Musculoskeletal Monday: The Shoulder

There has been an increase in rotator cuff surgical procedures performed after surgical consultation in patients presenting with shoulder pain. This has resulted in a 238% increase in the number of rotator cuff repairs in the last decade! Although large tears have been shown to benefit positively from surgery, it is important to note that there is evidence that physical therapy can have equal outcomes after 5 years. Anatomy Doesn’t Lie

Lewis (2009) in his article investigating RC tendoinopathy reported the supraspinatus, infraspinatus, teres minor and subscapularis tendons “interdigitate and fuse together before inserting into the humeral tuberosities”. He highlights that this will assist efficiency in the distribution of forces and reduce intratendinous stress with extremes of movement. He also notes that the RC is comprised of “six to nine structurally independent parallel fascicles”. His research concludes that the supraspinatus is not the only muscle to fire prior to movement of the shoulder, but the rotator cuff muscles contract in a “direction specific” pattern.

The Body Heals in a Predictable Manner

When considering tendon repair it is important to understand its response to loading. With inappropriate loading, (Benjamin et al., 2006) demonstrated delayed maturation of the supraspinatus enthesis during postnatal development in mice. Also, mice with reduced muscle loading demonstrated less mineral deposition, impaired fibrochondrocyte and matrix organization, and inferior mechanical properties at later time points (Thomopoulos et al., 2010). These studies continue to stress the importance of appropriate tendon loading in the rehabilitation process. (refer to the work of Jill Cook)

Pain Is In the Brain

According to Lewis presence of a tear/tissue damage does not correlate with pain. In fact, there is a better correlation with age and tissue damage then whether you have pain or not in your shoulder. (Lewis et al. 2015)

We Are Prone Clinical Reasoning Errors During a Busy Clinic Day

Mohamadi A, et al. (2017) questions the use of corticosteroid injections for rotator cuff tendonopathy. They discovered it only provided transient pain relief compared to a placebo group. Injections are expensive, can accelerate degeneration and a change in intervention is necessary. Let’s consider the routine PT interventions we routinely utilize as PT and always question what we do.

Treat the Person and You Win Every Time