An Evidence-Based Physiotherapy Case study : Assessment and Management of a Patient with Rotator Cuff Injury
A 42-year-old female presented to primary care with gradual onset of left shoulder pain. The patient reported pain ongoing from a couple of months as she used crutches bilateral. The patient reported pain gradually worsening with increase in pain and reduction in range of motion (ROM) and it's getting difficult to use crutches also affecting her activities of daily living (ADLs). The patient denied any trauma or injury to her shoulder. She reported symptoms persisting throughout the day and affecting her sleep when lying on the same side. She reported constant sharp pain but certain directions made the pain worse. She reported difficulty with overhead activities and carrying objects. She is not working currently due to her ongoing medical conditions. She reported taking over-the-counter medication for pain but they are not helping her much. She had bilateral Xray- Rt shoulder having early degenerative changes while left shoulder Xray was normal.
Past medical history :
The patient had a past medical history of lumbar degenerative disc disease. She had bilateral foot drop with no known cause yet after all the scans and specialist review which has been treated conservatively with orthotics and crutches bilateral to support her with walking. She had Known OA knee bilateral. She also had Hx of right shoulder dislocation that she told was alright- reported no recent episode. She also had a past medical history of epilepsy with ongoing management and is under control. She was non-diabetic with no thyroid-related problems. The patient on presentation was systemically well and showed no signs for infection, fracture, cancer. She had no sudden or abnormal weight loss, change in appetite, fever, fatigue, breathing problems, problem with urination. She reported no red flags or neurological signs. 5D’s and 3N's are absent. She consumes 1 or 2 units of alcohol a month. She is a non-smoker.
The patient walked into the room with crutches bilateral and wearing orthotics for foot drop bilateral. The sitting and standing posture was normal, good posture. On assessment no redness, warmth or swelling noted, no bruise or deformity noted. There was marked tenderness on the anterior aspect of the left shoulder joint over the insertion of rotator cuff tendon and scapular region on the left side predominantly supraspinatus and infraspinatus. There was limited AROM in all planes of the shoulder, shoulder flexion by 50%, shoulder extension by 40%, shoulder abduction by 60%, shoulder internal rotation by 70%, shoulder external rotation by 40%. Special tests completed including cross arm test, Speed’s and Yergason’s tests, Hawkin kennedy test, Neer impingement test, spurling test, upper limb tension testing were all negative. While Empty can test, resisted external rotation test, shoulder lag sign and painful arc sign was positive. Cervical and thoracic spine ROM were reviewed and cleared with no issues.
Rotator Cuff tendinopathy
Differential diagnosis :
The following differential diagnoses were considered
• Shoulder Osteoarthritis
• Bicipital tendinopathy
• Shoulder Impingement
• Acromioclavicular joint dysfunction
• Adhesive Capsulitis
• Instability or dislocations
• Cervical radiculopathy
X-ray of the shoulder was done already to rule out joint and bone pathology as the patient had Hx of arthritis but her x-ray left shoulder came out to be normal.
In the current patient scenario the management plan that was discussed is as below
• Patient education and advice about condition- education regarding the concerns about cause of pain and expectation of treatment.
• Education and advice about exercises- exercises sheet given and demonstrated-mobility and isometric strengthening exercises were provided to be done within limits of pain once on proper pain management.
• Education and advice about ice/heat for 15 to 20 mint 3 times a day or as appropriate.
• Education and advice about triggers and preventions.
• Safety netting done-Education and advice about red flags and when to seek emergency medical help
• Discussed with the patient about the medication review from the patient’s General Practitioner so her pain is adequately controlled to facilitate daily function in the interim but patient declined any analgesia.
• Discussion about Corticosteroid Injection and scan was done but the patient was happy to manage with Conservative management and reported if she wouldn’t be able to manage then she would like to try Corticosteroid Injection. For this purpose a follow up review was booked after 4 weeks and in that review the patient requested to try CSI.
• A referral was made for Corticosteroid Injection following review.
Rotator cuff injury ranges from tendinopathies to tears that usually result from trauma that could be either micro-trauma or macro-trauma. Micro-trauma leads to tendon degeneration with inadequate healing that sometimes leads to degenerative tears. Macro-trauma results in acute tears and is more common in younger generations (May et al. 2022).The rotator cuff is a group of four muscles that originate from the scapula and insert into the humeral head, superiorly increasing the stability of the shoulder joint. The subscapularis is the largest and strongest muscle among the rotator cuff, it attaches the lesser tubercle of the humerus and is the internal rotator. The supraspinatus attaches with the greater tubercle of the humerus and functions as abductor for 0-30 degree abduction movement. The infraspinatus muscle also has an attachment onto the greater tubercle and its primary function is external rotation. The teres minor muscle has an attachment onto the greater tuberosity and functions as an external rotator (Pandey et al. 2015).
Rotator cuff related atraumatic and traumatic problems ranging from tendinopathy to tears is one of the most common musculoskeletal disorders in the young and older population. Rotator cuff tears are highly prevalent ranging from 22% to 62% depending on age factor (teunis et al. 2014).The condition has a high impact on the ADL's, quality of life and can be associated to chronic pain, weakness and dysfunction of upper extremity (Lowe et al. 2014).
Rotator cuff injury runs the full spectrum from injury to tendinopathy to partial tears, and finally complete tears. The associated risk factors are:
-Age; Age is the most common factor for rotator cuff related pathologies as significant studies shows that rotator cuff non-traumatic involves age related degenerative process that is progressive (Dang et al. 2018)
-Smoking; systematic review demonstrated increased rate of rotator cuff involvement in smokers (Sambandam et al. 2015).
-Family History; systematic review demonstrated increased likelihood of rotator cuff involvement between individuals with RC disease up to third cousins (Sambandam et al. 2015).
-Poor Posture; rotator cuff tears were present in 65.8% of patients with kyphotic-lordotic postures, 54.3% with flat-back postures, and 48.9% with sway-back postures; tears were present in only 2.9% of patients with ideal alignment (Sambandam et al. 2015).
-Trauma, Hypercholesterolemia, Occupation or activities involving overhead activities; studies suggest evidence for increased rotator cuff injury chances (Moulton et al. 2016)
Physical examination and differential diagnoses:
Rotator cuff diagnosis is best made following exclusion of other painful shoulder pathologies (Pandey et al. 2017). Many shoulder conditions have alike sources and present features of limited ROM and pain. There can be various pathologies in a single joint (Neviaser et al. 1945). It is therefore important to distinguish between the pathologies and make an appropriate differential diagnosis. The history of rotator cuff disease all starts with pain but the patient usually present when they can no longer be able to carry on their activities ranging from sports to ADL’s. Moreover, patient will report increase in intensity of pain with overhead activities and carrying activities. (May et al. 2022). On physical examination and palpation tenderness can be felt along the insertion of the supraspinatus, infraspinatus, and teres minor muscles in the greater/lesser tuberosity (Hsu et al. 2015). Rotator cuff pathology will cause pain in the range of motion this is commonly known as painful arc (May et al 2022). Furthermore, special test can be use but there is limited evidence supporting specificity and sensitivity of the tests (Hegedus et al. 2012). However, The Jobe or empty can test and the full can test could be used to evaluate supraspinatus tendinopathy as they have high sensitivity (Sambandam et al. 2015). Resisted external rotation is used to evaluate for infraspinatus/teres minor muscle involvement while for subscapularis belly press test can be performed and for the test to be positive there should pain or weakness when performing these tests (Sambandam et al. 2015).
Blood tests: Blood investigations are not generally necessary with diagnosis of rotator cuff pathology. However, a full blood count, ESR and CK can be done to rule out inflammatory pathology and Rheumatoid factor if there is a multi-joint involvement as inflammatory and auto-immune pathologies are considered a risk factor.
Imaging: When it comes to shoulder imaging, there are three options: plain radiography, ultrasound, and MRI (May et al. 2022). In the current patient scenario, the X-ray imaging did not find any abnormality. Ultrasound and MRI could be used for this patient as both are considered excellent tools for the evaluation of rotator cuff tears and tendinopathies. In this case scenario patient wasn’t much keen for imaging or scans and was happy to manage conservatively so no further scan was warranted.
The management of a rotator cuff tear is multifaceted. Management as per the National Institute of Health and Care (NICE) guidance (2017) was reviewed and applied. NICE (2017) advises the importance of educating the patient about the condition and expected timeframe of recovery (NICE guidelines 2017).
Conservative management includes analgesia and anti-inflammatory medications, physical therapy, activity modification and subacromial injections of local anaesthetic and/or steroid (Pandey et al. 2015). During the painful phase, pain-relieving and anti-inflammatory medications may be advised along with ice therapy and physiotherapy management (Schmidt et al. 2015). Physiotherapy is the backbone of conservative management of rotator cuff related injuries (Kuhn 2019 ; Lin et al. 2019) Moreover, In a randomized controlled trial on effectiveness of exercise program by (Ribeiro et al. 2020) study have some positive results for exercises in management of rotator cuff injury (Ribeiro et al. 2020). Corticosteroid injections into the joint may also be offered if the pain continues and that was done in this case scenario as evidence suggest that corticosteroid is effective for conservative management of rotator cuff injuries. A systematic review by Giovannetti de Sanctis 2020 concluded that Corticosteroids Injection (CSI) are a useful and effective treatment option for rotator cuff injuries (Giovannetti de Sanctis et al 2020).
Secondary Care Referral :
Referral to secondary care is considered if pain is causing severe restriction in activities of daily living, if there is partial or full thickness tears and there has been no benefit from conservative management. Repairs of a torn rotator cuff has been considered to give predictable improvement in pain and function, with also having good overall patient satisfaction (Oh et al 2007). The results of open, mini-open and arthroscopic rotator cuff repair are considered to be having positive and favorable results but also sometimes results in post-operative complication (Mansat et al. 1997).
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