develop these tears as we age and as we have discussed in previous blog posts there is no difference in outcomes at 1 or 2 years if a patient elects for surgery or Physical Therapy for treatment of their symptoms. Our interventions in Physical Therapy are designed at optimizing shoulder function through manual therapy and strength training exercises allowing patients to return to their prior levels of activity without symptoms. Thankfully many rotator cuff tears improve over time due to the natural history of this injury, but a research study suggests Physical Therapy may accelerate this recovery if utilized early in a patient’s recovery.

Dickinson and colleagues studied 55 patients with rotator cuff tears for up to one and half years after the onset of their symptoms (J Shoulder Elbow Surg. 2019). Patients were broken into two different groups based on their utilization of Physical Therapy interventions. Authors reported patients who received Physical Therapy in the first three months after the onset of their symptoms reported greater improvements in pain and function compared to patients utilizing other interventions such as medication or a wait and see approach. Importantly, Physical Therapy was found most effective in the first 8 week of treatment with limited benefits after this 8 week time frame. Patients are encouraged to utilize Physical Therapy early in their recovery process to accelerate their recovery.

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Will The Bone Spur In My Shoulder Cause A Future Rotator Cuff Tear?
Photo Credit: radiopaedia.org

Photo Credit: radiopaedia.org

One commonly sighted reason to perform surgery is to prevent a worsening of an existing pathology. In the shoulder, clinicians aim to preserve important structures such as the rotator cuff with early vs. late surgical interventions despite prior research showing little to no change in progression of tears of rotator cuff tears in patients with a high grade tear. Choosing to delay surgery, without risk of rotator cuff progression, allows a patient to benefit from Physical Therapy. Evidence shows equivocal outcomes between Physical Therapy and surgery for patients with rotator cuff tears. Another structure of concern on a shoulder x ray is a acromion bone spur. In theory, bone spurs on this structure could reduce space between the ball of the shoulder joint and the overlying end of the shoulder blade. New research demonstrates these bone spurs are not as problematic as first theorized.

It has been suggested that a bone spur can lead to shoulder impingement and eventual tearing of the rotator cuff. A recent retrospective study challenged this theory. Yoon et al. examined 119 patients with an intact rotator cuff, diagnosis of impingement, and a 3mm sub-acromial bone spur (Arch Ortho Trauma Surg. 2018). The patients received conservative care including Physical Therapy and received a follow up image to check the cuff integrity as early as 2 years, but as late as 5 years after their initial x ray. The authors found no progression of rotator cuff tears in the 2-5 years after the initial evaluation suggesting the lack of importance the spur relating to tears in the cuff.

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Should I Stretch My Pectoral Muscles To Relieve My Shoulder Pain?
shoulder-pain-posture-stretching-pectorals

Our current understanding of posture has changed dramatically over the past 20 years due to the influx of scientific literature on posture and muscle and joint pain. Previously, posture was thought to be strongly associated with muscles imbalances including tightness or weakness. For example, forward shoulders were thought to be associated with shortened pectoral muscles. Our current understanding has reduced the importance of posture on both clinical decision making and an association with a patient’s current symptoms. Patient’s with poor posture can demonstrate normal muscle function and those with great posture can demonstrate significant muscle imbalances and pain. A recent research paper highlights these concepts on patient’s with shoulder pain.

Navarro-Ledesma and colleagues examined the muscle length and available joint space in patients with shoulder pain compared to their pain free peers (PT in Sport. 2018). Each participant’s pectoral minor length and shoulder joint (subacromial) space was measured clinically with ultrasound. The authors reported pectoral muscle length was poorly associated with both shoulder joint space and the presence of shoulder pain. These findings are consistent with our currently held belief on the limited importance of pectoral muscle length or flexibility and the presence or development of shoulder pain. Patient’s are encouraged to work with a local Physical Therapist on a shoulder and shoulder blade strengthening program instead of stretching their pectoral or chest muscles.

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No Additional Benefit Of Injection Over Physical Therapy Interventions For Shoulder Pain
injection-shoulder-pain-exercise-impingement

Subacromial impingement syndrome is the most common cause of shoulder pain. These symptoms are easily treated with Physical Therapy interventions including manual therapy and exercise. Specifically, strengthening exercises for the shoulder blade and shoulder improve both the quantity and quality of shoulder movements treating both the source of impingement pain and the underlying cause. Physical Therapy exercises remain the gold standard for treatment of impingement, but injections are still utilized by physicians to treat these symptoms. A recent research paper examined the benefits of an injection combined with Physical Therapy compared to Physical Therapy alone.

A randomized controlled trial in the British Medical Journal compared these two treatment approaches in 232 patients with shoulder impingement (Crawshaw et al. 2010). Patients were randomized to either a manual therapy, exercise, and an injection or manual therapy and exercise alone. Treating Physical Therapists were able to select the most appropriate manual therapy and exercise interventions based on the patient’s needs. Authors reported both groups improved over time, but no differences between groups on either pain or function were found at long term follow up. Thus, the improvements in shoulder pain and function can be attributed to the manual therapy and exercise interventions. No further benefit was found in the patients receiving injections.

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Which yoga poses are best for shoulder stability?
shoulder-strengthening-yoga-poses-exercises

Yoga is a popular form of individual and group exercise designed to improve flexibility, movement quality, and strength.  Participants benefit from sustained position holds designed to target different body regions.  As expected, the work of the stabilizing muscles increase with greater balance and weight bearing demands.  A recent study examined which exercises were best for recruiting the stabilizing muscles in the shoulder girdle.  

A recent article in the Journal of Sports Physical Therapy examined how muscle recruitment changed during a variety of yoga poses (Chopp-Hurley et al. 2018).  20 experienced and asymptomatic yoga participants were analyzed during 15 yoga poses.  The authors reported the greatest amount of upper, middle, and lower trapezius recruitment was found during the locust arms forward pose.  Further, the serratus anterior was effectively recruited during the majority of arm weight bearing poses.  Conversely, low levels of activity were found in the scapular muscles during dancer's pose right, reverse tabletop, and warrior II.  

Physical Therapy Improves Pain, Strength, and Function Among Patients with Full Thickness Rotator Cuff Tears
rotator-cuff-tears-strengthening-treatment

Previous research has documented no difference in long term outcomes between Physical Therapy and surgery for patients with rotator cuff tears.  Many patients with rotator cuff tears, including massive tears, do well with conservative treatment of their shoulder injuries demonstrating improvements in pain, strength, and function.  Strength training makes up the foundation of conservative care for this injury.  A recent review of the evidence documents the power of strength training for patients with rotator cuff injuries.

rotator cuff tear-treatment-exercise-strength

A review of the available evidence in the International Journal of Sports Physical Therapy highlights the evidence of 35 studies examining the use of strength training for patients with rotator cuff injury (Jeanfavre et al. 2018).  The authors reported on the results of strength training on 2010 shoulder with a rotator cuff tear.  Further, they found 73% of these tears were greater than 1 cm and 37% were classified as massive.  37% of these tears were traumatic in nature and 58% of patients experienced symptoms greater than 1 year.  Authors reported 78% of patients improved their symptoms and 85% improved their strength and function after Physical Therapy.  Interestingly, only 15% of patients elected for surgery following a course of Physical Therapy highlighting the effectiveness of conservative management of this injury.  

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