How to Overcome Rotator Cuff Issues

What is your Rotator Cuff?

Rotator cuff syndrome is very common shoulder injury. 

Your shoulder joint is a relatively unstable ball and socket joint that is moved and controlled by a small group of four muscles known as the rotator cuff.

The subscapularis, supraspinatus, infraspinatus and teres minor are your small rotator cuff muscles that stabilise and control your shoulder movement on your shoulder blade (scapula). 

As the name suggests, the rotator cuff muscles are responsible for shoulder rotation and form a cuff around the head of the humerus (shoulder ball).

What Rotator Cuff Injuries are Common?

Your rotator cuff muscles and tendons are vulnerable to rotator cuff tears, rotator cuff tendonitis and rotator cuff impingement and related rotator cuff injuries.

Rotator cuff injuries vary from mild tendon inflammation ( rotator cuff tendonitis), shoulder bursitis (inflammed bursa), calcific tendonitis (bone forming within the rotator cuff tendon) through to partial and full thickness rotator cuff tears, which may require rotator cuff surgery.

Some shoulder rotator cuff injuries are more common than others. 

These include:

• Rotator Cuff Impingement
• Rotator Cuff Tendonitis / Tendinopathies
• Shoulder Bursitis (fluid-filled sac that provides a cushion between a bone and tissues)
• Calcific Tendonitis
• Rotator Cuff Tears
• Bicipital Tendonitis

Where are your Rotator Cuff Muscles?

Your rotator cuff muscles hold your arm (humerus) onto your shoulder blade (scapula). Most the the rotator cuff tendons are hidden under the bony point of your shoulder (acromion), which as well as protecting your rotator cuff can also impinge into your rotator cuff structures.

What Causes a Rotator Cuff Injury?

Your rotator cuff tendons are protected from simple knocks and bumps by bones (mainly the acromion) and ligaments that form a protective arch over the top of your shoulder.

In between the rotator cuff tendons and the bony arch is the subacromial bursa (a lubricating sack), which helps to protect the tendons from touching the bone and provide a smooth surface for the tendons to glide over.

However, nothing is fool-proof. Any of these structures can be injured - whether they be your bones, muscles, tendons, ligaments or bursas.

Rotator cuff impingement syndrome is a condition where your rotator cuff tendons are intermittently trapped and compressed during shoulder movements This causes injury to the shoulder tendons and bursa resulting in painful shoulder movements.

What are the Symptoms of Rotator Cuff Injury?

While each specific rotator cuff injury has its own specific symptoms and signs, you can suspect a rotator cuff injury if you have:

• an arc of shoulder pain or clicking when your arm is at shoulder height or when your arm is overhead.
• shoulder pain that can extend from the top of your shoulder to your elbow. 
• shoulder pain when lying on your sore shoulder.
• shoulder pain at rest (in more severe rotator cuff injuries).
• shoulder muscle weakness or pain when attempting to reach or lift.
• shoulder pain when putting your hand behind your back or head.
• shoulder pain reaching for a seat-belt.

How is a Rotator Cuff Injury Diagnosed?

Your physiotherapist or sports doctor will suspect a rotator cuff injury based on your clinical history and the findings from a series of clinical tests.

A diagnostic ultrasound scan is the most accurate method to diagnose the specific rotator cuff injury pathology. MRI’s may show a rotator cuff injury but have also been known to miss them. X-rays are of little diagnostic value when a rotator cuff injury is suspected.

How to Treat a Rotator Cuff Injury?

Once you suspect a rotator cuff injury, it is important to confirm the exact type of your rotator cuff injury since treatment does vary depending on the specific or combination of rotator cuff injuries.

Your rotator cuff is an important group of control and stability muscles that maintain “centralisation” of your shoulder joint. In other words, it keeps the shoulder ball centred over the small socket. This prevents injuries such as impingement, subluxations and dislocations.

We also know that your rotator cuff provides subtle glides and slides of the ball joint on the socket to allow full shoulder movement. Plus, your shoulder blade (scapula) has a vital role as the main dynamically stable base plate that attaches your arm to your chest wall.

Researchers have concluded that there are essentially 7 stages that need to be covered to effectively rehabilitate these injuries and prevent recurrence. 

These are:

• Early Injury Protection: Pain Relief & Anti-inflammatory Tips
• Regain Full Range of Motion
• Restore Scapular Control
• Restore Normal Neck-Scapulo-Thoracic-Shoulder Function
• Restore Rotator Cuff Strength
• Restore High Speed, Power, Proprioception & Agility
• Return to Sport or Work
  
  This article originally appeared on physioworks.com.au and was written by Sam Moyle

What To Expect from an Osteopathic Treatment

If you are a new patient:

After taking an extensive case history, we do an initial structural assessment and perform motion tests and any necessary neurological and orthopedic tests. We may request other investigations if necessary for diagnosis.

We assess the range and quality of motion in joints and soft tissues and look at your general structural/ postural pattern.

The reason for taking a comprehensive case history and performing an initial assessment is to judge whether it is safe for us to use particular osteopathic techniques with you, and whether osteopathic treatment is appropriate.

We are interested in what has worked for you previously, and whether you have treatment preferences.

We can explain the treatment plan, and gain your consent before treatment. You should let us know immediately, even during the treatment, if you would like to change or stop and discuss the treatment we are giving you.

Your Osteopath will then explain to you what they have found and how they would like to approach the treatment, as well as explain what you may expect, any risks involved, and gain your consent for treatment .

The Osteopathic Treatment:

The treatment itself can vary practitioner to practitioner, but all will involve a hands-on approach.  Osteopaths have a wide variety of manual techniques they use to treat various complaints. They include:

• Massage (soft-tissue releases)
• Stretching
• Articulation (joints are passively taken through their range of motion by the osteopath)
• Muscle Energy Techniques (used to lengthen tight, contracted muscles)
• Counterstrain (releases tight muscles by positioning the affected muscle in a shortened position to stretch the opposing muscles)
• Manipulations (short, quick, precise low-amplitude movements used to improve range of motion at the joint)
• Functional Techniques (gentle mobilisation of joints)
• Visceral Techniques 
• Osteopathy in the Cranial Field

At the end of the treatment, your Osteopath will reassess the initial movements that you performed so that we can see how effective the treatment has been. Your Osteopath may organise a return consultation and may give you some stretches and exercises to do at home to help speed up your recovery or improve your body's function. We may be able to give you advice about suitable physical activity during this recovery period.

We have special pillows so that our pregnant patients can lie comfortably.

For your Osteopathic Consultation:

Bring:

•  X-rays, scans and results of investigations
• Private Health Insurance card /Workcover/Motor Vehicle claim numbers/ EPC form/ DVA referral form and card

Wear:

• Comfortable clothes. Depending on the Osteopathic Practitioner and the area of concern, some disrobing may be required, but at all times you will be draped with towels and/or provided with a gown to ensure you feel comfortable during the treatment. 

Time:

• Allow 5-10 minutes extra for your initial consultation to fill in your information sheet.
• Initial consults last 45-60 minutes
• Followup treatments run for 30-45 minutes

How many Treatments Will I Need?

The number of treatments needed depends on how long you have had the problem, how severe it is, and how your body responds to treatment. 

Like any other form of therapy/treatment, occasional unwanted reactions may occur.  These usually don't last long, but if you would like your osteopath to talk to you about what is happening, please ring us. 

On average, people have between 3 to 6 Osteopathic treatments for good results. However, you may only need 1 or 2 visits.

This article originally appeared on fremantleosteopathy.com.au

What does Osteopathy address? Here are 4 key areas.

Osteopaths see the body as a whole system and osteopathic treatment is known as a holistic therapy as it uses a number of different methods to treat you as an individual and whole person. In this way osteopathic treatment aims to restore the balance between the different mechanisms and systems in your body.

Symptoms That Can Be Treated With Osteopathy Overview

Your GP may suggest that you see an osteopath if you suffer from chronic back pain or have a working environment that encourages bad posture (which could result in pain in the future). Some employers also encourage (or insist on) preventative osteopathic treatment for drivers or people that work at desks for long hours.

Due to the holistic and flexible nature of osteopathy, it can be used to treat a wide range of symptoms including joint pain, muscular pain, arthritis, problems caused by pregnancy or repetitive strain etc. Different osteopaths will include different methods in their treatments so different osteopathy clinics may be more suitable for your particular symptom.

Osteopathic Treatment Methods

Osteopaths use a mixture of massage, joint movement, touch and stretching in order to treat your symptoms. The exact nature of the treatment will be highly personalised and no two people will have exactly the same osteopathic regime. Osteopaths will often ask you to carry out exercises at home between visits and will offer advice on how to alter your posture or change your habits in order to help you reduce your pain. This advice can also act as a preventative if you work in an environment that might encourage symptoms such as chronic back pain. Osteopathy as a preventative measure is often used by people who drive for a living or people who play a lot of sport that acts to wear out the joints or puts a lot of pressure on their back.

A Brief History of Osteopathy

Dr Andrew Taylor Still founded osteopathy in the USA around 1874 although it is thought that the concurrent establishment of bone-setting that was occurring in London around the same time was a large influence. These early “osteopaths” (although the name didn’t come until later) treated all sorts of different illnesses and used spiritualism as well as a number of other alternative treatment methods that were popular at the time (including magnetism). Osteopathy developed when a Scottish doctor met with Dr Still and exchanged the teaching of anatomy with the teaching of osteopathy. This enhanced the practice of osteopathy allowing practitioners to tailor their treatments more to the anatomy and physiology of the human body. Doctors practicing osteopathy moved to the UK and set up the British School of Osteopathy in 1915. This has led to the high importance of anatomic teaching that currently lies at the heart of modern osteopathic training. So, it is important to note that osteopathy was developed by medical doctors, illustrating how its methods were developed from scientific and physiological teaching.

Due to the holistic nature of osteopathic treatment, osteopathy can provide health benefits to most people. Here are 4 key areas an Osteopath can help you with:

1. Pain and Injury

Soft tissue pain could include pain in any area of your body (such as back, neck, shoulders) as well as muscular pain (such as pain in your ham strings or biceps). In addition, osteopathy can be used to treat joint pain (such as pain in the knees or hips). Joint pain treated by osteopathy can include pain caused by an underlying disease such as arthritis.

Osteopathy can also be used to treat injury such as whiplash, sprains and strains and to encourage healing after fractures. Treatment for any sports injuries or injuries caused to the back due to heavy lifting are also commonly treated by osteopaths. Car accidents and falls from horses act to jolt your body and may leave you with misaligned areas of your bone and soft tissue. You osteopath will be able to feel these areas and use gentle movements to realign your body structure. This will alleviate you pain and enhance your body’s function.

2. Relaxation and Posture

Many patients find the treatment methods used by osteopaths to be highly relaxing. So, if you find yourself overly stressed and in need of relaxation, you might consider visiting an osteopath as a form of stress relief. The holistic nature of osteopathy means that your osteopath will probably advice you on how to improve your posture. You may even find that it is poor posture that is the source of your pain (and this is especially common for people who visit an osteopath complaining of back or hip pain). In this way, osteopathy is able to treat problems caused by as bad posture as well as help you to manage your lifestyle in order to prevent further problems that you could otherwise develop due to poor posture.

3. Pregnancy and Baby

If you are pregnant you may find that your posture has changed (due to the extra weight that you are carrying) and this change in posture may cause you to develop pain (often in your back or lower joints). You might want to consider visiting an osteopath who may be able to advice you on your posture in a way that prevents you from developing pain, or who could reduce any pain that you have already developed. In addition, many mothers opt to have osteopathic treatment with their new born baby in order to treat any conditions/problems that may have arisen during birth. Mother and baby osteopathy can treat anything from conditions associated with periods of oxygen deprivation during birth to a simple requirement for relaxation and bonding after birth (which is a fairly traumatic experience for both mother and baby even if it goes well)!

4. Energy, Healing and Long Term Illnesses

Osteopathic treatment should be considered if you find that you have low energy levels, have trouble relaxing or problems sleeping. Many people find that they feel more alert and have higher energy levels whilst they are undertaking osteopathic treatment. This is due to the fact that osteopathy will enhance the efficiency of your whole body (by improving the blood flow, lymphatic system and nervous system). The increase in the efficiency of your lymphatic system will increase your healing speed and thus reduce the likelihood of succumbing to infection or illness. This coupled with the relaxing effect of osteopathy means that you might want to consider osteopathic treatment if you suffer with insomnia. The digestive system will also benefit from the restoration of balance between your body’s systems, so digestive disorders can also be treated by an osteopath.

Due to the beneficial effect on the body as a whole, patients will long term illnesses or injuries are often relieved by osteopathic treatment. If you are asthmatic, diabetic or suffer from any other chronic illness or disease you may find that osteopathic treatment can reduce the severity of your symptoms by enhancing your body’s own ability to heal.

This article originally appeared on healthcentre.org.uk and omwc.ca

Approach to Low Back Pain – Osteopathy

Case

A man aged 42 years, who works as a police officer, presented with severe lower back pain, which he had experienced for 24 hours after spending the previous day helping his brother to move house. He had difficulty ambulating and most movements aggravated the pain. There were no lower limb symptoms and no red flags present on history or examination. He was otherwise well and was not taking any regular medications.

Osteopaths are registered health professionals who work mainly in private clinics and manage various musculoskeletal complaints.1 ..with major studies in anatomy, physiology, pathology, research methods, and osteopathic philosophy and technique. There are similarities with other manual therapies, such as chiropractic and manipulative physiotherapy, but the differences in underlying philosophy, approach to diagnosis, and frequency and duration of consultations provide distinctive practice styles to each discipline.

Osteopathic approach and philosophy

The osteopathic approach to patient care is characterised by holism and places emphasis on the reciprocal relationship between anatomical and physiological structures. The holistic approach also acknowledges psychosocial, environmental and ergonomic factors2 that influence pain and disability. To reach a diagnosis, osteopaths assess symptomatic tissues and other related areas of the body that may influence optimal biomechanical function. Treatment includes manual techniques and patient education.

Research and osteopathy

Although there is a paucity of high-quality research investigating the effectiveness of osteopathic management for many conditions, limited but growing evidence offers support for treatment of low back pain (LBP).3–7 Isolated manual techniques, such as spinal manipulation, have been most thoroughly examined by researchers, but seem to have only a modest benefit for LBP.8 An integrated treatment approach using an eclectic set of manual techniques and advice – as commonly used in osteopathic practice – may be of greater benefit in LBP and a number of randomised controlled trials (RCT) have found improvements in LBP after osteopathic treatment.3–7 Recent RCTs reported that osteopathic treatment was more effective than placebo for chronic LBP interventions,5 more effective than usual medical care for acute LBP,3 and helpful for LBP in pregnant women.4

Initial assessment

Initial osteopathic consultations are up to 60 minutes in duration. The consultation includes obtaining a case history and other relevant medical and health information,9 assessment of red flags10 and gaining patient consent for treatment. If a red flag is identified, patients are immediately referred to their GP for assessment, and in more urgent cases (eg. cauda equina syndrome) referred directly to hospital emergency units. The patient completes a self-report pain questionnaire (eg. visual analogue pain scale) and assessment of changes in activities of daily living (ADLs) to assess pain and functional disability.

The information provided in this case scenario suggests differential diagnoses of lumbar facet joint sprain, lumbar disc pathology or sacroiliac joint (SIJ) sprain. The osteopathic physical examination is informed by the case history and aims to support or exclude differential diagnoses.

Physical examination for the case presented

A physical examination would include the following:

• observation of standing posture
• active and passive range of motion of lumbopelvic, hip and thoracic regions
• occupation and ADL-oriented functional movement testing
• assessment of lumbar and thoracic segmental mobility and tenderness
• palpation of lumbar spine, abdomen and hip soft tissues
• orthopedic tests, including straight leg raise, active straight leg raise test and SIJ pain provocation tests.

Management strategies

Immediate (at initial presentation as stated in the case scenario)

For the case presented here, the osteopath would address restricted and painful areas identified in the examination. Treatment may involve mobilisation or articulation of lumbar and thoracic facet joints, soft tissue massage and stretching of lumbar and hip musculature, and the use of gentle isometric contraction techniques (‘muscle energy’) to encourage better motion, muscle recruitment and decrease pain.11,12 Gentle application of spinal manipulation may be used for the lumbar and/or thoracic spine,13 but suspected intervertebral disc pathology would be a contraindication. The patient would be advised to consult their general practitioner (GP) or pharmacist for appropriate short-term pain relief medications and advised to keep moving within pain limits.

An advantage of the osteopathic consultation is the time available to educate patients and discuss concerns. In this case, the osteopath would explain the likely cause and prognosis, and offer reassurance to the patient that nothing serious was evident, that most acute back pain resolves without the need for ongoing treatment or surgery, and that the patient should aim to be active and return to work as soon as possible.14 The osteopath would discuss sick leave for 2–3 days and schedule a review consultation.

Short term (days to weeks)

Some improvement in symptoms would be expected due to the natural history of acute musculoskeletal conditions. Further manual therapy would be provided, advice given on ADLs, and approaches to return to work within a short period of time would be encouraged. Recommendations for alternative work duties may also be appropriate.

Medium term (up to 6 months)

It is unlikely that this patient would need treatment for more than a few weeks. In the case of other factors being present (ie. yellow, black or blue flags) or re-injury, treatment may include manual therapy, the focus being directed towards active treatment approaches, such as rehabilitation exercises. The implementation of additional outcome measures may be helpful for identification of patients requiring psychological intervention.

Long term (years, including prevention and maintenance strategies)

It is highly unlikely that the patient in this case would require long-term osteopathic treatment. Osteopaths encourage patients to invest time and effort into keeping muscles strong and joints mobile, either though occasional osteopathic manual treatment, ergonomic awareness, their own exercise and rehabilitation program, or a combination of all.

Conflict of interests: None
Provenance and peer reviewed: Commissioned; externally peer reviewed.

References

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This article originally appeared on racgp.org.au and was written by Brett Vaughan, Tracy Morrison, Della Buttigieg, Chris Macfarlane and Gary Fryer.