I was talking with a gentleman recently and the topic of shoulder pain came up. His shoulder had been hurting for a few months, and he had been having trouble lifting and reaching over head as well as getting comfortable enough for good sleep. So he went into see his physician and got some scans that showed a partial rotator cuff tear. He was afraid that his shoulder was permanently damaged, and that he was going to need surgery. I told him that he probably would not need surgery-- physical therapy and a few home exercises would most likely get him back to normal.

Let’s take a quick look at some of the current research.

First, rotator cuff tears are pretty darn common, affecting, very conservatively, 10% of those over the age of 60 or 5.7 million people in the United States.1-2 Other research suggests that rotator cuff tears are far more prevalent—about 35% of those in their 40s, 50% of those in their 60s and 80% of those in their 80s.3

Interestingly, a rotator cuff tear can be completely pain free, with up to 96% of people being unaware that they even have an injury or abnormality!3-4 This is because most tears arise from slow, age-related changes overtime that your body adapts and gets used to. No perceived threat or danger = no pain.5

However, when the change to the rotator cuff happens suddenly (during a fall, car crash, etc.) your body has no time to adapt. That’s when you really feel it!

Rotator cuff repairs are performed on between 75,000–250,000 patients per year in the United States.6,7However, rotator cuff repairs fail at a surprisingly high-- 25% to 90%.8 But here’s the real shocker… patient satisfaction and functional outcomes are the virtually identical regardless of the repair being intact or failing!9

How can that be?

Well, Kuhn et al, 2013 thought that the physical rehabilitation post-operatively may be the actual cause of the successful recovery in most people. They looked at more than 400 patients with atraumatic full-thickness rotator cuff tears (completely ruptured tendons). Instead of surgery these patients were treated by a physical therapist for 6 weeks (averaging 8 treatments) and given a good home program of therapeutic exercises. At the 6-week follow up patients could declare themselves 1) cured, 2) improved or 3) in need of surgery.

Only 9% felt that they needed surgery.

Of those that indicated “improved” an additional 6 weeks of physical therapy (averaging 7 treatments) and home exercise were given. Afterwards, only 6% felt they needed surgery—for a total of 59/399 or about 15%.

The physiotherapy stopped at this point, but patients could continue with the home exercises. However, Kuhn et al then kept track of the patients. At 1 year an additional 6% had opted for surgery. After 2 years the numbers got a little murky with about 15% of the patients not responding, but only 5% more reported electing surgical repair sometime in that 2nd year-- for a grand total of 26%.

Meaning that somewhere between 74-79% of people got better and stayed better with just 8-15 treatments with a physical therapist over a 6-to 12-week period and some home exercises!

What that tells us is that just because someone has a rotator cuff tear it doesn’t mean they are doomed to a lifetime of pain or need surgery to get back to normal. You might want to try some physical rehabilitation though!

Your outcomes at Optimum DPT would likely be even more favorable as we are an advanced practice physical therapy clinic with Osteopractic-and Fellowship-trained physiotherapists, the only one in northern Michigan.

First, Osteopractic Physical Therapy has been found to be 57% MORE effective for shoulder conditions compared to traditional physical therapy.10 Applied to Kuhn et al findings, this suggests that your odds of success with rehabilitation alone improves to about 89-91% when working with an osteopractic physiotherapist. Incidentally, osteopractic physical therapy was also found to decrease total health care utilization by 60% and the cost of care by 35% compared to conventional physical therapy.10 (Who doesn’t like saving time and money?)

Second, fellowship-trained physical therapists (Fellows or FAAOMPTs) have been found to be more efficient at treating musculoskeletal conditions, like rotator cuff tears, and produced better functional outcomes than residency-trained and entry-level physical therapists.11 So if you have body ache or pain working with a physical therapist who is a Fellow or FAAOMPT is the way to go if there is one practicing in your area!

Finally, Optimum DPT is one of a two physical therapy clinics in Michigan (and the only one in northern Michigan) certified to provide Personalized Blood Flow Restriction Rehabilitation.11I already talked about Blood Flow Restriction Rehabilitation in an earlier blog post; but to recap, Blood Flow Restriction supercharges rehabilitation for the maximum strength and endurance gains, muscle growth and tissue healing possible, even if an injury (like a rotator cuff tear) has made you too weak to perform traditional strengthening exercises.12-13

Check out this excellent video on BFR by Performance Physical Therapy & Wellness.

Bottom line, compared to traditional physical therapy, at Optimum DPT you are going to get better, faster… and, with our unique direct physical therapy practice, save a lot of money doing it!

If you or someone you know has been dealing with a rotator cuff issue or some other shoulder condition have them contact our Petoskey office at 231-881-9770 today.

Until next time,

Matthew Gaunt, DPT, ATC, Dip. Osteopractic, FAAOMPT

References:

1. Reilly et al., 2006. https://www.ncbi.nlm.nih.gov/pubmed/16551396

2. Werner, CA., 2011. (http://www.census.gov/prod/cen2010/briefs/c2010br-09.pdf)

3. Milgrom et al., 1994. http://bjj.boneandjoint.org.uk/content/jbjsbr/77-B/2/296.full.pdf

4. Girish et al., 2011. https://www.ncbi.nlm.nih.gov/pubmed/21940544

5. Moseley, L., 2011. https://www.youtube.com/watch?v=gwd-wLdIHjs

6. McCormick, H. Orthopaedic and Dental Industry News. Healthpoint Capital; NY, NY: Nov 22. 2004 ArthroCare closes opus medical acquisition

7. Vitale et al., 2006. https://www.ncbi.nlm.nih.gov/pubmed/17399623

8. Kuhn et al., 2013. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3748251/

9. Slabaugh et al., 2010. https://www.ncbi.nlm.nih.gov/pubmed/20206051

10. Fleury & Perreault, 2015. https://osteopractor.wordpress.com/2015/04/29/osteopractic-physical-therapy-cost-effectiveness-compared-to-national-average/

11. Rodeghero, et al., 2015. http://www.jospt.org/doi/pdf/10.2519/jospt.2015.5255

12. http://www.owensrecoveryscience.com/certified-providers/

13. Moore, Ciccone & Butts, 2017. https://osteopractor.wordpress.com/2017/08/16/the-science-and-evidence-blood-flow-restriction-training/

14. Hughes et al., 2017. http://bjsm.bmj.com/content/51/13/1003.long

Brief Case Report: A Runner with Lateral Foot Pain

One of our Optimum DPT members, a 36-year-old Petoskey man presented with complaints of sharp, 5-6/10 pain on the outside of his left foot. He woke with his pain after a 4-mile run down a gravel road the evening before. He noted several missteps (slight ankle rolls) during the jog due to pot holes; however, he denied pain at the time and indicated that he was able to complete the run without difficulty. He admitted to having had lateral ankle sprains (rolling his ankle) in his past during school sports, but otherwise had no history significant injury.

The gentleman could bear weight and walk, but he was limping. He indicated coming up onto the balls of his feet to be very painful, and that hoping and jogging were too painful to attempt. He presented with localized signs of inflammation--erythema (redness) and edema (swelling)-- at the lateral dorsal left foot but without ecchymosis (bruising). The area was tender to touch but not exquisitely so-- and the most acute tenderness located over the cuboid bone.

As he was able to bear weight at the suspected time of injury and in clinic, did not have sharp tenderness over his navicular bone nor at the base of his 5th metatarsal, he did not meet the Ottawa foot rules for referral for diagnostic imaging to rule out fracture.1

Active range of motion assessment was grossly normal save for pain with eversion. Strength assessment found mild loss of peroneal muscle strength and extensor strength of the lateral toes. A dorsal-plantar cuboid shear test reproduced familiar symptoms, and glide of the left cuboid seemed limited vs the right side.

Given the history, patient reports and findings an impression of an acute cuboid sprain with subsequent cuboid syndrome was made.

Cuboid syndrome is documented but not fully understood. Symptoms are believed to arise from the sprained cuboid impinging (pinching) the fibroadipose synovial folds surrounding the bone. In this condition the cuboid is not “out” of place, but may not moving normally with the surrounding bones. The sural, lateral plantar and other surrounding nerves may also be irritated by the sprain and/or subsequent inflammatory response.2

The condition has been found to respond favorably to manual therapy, specifically joint manipulation.2-4. The patient agreed to proceed with a high velocity, low amplitude thrust manipulation. A single cuboid manipulation was delivered, and an audible joint sound (pop) was felt and heard by both the patient and myself. The patient noted an immediate improvement in his point tenderness and ability to walk.

A follow-up appointment was schedule the next day. At that time the patient was walking normally, noting only trace discomfort, and had a marked reduction in the redness, swelling and point tenderness over his left cuboid. Left cuboid glide was found to be grossly equal to his right side.

About 24 hours after a high-velocity, low amplitude cuboid manipulation to treat the sprain.

No further treatment was indicated. The patient was advised to hold off running for week and return for further care if needed. He was contacted two weeks out and reported being pain free and to have resumed his usual runs.

If you or someone you know is experiencing foot or heel pain like the runner above (or any ache/pain really) click here and do not hesitate to contact Optimum DPT Osteopractic Physical Therapy Specialists of Michigan to see if we can help get you back to moving the way you want to move and doing the things you want to do! Click the link above or call our Petoskey office at 231-881-9770.

Until next time,

Matthew Gaunt, DPT, ATC, Dip. Osteopractic, FAAOMPT

References:

1. http://www.ohri.ca/emerg/cdr/docs/cdr_ankle_poster.pdf

2. Durall CJ. Examination and Treatment of Cuboid Syndrome: A Literature Review. Sports Health. 2011;3(6):514-519.

3. Jennings J, Davies GJ. Treatment of cuboid syndrome secondary to lateral ankle sprains a case series. J Orthop Sports Phys Ther. 2005;35(7):409-415

4. Blakeslee TJ, Morris JL. Cuboid syndrome and the significance of midtarsal joint stability. J Am Podiatr Med Assoc. 1987;77(12):638-642

Optimum DPT: Blog #5 Rotator Cuff Tears... it's not over for your shoulder!

Optimum DPT: Blog #3 A Runner With Lateral Foot Pain (Cuboid Sprain)

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