Top 5 Fridays! 5 Points for Elite Athlete Rotator Cuff Management | Modern Manual Therapy Blog

Top 5 Fridays! 5 Points for Elite Athlete Rotator Cuff Management


This is an informative 5 post series on instagram from @physicaltherapyresearch. If you're viewing on desktop, make sure to click the little arrow on the side to see all the pics/videos for the entire post before moving on!
๐Ÿ“š๐Ÿ”ฌ SERIES(0/5) Elite Athlete Rotator Cuff Injury Management โ„น️ Injuries to the rotator cuff are a common across all sports and levels of competition. โ„น️ A spectrum of severity exists, ranging from contusions and tendinopathies to tears and can be classified as either partial-thickness of full-thickness disruptions. โ„น️ Injuries to the rotator cuff can be treated either conservatively or surgically, and in the elite athlete, there are many factors for the treating clinician to consider, including: Sport Level of contact Positional demands Time of year Post-season and financial implications. โ„น️ Weiss et al. (2018) examined in-season management of rotator cuff injuries in elite athletes. . ๐Ÿ’ช๐Ÿผ๐Ÿ’ช๐Ÿผ RELEVENT ANATOMY: Supraspinatus: Abduction Infraspinatus and Teres minor: External rotators Subscapularis: Internal rotation ๐Ÿ’ช๐Ÿผ A disruption or injury can affect glenohumeral joint stability and disrupt normal shoulder kinematics. . ๐Ÿ“๐Ÿ“ CLASSIFICATION: Classification of a rotator cuff tear is important to guide treatment and to allow comparison between outcome studies. . ๐Ÿ“ A tear may be classified based on size of the lesion, the number of tendons involved, and signal abnormality in the tendon on MRI. . ๐Ÿ“ [A] Rotator cuff contusion: Acute MOI Increased signal intensity in the tendon and overlying bursa, but no tear. Associated bone marrow edema Fluid collection in the subacromial/sub-deltoid region, suggestive of an acute bleed . ๐Ÿ“ Tendinopathy: Abnormal signal intensity on MRI. Thickening of the tendon. Common in repetitive overhead athletes. ๐Ÿ“ [B] Tendonosis can also develop in football players from years of heavy weight lifting exercises. . ๐Ÿ“ Partial thickness tears may develop in tendons with underlying tendinosis ๐Ÿ“ A full thickness tear in a young athlete is less common, but often seen with pre-existing tendonosis (acute on chronic presentation). . ↗️↗️↗️ Don’t miss anything! Turn on Post Notifications ✅✅ Next Up: 1. Clinical Presentation 2. Early Rehabilitation 3. Intermediate Phase 4. Advanced/Late Stage Rehabilitation 5. Future Directions and Conclusions ๐Ÿ“š๐Ÿ“š๐Ÿ“š SOURCE: Weiss et al. 2018. Management of Rotator Cuff Injuries in the Elite Athlet
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๐Ÿ“š๐Ÿ”ฌ SERIES(1/5):Clinical Presentation Elite Athlete Rotator Cuff Injury Management ๐Ÿ”๐Ÿ” CLINICAL PRESENTATION: Can vary by type of injury and mechanism of onset. ๐Ÿ” Examination of the athlete should include: History including, arm position during MOI Thorough palpation. Cervical spine and elbow ruled out. Active & passive ROM Strength of shoulder & scapular musculature. Glenohumeral stability. ๐Ÿ” Athletes will often demonstrate a painful arc of active motion. . ๐Ÿ” Overhead athletes with rotator cuff pathology may present with GIRD; (excessive passive external rotation and limited internal rotation at 90 degrees of glenohumeral abduction (>20ยบ vs. normal side) ๐Ÿ–ฅ๐Ÿ–ฅ Imaging includes: Plain radiographs - rule out bony injury & assess for pre-existing degenerative changes . ๐Ÿ–ฅ MRI scan - gold standard to assess integrity of the rotator cuff tendon, musculature, labrum and articular cartilage. . ๐Ÿ–ฅ Diagnostic ultrasound - Dynamic assessment of rotator cuff injury ๐Ÿ–ฅ Particularly in the setting of elite athletes, it is beneficial to have a designated musculoskeletal radiologist who is experienced with athlete-specific pathology to partner with for such studies. . ๐Ÿ™Œ๐Ÿผ๐Ÿ™Œ๐Ÿผ REHABILITATION: Conservative management should include a comprehensive program. . ๐Ÿ™Œ๐Ÿผ A recent review by Edwards et al. (2016), provided an evidence-based 4-phase exercise protocol for the conservative management of rotator cuff injury. ๐Ÿ™Œ๐Ÿผ Including: 1. Range of motion 2. Flexibility 3. Strengthening 4. Advanced strengthening/proprioception. . ๐Ÿ™Œ๐Ÿผ Focused on: Eliminating initial pain Improving mobility Addressing stability, strength, power, and neuromuscular control Correcting identifiable issues along the kinematic chain. . ๐Ÿ™Œ๐Ÿผ Programs should be progressive and sport-specific for RTP preparation. ↗️↗️↗️ Don’t miss anything! Turn on Post Notifications ✅✅ Next Up: 2. Early Rehabilitation 3. Intermediate Phase 4. Advanced/Late Stage Rehabilitation 5. Future Directions and Conclusions ๐Ÿ“š๐Ÿ“š๐Ÿ“š SOURCES: Weiss et al. 2018. Management of Rotator Cuff Injuries in the Elite Athlete. Cur Rev Musc Med. . ๐Ÿ“š Edwards et al. 2016. Exercise rehabilitation in the non-operative management of rotator cuff t
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๐Ÿ“š๐Ÿ”ฌ SERIES(2/5): Early Rehabilitation Elite Athlete Rotator Cuff Injury Management โ„น️ Early rehabilitation should focus on the reduction of: Pain. Inflammation. Swelling. Restoring normal ROM. โ„น️ This can be accomplished using both local physical modalities in addition to manual therapies. โ„น️ The athlete should also avoid activities which reproduce symptoms. . ๐Ÿ™Œ๐Ÿผ๐Ÿ™Œ๐Ÿผ Manual therapies such as joint mobilization and passive ROM can help restore normal joint kinematics and improve shoulder ROM ๐Ÿ™Œ๐Ÿผ Grade I and grade II glenohumeral joint mobilization techniques can be performed to reduce pain, decrease muscle guarding and improve ROM. ๐Ÿ’ช๐Ÿผ Also, Codman’s pendulum exercise is safe and can reduce stiffness and improve ROM. ๐Ÿ’ช๐Ÿผ ROM exercises can be progressed to active-assisted, followed by active-unassisted exercises. . ๐Ÿ’ช๐Ÿผ Internal rotation limitations in overhead athletes, are commonly related to chronic tightness of the posterior rotator cuff and shoulder musculature caused by poor position of the scapula, or the posterior joint capsule. ๐Ÿค™๐Ÿผ [A] The modified sleeper stretch can effectively increase shoulder internal rotation. . ๐Ÿค™๐Ÿผ [B] the modified cross-body stretch can effectively increase horizontal adduction ๐Ÿค™๐Ÿผ Stretching the pectoralis minor may also help improve scapular mechanics and overall shoulder function. . ๐ŸŠ๐Ÿผ‍♂️ Aquatic therapy early in the rehabilitation process can help restore active ROM, normal shoulder kinematics, and prepare the shoulder for progression to land-based activities. . ⚡️ Neuromuscular electrical stimulation can assist with neuromuscular re-education and reducing muscle inhibition. ⚡️ Isometric exercises are also a safe and effective way early in the rehabilitation process to promote muscle activation. ↗️↗️↗️ Don’t miss anything! Turn on Post Notifications ✅✅ Next Up: 3. Intermediate Phase 4. Advanced/Late Stage Rehabilitation 5. Future Directions and Conclusions ๐Ÿ“š๐Ÿ“š๐Ÿ“š SOURCE: Weiss et al. 2018. Management of Rotator Cuff Injuries in the Elite Athlete. Cur Rev Musc Med.
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๐Ÿ“š๐Ÿ”ฌ SERIES(3/5): Intermediate Phase Elite Athlete Rotator Cuff Injury Management โ„น️ A progressive strengthening program focused on scapular musculature and the rotator cuff should be included. โ„น️ Neuromuscular control focused on proximal stability should be focused on prior to addressing distal segment mobility. โ„น️ Human and sports-related movement occurs in orchestrated interactions between many joints in multiple planes. โ„น️ Scapulothoracic articulation serves an essential bridge between the core musculature and lower extremity to transfer kinetic energy up the chain. โ„น️ Abnormal scapular kinematics can be caused by pain associated with injury, soft tissue tightness, strength imbalances, and deficiencies in muscle activity. โ„น️ Targeting serratus anterior and middle and lower trapezius, while minimizing upper trapezius activation, can enhance scapulohumeral rhythm and glenohumeral position in space, thus allowing better function of the rotator cuff during shoulder activities. ๐Ÿ’ช๐Ÿผ A progressive scapular strengthening program should include both: [A] Open kinetic chain activities; Ex. Wall Ball Bounces ๐Ÿ’ช๐Ÿผ [B] Closed kinetic chain activities; Ex. Roller + Ext Rot ๐Ÿ’ช๐Ÿผ The ‘Push-up plus” has also been shown to generate high muscle activation of the serratus anterior. ๐Ÿ’ช๐Ÿผ [C] Studies have demonstrated that sidelying external rotation produces high EMG activity in both the infraspinatus and teres minor. . ๐Ÿ’ช๐Ÿผ The “Thrower’s 10” program is a progressive isotonic strengthening program based on EMG data, addressing rotator cuff strength and scapular stabilization. . ๐Ÿ’ช๐Ÿผ Blood flow restriction (BFR) training is a newer technique that can be used as an adjunct to traditional resistance training during this stage. ๐Ÿ’ช๐Ÿผ Hypertrophy and strength similar to that of higher load resistance training have been seen with BFR. ๐Ÿ’ช๐Ÿผ However, further research is needed to determine the overall efficacy for athletes with rotator cuff injury. . ↗️↗️↗️ Don’t miss anything! Turn on Post Notifications ✅✅ Next Up: 4. Advanced/Late Stage Rehabilitation 5. Future Directions and Conclusions ๐Ÿ“š๐Ÿ“š๐Ÿ“š SOURCE: Weiss et al. 2018. Management of Rotator Cuff Injuries in the Elite Athlete. C
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๐Ÿ“š๐Ÿ”ฌ SERIES(4/5): Advanced/Late Stage Rehabilitation Elite Athlete Rotator Cuff Injury Management โ„น️ Advanced strength & endurance training, dynamic stabilization, and sport-specific activities should be considered. โ„น️ Including sport- and position-specific drills. โ„น️ Careful collaboration between medical, rehab, and strength & conditioning staff is required to progress the athlete back into full weight training activities. ๐Ÿ’ช๐Ÿผ Strength training should address: Upper body pulling exercises. Upper body pressing exercises. Core stability exercises. ๐Ÿ’ช๐Ÿผ [A] Upper extremity plyometric exercises can be introduced and can improve proprioception, kinesthesia, and muscular endurance for the rotator cuff. . ๐Ÿ’ช๐Ÿผ Plyometric exercises involve three distinct phases: 1. Eccentric pre-stretch 2. Amortization phase 3. Concentric contraction. . ๐Ÿ’ช๐Ÿผ The amortization phase, defined as the time between the eccentric and concentric phases, should be as short as possible to allow for adequate energy transfer. . ๐Ÿ’ช๐Ÿผ Upper extremity plyometric exercises usually include throws, which are progressed from two-handed to one-handed drills, and performed in a variety of conditions (tall knee, half kneel, unstable surface). . ๐Ÿ’ช๐Ÿผ [B] Rhythmic stabilization exercises can be progressed to more complex exercises to include unstable surfaces and performance on a physioball to improve overall neuromuscular control. . ๐Ÿ’ช๐Ÿผ For the overhead thrower, a throwing program can be initiated and should include a graded training, carefully monitoring quantity of throws, distance, intensity, and types of throws. ↗️↗️↗️ Don’t miss anything! Turn on Post Notifications ✅✅ Next Up: 5. Future Directions and Conclusions ๐Ÿ“š๐Ÿ“š๐Ÿ“š SOURCE: Weiss et al. 2018. Management of Rotator Cuff Injuries in the Elite Athlete. Cur Rev Musc Med.
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๐Ÿ“š๐Ÿ”ฌ SERIES FINALE(5/5): Make sure swipe for @rehabscience great video of ๐Ÿ’ฅ๐‘๐จ๐ญ๐š๐ญ๐จ๐ซ ๐‚๐ฎ๐Ÿ๐Ÿ ๐€๐ง๐š๐ญ๐จ๐ฆ๐ฒ๐Ÿ’ฅ ✅✅✅ RTP, Future Directions, Conclusions ๐Ÿƒ๐Ÿฝ‍♂️ Return-to-Competition: RTP decisions should be made collaboratively with the team physician, rehabilitation staff, and the athlete. . ๐Ÿƒ๐Ÿฝ‍♂️ Physical exam findings should be consistent with pre-injury levels of pain, ROM, stability, strength, and overall function. . ๐Ÿƒ๐Ÿฝ‍♂️ The athlete should demonstrate adequate: Power. Muscular endurance. Sport-specific demands. ๐Ÿƒ๐Ÿฝ‍♂️ RTP should be step-wise and the athlete should be carefully monitored to avoid a repeat injury. . ➡️➡️ FUTURE DIRECTIONS: Current options for biologic augmentation include: PRP injection Cell-based therapy. . ➡️ However, there is currently limited data to suggest that PRP is effective in treatment of tendinopathy or tendon healing. . ➡️ Cell-based approaches (“stem cells”) also appear to have great potential for improvement of tendon healing. . ➡️ Promising approaches in the area of stem cell research include: ➡️ Potential use of induced pluripotent stem cells (iPSC’s) Stimulating the endogenous stem cells (“intrinsic stem cell niche”) that are known to be present in many tissues, including tendon. . ➡️ Ongoing research can provides further insight into the development of novel pharmacologic agents and other approaches to improve tendon healing. . ❗️❗️ CONCLSIONS: Rotator cuff injuries remain a common cause of pain and dysfunction for the elite athlete and can result in time loss from participation. . ❗️ Many of these injuries can be managed conservatively in-season with anti-inflammatories, injection, and a comprehensive rehabilitation program. . ❗️ Non-Responders to conservative management may be managed surgically, during off-season or immediately based on current level of dysfunction and ability to meet sport-specific demands. . ❗️ Newer treatments such as blood flow restriction therapy, and biologics are supported by some early data but require more level I studies. ❗️ An early and accurate diagnosis followed by individualized rehab will allow the greatest opportunity to RTP both expediently and safely. . ๐Ÿ“š๐Ÿ“š๐Ÿ“š
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