Posts in Arm Injuries
Should I Undergo Surgery Or Physical Therapy For My Shoulder Pain?
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Shoulder pain remains one of the top 3 reasons patients seek care from their primary care physician and Physical Therapist. The most common diagnosis causing pain among these patients is subacromial impingement syndrome. Impingement can be found along with rotator cuff tendon pain (tendinopathy) or partial rotator cuff tears on clinical exam and imaging. Impingement is often found in patients with rotator cuff and scapular muscle weakness leading to pain and loss of arm function. Physical Therapy remains the first line of treatment for impingement but surgery has also been utilized to treat this condition. A recent review of the literature compared these two approaches.

Nazari and colleagues compared the available research on the effectiveness of Physical Therapy vs. shoulder surgery for patients with impingement (PLoS One. 2019). Authors included 11 randomized controlled trials including over 900 patients with follow up periods up to 10 years after the interventions were performed. Authors reported no difference in outcomes between Physical Therapy vs. Surgery plus post operative Physical Therapy at short or long term follow up periods. Based on this review of the literature Physical Therapy remains a first line treatment for shoulder pain.

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Physical Therapy Shown To Accelerate Recovery After Rotator Cuff Injury Compared To Wait And See
rotator-cuff-injury-tear-treatment

Shoulder pain remains the 3rd most common reason, behind the common cold and low back pain, patients seek out the care of their primary care providers. Impingement and rotator cuff tendon pain are the most common diagnoses associated with these symptoms. The vast majority of rotator cuff injuries do not require surgical intervention and patients are faced with conservative treatments including medication, Physical Therapy, and a wait and see approach. Unfortunately the natural history of shoulder pain is recurrent in nature and over 50% of all new shoulder patients experience continued symptoms at 6 months. A recent research article compared the effectiveness of Physical Therapy to a wait and see approach for patients with shoulder pain.

Dickinson and colleagues completed an analysis of healthcare outcomes in a multi centered cohort of patients with rotator cuff tears (J Shoulder Elbow Surg. 2019). Enrolled patients underwent clinical and demographic questionnaires at 3, 6, 12, and 18 months to determine their perceived recovery from either Physical Therapy or a wait and see or control condition. Authors reported patients who received Physical Therapy within the first 3 months demonstrated significantly better improvements in pain and function compared to those not receiving Physical Therapy. Authors reported similar scores between groups at long term follow ups demonstrating Physical Therapy had the greatest impact accelerating a patient’s recovery up to the 3 month time point.

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Does Treatment Of Trigger Points Improve Outcomes For Patients With Rotator Cuff Injury?
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Rotator cuff injuries span the spectrum from acute strains to chronic tendon pain (tendinopathy) and rotator cuff tears. Physical Therapy remains the gold standard, first line treatment for all rotator cuff injuries due to its’ cost and clinical effectiveness treating these disorders. A Physical Therapy first strategy has been reinforced by recent research demonstrating equivalent outcomes between surgery and Physical Therapy for patients with rotator cuff tears. Strength training exercises remain the most important intervention for patients due to their ability to reduce pain, heal injured tissues, and restore lost function. A recent study examined the effectiveness of adding trigger point treatments to an established Physical Therapy exercise program.

Akbaba and colleagues randomized patients with rotator cuff tears to one of two groups (J Back Musculoskelet Rehabil. 2019). Both groups received the same Physical Therapy strengthening program completed twice a week for 6 weeks, but one group also received manual soft tissue treatment of their shoulder’s trigger points. Authors assessed each patient’s pain, range of motion, function, and mental health outcomes initially and upon completion of the 6 weeks. Both groups improved pain, range of motion, function, and mental health but the addition of trigger point treatments did not improve clinical outcomes in patients with rotator cuff tears. This study highlights exercise remains the most important treatment in patients with rotator cuff injury and soft tissue interventions add little to the overall recovery of patients.

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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?
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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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