WAKEFIELD Shoulder Program

The Wakefield Shoulder program applies particularly for rotator cuff tendinopathy (also called rotator cuff tendinitis and impingement) but is also relevant for treating rotator cuff tears, and adhesive capsulitis (also known as frozen shoulder.)

Such disorders of the shoulder are best managed by an integrated team providing precise assessment and investigation, withevidence-based management comprising physiotherapy and other non-operative modalities, as well as surgical reconstruction and repair where appropriate – which aims to restore:

Where Do You Start?

A good history and careful examination will often provide an answer. Testing for range of motion, muscle power, and tenderness are key steps. Weakness of the Rotator cuff muscles is commonly the major issue in such shoulder problems, and can be quite subtle.

What Is the Best Way to Investigate?

A plain x-ray is the most useful primary investigation for shoulder pain and will provide important information on many conditions including arthritis, instability and indicators of the chronicity of the possible cuff tear.

This is consistent with published recommendations such as American College of Radiology Appropriateness Criteria – Click here to review the recommendations for shoulders: https://acsearch.acr.org/docs/3101482/Narrative/

Asymptomatic partial and full thickness rotator cuff tears are so common in patients over 60 that they are often within normal limits for age related tendon changes. Thus, simply finding a tear on ultrasound is not an indication for surgery.

Ultrasound and MRI studies should therefore not be ordered routinely, and certainly not as the first investigation. They can be considered as secondary investigations if the diagnosis is in doubt, or if surgery is being considered.

The key is to make a diagnosis based on the clinical findings, supplemented by plain x-rays, and progress to further investigation (Ultrasound and MRI) if the initial response to “appropriate” treatment is unsuccessful, or the diagnosis is not clear.

What About Sub-Acromial Steroid Injection for Rotator Cuff Tendinopathy?

There is no proven benefit for steroid injection in rotator cuff tendinitis, and although the can occasionally provide short term improvements in pain, can cause tendon softening and damage with increased risk of tearing.

Subacromial steroid should be avoided, and used sparingly, and only as part of an overall shoulder rehabilitation program.  They should virtually never be used as the first line treatment, and repeated injections could potentially cause major reversable damage to the shoulder structures.

What About Muscle Strength?

Rotator cuff weakness can be quite subtle, but can be demonstrated by a careful examination technique. Regaining strength of the rotator muscle using a targeted exercise program is a crucial part of the treatment for most patients.

The Key Muscle Is INFRASPINATUS (ISP)

The Deltoid can be activated with any degree of shoulder abduction, masking the underlying ISP weakness. Examination using a shoulder adduction strap can be very helpful in improving examination acumen.

The images below show how activation of deltoid can mask ISP weakness.

 
Apparent good ER power - but Middle deltoid recruited by subtle shoulder abduction adding to strength

Apparent good ER power - but Middle deltoid recruited by subtle shoulder abduction adding to strength

 
 
Shoulder abduction prevented by  Wakefield Shoulder Strap  - stopping Deltoid activation

Shoulder abduction prevented by Wakefield Shoulder Strap - stopping Deltoid activation

 
 
before-after er abduction.jpg
 
 

IF A WEAK INFRASPINATUS CAN NOT BE IDENTIFIED,
THE CORRECT TREATMENT CAN NOT BE PROVIDED

Failure to recognise the subtle rotator cuff strength imbalance will prevent a therapeutic strategy to address the MOST frequent underlying cause of symptomatology.

Management Stages:

Stage 1 - History and Examination
Specifically - Range of motion of each joint, painful arc location, rotator cuff strength, relevant provocative tests.

Shoulder pain can be the result of a variety of conditions including:

  1. Referred or related to another cause (e.g. from the cervical, thoracic, abdominal regions, neural and vascular tissues).

  2. Primarily related to a stiff shoulder (e.g. frozen shoulder, osteoarthritis, locked dislocation, neoplasm-such as osteosarcoma).

  3. Shoulder instability.

  4. Soft tissues (e.g. rotator cuff, bursa).

  5. A combinations of the above.

Correct treatment requires careful assessment and diagnosis.

Stage 2 - Diagnosis - Motion / Stability, Smoothness, Strength
 
 
Stage 3 - Restore Strength and Mobility to the Shoulder

Strengthening

Strengthen Infraspinatus muscle:

 
strengthening.jpg
shoulder-exersize.gif
 
  • Infraspinatus maximally recruited at 40% actual ER power, plus Adduction load

  • Strong ER favours Middle Deltoid

  • Post Deltoid acts with ISP and appears to be a weak adductor.

Optimise rehabilitation exercises for rotator cuff dysfunction by:

  • If ER weak→ Theraband™ loading is at 40% actual power (plus adduction)

  • Increase Theraband™ repetition and resistance as weakness improves

  • Individualised rotator cuff loading regimen and use of sEMG


Stretching

Posterior shoulder capsule stretching:

 
 

The Wakefield Shoulder Rotator Cuff Exercise Program needs specific implementation and graduated progression to achieve best results.

The Cuff Tendons are slow to strengthen and patience is required. It can take 6 weeks to 3 months to notice good improvement in shoulder symptoms and require ongoing maintenance exercises to keep that improvement.

Tendons need regular exercise loading with small changes for them to settle and improve and there can be hurdles to overcome along the journey.

Tendon pain can flare if overloaded and may fail to gain strength if not loaded adequately - the key is getting the loading progression just right.

The exercises require attention to detail as it is easy to use other muscles to perform the exercise and therefore not achieve best results.

Avoiding aggravation of the patient’s symptoms (especially in the early stages) is important in helping to settle the shoulder e.g. minimise reaching and overhead activities, avoid sudden movements and straining as well as avoiding prolonged static postures with the arm away from the body.

Dressing, hygiene and sleeping strategies need to be enforced to avoid discomfort.

Physiotherapy will be required infrequently to prescribe and progress the exercise program to achieve the best results.

For most shoulder pain, early surgery is very infrequently needed if utilising the correct rehab program.

Stage 4 - Surgical Management to Repair Tears / Remove Spurs etc.

Surgical intervention may be the next stage if non-operative management has not been successful in restoring adequate function or comfort.

The timing of surgery depends on the nature of the injury, and the degree of progress with the non-operative treatment.

The recovery can be quite long but is improved by optimal pre-operative mobilisation and strengthening.

When Is Urgent Surgery Possibly Required?

  1. Displaced Shoulder Fracture

  2. Dislocation (+/- fracture) with unstable joint

  3. Complete massive sleeve avulsion of rotator cuff

  4. Infection

  5. Tumours (early review for decision on management)

When Is Early (at About a Month) Surgery Possibly Required?

  1. Definite Subscapularis tendon tears

  2. Large multi-tendon tear with major strength loss

  3. Failure to gain strength despite correct rehab program

What Does Not Need Early Surgery?

  1. Acute partial rotator cuff tears

  2. Acute on Chronic Rotator cuff tears

  3. Long Head of Biceps tendon ruptures in the over 50 year old

  4. Patient who have not undergone the correct rehab program

  5. Frozen Shoulder

  6. Calcific tendonitis

  7. Arthritis

Wakefield Shoulder Clinic Referral

Medical (08) 8232 5833 Physiotherapy (08) 8232 5566 Orthopaedic Clinic (08) 8236 4100

www.wakefieldsports.com.au & wsc@wakefieldsports.com.au