PHYSIOTHERAPY INTERVENTION IN

ROTATOR CUFF TEAR

ORIGBEMISOYE A.O (B.PT UNIMED)

Department Of Physiotherapy,
Federal Medical Centre, Abeokuta.
6th September, 2023
 OUTLINE

 Introduction

 Anatomy

 Epidemiology

 Etiology

 Symptoms

 Diagnosis
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 OUTLINE CONTD’

 Differential diagnosis
 Outcome measures
 Medical/surgical Treatment

 Physiotherapy management
 Evidence based studies
 References
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 INTRODUCTION

 Rotator cuff tear is a micro/macro tear in the rotator cuff muscles or

tendons connecting the rotator cuff muscles to the humerus. It involves
one or more of the four tendons that constitute the rotator cuff.
 The Rotator Cuff (RC) is a common name for the group of 4 distinct
muscles and their tendons, which provide strength and stability during
motion to the shoulder complex.
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ANATOMY

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ANATOMY CONTD’
 ROTATOR CUFF CLASSIFICATIONS

There are a number of classification systems that are used to describe the
size, location and shape of rotator cuff tears which includes ;
 Cofield Classification of Rotator Cuff Tears (1982)
 Collins classification of rotator cuff tear
 Ellman and Gartsman Classification (Ellman 1993)

Most commonly, tears are described as partial or full-thickness.

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COFIELD CLASSIFICATION OF ROTATOR CUFF TEARS (1982)

 A commonly cited classification system for full- thickness rotator cuff

tears was developed by Cofield (1982). The classification system is:

1. Small tear: less than 1 cm

2. Medium tear: 1–3 cm

3. Large tear: 3–5 cm

4. Massive tear: greater than 5 cm.

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COFIELD CLASSIFICATION OF ROTATOR CUFF TEARS (1982)

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 COLLINS CLASSIFICATION OF ROTATOR CUFF TEAR

This is divided into 5 categories and it classifies based on location

 Type A: supraspinatus & superior subscapularis tears
 Type B: supraspinatus and entire subscapularis tears
 Type C: supraspinatus, superior subscapularis & infraspinatus tears
 Type D: supraspinatus & infraspinatus tears
 Type E: supraspinatus, infraspinatus & teres minor tear
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COLLINS CLASSIFICATION OF ROTATOR CUFF TEAR

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ELLMAN AND GARTSMAN CLASSIFICATION (ELLMAN 1993)

This classifies based on shape and is divided into 5

 Crescent

 Reverse L
 L shaped
 Trapezoidal

 Massive tear Full thickness rotator cuff tears

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ELLMAN AND GARTSMAN CLASSIFICATION (ELLMAN
1993)
 EPIDEMIOLOGY

 Rotator cuff tears are the leading cause of shoulder pain and
shoulder-related disability , the prevalence increases in age,
approximately 30% of adults age over 60 have a tear, and 62% of
adults over 80 have tears with incidence of partial-thickness rotator
cuff tears (PTRCTs) higher than full-thickness tears.

(Liu et al,2023) 14
 ETIOLOGY

Rotator cuff tears can be caused by severe traumatic injuries and atraumatic
injuries.
 Traumatic injury such as falling on an outstretched arm, an unexpected
force when pushing or pulling, or during shoulder dislocation.
 Atraumatic causes includes age-related degeneration, poor vascularity, and
excessive repetitive motions.

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 SYMPTOMS

Individuals with a rotator cuff tear may suffer from :

 Pain; it can be localized to anterior / lateral aspect of the shoulder, with
referred pain down the upper arm.
 Painful range of motion; Painful external rot / internal rot / abduction.
 Functional impairments
 weakness of involved muscle/ atrophy (Dang et al.,2018)
 DIAGNOSIS

1. Inspection ; muscle bulk, swelling etc.

2. Palpation; palpate the greater tubercle, lesser tubercle , acromion process.

3. Range of motion; AROM/PROM

4. Muscle power; abduction, external rot, internal rot

5. X- rays (to rule out OA, fracture, dislocation)

6. MRI(gold standard) and ultrasound (dynamic movement tears)

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MRI showing a rotator cuff tear 19
 DIAGNOSIS contd’

7. Specific tests for rotator cuff such as;

 Tests for subscapularis :

Lift-off test

Belly Press

Bear hug test

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 DIAGNOSIS contd’

 Tests for Supraspinatus and infraspinatus;

Jobe’s test/empty can test

Full can test

Drop arm test

 Test for Teres minor:

Hornblower’s Sign 21
TESTS FOR SUBSCAPULARIS

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TESTS FOR SUPRASPINATUS AND INFRASPINATUS

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TEST FOR TERES MINOR

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 DIFFERENTIAL DIAGNOSIS

 SLAP or other labral tears

 Subacromial impingement from bursitis, os acromiale, bone spurs
 Biceps tendinitis
 Cervical pathology (Cervical Radiculopathy, Cervical Spondylosis)
 Osteoarthritis (Acromioclavicular)
 Adhesive Capsulitis
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SHOULDER SPECIFIC TESTS IMAGING
CONDITIONS

SLAP or other labral tears Crank test, anterior slide test
Adhesive Capsulitis PROM assessment, capsular
pattern of restriction
Acromioclavicular Cross body adduction test, AC
Osteoarthritis shear test
MRI or MR athrography is
often required for definitive
diagnosis
Not necessary for diagnosis but
may be used to rule out other
conditions
X-ray

Biceps tendinitis Speed’s test, yegerson’s test MRI or ultrasound can help
confirm diagnosis

Subacromial impingement Neer’s test, Hawkins kennedy MRI or ultrasound for detailed
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syndrome test, painful arc test information
Xray used to rule out other
 OUTCOME MEASURES

 Constant-Murley Score (CMS)

 Shoulder Pain and Disability Index

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 MEDICAL/SURGICAL TREATMENT

 Medications such as NSAIDS, corticosteroids, subacromial lidocaine.

 Surgical repair; This includes open repair, arthroscopic repair , Mini-
Open repair.
 Some tears aren’t repairable due to their size/age of the tear ; reverse
shoulder replacement, tendon transfer or a debridement of scar tissue
without repair.
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 PHYSIOTHERAPY MANAGEMENT

Physiotherapy rehabilitation of non operative rotator cuff tears is divided

into;
 Acute phase ; Cryotherapy

Active assisted ROM exercises / isometric exercises

Codman exercises

kinesiotaping

Patients education 31
CODMAN EXERCISE

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KINESIOTAPING FOR ROTATOR CUFF TEAR

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 PHYSIOTHERAPY MANAGEMENT CONTD’

 Intermediate phase; Passive ROM exercises

Strengthening exercise using

TheraBand

Ultrasound/shock wave therapy

Continue acute phase exercises

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STRENGTHENING EXERCISE USING THERABAND

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 PHYSIOTHERAPY MANAGEMENT CONTD’

 Advanced strengthening phase ;

 Strengthening exercise using dumbbells
 Push ups
 Continue intermediate phase exercises

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USE OF DUMB BELL FOR STRENTHENING THE ROTATOR CUFF

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PHYSIOTHERAPY MANAGEMENT CONTD’

 Maintenance phase ; Continuation of shoulder exercises in

intermediate and advanced strengthening phase.
 Exercises should be done at least thrice a week
 Patient can return back to activities

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POST OPERATIVE PHYSIOTHERAPY MANAGEMENT

 Post operative phase; 6 weeks of intermittent sling use (no reaching or

lifting or actively elevating arm).
 AROM/PROM can be done
 Moderate Strengthening exercises begins at 4 months followed by another
3 -4 months for advance strengthening exercises
 Prognosis takes 9 months to 1 year to regain full strength.
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 EVIDENCE BASED STUDIES

 The inclusion of kinesiotaping in a physiotherapy program significantly

reduces subjectively perceived pain in the shoulder joint area, helps to
significantly increase the range of motion of arm flexion and show
significantly higher isometric arm abductor muscle strength in
individuals after tear of the rotator cuff.
(Bubelis et al.,2020)

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 EVIDENCE BASED STUDIES CONTD’

 This study shows that both shockwave and ultrasound therapies

were found to be effective in the treatment of rotator cuff tear
although shockwave therapy was superior to the ultrasound
therapy at 4 week post-treatment.

(Dedes et al.,2019)

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 EVIDENCE BASED STUDIES CONTD’

 This study shows that Exercise-based rehabilitation improves outcomes

for individuals with a range of Rotator cuff related disabilities.

(Boland et al.,2021)

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 CONCLUSION

 Physiotherapists play a vital role in non operative , pre

and post operative rehabilitation of rotator cuff tears in
relieving pain, increasing ROM/muscle power and
regaining functional activities.

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 REFERENCES

 Arosi M, Galeoto G, Gennaro SD, Berardi A, Valente D, Servadio A. Transcultural reliability and validity of an
Italian language version of the constant–Murley score. Journal of Orthopaedics, Trauma and Rehabilitation.
2020 Dec;27(2):186-91.

 Boland, K., Smith, C., Bond, H., Briggs, S., & Walton, J. (2021). Current concepts in the rehabilitation of rotator
cuff related disorders. Journal of clinical orthopaedics and trauma, 18, 13-19.

 Bubelis, j., & masiulytė, i. (2020). effect of kinesiology taping after rotator cuff tear. professional studies: theory
and practice, 22(7), 20-26.

 Codding JL, Keener JD. Natural History of Degenerative Rotator Cuff Tears. Curr Rev Musculoskelet Med.
2018 Mar;11(1):77-85.
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 REFERENCES CONTD’

 Dang A, Davies M. Rotator Cuff Disease: Treatment Options and Considerations. Sports Med

Arthrosc Rev. 2018 Sep;26(3):129-133.

 Dang A, Davies M. Rotator Cuff Disease: Treatment Options and Considerations. Sports Med

Arthrosc Rev. 2018 Sep;26(3):129-133.

 Dedes, V., Tzirogiannis, K., Polikandrioti, M., Dede, A. M., Nikolaidis, C., Mitseas, A., &

Panoutsopoulos, G. I. (2019). Comparison of radial extracorporeal shockwave therapy versus

ultrasound therapy in the treatment of rotator cuff tendinopathy. Folia medica, 61(4), 612-619.
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 REFERENCES CONTD’

 Fatima, A., Ahmad, A., Gilani, S. A., Darain, H., Kazmi, S., & Hanif, K. (2022). Effects of High-Energy
Extracorporeal Shockwave Therapy on Pain, Functional Disability, Quality of Life, and Ultrasonographic
Changes in Patients with Calcified Rotator Cuff Tendinopathy. BioMed Research International, 2022.

 Gray,H. Anatomy of the Human Body. Philadelphia: Lea and Febiger, 1918; Bartleby.com, 2000

 Khatri C, Ahmed I, Parsons H, Smith NA, Lawrence TM, Modi CS, Drew SJ, Bhabra G, Parsons NR,
Underwood M, Metcalfe AJ. The Natural History of Full-Thickness Rotator Cuff Tears in Randomized
Controlled Trials: A Systematic Review and Meta-analysis. Am J Sports Med. 2019 Jun;47(7):1734-1743.

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 REFERENCES CONTD’

 Ladermann A, Denard PJ,Collin P . Massive rotator cuff tears: definition and treatment. International
orthopaedics. 2015; 39(12): 1-12. (2C)

 Lazarides AL, Alentorn-Geli E, Choi JH, Stuart JJ, Lo IK, Garrigues GE, Taylor DC. Rotator cuff tears in
young patients: a different disease than rotator cuff tears in elderly patients. J Shoulder Elbow Surg. 2015
Nov;24(11):1834-43.

 Liu, J., Dai, S., Deng, H., Qiu, D., Liu, L., Li, M., ... & Tao, J. (2023). Evaluation of the prognostic value of
the anatomical characteristics of the bony structures in the shoulder in bursal-sided partial-thickness rotator
cuff tears. Frontiers in Public Health, 11, 1189003.

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 REFERENCES CONTD’

 May T, Garmel GM. Rotator Cuff Injury. [Updated 2023 Jun 26]. In: StatPearls [Internet]. Treasure Island
(FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK547664/

 May T, Garmel GM. Rotator Cuff Injury. [Updated 2023 Jun 26]. In: StatPearls [Internet]. Treasure Island
(FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK547664/

 Teruhisa, M. Chapter: Rotator Cuff Pathology in Textbook of Shoulder Surgery. Jan 2019. doi: 10.1007/978-
3-319-70099-1_8.

 Wilk, K. E., Arrigo, C. A., Colberg, R., & Dugas, J. R. (2019). Nonoperative Care of Rotator Cuff Disorders:
Physical Therapy, Modalities, and Injectables. Disorders of the Rotator Cuff and Biceps Tendon E-Book: The
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