Rotator Cuff Related Shoulder Pain: Non-Op Management

- Education

- Exercise

- Manual Therapy

- Shoulder Symptom Modification

What are the main parts of Phase I Management for RTC Related Shoulder Pain

- Discuss diagnosis, prognosis, factors contributing to symptoms

- Discuss strategies for modifying load

During Phase I Management for RTC Related Shoulder Pain what is the focus of education

- Mobility-based exercises targeting GH, CTJ, and others as needed

- Early loading of the RTC

During Phase I Management for RTC Related Shoulder Pain what is the focus of exercise

May be useful to facilitate more comfortable movement

During Phase I Management for RTC Related Shoulder Pain what is the purpose of manual therapy

- Education

- Exercise

- Manual Therapy/symptom modification

- Functional Task Training

What are the parts of Phase II: Management for RTC Related Shoulder Pain

- as needed during course of care to address concerns, load progression

- 'Speedbump' management

During Phase II Management for RTC Related Shoulder Pain what is the purpose of Education

- Progressive loading strategies with goal of returning to function

- Progression of load, sets, reps to match demands

During Phase II Management for RTC Related Shoulder Pain what is the focus of exercise

As impairments remain, but may be less pertinent here

During Phase II Management for RTC Related Shoulder Pain what is the purpose of manual therapy/symptom modification

Break an activity apart, and build the components back up

During Phase II Management for RTC Related Shoulder Pain what is the focus of functional task training

1. Higher patient expectation of recovery with PT.

2. Higher pain self-efficacy.

3. Lower pain severity at rest.

4. If not retired, being employed or in school.

What are the 4 factors that predict success with PT

- What activities should they avoid? Modify? Continue? For how long?

- How can they complete their ADL's, work, or leisure activities with less pain?

- Is it OK to have pain during activity?

What are important considerations when it comes to activity modification

- GH mobilization

- Scapular mobilization

- AC joint mobilization

- Cervical or thoracic spine mobilization

What are manual technique options for RTC related shoulder pain

- Strengthening for shoulder ER, flexion, AB

- Scapular muscle strengthening?

- Stretching?

- Load tolerance/progression likely more relevant than strength construct

What are General exercise recommendations for RTC related shoulder pain

- May need to perform exercises unloaded

- May only tolerate isometrics

What type of resistance exercise can be used when the shoulder is very irritable

- Education, education + strengthening, education + motor control had similar effects in clinical outcome (Dube 2023)

- Evidence does not suggest one superior contraction type (eccentric, ecc/con, iso, time under tension)

- More does not equal better (no difference in control vs. at least 2x time under tension)

What are key points about RTC resistance exercise based on the SExSI trial study

Gradually strengthen the deltoid to take over the role of the RTC

Thought to take 12 weeks

What is the key point about massive symptom RTC tears

RTC and scapular muscle strengthening and stretching

What type of exercise is effective for RCRSP?

It has greater effects than exercise alone

What does strong evidence show about exercise combined with manual therapy?

No. Many forms of strength training can be effective

Is one form of strength training universally best for RCRSP

Short-term benefits alone or when combined with exercise

What benefits do corticosteroid injections provide

Laser, shockwave, and ultrasound provide no benefit

What does evidence show about therapeutic modalities

Mild–moderate pain is acceptable if it does not cause a flare

Is pain allowed during exercise for RTC-related pain

Approximately 12 weeks

How long should exercise programs for RTC-related pain last

A wide variety of resistance exercise parameters can be effective

What did the FITT Odyssey study find about resistance exercise programs?

Programs should consider loading principles, patient goals, expectations, and irritability

Why is an individualized exercise approach important

Use basic loading principles while considering patient goals and severity/irritability

What is the main takeaway from the FITT Odyssey study

it acts as the prime mover

What happens to the RTC when the shoulder is supported

The RTC acts primarily as a stabilizer

What happens to the RTC when the shoulder is unsupported?

The deltoid, latissimus dorsi, pectorals, and other larger muscles

Which larger muscles does the RTC help stabilize against

The scapular muscles also work during RTC exercises

What other muscles work during RTC exercises

Isometric exercises in the direction of symptoms

What type of exercise can be used for a highly irritable shoulder

Ice wrap, after checking for contraindications

What modality may help manage a highly irritable shoulder

Slowly, with the forearm supported in a pain-free range

How should unloaded shoulder flexion be performed

In side-lying, slide the supported forearm or use a sling

Give an example of supported unloaded shoulder flexion.

Slide the forearm forward on a surface angled to 45°

How can short-lever shoulder flexion be performed

Keep the movement slow and within a pain-free range

What is important when performing unloaded shoulder flexion?

Slowly, with the forearm supported in a pain-free range

How should unloaded shoulder external rotation be performed

They work together during ADLs, work, and sport activities

How do the LE and shoulder work together functionally?

It mimics function and may help unload the shoulder/RTC

Why incorporate LE movements into shoulder exercises

How the LE and shoulder work together during functional activities

What should you consider when training the shoulder kinetic chain

Generally favorable with an appropriate conservative program

What is the prognosis for degenerative, full-thickness RTC

Significant “lag signs.”

What clinical signs are common with massive RTC tears