Roadblocks to Rotator Cuff Rehab and How to Achieve Optimal Outcomes
By Katlyn Jolly, PT, DPT, GCS
Physical Therapist
We have all been there: treating a patient with a rotator cuff injury or surgical repair that just isn’t improving the way that it should be. There are so many variables that can complicate a typical progression of shoulder pathology. Whether it be pain, fear, comorbidities, underlying pathology, or poor motivation and participation in a home exercise program, all are equally important in achieving functional goals.
Let’s break down the common signs and symptoms that often create roadblocks to successful rotator cuff rehab. With those in mind, we can then map out how to achieve optimal outcomes.
How to Identify and Progress Care for Common Rotator Cuff Deviations
For each pathology, there are a few key indicators that will assist you in determining the cause of delayed progress and will help guide you toward an appropriate treatment plan. Luckily, the treatment progression for these conditions is similar, especially in the later phases of rehabilitation. In the early phases, there are some differences that need to be addressed based on variations found during your skilled assessment. These are some of the more common deviations that can hinder the achievement of functional independence.
Instability
Glenohumeral instability is best identified with manual palpation, joint play resulting in excessive motion in one or multiple directions. There is not always pain involved in this pathology, however, poor muscle facilitation, motor control, and joint mechanics can potentially cause impingement or dislocation that will result in pain and poor outcomes.
How to Progress: Ideally with any instability in the shoulder, you will want to improve the positioning and control within the joint. Isometric holds and eccentric intervention will improve motor control which can be progressed with resistance or static hold on compliant surfaces, balls, etc. Strengthening of the rotator cuff and other scapular stabilizers is key to improve the ability to maintain appropriate alignment.
Scapular Mobility
Just like instability, scapular immobility is easiest to identify with manual palpation, joint play, and visual observation of motion. With all shoulder motion, there is a concurrent scapular motion. With shoulder flexion, abduction, adduction, and extension, you will have rotation in the scapula as well as protraction/retraction, elevation, and depression with other actions. If there is any irregularity in this motion it will lead to pain, impingement, and limitations in strength and range of motion. Another condition to consider in this category is scapular winging which is caused by weakness in scapular musculature. This is identified by a visual “wing” occurring at the scapula during movement of the glenohumeral joint. Winging may or may not be painful but is indicative of poor muscular balance in the joint overall.
How to Progress: If you determine that there are irregular movement patterns, an ideal place to start would be with manual therapy, stretching, and distraction of the scapula. After passive movement is improved, proceed with mobilization with movement, where the therapist provides tactile cueing at the scapula for the appropriate pattern while the patient moves the upper extremity. Once the patient is able to perform AROM with appropriate scapular motion, progression of strengthening intervention is indicated.
Postural Abnormalities
This deviation is possibly more obvious than the others with a visual assessment of the patient. However, with any UE pathology, a postural assessment is imperative whether the severity is obvious or not. Along with visual observation, postural deficits may be noted by shoulder hikes with active motion, muscle tension, tenderness in the upper back, cervical or chest musculature, and ROM restrictions. This can affect shoulder progression due to poor joint alignment, causing poor tracking of joints and inappropriate muscle recruitment due to tension and ROM limitation.
How to Progress: The treatment for this deviation is very similar to cervical pathology. Initially, you will want to address any muscular tension in the neck, upper back, shoulders, and chest to improve the ability to achieve and maintain an appropriate upright posture. More common postural deviations include forward head, rounded shoulders, and thoracic kyphosis all leading to tight pecs, internally rotated shoulders, tension in posterior neck muscles, and weakness in upper back musculature.
Bicep Impingement
An impingement pathology will typically present with pain in the anterior shoulder, down into the biceps muscle with shoulder flexion, abduction, and IR. It can be caused by instability in the glenohumeral joint, forward shoulders/head, excess IR of the shoulder. This pathology will limit the progression of treatment due to increased pain in the mentioned planes, and inappropriate muscle recruitment as well as increased stress on accessory muscles.
How to Progress: The key to treating biceps impingement is to improve joint positioning and stability. As stated before, you will likely note postural deviations such as forward head, rounded, internally rotated shoulders, so this needs to be addressed first. External rotation range of motion and strength intervention as well as shoulder mobility in all planes with appropriate rotation at the shoulder joint, generally meaning you will want the patient to be in a “thumbs up” or “full can” position. Progressive concentric strengthening in all planes is important along with isometric and eccentric intervention to improve joint stability and motor control. Another option to consider with this pathology is the use of manual distraction of the shoulder as well as stretching to improve mechanics and muscle tension.
Cervical Radiculopathy
This pathology is potentially the most difficult to identify as it may present as any of the other deviations previously mentioned. Many will have pain or ROM limitation with cervical motion which may or may not refer pain into the shoulder joint or down the affected upper extremity. Headaches are another potential sign that may be overlooked as cervical pathology. It is not hard to imagine that pain and motion restriction from a shoulder injury will lead to muscle tension in the cervical region. However, if there was dysfunction in the region prior to the injury or surgery these issues will likely be exacerbated.
How to Progress: Stretching, Neural Glides, and postural exercises will be imperative to addressing any radiculopathy noted. Starting with stretching and neural glides will assist with pain and range of motion deficits. Once muscle tension is improved, it will be easier for the patient to perform postural exercises appropriately and effectively without pain.
Adhesive Capsulitis
Adhesive capsulitis typically occurs due to an injury, pain from arthritis, or surgery that leads to prolonged immobilization of the arm. It is difficult to identify this pathology in the beginning stages, especially if it is occurring post-injury or surgery because the signs include pain with movement and aching at rest. However, pain and range of motion continue to worsen over time with continued treatment. In general, the most limited motion will be external rotation, but shoulder flexion and internal rotation will be greatly affected as well. In addition, pain at rest, especially at night, is a very strong indication that “freezing” is occurring. Unfortunately, this condition can last for a year or more, however, there can be recovery of range, strength, and function with appropriate treatment.
How to Progress: Rehab of adhesive capsulitis is an extended process and occurs in multiple phases depending on what stage of this condition the patient is in. In the first two stages, the main goal with treatment will be to maintain what motion the patient has via manual therapy or PROM/AROM, aggressive stretching will likely increase pain, so you will want to avoid that. You will also want to make sure you educate your patient on pain management modalities as well as HEP of gentle stretching and AROM. During the “frozen” stage, manual therapy, increased intensity of stretching and some strengthening are appropriate to encourage the joint to loosen and regain mobility. Lastly, during the fourth stage, you will continue to progress the range of motion and strength to return to a prior level of function. As mentioned earlier, this condition could last for up to a year, therefore, a HEP and education on pain management are imperative for this patient’s success.
After addressing any of these deviations from the typical plan of care, you will be able to continue to progress your patient’s range of motion and strength with progressive strengthening intervention. PNF exercises are a great way to improve strength with functional movement patterns as well as the use of Bosu balls or other compliant surfaces to improve the strength and stability of the shoulder joint.
The ideas are endless when attempting to improve your patient’s functional strength, just remember to keep it relevant to the patient and their goals.
Pain with Shoulder Rehab
Pain is likely going to be a part of the rehabilitation process whether the progression is typical or not. The key is to determine what normal pain is, what is causing the pain and if there are other factors affecting the severity of the pain. High numbers of comorbidities, mental health issues, low self-reported health status, and a low expectation of outcomes can all be indicators of a cognitive, emotional driver of pain. These individuals may be more apt to shy away from progressing intervention due to a fear of increased pain, beginning a negative cycle of avoidance and poor outcomes.
As a therapist, there are several ways you can assist your patient with getting out of this cycle. While we are not mental health professionals, we are able to educate our patients on the cognitive drivers of pain. Through education and discussion with our patients, we may be able to break down negative emotions and change the patient’s frame of thinking to encourage mobility and decrease fear. We can also provide education on stress management as well as pain management. Pain causes stress and stress will increase tension, decrease sleep quality and in turn increase pain and decrease motivation. Other strategies that can be utilized are a focus on breathing, guided imagery, and progressive muscle relaxation. If you are unfamiliar with these techniques, there are many resources like our Shoulder Rehabilitation Tips available to aid in instruction during treatment.
As always, if you do not feel comfortable addressing these issues or feel your patient’s needs fall outside of your scope, you can refer to a counselor or other mental health professional that will be able to work alongside you for total wellness.
Choosing the Right Rotator Cuff Interventions for Your Patient
Along with these techniques and treatment strategies, an individualized and reasonable home exercise program will be required for success. Based on the patient’s pain, activity, strength, and motivation levels, try to pick two to three interventions that will best serve patient progress. You want to refrain from picking an intervention that will greatly increase pain as it is likely that the patient will stop doing the HEP altogether. Starting with passive stretching with a cane or broomstick as well as AROM are excellent choices with progression to isometrics and resisted intervention as appropriate.
As with any plan of care, some patients will not achieve optimal outcomes for a variety of reasons. However, with these assessment and treatment strategies, our ability to identify barriers and optimize the individualization of intervention will only improve outcomes and the quality of life of our patients.