Current trends in rehabilitation of rotator cuff injuries

Abstract

Rehabilitation has a fundamental role in the management of rotator cuff pathology whether the final choice is conservative or surgical treatment. Conservative treatment can give excellent results in cases of rotator cuff tendinopathies without rupture, partial tears less than 50% of the thickness of the tendon, chronic full-thickness tears in elderly patients and irreparable tears. It is an option prior to reconstructive surgery in non-pseudo paralytic cases. When surgery is indicated, adequate postoperative rehabilitation is the best complement to obtain a successful result. No consensus has still been established on the optimal postoperative protocol to follow. No differences were found between delayed, early passive and early active protocols after rotator cuff repair. However, early motion improved the range of motion in the short and mid-term, allowing faster recovery. A 5-phase postoperative rehabilitation protocol is described. Rehabilitation is also an option in specific failed surgical procedures. To choose a therapeutic strategy in these cases, it is reasonable to differentiate between Sugaya type 2 or 3 (tendinopathy of the tendon) and type 4 or 5 (discontinuity/retear). The rehabilitation program should always be tailored to the individual patient.

Keywords: Rehabilitation; Rehabilitation protocol; Rotator cuff; Rotator cuff repair; Shoulder.

Figure 1

A 67-year-old patient with a history of left shoulder pain for more than one year. He was treated with more than 30 rehabilitation sessions and indicated surgery. (a) Initial image in which the circle marks the rotator cuff lesion. Nobody noticed the alterations of the humeral head. (b) X-rays were requested that had not been requested in the previous consultations in which an alteration in the metaphyseal-epiphyseal region was observed. c) Scintogram showing pathologically increased uptake in different regions of the skeleton and especially in the proximal end of the humerus. The final diagnosis was a metastasis of prostate carcinoma.

Figure 2

37-year-old patient with a history of right shoulder trauma of 2 months of evolution. He was treated with three local injections of platelet-rich plasma. a) X-rays showed a displaced acromion fracture and magnetic resonance showed a massive rotator cuff tear. Clearly, the initial indication was surgical.

Figure 3

Sugaya’s classification rates (a) type 1 as fully healed, (b) type 2 and (c) type 3 as persistent signs of tendinopathy or (d) type 4 minor and (e) type 5 major as discontinuity [2].

Figure 4

Treatment algorithm for failed rotator cuff tear. With persistent pain or loss of function for more than 6 months an MRI should be performed. Based on the Sugaya classification [2] tendinopathy and retear are differentiated. Non-operative treatment for tendinopathy should include eccentric exercises to promote tendon healing. When a retear is confirmed, surgical options are evaluated. If surgery is not favourable, pillars for non-operative treatment are compensation, adaption, and patient education.