INTRODUCTION
The rotator cuff is a group of muscles that surround the shoulder joint. These rotator cuff muscles keep the head of the humerus in the glenoid cavity of the scapula that means these muscles are the stabilizers of the glenohumeral joint.
There are 4 muscles in rotator cuff:-
👉 supraspinatus
👉 infraspinatus
👉 teres minor
👉 subscapularis
RC injuries are common injuries that can occur at any age. In younger group, overhead activity performed in repetitions can lead to trauma on muscles, as seen in throwers, badminton players, bowlers, painters, cleaners, etc. With increase in age, the RC injuries may be due to muscle degeneration, impingement and tearing.
CLINICAL FEATURES OF RC INJURIES
Clinical features will depend upon the size of tear. The rotator cuff tear can be divided into grades:-
👉 grade 1- a tear of less than 1cm
👉 grade 2- a tear of 1-3cm
👉 grade 3- a tear of 3- 5cm.
👉 grade 4- complete tear of more than 5cm
Symptoms will depend upon the grades and location of tear. Normally, tear are located in 3 region:-
👉 Superior region
👉 supero-posterior region
👉 supero-anterior region
Pain is the chief complaint of the patient with RC tear.
Supero-anterior location of tear will have pain in bicipital groove area. Supero-posterior location of tear will have pain on the posterior region of humerus and will also have subscapularis muscle affected. Such patient will completely unable to perform internal rotation.
Restriction of movement will also vary with above grades and location. Grade 1 and grade 2 will have difficulty in performing overhead activity and repeated external rotation. Grade 3 and 4 will show sign of superior instability.
Strength of rotator cuff muscles will be diminished not beyond 2+ although scapular stabilisers will be strong.
Functional inability will be noted in performing activities like combing, wearing clothes, reaching overhead objects, etc.
DIAGNOSTIC TEST OF RC PATHOLOGY
Hawkins Kennedy test
Neer's Impingement Test
Empty Can test
Painful arc test
MANAGEMENT
Grade 1 and Grade 2 tear can be treated conservatively, like pain management by TENS, IFT, U.S. LASER, etc
If conservative treatment is not giving any result then we have to undergo surgical treatment and same protocol is followed for grade 3 and grade 4.
GOALS OF TREATMENT
👉 to maintain the integrity of rotator cuff, do not overuse the healing tissue.
👉 to reestablish dynamic humeral head control which means maintenence of scapula rythm and avoiding shoulder shrugging movement
👉 to reestablish muscular balance.
👉 to improve the R.O.M. of shoulder especially in external and internal rotation and elevation
👉 to restore the patients functional ability.
PROTOCOL FOR THE MANAGEMENT OF SURGICAL CORRECTION
It was given by Cohen and Romeo.
Immediate post operative, Iceing to the/ localised cryotherapy around the site of incision, no R.O.M exercises at shoulder and full R.O.M. at elbow and hand.
Initiation of R.O.M. at shoulder will depend upon size of tear. If the tear is 1cm, then the exercise should be started from 15 days, medium tear (1-3)cm- no R.O.M. for 3 weeks. Large tear (3-5)cm - no R.O.M. for 5 weeks. Massive tear - sling is applied for 6 weeks.
Perform isometrics of all shoulder muscles to prevent muscular weakness due to immobilisation.
If R.O.M. is initiated in shoulder, it is done passively by the therapist upto a limit of flexion 120 degree, abduction not beyond 90-100 degrees and rotation not 30 degrees.
No strengthening of muscle in this range is done.
6-8 weeks, strengthening of muscles in the available range can be started and continued for further 2 weeks using theraband.
10-12 weeks, increase the R.O.M. of shoulder performing active assisted exercises using WAND and PULLEY exercises upto the limit of forward flexion upto150-160 degree, abduction upto 120 degrees and rotation upto 60 degrees.
12-14 weeks, begin with strengthening exercises of shoulder using weight cups or manual resistence.
Upto 16 weeks, the patient achieves full R.O.M. full strengthening and full functional ability.
After 4 months, the patient is put on a home exercise programme which requires performence of capsular stretches in anterior, posterior, and inferior direction maintaining of shoulder strength by performing resisted exercises of shoulder using weight, cuff, medicinal balls.
In case of instability, due to injury to surrounding ligaments and labrum with R.C. muscle tear, the protocol of management will be the same except the duration of rehabilitation will increase.
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