Rotator Cuff Impingement Physiotherapy

Physiotherapy treatment for Rotator Cuff Impingement

The shoulder joint is a ball and socket joint. It is formed from a ball on the top of your arm bone (the humerus) and a shallow socket. Above the shoulder joint is a ligament that is attached to a bony prominence (acromion). This forms an arch. The area between the top of the humerus and the arch is known as the sub-acromial space.

When you move your shoulder you control the position of the joint by using a group of muscles and tendons known as the Rotator Cuff. The Rotator Cuff is very important in stabilising the shoulder joint. The four muscles of the rotator cuff attach from the shoulder blade (scapula) onto the humerus. They blend together to form a cuff passing through the sub-acromial space. One tendon in particular - the supraspinatus sits in the middle of the sub-acromial space. A small fluid lining (bursa) cushions the tendon from the roof of the arch.

When you move your arm away from your side, the Rotator Cuff works to keep the humerus centred in its socket. At heights above 90°, the sub-acromial space is narrowed

The Rotator Cuff is vulnerable to tendon damage or degeneration, particularly affecting the supraspinatus tendon in the subacromial space. As you get older the muscles and tendons degenerate and become thinner. The tendons are also worn down by the acromion bone which rubs on the Rotator Cuff. With years of repeated rubbing the muscle and its tendon can eventually lead to problems ranging from mild inflammation to full thickness tears. Sometimes there is a precipitating event e.g. overuse of the shoulder such as tennis, DIY, hedge trimming or carrying luggage.

Once the tendon becomes affected it gets inflamed and swells, filling more of the sub-acromial space, which can cause the tendon and bursa to become pinched. This is known as Rotator Cuff impingement. Tears in the Rotator Cuff tendons can occur from sudden injuries such as falling, but more commonly they develop gradually as a result of wear and tear on the tendon. This is partly age related, but may result from longstanding impingement.

Impingement is the most common shoulder problem. 20% of people will have symptoms at some time in their lives.

The main complaint is pain, it is often felt on the outside and front of the upper arm. A classic presentation is of a pain on movement when the arm is lifted out to the side, around shoulder height. When the inflammation is severe, you may experience pain at night especially when trying to lie on it, and when your arm is resting.

Helpful Investigations may include X-ray, Ultrasound or MRI scan. However this not always necessary.

Physiotherapy

Physiotherapy is very important. This condition can be completely curable with correct non operative treatment.

Physiotherapy treatment is aimed at determining how and why the tendons have become swollen and inflamed, and this may be because of the tightness or weakness of other muscles and structures around the shoulder area, which cause extra strain to be placed on the rotator cuff. During your initial consultation, a complete assessment of your shoulder will be undertaken to accurately diagnose the problem, and from this an individual treatment programme will be designed. The swelling of the tendons will be addressed with ice and or ultrasound and with rotator cuff exercises. Other treatment may include postural exercises, stretches for your shoulder, activity modification, mobilisations to try to increase the sub-acromial space, taping and ergonomic assessment. Once the swelling has subsided and the range of movement returned to normal then the exercises progress to strengthening of the cuff muscles and the other muscles around the shoulder ensuring an adequate pattern of movement is occurring.

Other options

Unfortunately, if the damage is severe some Rotator Cuff impingements may not respond to conservative treatment and may require more invasive treatment. Injections are given into the sub-acromial space and are usually a mixture of local anaesthetic and steroid. It acts on both acute and chronic phases of inflammation to reduce both tissue swelling and subsequent scar formation. Cortisone injections make up a very important part of the treatment of shoulder injuries in combination with an active rehabilitation program they may significantly reduced the need for surgery in shoulder impingement syndrome.

In some cases if your symptoms do not settle an operation may be suggested. If shoulder impingement fails to improve over 3 to 6 months then surgery may be required. The operation done most frequently is an Arthroscopic Acromioplasty. This is usually performed arthroscopically (keyhole or minimally invasive surgery) and is aimed at increasing the size of the sub-acromial space.