Rotator Cuff Related Shoulder Pain

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Rotator cuff related shoulder pain (RCRSP) is a commonly experienced ailment that often involves pain over the front and sides of the shoulder that is aggravated by movement – particularly during shoulder elevation and external rotation (Lewis, J 2016).

Shoulder pain accounts for roughly 1.2% of all visits to General Practitioners in Australia with rotator cuff related shoulder pain accounting for roughly 70% of visits. In 2016/17, shoulder pain was the 3rd most common reason for imagining through the Medicare benefits scheme in Australia (Naunton et al., 2020) so it's safe to say that RCRSP is quite common!

How important is imaging for RCRSP?

Although imaging for shoulder pain is common as mentioned above, it is only necessary in very rare situations. Imaging is indicated if the injury was traumatic or if there are signs and symptoms indicating something more serious is present. These are referred to as red flags and will be identified by your healthcare practitioner and addressed appropriately if present.

If no red flags are present, imaging is often not required as it is common for there to be findings on these images that may not be relevant to the presenting complaint. This can be problematic as it can draw focus to a specific structure that may not be related to your current pain experience and can also be financially burdensome. There are many examples in the literature showing structural changes within the shoulder in patients that are completely asymptomatic (Girish et al.,2011).

Studies have also found that for patients presenting with their primary symptom being pain, there appears to be no correlation between the level of pain and any measure of rotator cuff injury severity which may indicate that there is much more at play in the individuals pain experience than the specific structure alone (Dunn et al., 2014).

What is a full thickness rotator cuff tear?

While it may sound quite scary, a full thickness tear of a rotator cuff muscle does not mean we are broken and requiring repair. A great way to imagine what is happening to the muscle in this situation is to take a surgical mask and put a hole through the centre with a pencil. This is essentially what has happened to the muscle when we see the term ‘full thickness tear’ on an imaging report. It is not a tear in the muscle from top to bottom like a lot of us would imagine, but a tear or hole through the muscle. If you were to now grab the edges of your mask and pull them apart you will find that there is still quite a lot of structural strength and resilience in the mask. Now think about this in relation to a muscle - while there may still be a tear in the muscle, it does not always mean that the muscle is severely compromised. It is entirely possible to improve and progress without surgery even with these findings and the literature reflects this. (Dunn et al., 2014), (Naunton et al., 2020), (Curry et al.,2015),(Lewis,2016), (Minagawa et al., 2013).

Interestingly, there has been research that shows that the size and thickness of a rotator cuff tear showed no association with pain and function (Curry etal., 2015).

So, what should you do to help improve your injury?

We know that patients with high self-efficacy (a strong belief in their own ability to carry-out and complete tasks and goals regardless of their shoulder pain) and a greater expectation of treatment had better predicted outcomes regardless of the level of pain they experienced (Chester et al.,2019.)

There is good evidence to suggest that an exercise-based approach to rotator cuff tendinopathy, subacromial impingement and a traumatic partial and full thickness tears of rotator cuff muscles show comparable outcomes to surgery. That is great news in my opinion – I would much rather undertake an exercise-based rehabilitation program over 12 weeks than go through the stress of an operation that involves pre- and post-surgery rehabilitation anyway! (Littlewood etal., 2019), (Lewis, 2016).

There is also evidence to show that there is no difference between the clinical effectiveness of a single exercise given to a patient to complete on their own versus sessions of usual physiotherapy (including advice, stretching, massage, manual therapy, acupuncture, shock therapy, corticosteroid injections and exercises) for rotator cuff tendinopathy.

An interesting aspect of the study was that the exercise needed to illicit symptoms at a tolerable level to the patient and be no worse afterwards. This self-management is important in developing self-efficacy inpatients which has been shown to be important in positive outcomes. (Littlewood etal., 2015)

Exercising with pain has shown to be no better or worse than exercising without pain providing it is at a tolerable level! (Littlewood,Malliaras and Chance-Larsen, 2015).

So, what do we take from all this information? It’s pretty clear that exercise is a good place to begin when treating rotator cuff related shoulder pain!

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Should you see someone?

As mentioned above, there is evidence suggesting that there is not a significant difference between an individual doing one or multiple exercises and no real difference between doing this under supervision or on their own; it is completely individual. If you are a person that thrives with the extra support and accountability, then seeing a practitioner may be highly beneficial to you. However, if you prefer to be shown what to do on your own – that is fine too!

If seeking out healthcare I would recommend you find a practitioner that listens to your story, helps you to create meaningful goals and leads with you in developing a suitable plan forward.

Here at The Biomechanics our team of Osteopaths, Physiotherapists and Exercise Physiologists are motivated to lead you through this journey and back to what you love doing most!

References:

Lewis, J., 2016.Rotator cuff related shoulder pain: Assessment, management and uncertainties. Manual Therapy, 23, pp.57-68.

Naunton, J.,Harrison, C., Britt, H., Haines, T. and Malliaras, P., 2020. General practice management of rotator cuff related shoulder pain: A reliance on ultrasound and injection guided care. PLOS ONE, 15(1), p.e0227688.

Girish, G., Lobo,L., Jacobson, J., Morag, Y., Miller, B. and Jamadar, D., 2011. Ultrasound of the Shoulder: Asymptomatic Findings in Men. American Journal ofRoentgenology, 197(4), pp.W713-W719.

Minagawa, H.,Yamamoto, N., Abe, H., Fukuda, M., Seki, N., Kikuchi, K., Kijima, H. and Itoi,E., 2013. Prevalence of symptomatic and asymptomatic rotator cuff tears in the general population: From mass-screening in one village. Journal ofOrthopaedics, 10(1), pp.8-12.

Dunn, W., Kuhn,J., Sanders, R., An, Q., Baumgarten, K., Bishop, J., Brophy, R., Carey, J.,Holloway, G., Jones, G., Ma, C., Marx, R., McCarty, E., Poddar, S., Smith, M.,Spencer, E., Vidal, A., Wolf, B. and Wright, R., 2014. Symptoms of Pain Do Not Correlate with Rotator Cuff Tear Severity. Journal of Bone and Joint Surgery, 96(10), pp.793-800.

Curry, E.,Matzkin, E., Dong, Y., Higgins, L., Katz, J. and Jain, N., 2015. Structural Characteristics Are Not Associated With Pain and Function in Rotator CuffTears. Orthopaedic Journal of Sports Medicine, 3(5),p.232596711558459.

Littlewood, C.,Bateman, M., Connor, C., Gibson, J., Horsley, I., Jaggi, A., Jones, V., Meakins, A. and Scott, M., 2019. Physiotherapists’ recommendations for examination and treatment of rotator cuff related shoulder pain: A consensus exercise. Physiotherapy Practice and Research, 40(2), pp.87-94.

Littlewood, C.,Bateman, M., Brown, K., Bury, J., Mawson, S., May, S. and Walters, S., 2015. A self-managed single exercise programme versus usual physiotherapy treatment for rotator cuff tendinopathy: a randomised controlled trial (the SELFstudy). Clinical Rehabilitation, 30(7), pp.686-696.

Littlewood, C.,Malliaras, P. and Chance-Larsen, K., 2015. Therapeutic exercise for rotator cuff tendinopathy. International Journal of Rehabilitation Research,38(2), pp.95-106.

Chester, R., Khondoker, M., Shepstone, L., Lewis, J. and Jerosch-Herold, C., 2019.Self-efficacy and risk of persistent shoulder pain: results of a Classification and Regression Tree (CART) analysis. British Journal of Sports Medicine,53(13), pp.825-834.

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