Rotator Cuff Syndrome - A Problem of Incomplete Diagnosis

on Monday, 05 October 2015.

The rotator cuff is a group of muscles that envelope the shoulder. These muscles originate from the shoulder blade (scapula) and insert onto the head of the humerus. They wrap around the glenohumeral joint like a glove to provide compression, depression, stability, and some measure of rotation. These muscles play an essential role in stabilizing the shoulder; they are also a common source of shoulder pain and dysfunction. 

 

Rotator cuff syndrome is a catch all term used to describe pain and pathology of the rotator cuff. Unfortunately, people are frequently diagnosed with rotator cuff syndrome without further clarification as to the specific nature of the injury; this diagnosis is not specific enough to direct best treatment and rehabilitation. As a general rule, if you ever get diagnosed with a "syndrome" - ask questions. The word syndrome means "a group of symptoms that consistently occur together or a condition characterized by a set of associated symptoms". A syndrome diagnosis is often used when the condition, disease or injury is complex in nature and requires a blanket term to capture all facets of the condition. A diagnosis of rotator cuff syndrome will never be "wrong" in the presence of rotator cuff pathology but it will also never be specific enough to know what steps you should take to rehabilitate it. 

In order to get best management of a rotator cuff injury it is essential to know:

  • the cause (overuse, disuse, postural dysfunction, imbalance of mobility/flexibility of the rotator cuff and joint capsule, stability or movement pattern dysfunction of the glenohumeral joint or shoulder blade - often called "scapular dyskinesis"
  • which of the 4 rotator cuff muscles and/or tendons are involved - Teres Minor, Infraspinatous, Supraspinatous, Subscapularis
  • is there an impingement syndrome present and if so is the impingement syndrome primary or secondary?
  • is the injury resulting from: instability, stiffness, weakness?
  • the pathophysiology of the muscle and tendon - is it degenerative or inflammatory, calfication, intact tendon or is there partial to full thickness tear? 
  • is there involvement of other structures: bursa, biceps tendon, labrum, cartilage, capsule/ligament
  • what provokes it / relieves it?
  • contributing factors (diet, lifestyle, etc)

Once the diagnosis has been established the type of treatment and rehab can be decided on. Below is a shoulder diagnosis that is commonly labelled as "rotator cuff syndrome" that I have provided as an example to facilitate discussion pertaining to the importance of diagnostic specificity and treatment options:

(1) Supraspinatous Tendonosis with (2) Subacromial Bursitis and Associated (3) Postural Dysfunction, (4) Scapular Dyskinesis, and (5) Glenohumeral Internal Rotation Deficit (GIRD)

Sounds complicated, right? Well, there is a lot information that can be gleaned from the diagnosis but it isn't necessarily complicated... when we break down the diagnosis we can see how being specific in diagnosis facilitates best management. 

Breaking it down:

(1) the supraspinatous is a muscle on top of the rotator cuff (see image). It is strained, activated, provoked and relieved by predictable postures, movements and exercises - knowing which rotator cuff muscle is injured can help guide treatment and rehabilitation. The suffix 'osis' implies a degenerative condition. Almost all chronic tendon disorders are marked by a degenerative process whereby the physiology and structure of the tendon is compromised. This is important to know because unlike an inflamed tendon disorder, called a tendonitis, a tendonosis requires a different approach that necessarily includes progressive loading of the tendon to facilitate positive adaptation to promote strengthening and remodelling of the tendon. In short, tendonitis requires rest and anti-inflammatory measures whereas a tendonosis requires systematic and progressive strengthening.

(2) a bursa is a fluid filled sac lined by an inner membrane that secretes a viscous fluid, which allows the bursa to reduce friction and provide cushion between muscles, tendons and bones. The subacromial bursa, when inflamed called subacromial bursitis, necessarily requires methods to reduce inflammation. Due to their close proximity in location and in function the subacromial bursa is often involved with supraspinatous tendon disorders. Chronic irritation and swelling of the bursa can result in fibrosis (formation of scar tissue) and thickening of the bursa, which requires treatment to promote normal mobility of the bursa and a reduction in abnormal fibrotic tissue deposition.

(3) postural dysfunction requires, well, modification of posture. Manual therapy, exercise, and forming new movement and posture habits are known methods to address postural dysfunction. 

(4) Scapular dyskinesis is abnormal movement, often due to weak or poor stabilization of the scapula, and is known to be associated with and a risk factor for shoulder injuries. It can be treated through strenghtening and normalizing the coordination of the muscles related to scapular stabilization. 

(5) Glenohumeral Internal Rotation Deficit (GIRD) is defined as the limitation of internal rotation of the shoulder, and is also a known cause of shoulder injuries including rotator cuff and labral tears. It is assessed by one of our practitioners in a specific position and compared to total range of motion and to the assymptomatic side. If GIRD is diagnosed it is essential to normalize the range of motion and is done so through soft tissue manipulation (Active Release Technique, Functional Range Release, Massage), assisted stretching / mobilization, and prescribed home exercise.

The diagnosis or rotator cuff syndrome does very little to help guide appropriate management of a rotator cuff injury. There is a whole lot more behind the diagnosis of "rotator cuff syndrome" that if well defined provides essential information to appropriately manage the condition. Unlike the diagnosis of rotator cuff syndrome, which doesn't allow for any specific recommendations, a detailed diagnosis allows us to sink into some specific treatment and rehab options.

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