Shoulder pain is a prevalent musculoskeletal condition, affecting up to 50% of the population annually. It's the third most common issue seen in primary care and has significant impacts on physical and mental well-being. One in four individuals may experience recurrent shoulder pain, with up to 40% of new cases persisting after a year. Fortunately, accurate diagnosis and targeted physiotherapy can improve pain and function effectively.
What is RCRSP and Shoulder Instability?
RCRSP refers to pain originating from the rotator cuff muscles-tendon unit and the subacromial bursa. It includes conditions such as subacromial bursitis, rotator cuff tears, and tendinopathies. The rotator cuff is involved in 80% of shoulder pain cases.
Shoulder instability involves excessive movement of the humeral head on the glenoid, leading to pain or apprehension. This condition can manifest as fear or sensations of instability during specific movements and is categorised by the direction of instability, mechanism of injury (traumatic or atraumatic), and the extent of structural or muscular deficits.
Why is Shoulder Stability Important?
The shoulder joint is a ball-and-socket structure formed by the humeral head (the ball) and the glenoid (the socket). The shallow glenoid cavity requires significant support from soft tissues—such as the rotator cuff, labrum, joint capsule, and ligaments—for stability. This setup allows for a wide range of motion, enabling various activities, from overhead reaching to throwing.
What Are the Rotator Cuff Muscles and Their Role in Stability?
The four rotator cuff muscles originate from the scapula and attach to the humerus. They are integral in stabilising the humeral head during arm movements, working alongside the periscapular muscles to position the scapula effectively. This collaboration allows the shoulder to bear loads in vulnerable positions, enabling activities like swimming, weightlifting, and throwing.
Causes and Risk Factors for RCRSP
RCRSP is a multifactorial condition influenced by various factors, including:
Age: The risk of rotator cuff tears increases significantly after age 50. Surprisingly, older individuals may have asymptomatic tears more often than painful ones.
Load: Excessive or insufficient loading can lead to sensitivity and pain. Those in jobs or sports with repetitive overhead activities are particularly at risk.
Lifestyle Factors: Smoking, obesity, and metabolic syndrome contribute to systemic inflammation, negatively affecting tendon health.
Strength: Deficits in external rotation and abduction strength are common but do not necessarily correlate with pain or disability.
Genetics: Certain genetic factors may increase susceptibility to RCRSP, with familial links observed in full-thickness rotator cuff tears.
Physio or Surgery for RCRSP?
Non-operative management, particularly physiotherapy, should be the first line of treatment for RCRSP. A significant majority of individuals with atraumatic full-thickness rotator cuff tears can achieve favourable outcomes through a structured physiotherapy program.
Surgery should be considered only for specific populations, such as:
Individuals under 65 with symptomatic, traumatic full-thickness tears aiming to return to high-level sports.
Those experiencing persistent pain and disability despite extensive physiotherapy.
Surgical options typically include subacromial decompression or rotator cuff repair, but recent studies question their efficacy compared to conservative treatments.
What About Injections?
Corticosteroid injections may provide temporary relief for RCRSP, but they do not alter the condition's natural progression and could increase future tear risks. Platelet-rich plasma injections have shown no significant advantages over placebo in clinical trials.
Common Misconceptions About RCRSP
"My scan shows a rotator cuff tear; I need surgery.": Many rotator cuff tears are found in asymptomatic individuals. Surgery may not improve outcomes compared to exercise therapy.
"My pain is due to impingement.": Subacromial impingement is not necessarily the primary cause of shoulder pain, and research shows it can occur without pain.
"Tear size predicts my pain.": The size of a rotator cuff tear does not correlate with pain or disability, which are often influenced more by psychological factors.
Improving Your Prognosis
A structured, progressive shoulder strengthening program for at least 12 weeks can lead to significant functional improvements. Physiotherapy can guide activity modification and symptom management. Maintaining a positive outlook, being patient, and addressing modifiable lifestyle factors can further support recovery.
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