Chronic Rotator Cuff Disorders
By Associate Professor Sally Green

Shoulder pain is common, with prevalence reports ranging from 7 to 36%. Shoulder pain accounts for 1.2% of General Practice encounters in Australia [1] and Chronic Rotator Cuff Disorder (RCD) is the third most common presentation to Australian Sports Medicine Facility [2].

Classification of common shoulder problems
One of the difficulties associated with treating shoulder disorders is associated with classifying shoulder pain into different diagnostic entities. This holds for both clinical practice and research. On the whole, most studies are conducted in either RCD, or adhesive capsulitis. Clinical diagnosis is hindered by overlap of signs and symptoms between these categories with 40% of patients having overlap of signs and symptoms [3].

In a formal reliability study of the diagnosis of shoulder pain, agreement between three rheumatologists on clinical diagnosis was 46%. This increased to 78% when the patient was examined by all rheumatologists together [4].

The various conditions which should be considered are:

Subacromial

• Bursitis
• ACJ arthritis
• Rotator Cuff Disease (RCD)

Glenohumeral (intra-articular)

• Arthritic glenohumeral joint
• Internal derangement (labral tears, SLAP lesions, Hill-sach’s lesions, fractures)

Glenohumeral (peri-articular)

• Instabilities, structural
• Instabilities, dynamic
• Posterior/internal impingement
• Capsulitis
• Subcorocoid impingement

Referred

• Cervical, thoracic, neuromeningeal (brachial plexus), visceral

Management of RCD

Aims of treatment for patients with RCD are to decrease pain, improve functional range of motion, improve scapular control, strengthen scapular stabilizers and rotator cuff muscles, improve thoracic and shoulder posture and regain normal shoulder biomechanics.

Global strengthening of rotator cuff muscles, deltoid and scapular stabilizers is important and the best approach is low weight, high repetition and high frequency.

Improved proprioception and biomechanics is the key to a successful outcome as it teaches control of the shoulder. It is not good enough to have a strong shoulder. The patient needs to know how and when to use it in high-speed situations. A graduated program incorporated with strengthening is ideal.

Table 1 summarises the available evidence for common treatments addressing these aims.

Table 1

Intervention	Levela	Quality	Strength	Relevance	Conclusion
NSAID	I	Poor	Significant but not strong	Yes	Short term benefit for pain
Subacromial steroid injection	I	Poor	Significant but not strong	Yes	Short term benefit for pain
Laser therapy	II	High	Significant	?	Medium term benefit ROM
Exercise	II	Poor	Significant but not strong	Yes	Medium term benefit ROM, no benefit pain
Surgery (arthroscopic)	II	Good	Significant and strong	Yes	Benefit for function
Acupuncture	II	Poor	No significant difference	?	No benefit

^a I = systematic review of randomised controlled trials, II = single randomised controlled trial

Management of Subluxation/Impingement

Hypermobility of glenohumeral joint (subluxation) leads to lack of ability to centre humeral head and impinges the supraspinatus tendon, resulting in secondary pain and inflammation of the tendon.

Treatment aims to address tendonitis, then treat subluxation (ie. underlying cause). Important to include glenohumeral and scapular strengthening exercises as well as proprioception exercises.

Management of Rotator Cuff Tendonitis/Partial Tear

Chronic wear and tear and over or inappropriate use leads to intra-tendon damage and tearing. The treatment should consist of using local modalities. Manual therapy should include inferior glide techniques in abduction to gap the joint space. Improve the scapular and humeral head control. Appropriate rest as required. Always assess the cervical component for referred pain. Consider non-manual therapy options.

Management of Full Thickness Tears

If painful, consider surgical repair.

If not painful and surgery not advised, treat parafunction (neck, thoracic and other muscles) and educate regarding limited aims.

References:

1. Bridges-Webb, C., et al., Treatment in general practice in Australia. Medical Journal of Australia, 1992. Suppl:S1-S56.
2. Bacquie, P. and P. Brukner, Injuries Presenting to an Australian Sports Medicine Centre: A 12-month study. Clinical Journal of Sports Medicine, 1997. 7(1): p. 28-31.
3. Binder, A.I., et al., Frozen shoulder: a long-term prospective study. Annals of Rheumatic Diseases, 1984. 43: p. 361-364.
4. Bamji, A., et al., The painful shoulder: can consultants agree? British Journal of Rheumatology, 1996. 35: p. 1172-1174.