Continuing our series of blog posts about the shoulder (check it out Part 1 and Part 2), here is the latest evidence about conservative and surgical approach for Rotator Cuff tear and impingement.
The latest evidence: Conservative versus Surgical approach
A systematic review + meta-analysis (the highest level of scientific research credibility) from Longo at al. (2021) showed that rotator cuff (RC) re-tear rates after surgery can range from 11%-94%. RC re-tear rates were higher with previous larger tears and with patients 60+ years. In this study, only patients with full-thickness rotator cuff tears who underwent surgery were included.
As per Longo et al (2021), RC re-tear rates were:
- 15% at 3 months
- 21% at 3-6 months
- 16% at 6-12 months
- 21% at 12-24 months
- 16% at follow-up + 2 years
Another Cochrane Journal review conducted by Karjalainen TV (2019), showed no clinically differences in pain, function, or health-related quality of life in surgical treatment of symptomatic, atraumatic rotator cuff tears.
Khan et al. (2019) conducted a systematic review and meta-analysis of controlled trials on surgery for shoulder impingement. They looked for improvements in pain up to 2 years and functional outcomes (up to 1 and 2 years). Participants of the studies had a mean age of 48 years and 45% were men. Results had shown that surgical intervention for shoulder impingement did not demonstrate benefits with respect to pain relief or short-term outcomes. Surgical intervention did show a small but clinically unimportant improvement in long-term functional outcomes.
Another study conducted by Nazari et al., (2020) comparing conservative versus surgical interventions for shoulder impingement, concluded that there were no clinically significant differences in outcomes between the two interventions for shoulder subacromial impingement. Hence, conservative management must be considered the first line of treatment, with shoulder specific exercises addressing muscle flexibility and strength.
To conclude, conservative treatment must be the first choice in managing RC tears and impingement. Physiotherapy treatment composed of tailored home exercise program, activity modification, pain management strategies and soft tissue healing techniques are some of the rehab components. Treatment will vary depending on the patient’s age, lifestyle, level of functional impairment, and compliance with the physiotherapy sessions.
Exercises
Imagine your shoulder complex as a unit (Neck, shoulder and shoulder blades) where all muscles are connected and interact with each other. The exercises below are a good stating point on your rehab journey.
Bonus: You can perform them from the comfort of your home with an elastic band 😊
1-Shoulder External Rotation
- Keep elbows always bent to 90 degrees and on the side of the body.
- Squeeze the shoulder blades inwards
- 3 sets of 12 reps – 30 sec break in between sets
2-Shoulder Internal Rotation
- Keep elbows bent to 90 degrees and on the side of the body at all times.
- Perform one side at the time
- 3 sets of 12 reps – 30 sec break in between sets
3-Sword up
- Start with elbow straight across body, hand pointing down
- Pull band up ‘as if removing a sword out of the pocket’ – twist arm facing out
- Start with lower pain-free shoulder range of motion. Progress shoulder height as symptoms decrease.
- Perform one side at the time
- 3 sets of 12 reps – 30 sec break in between sets
3-Wall Slides
- Start with elbow bent at 90 degrees on the wall
- Open and keep band resistance throughout the movement, engaging shoulder blades inwards
- Slide hands up to without losing the band resistance
- 3 sets of 12 reps – 30 sec break in between sets
4-Wall walk
- Start with elbow bent at 90 degrees on the wall
- Open and keep band resistance throughout the movement, engaging shoulder blades inwards
- Walk one hand at a time on the diagonal and back to center – without losing the band resistance
- 3 sets of 12 reps – 30 sec break in between sets
4-Chin tuck
- Start sitting straight or lying on your back with pillow under head
- Tuck chin into throat without moving the head up or down (NO nodding movement).
- Your ears, shoulder and spine should align vertically. Eyes looking at the horizon.
- 3 sets of 10 reps with 10 sec hold at the end – 30 sec break in between sets
4-Neck stretch
- Sitting or standing straight, pull one shoulder down and head towards opposite side by your self or with with your hand
- Try different angles – Find that sweet spot
- 3 sets of 30 sec hold each side – 2/3 times over the day
