Rotator Cuff Injury Assessment & Suggested HEP

Every day I am reminded that certain structures of the shoulder tend to play more of a critical role than others. Not to say that some structures are useless or less important, but it seems like I am educating clients daily on how to improve the integrity and function of their rotator cuff complex.

Patient History and Assessment

In assessing the rotator cuff, I need to fully understand how it is affecting the patient’s ability to lead a normal life, i.e. grab a dish, lift their coffee, brush their hair, throw a baseball or any other desired function.

There are many factors that I need to consider:

• Age
• Activity level
• Injury history to that shoulder
• Response to previous treatment
• What the person felt helped them the most
• Any imaging and findings
• Medical history
• Joint status (hypermobile or hypo-mobile)
• The patient’s thoughts on what is going on with their shoulder
• The ultimate goal of the client

As I take the history, I keep a mental checklist that helps to guide the conversation and give me the answers that I need to hone in on a particular diagnosis and a treatment plan.

Once I formulate a theory about the potential issue and proper treatment strategy, I outline a plan to safely and effectively return the client back to their prior level of function. A critical aspect of my care is to educate on what I think MAY be going on and giving them a home exercise program that won’t overwhelm them.

Example of a Typical Program

At my practice, I only see most of my clients once per week or once every other week so the HEP is critical!

When people present with some form of shoulder pain, there are many potential treatment plans. For the purpose of this blog post, I will keep it simple and outline a generic program that will help restore pain-free ROM, strength, and slowly return them back to their function. In reality, I am constantly tweaking the program based upon response to the exercises, and most people certainly don’t take a linear recovery process.

Education Phase

It’s important to provide appropriate and accurate patient education. MedBridge makes this easy with an integrated patient education library that includes 14 different education videos on shoulder conditions. Below is an example of an assignable education video on Rotator Cuff Tear:

Acute Phase

In my acute series, I want to get the shoulder joint moving through self-ROM activities. I like to have the client foam roll their thoracic spine and lat muscles to help aid overhead mobility. I’ll then have them use a golf club to work on external rotation ROM at 45 degrees and 90 degrees of abduction. Following this, I’ll have them work on shoulder flexion AAROM while supine to get them comfortable with some form of active motion.

For initial strengthening, I like to begin with isometric activities to help with pain control because numerous studies have shown the analgesic effects.

Here’s an example of a few exercises that can be helpful in this phase:

Acute Phase Exercises

The author recommends the following exercises during this phase – Download the full program below.

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Note: It is the responsibility of the treating practitioner, relying on independent expertise and knowledge of the patient, to determine the best treatment and method of application for the patient.

Strength Phase

Once the client is feeling better, they can progress onto strengthening activities. I like to add isotonic strength training such as band work, full can, side-lying external rotation, prone horizontal abduction, prone extension and prone full can.

Numerous studies have shown the EMG activity of the rotator cuff and scapula stabilizers to be relatively high with most of these activities. Because of that, I like add all of these to a program but will change the weights, sets and rep schemes for each exercise based upon their tolerance I see while each exercise is performed. A periodized approach is critical. I will rarely have my clients perform three sets of ten repetitions, so the goal of the exercise needs to be fully understood in order to prescribe it correctly.

Here’s an example of a few exercises that can be helpful in this phase:

Strength Phase Exercises

The author recommends the following exercises during this phase – Download the full program below.

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• 
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Note: It is the responsibility of the treating practitioner, relying on independent expertise and knowledge of the patient, to determine the best treatment and method of application for the patient.

High-Level Strength Phase

Once an adequate base of strength is achieved, I will add higher level strength training for the shoulder and surrounding muscles. Depending on the situation and the athlete presenting in front of me, I will focus on higher level strength training to maximize strength and underlying power production.

I incorporate plyometric strength training to allow the athlete to produce and dissipate a force, hopefully helping them in their return to their sport. This may include medicine ball chest passes, overhead throws, and rotational throws, amongst many others.

Pull ups, push-ups, bench pressing and overhead pressing are also added to make sure the athlete is strong in multiple planes and can withstand the forces that will be generated when they get back to their normal function.

Return to Sport Phase

Finally, I like to outline a gradual return to sport program.

For example, in my baseball niche, I begin by having the athlete toss from 30 feet, then progress them out to approximately 150 feet. If they can get out that far, then I begin doing pull downs in which they throw more on a line and with full effort to continually work on arm strength. I tend to avoid throwing from further than 220 feet at this point because of the stresses on the shoulder and elbow.

If this goes well, then I will begin a mound program and slowly add fastball effort, and an increase in the number of throws over a period of weeks. Gradual mound progressions can take weeks to months depending on the situation and the goal of the athlete (and the timing of the season!).

Listen to the Patient

There are many variables that need to be considered when returning a patient back to their highest functional level after a rotator cuff injury. It starts with a well thought out and thorough subjective exam. It is extremely important to connect with the patient from the first visit and to continually assess and adjust as they report back to you.

In this post, I outlined a general program for an athlete with a rotator cuff issue, and what my thought process may be. It is by no means the only way to rehab a patient with a shoulder injury but it may be a good starting point. Remember, listen to their issues…they may just tell you what program is best for them!