It was the first time I’d seen this patient.
When I asked what brought them in they showed me how they could only get their shoulder to about 90* abduction and it had been this way for two years.
Digging a little deeper to find out what happened, they explained they had a rotator cuff surgery due to a tear.
This was life-changing for them.
Not only could they not move their shoulder correctly, but it also resulted in a change from a job they loved to one they hated due to the lack of mobility.
So, was surgery the best approach in this case?
While I’ll never know the true answer to this, I can look at the most up-to-date research and attempt to make an educated guess ( and I think I know where this is going).
Rotator Cuff Disease
A recent paper¹ came out on this topic, and I’ll admit I was surprised to see them refer to this condition as a “disease.”
However, when we look at the dictionary definition of disease² it states:
“disease, any harmful deviation from the normal structural or functional state of an organism, generally associated with certain signs and symptoms and differing in nature from physical injury.”
So, in this case, the limited function of the shoulder has deviated from its normal functional or structural state, so I guess it can be classified as such. But, I would never want to communicate it to a patient that way as it suggests a more damning diagnosis than it is.
Now, in order to define this “disease” they put some classification around it which includes:
- Pain that is worse at night
- Pain exacerbated by specific movements which included overhead activities
- Loss of function and weakness
In addition to the above rotator cuff disease was basically used as an umbrella term to classify issues with the rotator cuff regardless of the cause and would include:
- Positive painful arc test (physiotutors gives a great example of how to perform the test HERE)
- Positive external rotation resistance test
These tests together were the most accurate diagnosis unless it was a full-thickness tear. In this case, the use of a positive lag test was most appropriate. Here is one example of how to do the test, but this can also be done with the shoulder at 90′ rotation, called the “drop arm sign.”
It is also worth noting that the review found an increased prevalence of this with age, especially in those people who performed repeated overhead activities.
What Do We Do For Treatment?
So, this paper was a BIG review; there were 3620 participants in 60 different trials with a median age of 51. 52% of these were women and the average duration of symptoms was 11 months.
What they found was that people were rarely given just one intervention.
This makes it really difficult to say if just manual therapy, just exercise, or a single other intervention was the best approach as there was always a combination of things offered.
The average duration of therapy offered was six weeks. When they looked at what manual therapy was offered, this included:
- Joint mobilizations
- Spinal or neck mobilizations
- PNF stretching
- Dicutaneous Fibrosis (I had to google this as I’ve never heard of it, but it’s IASTM with a stainless steel hook)
Exercise interventions included:
- Progressive resistance
- Pendulum exercises
- Eccentric training
- Postural training
- Motor control
- Proprioceptive training
- Self-mobilization (yay for self-care)
- Dynamic humeral centring (movement aimed at humeral head depression)
Interestingly, they compared the above to some other trials that included things like steroid injection, NSAIDs, surgery, naturopathic care, and a few other interventions.
When it was all said and done, they compared what was seen as high-quality evidence to low-quality evidence.
Under the umbrella of “high quality evidence,” their findings showed no difference between manual therapy, exercise, and placebo for overall pain, disability, and function. But there was also a risk as manual therapy and exercise were frequently associated with adverse effects like short-term pain (although very mild).
When looking at “low quality evidence,” it was pretty consistent with the aforementioned high-quality evidence but also showed that the use of glucocorticoid steroid injections helped with global treatment success.
Overall, this doesn’t sound like a real positive for manual therapy and exercise, but there are some things to consider. Throughout the studies, manual therapy and exercise were always incorporated with some other type of therapy. Also, much of the exercise used was very vague by description and didn’t include whether this was done supervised in the clinic, or at home. Finally, while the comparison to glucocorticoid steroid injection seems like it could be of benefit, this was based on low-quality evidence, so this doesn’t give the intervention much credence.
Looking at what they considered placebo, they used modalities like ultrasound (which in other studies has been shown to have a high level of placebo). This review doesn’t really talk about the interaction between patient and therapist or other contextual factors of treatment. We might see a more detailed description of the exercises and modalities used as interventions if these were included.
However, when we look at other papers that discuss the clinical guidelines of MSK care the best steps are typically shown to be:
- Some manual therapy
If we were to apply the same to issues with the rotator cuff, we’d likely see better outcomes than if these weren’t used. Even though this review says there is no clinically important benefit to manual therapy and exercise over placebo, it doesn’t mean they aren’t of benefit. But if we used those as a combination in treatment the high-quality evidence shows this to be the best approach. So, with any shoulder issue, continue to use exercise and massage. Just remember there are other factors that contribute to a successful treatment. Things like patient preference, demeanour, education, reassuring them, and providing validation will all help contribute to better patient outcomes. Let’s just remember to incorporate as much as possible.
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