WAKEFIELD SHOULDER PROGRAM

The Wakefield Shoulder program applies particularly for rotator cuff tendinopathy (also called rotator cuff tendinitis and impingement) but is also relevant for treating rotator cuff tears, and adhesive capsulitis (also known as frozen shoulder.)

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​​Such disorders of the shoulder are best managed by an integrated team providing precise assessment and investigation, with evidence-based management comprising physiotherapy and other non-operative modalities, as well as surgical reconstruction and repair where appropriate – which aims to restore:

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Where do you start?

A good history and careful examination will often provide an answer.  Testing for range of motion, muscle power, and tenderness are key steps.  Weakness of the Rotator cuff muscles is commonly the major issue in such shoulder problems, and can be quite subtle.

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What is the best way to investigate?

A plain x-ray is the most useful primary investigation for shoulder pain and will provide important information on many conditions including arthritis, instability and indicators of the chronicity of the possible cuff tear.

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This is consistent with published recommendations such as American College of Radiology Appropriateness Criteria – Click here to review the recommendations for shoulders: https://acsearch.acr.org/docs/3101482/Narrative/

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Asymptomatic partial and full thickness rotator cuff tears are so common in patients over 60 that they are often within normal limits for age related tendon changes. Thus, simply finding a tear on ultrasound is not an indication for surgery.

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Ultrasound and MRI studies should therefore not be ordered routinely, and certainly not as the first investigation. They can be considered as secondary investigations if the diagnosis is in doubt, or if surgery is being considered.

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The key is to make a diagnosis based on the clinical findings, supplemented by plain x-rays, and progress to further investigation (Ultrasound and MRI) if the initial response to “appropriate” treatment is unsuccessful, or the diagnosis is not clear.

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What about Sub-Acromial Steroid Injection for Rotator Cuff Tendinopathy?

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There is no proven benefit for steroid injection in rotator cuff tendinitis, and although the can occasionally provide short term improvements in pain, can cause tendon softening and damage with increased risk of tearing.

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Subacromial steroid should be avoided, and used sparingly, and only as part of an overall shoulder rehabilitation program.  They should virtually never be used as the first line treatment, and repeated injections could potentially cause major reversable damage to the shoulder structures. 

What about muscle strength?

Rotator cuff weakness can be quite subtle, but can be demonstrated by a careful examination technique. ​ Regaining strength of the rotator muscle using a targeted exercise program is a crucial part of the treatment for most patients.

The key muscle is INFRASPINATUS (ISP)

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The Deltoid can be activated with any degree of shoulder abduction, masking the underlying ISP weakness. Examination using a shoulder adduction strap can be very helpful in improving examination acumen.

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The images below show how activation of deltoid can mask ISP weakness.