Shoulder pain

The success of operative rotator cuff repair is variable, with rates of failure reported between 25% and 90%. Massive rotator cuff tears (an anteroposterior tear size > 5cm, coronal retraction to the glenoid rim, or ≥ 2 tendon involvement) have high rates of non-healing or re- rupturing and some even being irreparable. A deltoid strengthening program may be the most appropriate mode of treatment for these kinds of tears; particularly, in the elderly population. Deltoid re-education works by optimizing the function of the deltoid and remaining rotator cuff muscles. In the uninjured shoulder, the deltoid and rotator cuff muscles work synergistically to maintain a balanced between transverse and coronal force couples that stabilizes the glenohumeral joint. 📌Indications and Contraindication s In elderly patients who are unable or unwilling to undergo surgery, then deltoid re- education is the ideal option. Some would strongly argue that physiotherapy should be the first line of treatment for the massive rotator cuff tear. Also, patients who are relatively asymptomatic, who have acceptable pain levels (particularly absence of night pain) and a reasonable functional level may not see the benefit from surgical intervention, and instead may choose to be managed with non-surgical modalities. Deltoid retraining program is contraindicated in patients with antero-superior escape with glenohumeral arthritis and younger patients who request return of shoulder strength, particularly external rotation. Deltoid retraining program A full range of motion is desirable. This is achieved using passive self-assisted exercises (using the alternate limb, pulleys or walking stick) in the supine position initially, to eliminate any stiffness within the shoulder. The deltoid rehabilitation exercises are initially performed with the patient supine and the head supported. The patient is instructed to bring his arm to the upright position first and try to keep it upright with the contraction force of his deltoid muscle. Then, the aim is to actively move the arm with gravity eliminated within a comfortable forward active elevation arc. ➡️The next phase is for the patient to hold a small weight (e.g., a small bottle of water or tin of beans in their hand, again increasing the arc of motion as confidence increases. ➡️The final stage progresses to using the arm against gravity, initially in a semi-sitting and then in a standing position, first without the additional weight held in the hand and later with the weight. Assurance and education For patients to engage in the rehabilitation process it is important that they are educated about their condition. They should be reassured that pain in the shoulder does not correlate with harm, although conversely there is little to be gained by working the shoulder to the point of irritability. Realistic and achievable goals should be set as this maintains motivation and engagement in the programme. Posture Any postural issues of the shoulder girdle should be corrected from the outset, as this affects scapula positioning and physiotherapy sometimes needs to be directed here first. Activities to encourage proprioception by weight-bearing through the limb should also be included as there is usually a proprioceptive deficit in this situation. 🔖Takeaway message Chronic irreparable rotator cuff tears can cause substantial shoulder pain and disability. Many chronic irreparable rotator cuff tears can be treated non-operatively, especially when the shoulder has reasonably good function. Rehabilitation for rotator cuff tears is a valid and successful treatment modality. It should be particularly considered in those patients with chronic irreparable cuff tears, who are too frail or do not wish to consider surgery. The deltoid “re-education” program outlined in this chapter is a very useful tool.

Effectiveness of physical therapy treatment of clearly defined subacromial pain: ▸ Exercise therapy based on stretching and strengthening of rotator cuff and scapular muscles is as effective as surgery intervention. ▸ Exercise therapy associated with manual therapy based on joint and soft tissue techniques is more effective than exercises alone to reduce pain in the short term in patients with subacromial pain. ▸ Low-level laser therapy and pulsed electromagnetic field are no better than placebo treatment or exercise therapy to improve pain or function in patients with subacromial pain. Full article : http://bjsm.bmj.com/content/50/18/1124.long

Is it time to try something similar when treating patients with chronic shoulder pain? It is our role as physiotherapists, who provide exercise treatment will need to consider a change in our management, considering that active exercises is equally as effective as surgery.