A thorough examination of the shoulder should include evaluation of the cervical spine and an upper extremity neurologic examination. The opposite shoulder must also be examined for comparison. Inspection, palpation for tenderness, and range of motion (ROM) tests should be completed. Palpation should include the AC joint, sternoclavicular (SC) joint, subacromial space, biceps tendon, trapezius muscle, and cervical spine. Impingement sign tests as described by Hawkins, Misamore, and Hobeika13 (i.e., forward flexion to 90° and internal rotation) and by Neer and Welch¹⁴ (forward elevation and internal rotation) are performed to elicit pain. If these tests produce pain, then they are considered positive signs of impingement and suggest rotator cuff dysfunction. The rotator cuff muscles are tested for strength. Subscapularis muscle strength tests include the lift-off test and the belly-press test. The lift-off test places the arm behind the back and up the spine. The patient is then asked to lift the hand off the back against restriction. The belly-press test places the arms onto the elbows bent to 90°, and the elbows are then lifted anteriorly against resistance. Examination for instability is performed. Apprehension sign, a positive-relocation test, or inferior sulcus sign are all indicative of instability. Stability testing should be performed in different positions (i.e., seated, supine) to eliminate instability as the cause of secondary impingement. Evidence of rotator cuff pathology includes painful impingement signs or weakness and a painful arc of motion.⁵

Convention radiography is an important tool in the evaluation of rotator cuff tear pathology and is used to rule out arthritis and fractures, assess the morphology of the acromion, and look for calcifications about the shoulder. Arthrography is no longer the gold standard for identification of rotator cuff tears. Although reliable for the diagnosis of complete rotator cuff tears, it is less reliable for the evaluation of partial-thickness rotator cuff tears. MRI has evolved to provide an excellent noninvasive tool in the diagnosis of rotator cuff pathology and the shoulder labrum and is the modality of choice for the evaluation of cuff tear pathology, followed by ultrasonography. MRI provides information not available by other diagnostic testing, including muscle atrophy, amount of rotator cuff retraction in full-thickness tears, bursal swelling, the status of the AC joint, and the shoulder articular cartilage. The combination of intraarticular contrast (gadolinium) and MRI (magnetic resonance arthrography) has been developed to better delineate abnormalities of the rotator cuff and labrum including partial surface rotator cuff tears.15,16 Ultrasonography of the shoulder has increased in popularity, and as technical advances continue to improve, it has become an increasingly useful tool in the diagnosis of cuff pathology. Ultrasonography has several advantages. These include a relatively low cost, the lack of the contraindications as with MRI, and its use in the examination of the patient both statically and dynamically. Unfortunately, the accuracy of ultrasonography is operator dependent and typically requires a long learning curve.

Nonoperative treatment programs usually continue for 3 to 6 months. Success varies from 50% to 90%.17–21 Approximately 50% of patients with complete symptomatic rotator cuff tears have satisfactory results with nonoperative measures, but these results may deteriorate with time.²² This wide range of outcomes is likely the result of lack of uniformity in classification, indications, and treatment. Some individuals have rotator cuff tears with no pain and normal function, whereas others may have debilitating pain. This demonstrates a need for better understanding of the factors that lead to symptoms.

Indications for rotator cuff surgery include failure of 3 to 6 months of conservative care or an acute full-thickness tear in an active patient younger than 50 years. Failure of treatment can be determined before an entire rehabilitation course is completed. Indications for earlier surgical treatment can include return to full strength with persistent symptoms, failure to tolerate therapy because of pain, or plateau of initial improvement with persistent symptoms. Early surgical intervention is also indicated for patients sustaining acute trauma with full-thickness tears associated with significant rotator cuff weakness and posterior cuff involvement, particularly in young patients with higher functional demands. In addition, patients with acute tears or extension of chronic cuff tears may benefit from early surgery.23

In general, the duration of nonoperative treatment must be individualized based on pathology involved, the patient’s response to treatment, and individual functional demands and expectations.

Surgical management for impingement syndrome generally involves open anterior acromioplasty as described by Neer63 or arthroscopic subacromial decompression (SAD) with release or partial release of the coracoacromial ligament. The coracoacromial ligament is released from the undersurface of the anterior and lateral acromion. An acromioplasty is performed using a burr to achieve a flat acromion. If osteophytes are present on the inferior surface of the AC joint, they are removed from the distal clavicle. Partial thickness cuff tears may be bursal or articular sided. Partial thickness cuff tears may be treated with débridement alone, débridement and acromioplasty, or rotator cuff repair. A subacromial decompression/acromioplasty is generally indicated if the partial tear is bursal sided or there are signs of mechanical impingement. Partial rotator cuff tears greater than 50% of the width of the tendon generally are treated with arthroscopic repair insitu or transtendineus repair, or may be treated with takedown and repair of the rotator cuff either miniopen or arthroscopic.²⁴ Repair of partial-thickness tears improves results compared with débridement alone in this patient group. The overhead throwing athletes with rotator cuff disease have different requirements. Acromioplasty is rarely necessary in the throwing athlete.

Results of surgical treatment of low-grade (<50%) partial-thickness rotator cuff tears after débridement with and without acromioplasty have reported 75% to 88% satisfactory outcome on short-term follow-up.^18,25–27 Repair of a high-grade (>50%) partial-thickness tear has had similar outcome to débridement of a low-grade partial-thickness tear or repair of a small full-thickness cuff tear.²⁸

In the miniopen procedure, the lateral subacromial portal incision is extended either longitudinally or transversely to expose the deltoid fascia. The deltoid fascia is then split in line with its fibers directly over the tear. The anterior deltoid insertion of the anterior acromion is preserved. The deltoid fibers should not be split more than 4 cm lateral to the lateral acromion to avoid axillary nerve injury (Fig. 5-1). Rotation of the arm provides access to the tear. Digital palpation can be used to assess the adequacy of the acromioplasty. A bony trough is prepared in the greater tuberosity of the humerus. The rotator cuff may then be repaired through a bony bridge or with suture anchors. The permanent sutures are tied, pulling the rotator cuff down into its trough on the humerus.

Tears that are fixed, retracted, but reparable, may be repaired open using principles developed by Neer.5,6 An oblique incision in Lagers line from the anterior edge of the acromion to a point about 2 cm lateral to the coracoid process is made. The anterior deltoid is released from the anterior aspect of the acromion and splitting the deltoid no more than 4 cm lateral to the acromion (Fig. 5-2). The deltoid origin over the acromion is elevated subperiosteally. The coracoacromial ligament is released.

The anterior acromion is osteotomized. The acromion anterior to the anterior aspect of the clavicle is removed, and the undersurface of the acromion is flattened from anterior to posterior. The AC joint may be removed if arthritic and symptomatic. The distal clavicle is excised parallel to the AC joint so that no contact occurs with adduction of the arm.

The cuff tear is visualized and mobilized. A bony trough 0.5 cm in width parallel to the junction of the humeral articular cartilage and greater tuberosity of the humerus is made. The rotator cuff tear is repaired to bone with suture anchors or through a bony bridge in the greater tuberosity using permanent sutures (Fig. 5-3). The goal is to repair the cuff with minimal tension with the arm at the side.

Watertight repairs are not necessary for good functional outcome. Excellent and good results have been shown in patients with residual cuff holes.^29,30 The anterior deltoid is repaired back to the acromion by preserved periosteum or through drill holes with permanent sutures. Routine skin closure is performed.

Postoperative management of cuff repairs must be individualized to incorporate tear size, tissue quality, difficulty of repair, and patient goals. Passive motion is initiated immediately. In general, supine active-assisted motion is started on the first postoperative day. Waist-level use of the hand can usually be started after surgery. Active ROM and isotonic strengthening are started 6 to 8 weeks after surgery. Progress of strengthening is individualized with full rehabilitation taking from 6 to 12 months. Function can continue to improve for 1 year after surgery.

GOALS: Comfort, maintain integrity of repair, increasing ROM as tolerated without progressing to full range, decreased pain and inflammation, minimal cervical spine stiffness, protection of the surgical site, maintenance of full elbow and wrist ROM (Table 5-1)

Refer to Box 5-2 for a shoulder evaluation following a rotator cuff repair. The therapist must maintain the protection of the patient and the surgical repair while obtaining an evaluation; therefore, some tests will need to be deferred until later in the treatment process.

To reduce pain and swelling, use cryotherapy. Electrical stimulation may also be used for pain reduction. Instruct the patient in posturing for comfort. Encourage the patient to experiment with different positions. Usually a loose packed GH position (shoulder in some flexion, abduction, and internal rotation) with the arm supported by pillows while supine or sitting is more comfortable. Usually patients cannot sleep much after surgery in the supine position. Therefore suggest sleeping semireclined in a recliner chair with the upper extremity supported in the loose packed position. The patient may also try the supine position in bed, with the arm supported by pillows in a loose packed position.

Gentle mobilizations using grades I and II oscillations, and distractions may help reduce pain, muscle guarding, and spasms. These mobilizations also help maintain nutrient exchange and therefore prevent the painful and degenerating effects that long periods of immobilization produce (i.e., a swollen and painful joint).¹⁸ Occasionally, some people produce increased levels of scar tissue and tighten up quickly. For these cases, passive exercises provide nourishment to the articular cartilage and assist in collagen tissue synthesis and organization.^49–51 The organization of collagen may then follow stress patterns, and adverse collagen tissue formation may be minimized. Limited periods of PROM and pendulum exercises are initiated during this initial stage. For large to massive tears, consider withholding PROM exercises until 4 weeks postsurgery. Recently, it has been suggested that early ROM or excessive ROM treatment of the GH joint may delay tissues from healing. Therefore, when conducting PROM treatments, be careful to protect healing tissues from too much stress from ROM exercises. PROM exercises are done in protected planes. PROM exercises for shoulder flexion are initiated in the scapular plane with the elbow flexed 90°, and external rotation is done with the palm facing the patient and beginning at 45° of abduction.⁵² Performing PROM exercises in the scapular plane is beneficial because of decreased tension on the capsuloligament-tendon complex.⁵² “Rotation exercises should be initiated at 45° of abduction to minimize tension across the repair.”⁵²

Remember to avoid horizontal adduction, extension, and internal rotation during this phase. Also advise patients to avoid leaning on the elbow, sleeping on the affected side, sudden movements, pushing/pulling, lifting, and carrying for 12 weeks.⁵³

A general guideline to use in judging the force being applied is slight discomfort with a slight increase in motion after several repetitions. Remain sensitive and aware of the feedback the patient’s body is exhibiting during ROM or mobilization techniques. The patient’s response will dictate the amount of force applied or the plane of movement chosen. If muscle guarding continues to increase after several repetitions, the force being applied should be reduced or the plane of movement chosen needs to be slightly altered or decreased (or both need to be done) to avoid pinching sensations or increased pain. The therapist usually can find a groove (i.e., line of movement that can be progressed more easily) or line of motion with less muscle guarding. Therefore, constantly assess treatment application while treating the patient with manual PROM. Vary the treatment application as the patient’s feedback dictates (i.e., exact plane of movement, force, and repetitions). An increase in ROM will often accompany a decrease in pain if executed with a sensitive hand. However, general treatment soreness may be expected. Treatment soreness is usually more pronounced when progressing the patient from PROM to active range of motion (AROM) and then again when progressing to resisted ROM exercises. Remember during this stage we do not want full ROM. The superseding goal is to provide an environment where the tissues can heal while preventing stiffness.

Patients usually exhibit protective muscle guarding from the necessary insult of the surgery and the preceding shoulder pathology. Muscle guarding is present in the cervical region and the shoulder musculature. Therefore patients perform cervical AROM exercises and stretches. Appropriate cervical spine mobilization techniques may be valuable for decreasing cervical joint stiffness and muscle guarding, allowing more unrestricted movement of the shoulder complex.

GOALS: Protection of surgical site, improvement of ROM, increase in active strength, decrease in pain and inflammation, maintenance of elbow and wrist ROM, and minimizing of cervical stiffness (Table 5-2)