A  Practical  Guide  to  Rotator  Cuff  Rehabilitation

Julia  Walton  Specialist  Shoulder  Physiotherapist  

Manchester  Shoulder  Clinic  &  

Wrightington  Hospital

Its  been  a  journey………

● Joined  The  Nottingham  Shoulder  Unit  2002  

● Picked  up  lots  of  ideas  on  the  way…  

● Isolated  rotator  cuff  work  

● Kinetic  chain  

● No  recipe….  

● BUT  there  are  key  ingredients………

●Controls  humeral  head  ●Push/shoulder  flexion  

●Supraspinatus,  infraspinatus.  deltoid,  trapezius  and  serratus  anterior  higher  activation    

●Pull/shoulder  extension  ●Subscapularis  &  Lat  dorsi  higher  activation  (Wattanaprakornkul  et  al  2011)  

●In  combined  ER/Abduction    Supraspinatus  main  stabiliser.  Deltoid  has  a  role  too  ●  Subscap  less  (Tardo  et  al  2013)

What  does  the  rotator  cuff  do?  Stabilisers

●Infraspinatus  -­‐    Torque  producer  in  90  degrees  abd  for  IR/ER  (Tardo  et  al  2013)  

The  cuff  has  different  roles  in  different  positions  

 BUT  all  works  synergistically

What  does  the  rotator  cuff  do?  Torque  Producer

Where  do  we  begin?

● Improvement  testing  is  the  way  in  ● Positive  predictor  of  physio  success  

● Scapula  assist  ● ER/IR  recruitment  ● Kinetic  chain    ●Grip  ● Reinforce  afferent  input  

● visual    ●manual  ● audible  ● tactile

improvement    test!

What  does  the  rotator  cuff  need?

● Intact/functional  

● Comfortable  as  possible  

● Functional  range  of  movement    

● Good  mechanical  position  throughout    

●With  support  from  proximal  control    

● AND  tap  into  the  kinetic  chain  to  generate  functional  power  

All  of  these  LEAD  to  happier  rotator  cuff

What  goes  wrong?

● Ageing/Damage/injury  ● Stiffness  ● Disuse  ● Pain  inhibition  ● Poor  timing  ● Poor  control

● Doesn’t  switch  on    

● Poor  centralisation  of  HH  

● Can’t  cope  with  load  

● Fatigues

How  do  we  rehab  the  rotator  cuff? What  and  Where  do  we  need  to  train?

● So  is  it  all  about  strength?  

● Control  ● Proprioception  ● Timing  -­‐  presetting  ● Load    ● Endurance  -­‐  can  it  cope?

How  do  we  rehab  the  rotator  cuff? What  and  Where  do  we  need  to  train?

● So  is  it  all  about  strength?  

● Control  ● Proprioception  ● Timing  -­‐  presetting  ● Load    ● Endurance  -­‐  can  it  cope?

● Through  range  

●What  is  functional  to  them?

● So  is  it  all  about  strength?  

● Control  ● Proprioception  ● Timing  -­‐  presetting  ● Load    ● Endurance  -­‐  can  it  cope?

● Through  range  

●What  is  functional  to  them?

How  do  we  rehab  the  rotator  cuff? What  and  Where  do  we  need  to  train?

How  do  we  rehab  the  rotator  cuff? What  and  Where  do  we  need  to  train?

● So  is  it  all  about  strength?  

● Control  ● Proprioception  ● Timing  -­‐  presetting  ● Load    ● Endurance  -­‐  can  it  cope?

● Through  range  

●What  is  functional  to  them?

Key  components  for  RC  exercises

● Proprioception  

● Kinetic  chain  

● Rotational  control  &  loading  through  range

Which  exercises?  Consider  their  value

Key  components:   Proprioception  

● Vital  for  RC  function  

● Reflex  arc  from  capsule  to  shoulder  musculature  

● Mechano-­‐receptors  influence  muscle  recruitment  

● Enhancing  gleno-­‐humeral  control

● Stretch  

● Compression  

● Hand  grip    

● Isometrics  

● Reinforce  with  afferent  input

Key  components:  Kinetic  chain

●What  is  the  rotator  cuff  attached  too?  

●Mobility  vs  stability  

●Where  does  the  functional  power  come  from?  ● 50%  lower  limb  ● 30%  thoracic    ● 20%  arm

Key  components:  Kinetic  chain

• A  step  increases  scapulothoracic  recruitment  by  10%  

• Rotator  cuff  strength  improves  by  24%  when  scapula  is  retracted/stabilised  

Kibler et al 2006 Tate et al 2008

STOP  THE  PRESS!

Key  components:Kinetic  Chain  

● All  these  exercise  are  functional  patterns  we  can  recognise  for  a  reason  

● Textbook  ways  to  move  

● We  become  lazy  or  adapt  to  pain  and  injury    

● TROUBLE!

Key  components:Rotator  cuff  rotational  control  and  loading  

● Sometimes  rotator  cuff  with  kinetic  chain  is  not  enough…    

● RC  constantly  switches  its  roles  depending  on  position  and  gravitation  pull  (eccentric/concentric,  mover/stabiliser)    

● Large  ROM  -­‐  EOR  often  neglected  

● Proprioceptively  deficient  -­‐  appears  stiff!    

● Complements  Kinetic  chain