A WEIGHT OFF YOUR SHOULDERS

As previously mentioned in our ‘Live. Pain. Free’ blog, pain is a complex issue and varies greatly between each of us. This blog echoes the message that although a structural fault may have been found on a scan, the symptoms you experience may not be directly linked to the structural fault – it may just be another part of the dysfunction. So how do I determine the dysfunction causing the diagnosis? With regards to the shoulder, this can be tricky, watching the video we shared on Wednesday will show the structures and function of the key parts of the shoulder.

Shoulder complaints are the third most common musculoskeletal presentation after back and neck disorders in primary care (Mitchell et al, 2005

Many injuries come from a dysfunction, put simply: something isn’t working as it should.  This puts pressure on something else, usually leading to this area getting overloaded and signalling a pain response. The pain response elicits compensations and the dysfunction grows often accompanied by greater pain or pain in another area.

Structural faults can be changed with surgery, but the dysfunction is best addressed with exercise and movement.  Surgery alters structure. Rehabilitation alters mechanics and tissue state. When it comes to making decisions about surgery vs rehab – time and time again – rehab wins as a first line of treatment for shoulder pathology (BJSM, 2015). Essentially Physiotherapists are Jedi who, to parody Star Wars, restore balance the forces of the shoulder.

As we found in our ‘to scan, or not to scan’ with regards to lower back issues, similar findings can be noted in studies in patients with shoulder pain.  As far back as 1999 research highlighted that rotator cuff tears must be regarded as “normal” degenerative attrition, not necessarily causing pain and functional impairment. The patents in the table below had no symptoms….(Tempelhof, Rupp and Siel, 1999)

Age Range (years)

Percentage of group with evidence of rotator cuff findings on an MRI
50 – 59 13%
60 – 69 20%
70 – 79 31%
80+ 51%

So you have shoulder pain, you have had a scan, the scan says you have a rotator cuff tear. How do you know if you go down a surgical route or a therapy route? To help inform your decision here is some information on the types of surgery you may face with this type of surgery:

  • Rotator cuff repair: Surgery to repair a torn rotator cuff most often involves re-attaching the tendon to the head of humerus (upper arm bone). A partial tear, however, may need only a trimming or smoothing procedure called a debridement. A complete tear is repaired by stitching the tendon back to its original site on the humerus. (Orthoinfo, 2017). This procedure has been show to be 72% effective. However, to throw a spanner in the works – the success rate has not been linked to the repaired state of the rotator cuff as often follow up studies show the repaired rotator cuff re-tears. So the success of an operation to repair the rotator cuff is not down to the rotator cuff being repaired (McElvany et al, 2014).
  • Arthroscopic acromioplasty: Involves excision of the bony spur on the anteroinferior surface of the acromion, the bursal tissue on the under surface of the acromion and release of the coraco-acromial ligament. The procedure aims to increase the volume of the subacromial space thereby reducing the painful mechanical irritation of the rotator cuff tendons (BOA, 2014). Unfortunately there is very little evidence to support the procedure at all. In fact it has been shown to be no more effective than sham or placebo control in studies (Ketola et al, 2013).

If there is little evidence to support surgical intervention for shoulder pain then is there evidence to support conservative measures I hear you cry – well yes indeed there is:

 

  • Conservative management is now the recommended first line treatment for shoulder pain (BJSM, 2015). Many studies show that clinical outcomes are better than having to go under the knife (Steuri et al, 2016) both in terms of outcome and cost. What is more, even if conservative measures fail and you do have surgery – your recovery will be hugely accelerated if you have a well balanced shoulder going into the procedure.

In short:

  • Exercise therapy trumps surgery every time.
  • Specific exercises are better than general exercises.
  • Rotator cuff tears are inevitable.
  • Cuff tears are not necessarily a sign of pathology.
  • Shoulder pain is part of a bigger picture of dysfunction rather than one specific cause.
  • Physiotherapy is the first line treatment for shoulder pain.
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