They came in frustrated, it was a two-year ordeal, I had never seen this patient before, but they clearly needed some help.
“Jamie, for the past two years, I haven’t been able to lift my arm past this point”!
They raised their right arm to about 90° abduction. When asked I why they explained there had been a previous surgery to repair a torn rotator cuff. The frustration had more to do with life circumstances than just the limited range of motion.
Two years ago a surgery had taken place to repair this torn rotator cuff, but more concerning was the altered life because of it.
This person had a job they loved but were unable to do anymore due to the surgery.
You see, the job required holding their arms up for extended periods, so they had to quit that job in favour of a desk job. The worst part (other than the limited range of motion) was they HATED the new job. Sitting at a desk doing computer work was not what they had in mind as a satisfying career.
When asked why they weren’t doing the job they loved the response was bone-chilling to hear as a healthcare practitioner:
“My surgeon said I could never go back to that job, and the other therapist I went to told me that if I went back to my job, the surgery I just had would pale in comparison to the surgery I would need if I continued”.
I hope my face didn’t reflect what was happening in my head after hearing this, otherwise, the patient probably would have walked out the door. How could two other healthcare professionals say this to a patient!?
Reliability Of Orthopedic Tests
The rotator cuff consists of the “SITS” muscles: supraspinatus, infraspinatus, teres minor, and subscapularis which all work together to produce movement and stability of the glenohumeral joint.
While rotator cuff tears are quite common, it doesn’t always mean the person is going to experience pain as this generally depends on the degree of the tear. A partial tear is when one of the muscles is frayed or damaged, whereas a full tear indicates the muscle is completely torn, or the tendon has pulled off the bone.
When we look at some of the orthopedic tests recommended to use clinically as a test for rotator cuff tears, it is important to look at how accurate they are between sensitivity and specificity. Sensitivity is the ability to detect that something is actually happening (in this case it could just be a sore shoulder), whereas specificity is used as a true representation of the condition you are trying to test for (in this case specific to a rotator cuff tear).
There are three orthopedic tests generally used, so we will look at two of them here.
The drop arm test has a sensitivity of 73% and a specificity of 77% and also has a 26% chance of coming up with a false positive and a 4% chance of a false negative. This tells us this test isn’t likely to give us an accurate chance at predicting a full-thickness tear of supraspinatus or infraspinatus.
The external rotation lag test has a sensitivity of 46% and specificity of 94% which tells us that we have a good chance of a positive test indicating full-thickness tears in supraspinatus and infraspinatus.
It has also been suggested that the subacromial bursa contains a high amount of nociceptors and doing the orthopedic tests we talked about could place pressure on the bursa, in turn recreating the pain.
While we can still use these tests to give us an idea what’s going on with a patients shoulder there is no guarantee these tests will conclusively tell us there is a full rotator cuff tear. While it can be more accurate to use imaging to see the difference between partial and full-thickness tears, there is poor relation between imaging and clinical signs.
Using Education To Help
Time and again we are told biopsychosocial aspects are crucial to treating our patients, and this pathology is no different. Although the “bio” may be less important as we think. When looking at the movement of the glenohumeral joint in the scapular plane between symptomatic and asymptomatic people with tears, pain-free movement was still possible even with abnormal kinematics.
So this shows us that abnormal biomechanics alone are not the only reason for painful symptoms.
One study showed that 55% of rotator cuff tears are asymptomatic, had more to do with age, and didn’t correlate with pain. In fact, one study showed just how much age is a part of the degeneration and should be considered normal with age. They found:
- Age 50-59, 13% had tears.
- Age 60-69, 20% had tears.
- Age 70-79, 30% had tears.
- Those aged over 80, 51% had tears.
While asymptomatic tears can become painful, studies show it is probably more important to take care of pain management with these patients in order to maintain functionality, rather than being concerned about the tear itself. In fact, one study points out that our treatment should centre around clinical findings and not imaging results.
So, if we understand how pain management should be our primary concern, we have a massive opportunity to make a difference for these patients.
How many people over the years have come into your clinic either waiting on surgery or at least contemplating it for their rotator cuff issue? If we can educate them how this is usually an age-related issue (unless there was a traumatic injury), reduce pain, and increase their functionality maybe we can negate a surgery.
While surgery is usually recommended for full-thickness tears or more extreme disability, conservative measures can and should be recommended before going under the knife. The person I spoke about at the beginning of this post was obviously post-surgery for two years but still had limited mobility and functionality. This was certainly a case where biopsychosocial factors were a major influence. The person was told by two practitioners they would never get better and their shoulder would always be damaged, to the point they had to change careers. Once we actually got the shoulder moving, used a little education, and were told they were going to be okay…that shoulder went from 90° to 160° abduction. It was also followed up with the statement: “how the hell did you do that!?” It’s amazing how giving a patient a little confidence can make a massive difference. In the coming weeks, we will go over some movement techniques that can help with this.