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1

Rotator Cuff Dysfunction Injury Prevention and Non-operative

Treatment

Brian Schiff PT OCS CSCS

Provider Disclaimer

bull Allied Health Education and the presenter of this webinar do not have any financial or other

associations with the manufacturers of any products or suppliers of commercial services that may be

discussed or displayed in this presentation bull There was no commercial support for this

presentationbull The views expressed in this presentation are the views

and opinions of the presenterbull Participants must use discretion when using the

information contained in this presentation

Backgroundbull Supervisor - Raleigh Orthopaedic Performance Center

bull Practiced since 1996 in outpatient sportsortho clinics

bull S amp C coach for MLS - Columbus Crew 2002-2006

bull Owned my own training facility 2000-2010

bull FMS certified board certified orthopaedic clinical specialist (OCS) credentialed in dry needling

bull Write for PFP Magazine

bull PT consultant for Carolina Hurricanes

2

Objectives

bull Review rotator cuff dysfunction and relevant research with respect to exercise and conservative

care

bull Discuss specific weight training and exercise related modifications to prevent shoulder injuries

bull Outline a comprehensive non-operative

rehabilitation approach to rotator cuff injuries including manual interventions and therapeutic

exercise

bull Review return to sportactivity considerations

Rotator Cuff Risk Factors

bull GHJ Laxity

bull Scapular dyskinesia

bull Postural dysfunction

bull Muscular imbalances

bull Overuse

3

Pertinent Anatomy

bull Scapula

bull Humerus

bull Ligaments

bull Labrum

bull Dynamic stabilizers

Static Restraints

Acromial Type

4

Rotator Cuff

Rotator Cuff

Shoulder Injuriesbull Up to 36 of weight lifting injuries

involve the shoulder

bull Why NWB joint becomes WB

bull Study ndash 90 men (19-47) w60 doing

RWT

bull darrrsquod L Trap strength darrrsquod IR ROM gt post shoulder tightness amp gt ER ROM

bull Need cuff amp scapular stabilizer workKolber et al J Strength Cond Res 2009

5

Recipe for Overuse bull Repetitive motion

bull Faulty muscle recruitment (poor stability)

bull Pec and lat tightness

bull Bad posture

bull Limited T-spine mobility

Balance Prevents Overtraining

Stress

Recovery

Youth Baseball bull Olsen et al revealed that

averaging more than 80 pitches

per game nearly quadrupled injury risk and pitching more than 8 months out of the year

raised it fivefold

bull Olsenrsquos study concluded pitching with a fatigued arm

increased chances of having surgery 36x

bull Fleisig et al showed that

pitching more than 100 competition innings per year more than tripled the risk for

serious shoulder or elbow injury In addition playing catcher as well as pitcher increased the

odds ratio of injury 27 times

Fleisig et al Sports Health 2012

6

bull 23 adolescent pitchers (age 157 plusmn 14 years) were tested

bull 12 pitchers had throwing-related pain in the prior season and were currently symptom-free while the remaining 11

pitchers had no such history of pain

bull 23 pitchers had a loss of internal rotation ROM (13deg plusmn 10deg P

lt 001) and gain in external rotation ROM (11deg plusmn 10deg P lt 001) on the dominant versus non-dominant arm with no

effect on total ROM (2deg plusmn 7deg loss P = 14)

bull Throwing-related pain in this population may be due to the inability of weakened posterior shoulder musculature to

tolerate stress imparted on it by adaptively strengthened propulsive muscles

Trakis et al AJSM 2008

GIRD

Image from Manske et al Int J Sports Phsy Ther 2013

ERD and GIRDbull ERD (ext rot deficiency) - 5 deg or less

wPROM increases injury risk in throwers

23x (unpublished data)

bull Anatomical GIRD - normal loss of IR (18-20 deg) with adequate ER gain and TROM

within 5 deg of the uninvolved side

bull Pathologic GIRD - A shoulder that has

GIRD more than 18-20 deg and a

concomitant loss of TROM gt 5 deg (= 25x

injury risk)Manske et al Int J Sports Phys Ther 2013

7

More on GIRDbull Burkhart reports that an acceptable level of

GIRD is defined as

bull 1) less than 20 deg loss of shoulder IR comparing shoulders bilaterally or

bull 2) no greater than 10 loss of the total rotation seen in the non-throwing

shoulder (Non dominant shoulder IR +

ER ROM) x 10)

bull 3) Ratio of GIRD to ERG needs to be 1

or lessManske et al Int J Sports Phys Ther 2013

Internal Impingement

bull Pathologic GIRD creates altered

biomechanics for overhead athletes

leading to posterosuperior glenoid impingement a common cause of pain

in throwing athletes

bull IR decreases with throwing as season goes along

Scapular Positioningbull The dominant-side scapula of overhead

athletes was more internally rotated and anteriorly tilted than the non-dominant side

scapula

bull The dominant-side scapula of tennis

players was more protracted than that on

the non-dominant side

bull Scapular posture asymmetry in unilateral

overhead athletes may be normal

Oyam et al J Athl Train 2008

8

Common Injuries

bull Tendinitis

bull Tendinosis

bull Impingement

bull Partial thickness tears

bull Full thickness tears

Exercise Trends

bull Crossfit

bull Kettlebells

bull HIT workouts

bull Extreme races

bull Obstacle course training

Crossfit Injury rates

bull An injury rate of 31 per 1000 hours trained was calculated

bull Injury rates with CrossFit training are similar to

that reported in the literature for sports such as Olympic weight-lifting power-lifting and

gymnastics and lower than competitive contact sports such as rugby union and rugby league

bull Shoulder and spine injuries predominate with no incidences of rhabdomyolysis obtained

Hak et al J Strength Cond Res 2013

9

Crossfit Injury ratesbull 486 CrossFit participants completed the survey

bull The overall injury rate was determined to be 194 (75386)

bull Males (53231) were injured more frequently than females (21150 P = 03)

bull Across all exercises injury rates were significantly different (P lt 001) with shoulder (2184) low back (1284) and knee (1184) being the most commonly injured overall

bull The shoulder was most commonly injured in gymnastic movements and the low back was most commonly injured in power lifting movements

Weisenthal et al Orthop J Sports Med 2014

Weight Training Considerations

bull Age

bull Acromial type

bull Prior injury

bull Instability

bull Scapular dyskinesia

bull Clavicular osteolysis and bone spurs

Instability

bull Acquired laxity gt anterior micro

instability

bull MDI

bull Secondary RC bicipital and labral

stress

bull Caution with loading (snatch jerks flies

pressing dips etc)

10

The Scapulabull Resting alignment

bull Dynamic mechanics

bull SICK scapula

1 Inferior border prominence

2 Medial border prominence

3 Superior border prominence

Distal Clavicle Osteolysis

Threatening Exercises

bull Full range chest press flies and dips

bull Long lever side raises

bull Wide grip pull-ups

bull Heavy overhead press hand stand push-ups

bull Burpees bear crawls undulating ropes

bull Overhead lifts (eg snatch) with improper form

and certain squat variations

11

Differential Diagnosis

bull Labral tears

bull AC joint pathology

bull Bicipital tendinopathy

bull Brachial plexus

bull Radicular pain

bull Myofascial pain

Shoulder Imaging

bull Common X-rays

1 AP (external rotation)

2 Lateral (Y View)

3 Axillary

12

AP View

Lateral View

Source - AAOS Website

Axillary View

13

MRI - Partial Tear

Angled oblique MRI views - source Medscape

MRI - Full Tear

Angled oblique MRI views - source Medscape

PRP vs Dry Needlingbull 39 patients with a supraspinatus tendon lesion

(tendinosis or a partial tear less than 10 cm but not a complete tear) who met the inclusion criteria recruited

between June 2010 and February 2011

bull The clinical effect of the platelet-rich plasma injection

was superior to the dry needling from 6 weeks to 6 months after initial injection

bull At six months the mean Shoulder Pain and Disability Index was 177 plusmn 37 in the platelet-rich plasma group versus 295 plusmn 38 in the dry needling group

bull No severe adverse effects were observed in either group

Rha et al Clin Rehabil 2013

14

PT Evaluation

bull Observe posture

bull APROM

bull MMT

bull Joint mobility

bull Palpation (TrPrsquos)

bull Special tests

Key Special Tests

bull Hawkins Neer impingement signs

bull OrsquoBrienrsquos pronated load Speedrsquos for labrum

bull AC joint provocation

bull Sulcus sign Apprehension Jobe

relocation

bull C-spine clearing tests

OrsquoBrien Test (video)

15

Speedrsquos Test

Pronated Load Test

Kinetic Assessmentbull Thoracic spine mobility

bull Core stability

bull Hip mobility

bull Hip stability

bull SL stance

bull Ankle mobility

bull Integrated movement (FMS)

16

T-spine Rotation

Tall Plank Diagonal

FMS

17

QuickTimetrade and a decompressor

are needed to see this picture

Shoulder Mobility FMS (video)

Trunk Stability Push-Up FMS (video)

Key Recovery Principles

bull Respect healing tissue

bull Progressive sequential amp functional

bull Embrace individual differences among clients

bull Avoid loads to failure especially as they ease

back into training

bull Consistently assess and involve the client with pain threshold training

18

Pain Threshold

bull Journal pain before during and after activity

bull Mild soreness may be acceptable but should not have pain with throwing

bull 24 hour rule = elevated soreness after a

workout or training session must return to baseline level or less in 24 hours (or less)

bull Rehabtraining progression is based 100 on

pain response

Non-operative Rehabbull Resolve soft tissue

restrictions

bull Resolve unwanted GIRD

bull Strengthen cuff and scap stabilizers

bull Emphasize stability

bull Incorporate entire

kinetic chain

Effective for RC Tearsbull Moon group cohort consists of 452 patients

wFT tears

bull Patient reported outcomes improved significantly at 6 and 12 weeks

bull Patients elected to undergo surgery less than 25 of the time

bull Patients who decided to have surgery generally did so between 6 and 12 weeks

and few had surgery between 3 and 24 months

Kuhn et al J Shoulder Elbow Surg 2013

19

Rehab Approachbull Visit 1 = HEP for cuffscapular PREs

STM and stretching

bull Manual techniques

bull Limit andor restrict throwing hitting and OH training initially

bull Below shoulder height then scapular plane and gradually move to overhead

bull Educate regarding pain and progression

Manual Therapy

bull GHJ mobilization

bull IASTM

bull Stretching

bull Dry Needling

Dry Needling Efficacybull A total of 56 subjects with neck or shoulder girdle

pain gt 3 months duration and active MTrPs were

recruited from a campus-wide volunteer sample 52 completed the study (23 male and 33 female) and

mean age was 358 years

bull 3 weekly dry needling treatments of a single active MTrP

bull A total of 41 subjects had a change in trigger point

status from active to latent or resolved and 11 subjects had no change (P lt 001) Reduction in all

pain scores was significant (P lt 001)Gerber et al PM R 2015

20

Rehab Phases

1 Relative Rest Mobility amp Stabilization

2 Activation amp Strengthening

3 Integrated CKC Strengthening amp Power

4 Return to Activity

Mobility Priorities

bull Pec majorminor

bull Lats

bull Posterior rotator cuffcapsule

bull Upper trap amp levator (TPDN amp IASTM)

21

9090 Arm Sweep

Shoulder STM (Video)

Stretches

22

Posterior Shoulder

Stretching

bull Low load long duration

bull 30 seconds (8-10x)

bull Do not stretch into pain or impingement

bull Modified sleeper amp cross body stretch can be used (roll posteriorly 20-30 deg)

bull Not encouraged prior to throwing or prior

to tennis match

Wilk et al JOSPT 2013

Stretching (Video)

RC Exercises

bull Side lying DB external rotation

bull Scaption

bull Prone I T Y and Ws

bull HER and HIR

bull D2 exercises

23

EMG Activity

bull Side lying ER produced the greatest amount of EMG activity for the infraspinatus (62 MVIC)

and teres minor (67 MVIC)

bull The greatest amount of activity of the supraspinatus (82 MVIC) middle deltoid

(87 MVIC) and posterior deltoid (88 MVIC) was observed during prone horizontal abduction at 100 degrees with full ER

Reinold et al JOSPT 2004

Blood Flow Restriction (BFR) Training

Low-load BFR training increased muscle

size and strength in limbs located proximal

(chest shoulders) and distal (biceps triceps) to the restrictive stimulus

Dankel et al Sports Med 2016

BFR Exercise Video

24

Full Can vs Empty Can

bull Participants with SAIS (n = 28) performed 5 consecutive repetitions of FC and EC exercises

bull Participants reported greater pain during the EC exercise vs the FC exercise

bull During the EC exercise participants were in greater scapular upward rotation internal rotation and clavicular elevation and in less scapular posterior tilt

thus decreasing subacromial space

bull Scapular muscle activity was generally higher with the

EC which may be an attempt to control the impingement-related scapular motion

Timmons et al J Shoulder Elbow Surg 2015

Full Can vs Empty Can

bull Dominant shoulder MVIC tested wEMG for 3 exercises full can standing empty can standing and prone hor ABD at 100 with full can

bull While all 3 exercises produced similar amounts of supraspinatus activity the full can exercise produced

significantly less activity of the deltoid muscles and may be the optimal position to recruit the supraspinatus muscle for rehabilitation and testing

bull The empty can exercise may be a good exercise to recruit the middle deltoid muscle and prone full can exercise may be a good exercise to recruit the

posterior deltoid muscle

Reinold et al J Athl Train 2007

Scapular Exercises

bull Quadruped and tall plank exercise

bull Serratus anterior variations

bull Pulls rows depressions wall walks

wall slide shrugs

bull Integrated shoulder core and hip

exercise

25

Scapular Activation

Benefits of unstable training surfaces include increased scapular activation In a recent study

published in the J Phys Ther Sci 2013 Seo et al revealed greater uppermiddle trap and serratus

activity while doing a push-up plus on a stability ball

Stability Exercises (video)

26

Strengthening (Video)

Rehab to Performance

bull Rehab exercises should include core and LE strengthening as well

bull Must modify ldquoriskyrdquo exercises in the gym

bull Develop pre-practicegame dynamic warm-up

routines

bull Plyometric progressions (wall dribbles chest pass etc) if applicable

bull Unilateral loading (sliders pressing pulling)

Exercise Prescriptionbull Risk vs reward

bull Kinetic chain mobility and stability define risk and ability

bull Recreational vs elite

bull Individualized plan

based on history needs analysis and

goals

27

Exercise Modifications (video)

Return to Activitybull Re-assess FMS (if needed)

bull Observe Upper Quarter Y-Balance Test

bull Maintain daily mobility work and essential

scapular and RC exercises 2-3xweek

bull Gradually work back to overhead work

bull Begin interval throwing hitting lifting or swimming training program (evidence-

informed and graded dosage)

Upper Quarter YBT (Video)

28

Interval Throwing

bull Typical program in non-operative thrower lasts 4-6 weeks

bull Post-op throwing depends on procedure

bull Demands vary based on position

bull Pitchers must work up to 120 feet in long toss in most cases before mound throwing

bull Focus on fastball and change up initially

Long Toss Research

bull Hard horizontal flat-ground throws have biomechanical patterns similar to those of

pitching and are therefore reasonable exercises for pitchers

bull However maximum-distance throws produce

increased torques and changes in kinematics

bull Caution is advised in the use of these max distance throws for rehabilitation and training

Fleisig et al JOSPT 2011

Conclusion

bull Find right balance bw mobility amp stability

bull Assess the entire kinetic chain

bull Consider modifying or eliminating ldquoat riskrdquo positions and exercises to prevent injury

bull Utilize evidence-based client-specific

exercises and functional progressions

29

Contact Info

bull Brian Schiff PT OCS CSCS

bull wwwBrianSchiffcom

bull infoBrianSchiffcom

bull Twitter - brianschiff

Referencesbull Batalha NM Raimundo AM Tomas-Carus P Barbosa TM Silva AJ Shoulder rotator cuff

balance strength and endurance in young swimmers during a competitive season J

Strength Cond Res 2013 Sep27(9)2562-8

bull Crotin RL Ramsey DK Injury prevention for throwing athletes part II critical instant training Strength Cond J 201234(3)49-57

bull Dilisio MF Noble JS Bell RH Traumatic supraspinatus tears in patients younger than 25

years Orthopedics 2015 Jul 138(7)e631-e634

bull Ellenbecker TS Kibler WB Bailie DS Caplinger R Davies GJ Riemann BL Reliability of scapular classification in examination of professional baseball players Clin Orthop Relat

Res 2012 Jun470(6)1540-4

bull Ellenbecker TS Sueyoshi T Bailie DS Muscular activation during plyometric exercises in 90deg of glenohumeral joint abduction Sports Health 20157(1)75-9

bull Escamilla RF Hooks TR Wilk KE Optimal management of shoulder impingement

syndrome Open Access J Sports Med 2014 Feb 28513-24

Referencesbull Fleisig GS Andrews JR Dillman CJ Escamilla RF Kinetics of baseball pitching with

implications about injury mechanism Am J Sports Med 199523(2)233-239

bull Fleisig GS Barrentine SM Escamilla RF Andrews JR Biomechanics of overhand throwing with implications for injuries Am J Sports Med 199621421-437

bull Fleisig GS Bolt B Fortenbraugh D Wilk KE Andrews JR Biomechanical comparisons of baseball pitching and long-toss implications for training and rehabilitation J Orthop Sports

Phys Ther 201141 296-303

bull Gerber LH Shah J Rosenberger W Armstring K Turo D Heimur J Thaker N Sikdar S Dry needling alters trigger points in the upper trapezius muscle and reduces pain in subjects with chronic myofascial pain PM R 20157(7)711-8

bull Gillet J OrsquoBrien L Ryan M Rogowski J Strategic Exercise prescription for baseball bridging the gap between injury prevention and power production Strength Cond J 200935(1)81-88

bull Harshbarger ND Eppelheimer BL ValovichMcLeod TC Welch McCarty C The effectiveness of shoulder stretching and joint mobilizations on posterior shoulder tightness J Sport Rehabil

2013 Nov22(4)313-9

bull Kolber MJ BeekhuizenKS Cheng MS Hellman MA Shoulder injuries attributed to resistance training a brief review J Strength Cond Res 201024(6)1696ndash1704

bull Manske RC Ellenbecker TS Current Concepts in Shoulder Examination of the Overhead

30

Referencesbull Manske RC Meschke M Porter A Smith B Reiman M A randomized controlled single-

blinded comparison of stretching versus stretching and joint mobilization for posterior shoulder tightness measured by internal rotation motion loss Sports Health 20102(2)94-10

bull Oyama S Myers JB Wassinger CA Ricci RD Lephart SM Asymmetric resting scapular posture in healthy overhead athletes J Athl Train 200843(6)565ndash570

bull Reinold MM Escamilla R Wilk KE Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature J Orthop Sports Phys Ther 200939(2)105-117

bull Reinold MM Gill TJ Wilk KE Andrews JR Current concepts in the evaluation and treatment of the shoulder in overhead throwing athletes part 2 injury prevention and treatment Sports Health 20102(2)101-15

bull Reinold MM Macrina LC Wilk KE Fleisig GS Dun S Barrentine SW Ellerbusch MT Andrews JR Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises J Athl Train 2007 Oct-Dec42(4)464-9

Referencesbull Reinold MM Wilk KE Fleisig GS Zheng N Barrentine SW Chmielewski T Cody RC Jameson GG

Andrews JR Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises J Orthop Sports Phys Ther 2004 Jul34(7)385-94

bull Reinold MM Wilk KE Macrina LC Sheheane C Dun S Fleisig GS Crenshaw K Andrews JR Changes in shoulder and elbow passive range of motion after pitching in professional baseball players Am J Sports Med 200836(3)523-527

bull Rha DW Park GY Kim YK Kim MT Lee SC Comparison of the therapeutic effects of ultrasound-guided platelet-rich plasma injection and dry needling in rotator cuff disease a randomized controlled trial Clin Rehabil 2013 Feb27(2)113-22

bull Roetert PE Ellenbecker TS Reid M Bioemchanics of the tennis serve implications for strength training Strength Cond J 200931(4)35-40

bull Roy JS Braen C Leblond J Desmeules F Dionne CE MacDermid JC Bureau NJ Fremont P Diagnostic accuracy of ultrasonography MRI and MR arthrography in the characterisation of rotator cuff disorders a meta-analysis Br J Sports Med 20151316-28

Referencesbull Shanley E Rauh MJ Michener LA Ellenbecker TS Garrison JC Thigpen CA Shoulder range of

motion measures as risk factors for shoulder and elbow injuries in high school softball and baseball players Am J Sports Med 2011 391997-2006

bull Timmons MK Ericksen JJ Yesilyaprak SS Michener LA Empty can exercise provokes more pain and has undesirable biomechanics compared with full can exercise J Shoulder Elbow Surg 2015 Nov 11 pii S1058-2746(15)00483-8 doi 101016jjse201508046 [Epub ahead of print]

bull Tyler TF Nicholas SJ Lee SJ Mullaney M McHugh MP Correction of posterior shoulder tightness is associated with symptoms resolution in patients with internal impingement Am J Sports Med 201038(1)114-119

bull Wilk KE Hooks TR Macrina LC The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete J Orthop Sports Phys Ther 201343(12)891-4

bull Wilk KE Reinold MM Macrina LC Porterfield R Devine KM Suarez K Andrews JR Glenohumeral internal rotation measurements differ depending on stabilization techniques Sports Health 200912131-136