Evidence supports at least 3 months of physio for shoulder injuries before considering surgery
Shoulder problems account for a large proportion of our caseload, second only to back pain. And of those, the two big ones we see are rotator cuff problems & shoulder impingement syndrome (SIS), and often both.
Surgical procedures have very limited windows of favourable outcomes compared with conservative management for these two problems, and other medical intervention such as cortisone injections even more limited.
Recent evidence shows that conservative management, or physiotherapy and exercises, should always be considered first for any rotator cuff injury or SIS for a period of at least 3 months. .
These issues generally respond effectively to physiotherapy, with earlier intervention always bringing a more responsive treatment effect, sometimes even when there appears to be significant damage on ultrasound or MRI.
At the end of this article is a basic anatomy lesson, so please refer to that if you get lost in the text below!
How are these diagnosed?
Specific tests by an experienced physiotherapist or sports medicine practitioner in conjunction with radiology will yield a more accurate diagnosis than radiology alone. Often there is no need for radiology whatsoever.
For radiology, ultrasound can be effective in diagnosing very large rotator cuff tears only. MRI, whilst much more accurate, should be read with caution. One 1995 study (Sher et al) showed that in an asymptomatic, painless group of 97 patients across all age groups, 34% had rotator cuff tears, and 15% were full-thickness. Yet they had no symptoms!
Similar studies show bursitis (inflamed bursae) in up to 60% of men and 80% of women regardless of symptoms. We constantly have patients referred for bursitis when the problem is really SIS.
Some basic anatomy!
The rotator cuff muscles sit around the scapula (shoulder blade) and send their attachments to the front, side and back of the top of the humerus (your upper arm bone). Injuries occur in the tendon or the musculo-tendinous junction near where they insert into the humerus. Around 90% of injuries are degenerative in nature, and as such, are often part of the normal wear and tear in our bodies. The job of the rotator cuff is to control the head of the humerus when we lift our arm, largely so that it doesn’t jam up into the bone above it.
Shoulder Impingement Syndrome (SIS) occurs when the supraspinatus tendon and overlying bursa (which acts as a cushion and to reduce friction on the tendon) get pinched in the sub-acromial space where they sit between the acromion (pointy edge of your shoulder) and the top of the humerus. When there is an injury to the rotator cuff, or if they aren’t working together well, then the humeral head moves upward into the subacromial space on lifting of the arm causing impingement of the supraspinatus tendon and bursa. Hence why we often get rotator cuff injury and SIS occurring together.
Other factors that influence the onset of both of these problems are:
- Slouched posture, causing the scapula to sit forward or tilt down, reducing the sub-acromial space
- Weak or poorly functioning scapula muscles and postural muscles of the back
- History of occupational or sports using the arm above the head repetitively, or with heavy lifting
- History of cortisone into the subacromial region increases risk of degenerative rotator cuff tendons
- Presence of autoimmune disease (Ankylosing spondylitis, Rheumatoid Arthritis) or Diabetes
What is the treatment?
Physiotherapy involves addressing postural and biomechanical causative factors as well as providing symptomatic relief in the early stages with hands-on treatment (massage, dry needling, spinal mobilisation if required). The most important thing is to address the function of the scapula (shoulder blade) muscles and to correct the position of the scapula itself with postural exercises. Strengthening for the upper limb is progressed as pain reduces and graded toward returning to full activity over time.
The patient should also rest from aggravating activities in the early stages of rehabilitation, such as repetitive overhead movements, holding dead weights by the side (eg shopping bags) and slouching whilst working, relaxing or driving. Symptoms should start to improve within two weeks for most people. Full recovery can take between 6 – 26 weeks, and for rotator cuff tears there is often some ongoing rehab required.
Evidence suggests that surgery for SIS, where the pressure is relieved in the sub-acromial space by removing part of the acromion bone or the bursa itself, is no more effective than conservative treatment (Setola et al, 2015, & Saltychev et al, 2013). And cortisone injections are only effective for short term pain relief, and much more effective when combined with conservative physiotherapy management.
Surgical opinion for rotator cuff tears should only be considered for a healthy population under 50 years old that require high level use of the upper body for work or recreation, and only for tears greater than 3cm in length, and always after attempting at least 3 months of conservative management first.