ROTATOR CUFF TENDINITIS

Published in the AMT Journal "In Good Hands", September 2008
© AMT 2008, © Colin Rossie 2008. Not to be printed or used without permission of the copyright holders and acknowledgement of original publication.


Clients with shoulder conditions often self diagnose and report having either frozen shoulder or “rotator cuff”, as though that in itself is the name of a disorder! Often GPs tell their patient that is what they have without even looking at them.

All joints are a compromise of stability versus mobility. In the case of the shoulder, the requirement for mobility has the upper hand (excuse the pun). The functioning of the shoulder requires it to be a highly mobile structure, especially at the Glenohumeral Joint (GHJ). The four muscles of the rotator cuff (Supraspinatus, Infraspinatus, Teres Minor and Subscapularis) attempt to give it greater stability. They enclose the joint capsule, their tendon fibres often blending with the joint capsule, acting as soft tissue stabilisers for the GHJ. The highly mobile nature of the shoulder means they are readily susceptible to injury.

Tendinitis is an acute inflammation, often a partial tear of the tendon. Tendinosis is a more chronic manifestation, being disorganised and chaotic scar tissue within the tendon, the result of poorly healed past injury and poorly formed collagen. In extreme cases, tendons can be quite calcific.

Physiology and assessment

Supraspinatus acts to initiate abduction. Infraspinatus and Teres Minor act to externally rotate the humerus; Subscapularis internally rotates the humerus. As noted earlier, all four muscles stabilise the humeral head in the glenoid fossa, both in static posture as the arms hang by the side and dynamically during gait and in using the upper limb for activities such as reaching, eating and bringing objects toward us.

The movements available at the GHJ are flexion/extension, abduction/adduction and internal/ external rotation. I would test all these to determine how the function is affected. Apley’s scratch test in its various stages covers all of these movements. Two tests that indicate general dysfunction in the rotator cuff complex are the Drop Arm test (also known as Codman’s test) and the Abrasion Sign 1,2 .

Many structures in the glenohumeral area can create pain (bursa, ligaments, nerves etc). With a client presenting with rotator cuff tendonitis or tendonosis, I would take a history, consider differential diagnoses and refer them to their medical practitioner for further testing if I sensed any red flags, had any doubts or felt further investigation or information was required.

Assuming that all red flags were addressed and it was safe to proceed with treatment, initially I would observe the client’s pain free active ROM then gently take them through passive ROM testing. I’d emphasise the need to do active ROM gently and would perform the passive ROM within their limit. The last thing l’d want is to further tear an already damaged tendon. For the same reason, any resisted testing should be done gently- if at all- with the emphasis on monitoring muscle function rather than opposing it. Avoid any extreme stretching with rotator cuff tendonitis. I would also avoid treatment techniques that involve an element of stretching, such as MET, CRAC or PNF. In the more chronic tendinosis scenario or in subacute tendinitis, these techniques could perhaps be used with appropriate care and caution. In partial or complete tears they should be avoided altogether.

After the initial health screen, questioning, ROM and special tests, I would then observe the client’s total posture, noting any left / right differences in the shoulder girdles and anything unusual in their thorax and torso that may be contributing to their presentation.

I have two approaches to working with clients. One I term ‘fix – it’, where I‘m working primarily with the local phenomena that clients present with on that day. The other is a more integrative approach, looking at the body globally and seeing local dysfunctions as part of that person’s totality- this approach heavily influenced by my training in Rolfing® Structural Integration (2,3,4). Often, when we’re training as Massage Therapists, we are taught to view the musculoskeletal system as the 435(6)- 650 (approx)(7) separate skeletal muscles that act in specific ways on the joints. From the structural integration perspective descended from Dr Rolf’s work, an inverse view can be taken – that there is one fascial continuity, muscles being spacers within the fascia (8).

Communicating openly with the client and sensing from the dialogue what they expect from the treatment and what will produce the best results given those expectations basically determines the direction I take (more fix-it or more integrative). As a conscientious practitioner, I would always do the best for my client by utilising every technique in my therapeutic toolbox that seems appropriate for them. What follows are descriptions of possible methods of treatment, however, nothing is intended as rigid or prescriptive. One should be responsive to the client as they present. I fiercely hate the concept of formulas when applied to the body. As an ex-chef I much prefer the metaphor of a recipe that is adaptable to the circumstances at hand.

Much of what follows is from a fix it perspective, as I feel Paul Doney has quite thoroughly addressed the wholistic perspective.

Remedial Treatment Perspective

In the acute phase, the treatment is protection, rest, ice, compression and elevation. Send the client to their doctor for testing.

In the subacute phase, the aim of the treatment is to decrease swelling, then work to bunch tissue into the area of injury to encourage collagen cross linkages and scar formation.

In the chronic phase, or if you are seeing the client for the first time, determine what rotator cuff muscles are involved. Palpate the myofascia to get a more discriminating sense of its condition, and to confirm or refute your observations. Deactivate any obvious, palpable trigger points that are present, then continue and deepen the palpation so that you are working the myofascia, using both the gentle Barnes style myofascial release and the more direct myofascial techniques popularly associated with Rolfing (9,10). This latter could take two forms, either ‘spots’ or ‘stripes’. ‘Spots’ involves palpating then holding one spot that feels restricted until the tissue changes texture and tension. ‘Stripes’ involves sinking into and then following a line of restriction within the myofascia, again sensing changes in texture and tension, similar to cold butter warming and giving way. One could use a variety of options as tools: the whole fingers, the whole palm, the finger pads, the thenar eminence, the heel of the hand, one or two fingers, the knuckles (either the proximal or the medial phalanges), the thumb pad, the distal phalanx of the thumb, and reinforced fingers.

Supraspinatus

Supraspinatus is the most commonly torn rotator cuff muscle. It initiates abduction and assists the middle deltoid in all abduction. However, it is nowhere near as strong as the middle deltoid. When in dysfunction, it can be active even with the arm just hanging by the side. The Painful Arc will be positive in the 85º -110º range, but I find this test moderately useless as it could also indicate other things, such as subacromial bursitis, calcium deposits etc. A positive Empty Can Test is an indicator of a supraspinatus tear. Various impingement tests (such as the Neer and the Hawkins–Kennedy)(1) also indicate supraspinatus involvement.

Initially I would primarily target the belly of the muscle, continuing carefully into the tendon. View the tendon as a continuation of the fascia past where the muscle fibres finish: once the myofascia has been suitably addressed start working the tendon more specifically. In chronic or calcific tendinitis and tendinosis, tendon damage and reduced function is present but without the inflammatory process to initiate the repair. Transverse frictions to the tendon induce controlled damage, re initiating the inflammatory response and renewing the ability for repair. It also encourages increased vascularity in otherwise vascularly undersupplied tissue. After working transverse, work along the line of pull of the structure with the intent of aligning the freshly redamaged tissue. Fibrinogen, the precursor to creating collagen fibres, realigns appropriately if encouraged in this way (11,12). I would be more circumspect with acute tendinitis and wait for the healing process to be under way before attempting transverse friction work. The two places on the tendon most prone to damage are the myotendinous junction (where the muscles cease within the connective tissue) and the tenoperiosteal junction where the tendon fibres insert into the periosteum of the bone.

All the techniques described above could be applied to the supraspinatus with the client seated or side lying. The U formed by the clavicle and spine of scapula is a good spot to access the supraspinatus tendon, especially its myotendinous junction. The tenoperiosteal junction of supraspinatus is on the humeral head; to access it in order to apply transverse frictions have the client side lying, involved side up, and passively extend the humerus, which moves the humeral head forward of the acromion allowing access to the tendon.

Subscapularis

If subscapularis requires work, I follow a similar protocol but with the client supine. Work the posterior aspect of the axilla, on the anterior surface of the scapula (just antero-medial to the lateral border of the scapula.) Commence by applying a discriminating palpation, identifying the condition of the tissue, deactivate trigger points if present, and continue that discriminating palpation to work on the totality of the myofascia using the myofascial methods outlined above. Have the client’s elbow flexed 90º and GHJ abducted 90º and externally rotated to allow greater access to the muscle. Ask for movement, getting them to abduct further by reaching away with their fingers and then move back to 90º with their elbow leading the way. The subscapularis tendon is on the lesser tubercle of the humerus: when working it, be sure that it is what you are on. If it moves in elbow flexion it is the long head of biceps brachii (a common mistake). Superiorly it attaches to the GHJ articular capsule; so again I emphasis the palpate / discriminate aspect of this work.

Infraspinatus

Infraspinatus rarely exhibits tendinitis, except as a result of impact injury. However, this muscle often has trigger points and the kind of chronic, fibrotic change associated with constant low-level stresses. This results from its stabilising role - when other rotator cuff muscles are damaged it becomes over-active.

To work supraspinatus, I have the client prone, GHJ abducted 90º and forearm dangling over the edge of the table (in more precise anatomical terms, the humerus is also partially externally rotated and elbow flexed 90º). Trigger points are almost always present so I deactivate them first. Then work, initially lightly with the finger pads, along the fibres from the medial scapula border to the insertion in the humerus. Have the client extend and flex the elbow joint as you pass along the muscle. You can gradually increase the depth of your work each pass and ask the client to increase the internal rotation of the humerus as they raise their forearm. Please note that increased depth does not necessarily equate with greater pressure, more a case of gently exploring and exploiting any opening that the tissue allows. With their elbow flexed, the client can also internally and externally rotate the humerus in an ever-increasing range as you work on them.

Teres Minor

When treating Teres Minor, I have the client side lying, arm abducted so that the upper arm rests on the side of the head. If the client’s ROM doesn’t allow this, have it rest on the table in front of them. Apply the same protocols as before, working along the muscle from origin to insertion. In my clinical experience, it is rarely a player in rotator cuff tendinitis but feels good to be worked. Damage is most likely in those who overdo weight training. (13)

The Integrative Perspective

From a global perspective, I would look at the position of the scapula and the forces operating on it. Pectoralis minor, serratus anterior, the rhomboids, coracobrachialis, levator scapulae and the trapezius all influence scapula position directly. Consider the myofascial sling created by the rhomboids and serratus anterior: the scapula can be viewed as a ‘sesamoid’ bone within this sling. Don’t overlook pectoralis minor: it affects scapula position and in my clinical experience is usually a major player in clients with rotator cuff tendinitis. Pectoralis major and latissimus dorsi also affect scapula position indirectly. Omohyoid and sub clavius can be bit players. The function of biceps brachii and attendant muscles coracobrachialis, brachialis and supinator, can affect glenohumeral function. Really obvious is the middle deltoid: its function is intimately tied to supraspinatus. Also, thoracic rotations are a major consideration in glenohumeral function: in scoliosis, for example, one scapula will be protracted, the other retracted; one in internal rotation, one external. Thus the forces operating on each shoulder complex will be different, which can either create or aggravate already existing tendinitis. Don’t forget the fascia, especially the clavi-pectoral fascia. Work around the clavicle generally can be helpful. Compensation is another factor: avoiding using the involved side will lead to overuse of the other side and the same condition manifesting. Also, remember that trigger points from the rotator cuff muscles can refer into the wrist and lead to a mistaken carpal tunnel diagnosis


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