Rotator Cuff Tendinopathy
Original Editors - <a href="User:Miguel Gonzalez-Rodriguez">Miguel Gonzalez-Rodriguez</a> as part of the <a _fcknotitle="true" href="Vrije Universiteit Brussel Evidence-based Practice Project">Vrije Universiteit Brussel Evidence-based Practice Project</a> evidence based practice project.
The patho-etiology of rotator cuff tendinopathy is multifactorial. Rotator cuff tendinopathy can be attributed to extrinsic and intrinsic mechanisms, as well as to environmental factors. Rotator cuff tendinopathy is not a homogenous entity because of the diverse nature of the factors involved and hence, different treatment interventions are required which take these specific mechanisms/factors into account. Rotator cuff tendinopathy can be classified into subgroups based on the underlying mechanisms. The treatment outcomes can be improved when the diagnosis is based on the classification showed below.
<img src="/images/1/15/Schema_rotator_cuff_tendinopathy.png" _fck_mw_filename="Schema rotator cuff tendinopathy.png" alt="" />
Extrinsic factors are causing compression on the rotator cuff tendon, the bursal side and encroach upon the subacromial space. This compression can be caused by anatomical variants of the acromion, alterations in scapular or humeral kinematics, postural abnormalities, rotator cuff and scapular muscle performance deficits and decreased extensibility of the pectoralis minor or posterior shoulder. There is also an unique extrinsic mechanism, termed internal impingment where there is compression of the posterior articular surface of the tendons between the humeral head and glenoid and which is not related to the subacromial space narrowing.
Intrinsic factors that contribute to rotator cuff tendon degradation with tensile or shear overload are alternations in biology, mechanical properties, morphology and vascularity. So the intrinsic factors have an influence on the morphology and performance of the tendon.
(SEITZ A., McCLURE P., FINUCANE S., BOARDMAN D., MICHENER L.; Mechanics of rotatot cuff tendinopathy: intrinsic, extrinsic, or both?; ‘http://www.clinbiomech.com/article/S0268-0033(10)00221-4/fulltext’; 16 september 2010, clinical biomechanics. Level of evidence: 2C Level: 2C, LEWIS J., Rotator cuff tendinopathy: a model for the continuum of pathology and related management; ‘http://bjsm.bmj.com/content/44/13/918.long’, Br J Sports Med 2010;44:918-923 doi:10.1136/bjsm.2008.054817. Level of evidence: 2C level: 2C)
Clinically Relevant Anatomy
The four insertions from the (Rotator Cuff) muscles along with the M. Biceps tendon keep the caput Humeri of the Humerus locked in the cavitas glenoidalis of the Scapula allowing you to have a high mobility in your glenohumeral-joint. There are also intervening bursa within those anatomic structures who provide an extra smooth movementPrometheus Anatomische Atlas Deel 1 + 2 + 3 [Level 5].
The rotator cuff is actually a group of four muscles and their tendons that has as main function to stabilize the shoulder by pressing the humeral head in the glenoid. The muscles form a cuff at the glenohumeral joint by connecting the scapula and the humerus.
It is common for people who participate in repetitive throwing sports like basketball or volleyball. Also for people who need to work a lot above shoulder height for example painters. Aging is also a factor that needs to be taking into account when we talk about Rotator Cuff problems.
A prevalence up to 30% experience shoulder pain in their lives and up to 50% of the population experiencing at least one episode of shoulder pain annually. We can say that shoulder disorders are extremely common. 54% of people with shoulder disorders reports there symptoms are still standing after three years. 
Occupational Risk factors for soft tissue disorders of the shoulders include:
• Awkward or static postures
• Heavy work
• Direct load bearing, repetitive arm movements
• Working with hands above shoulder height
• Lack of rest
Risk factor for tendinopathy:
• Adiposity 
• Metabolic disorders: non-familial hypercholesterolaemia, diabetes 
• Muscle imbalance
• Decreased flexibility
• Advancing age
• Certain sports (repetitive arm motion)
The symptoms or characteristics of a rotator cuff tendinopathy are pain in the area of the four rotator cuff tendons and tenderness located in the shoulder-joint with a dull character, especially when you’re reaching overhead, reaching behind your back, lifting and sleeping on the affected side. More relevant in elevation of the shoulder and abduction, unable to reach higher than 90° abduction, anteflexion of the upper arm. The ADL-activities can cause quite a bit of pain. The pain is not sudden but will gradually increase and is been there for some time. Associated with pain is the growing weakness of your shoulder and immobility to move.Barbara A Silverstein, PhD,1 Eira Viikari-Juntura, DMedSci,2 Z Joyce Fan, PhD,1 Dave K Bonauto, MD,1 Stephen Bao, PhD,1 Caroline Smith, BA 1 Natural course of non traumatic rotator cuff tendinitis and shoulder symptoms in a working population [Level 2B]OREST SZCZURKO,1KIERAN COOLEY, EDWARD J. MILLS, QI ZHOU, DAN PERRI AND DUGALD SEELY. Naturopathic Treatment of Rotator Cuff Tendinitis Among Canadian Postal Workers: A Randomized Controlled Trial [Level 1B]There could also be a local swelling.
Shoulder pain is a common presenting problem with a number of different causes. Therefore you don’t need to confuse a Rotator Cuff problem with other problems. For example A Frozen shoulder, small fracture of the caput humerus, a rupture of the Rotator Cuff tendons, a M. biceps tendinitis, a M. biceps tendon rupture or luxation of the humerus can also cause pain in the shoulder and shoulder-joint. So it is essential to determine the difference between a rotator Cuff problem and other shoulder problems.
To test the weakness and pain of the supraspinatus, the “empty can test” can be used. The patient internally rotates, abducts and flexes the arm 30° forward while the physiotherapist tries to adduct the arm while the patient resists.
To test whether the patient has an impingement, the “Hawkins-Kennedy impingement test” can be used. (SEE: <a href="Hawkins / Kennedy Test">Hawkins / Kennedy Test</a>) (KAREN P. BARR; Rotator cuﬀ disease, Elsevier saunders, KAREN P. BARR, Rotatorcuff disease, Phys Med Rehabil Clin N Am, 15 (2004) 475–491 Level of evidence: 2C: Level of evidence 2C)
Diagnosing is based on several aspects like the history of the patient. In addition, tests will be used to implicate an isolated structure. The diagnose of a rotator cuff tendinopathy will achieved, based on the response the the clinical tests. Supporting examinations like ultrasound, radiographs, radionucleotide isotope scan, magnetic resonance imaging (MRI), computed axial tomography (CT), electromyography, nerve conduction, single photon emission computed tomography, diagnostic analgesic injection and blood tests are sometimes used to strengthen the diagnosis.
To diagnose Rotator Cuff problems you can use an MRI-scan. It is not standard procedure, but it will give you more information about the weak tissue in that area. So it will give you an idea if there is something not right with the tendons, the joint and the muscles. You can also take an echo to determine if there is something wrong.
An Visual Analogue scale is used to describe pain in the shoulder-joint after the joint is palpated by the physiotherapist. This is not the only one, you can also use the Shoulder Pain And Disability Index (SPADI). A questionnaire filled in by the patient.Roach KE, Budiman-Mak E, Songsiridej N, Lertratanakul Y. Development of a shoulder pain and disability index. Arthritis Care Res. 1991 Dec;4(4):143-9. [Level 2C]
Two clinical test can be performed to assess Rotator Cuff tendinopathyM.H. Moen, R.-J. de vos, E.R.A. van Arkel, A. Weir, J. Moussavi, T. Kraan, D.C. de Winte : De meest waardevolle klinische schoudertesten [Level 4]http://www.nismat.org/orthocor/exam/shoulder.html [Level 5]Phillip C Hughes, Nicholas F Taylor and Rod A Green La Trobe University Australia: Most clinical tests cannot accurately diagnose rotator cuff pathology: a systematic review [Level 1A]
The first is called the “Empty Can test”. The patient stands up with his shoulders in 90°abduction, 30° horizontal adduction and in complete endorotation. The therapist fixates his hands on the upper arm of the patient and gives downward pressure while the patient tries to maintain his position.
Than the “Hawkin’s Test”. The patient is standing up with the shoulders abducted in 90° and internally rotate the fore arm. The presence of pain with movement is an indicator of a possible pathology.
With the modified Belly Press Test the patient satnd or sit with the affected hand flat on the abdomen and elbow close to the body. Than he patient need to bring the elbow forward and straighten the wrist. the final belly-press angle of the wrist need to be measured with a goniometer. A belly-press angle difference of 10° between affected and unaffected side indicates a tendinopathy. 
There can be different treatment used in medical management. But not all are strongly evidence based. The use of non-steroidal anti-inflammatory drugs (NSAID’s) like ibuprofen and aspirin may have a pain reducing effect. As second you have the corticosteroid injections who are a commonly administered treatment for tendon disorders. But have also side-effects like skin atrophy, oversensitivity at the place of the injection and discoloration of the skin. Repetitive injections will also weaken the structure of the tendons. Medical examiners often prescribe immobilization. And the last medical management is surgical treatment, very good results were achieved with surgery, but will only be chosen if conservative treatment doesn’t work.
Studies show that there may be no difference in pain between surgery and different exercise programs. There would be also no difference in end-result between an open surgery and arthroscopic surgery but people might recover sooner with arthroscopic surgery. 
There might be also several side effect after the surgery like pain, infection, difficulty moving the shoulder after the operation, wasting of the shoulder muscle, and the need to have another surgical procedure. Those side effects were independent of the type of surgery (open or arthroscopic).  (Level of evidence: 1A)
The effect of of subacrmial corticosteroid injection is sustained by the available evidence. Although the effect may be small and short-term. Furthermore, it wouldn’t be better than NSAID.
For adhesive capsulitis, intra-articular steroid injection may have a small and short-term effect.  (level of evidence: 1A)
Also the effects of localized microwave diathermy on disability, shoulder function and pain are equivalent to those elicited by subacromial corticosteroid injections. (level of evidence: 1B) 
Further the injection of patlet-rich plasma also proves to be effective for significant improvement on pain, function and painoutcomes. (level of evidence 1B)
Physical Therapy Management
Physical therapy of rotator cuff problems reduces pain and swelling of the tendons, gaining again your normal range of motion and eventually getting your shoulders again strengthened. The first step before the actual treatment is enough rest and putting ice on the affected shoulder. It’s very important that in the beginning the patient avoids activities that aren’t promotional for the shoulder. He can slowly start them up again if he feels that he is ready. That will be talked about with the physiotherapist.
The physiotherapist can use massage and deep frictions to prepare the muscles for the range of motion and strength exercises. He does that to relax the muscles because they probably will be stiff. It’s important that you practice your exercises in the correct order. Meaning first stretching and range of motion exercises and then muscle strength exercises.
It has been shown that exercises are effective and support the improvement of the shoulder tendinopathy compared to no treatment or placebo. (level of evidence 2A) 
Stretching and range of motion exercises : - pendulum stretching exercise: helps to stretch the space in which the tendons pass. -wand exercise: fully extend the arm at shoulder height 90° from the body -posterior capsule stretching: reach with your affected arm across your body and use the other arm to pull the affected arm closer to your body.
Studies have shown that other interventions like laser-and ultrasound therapy don’t support the effectiveness of therapy progression. (level of evidence 2A)  On the other hand beneﬁt from ESWT (Extracorporeal shock wave therapy) has been demonstrated in calciﬁc tendonitis of the rotator cuff. (level of evidence 1B)
We can also bring shock wave therapy into the physical treatment at this stage of the treatment. After a while when the symptoms allow it (5-6 weeks) depending from patient to patient, you can begin by giving strengthening exercises. They are necessary to prevent further injury.
Some exercises are:
- scapular squeezes - outward rotation exercise - inward rotation exercise - abduction exercise (SEE: <a href="Therapy exercises for the shoulder">Therapy exercises for the shoulder</a>)
Once the rehabilitation is complete it is important to keep the shoulder muscles strong to maintain fitness and to prevent injury. Most people with rotator Cuff Tendinopathy see improvement after 6-12 weeks of rehabilitationC. A. Speed, C. Richards, D. Nichols, S. Burnet, J. T. Wies, H. Humphreys, B. L. Hazleman From Addenbrooke’s Hospital, Cambridge, England: Extracorporeal shock-wave therapy for tendonitis of the rotator cuff A DOUBLE-BLIND, RANDOMISED, CONTROLLED TRIAL [Level 1B]Martti Rechardt, 1 Rahman Shiri,1 Jaro Karppinen,1,2 Antti Jula,3 Markku Heliövaara,3 and Eira Viikari-Juntura: Lifestyle and metabolic factors in relation to shoulder pain and rotator cuff tendinitis: A population-based study [Level 4]
a) Information, advice and instructions
Rotator Cuff Tendinopathy indicates a problem with your shoulder muscles. It can be caused by an overload of the four muscles located in that region, or an inflammation of one of the tendons. Other causes of a tendinopathy can be found in impingement of the bursa and calcification of the tendons from the rotator cuff muscles.
-Mobilization exercise with a cane
At the beginning of the training program, patients have a lack of range of motion. Active assisted motion may for instance be performed with a cane. It is important that the exercises are performed within the pain limits.(POST‐OPERATIVE ROTATORCUFFREPAIR PROTOCOL, MOON SHOULDER GROUP, Vanderbilt University Medical Center IRBApproval , ‘http://www.mc.vanderbilt.edu/documents/orthopaedics/files/postop%20rehab%20booklet%20for%20therapists.pdf’,MICHAEL D., BAMG PT1, GAIL D., DEYLE; Comparison of Supervised Exercise With and Without Manual Physical Therapy for Patients With Shoulder Impingement Syndrome; Journal of Orthopaedic &amp;amp;amp;amp; Sports Physical Therapy 2000;30(3):126-137; Level of evidence: 1B; Level of evidence 1B)
Start position: The patient lies on his back, with bended knees, on the table with the cane in his two hands. He puts his unaffected arm at the bottom of the cane and the affected arm at the top.
Exercise: The patient moves the cane with his unaffected arm. He brings his affected arm slowly upwards and downwards and repeats the exercise 25 times. (Elevation and depression)(TODD S., ELLENBECKER, TETSURO SEYOSHI, MATTHEW WINTERS, DAVID ZEMAN; Descriptive report of shoulder range of motion and rotational strength six and 12 weeks following arthroscopic superior labral repair; North American journal of sports physical therapy, may 2008 ,volume 3, number 2. ; Level of evidence: 2B; Level of evidence 2B,<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="5" /> , JOHN E.KUHN, MD, NASHVILLE, TN; Exercise in the treatment of rotator cuff impingement: Asystematic review and a synthesized evidence-based rehabilitation protocol; Journal of Shoulder and Elbow Surgery, 2008; Level of evidence: 1A; Level of evidence 1A)
<img src="/images/5/53/Elevatie_met_stok.png" _fck_mw_filename="Elevatie met stok.png" alt="" />
Other movements: external rotation (<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="4" />; Level of evidence 2B, <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="5" />, <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="7" />; Level of evidence 1A) and abduction(<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="4" />; Level of evidence 2B, <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="5" />, <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="7" /> Level of evidence 1A).
Upon external rotation the patient also lies on his back on the table with a cane in his hands. The elbows are bend in ninety degrees. Just like in the other exercise, it’s the unaffected arm that moves the other arm in external rotation.
<img src="/images/d/d3/External_rotation.png" _fck_mw_filename="External rotation.png" alt="" />
For abduction the patient moves the cane as far as possible away from the body without compensation.
<img src="/images/9/94/Abduction.png" _fck_mw_filename="Abduction.png" alt="" />
You can make this exercise more difficult when you ask the patient to lie on a 45° support or to perform the exercise in a standing position. (<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="4" />; Level of evidence 2B, <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="5" />, <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="7" />; Level of evidence 1A)
The frequency of every exercise is 2-3 times a day, every day.(<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="4" />; Level of evidence 2B, <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="5" />)
<img src="/images/0/08/Patient_45%C2%B0.png" _fck_mw_filename="Patient 45°.png" alt="" />Patient 45°
<img src="/images/6/67/Standing_position.png" _fck_mw_filename="Standing position.png" alt="" />Standing position
- Exercise without a cane
To improve the range of motion with rotator cuff tendinopathy we can start performing pendulum exercises. To do this you must lean with your non-affected arm on a table. The affected arm is just hanging and you let it dangle. Then you can make different figures with your arm, so it swings like a pendulum. You can make small or large circles (clockwise or counterclockwise), you can go forward and backwards or from side to side (<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="7" />; Level of evidence 1A). It is important that the patient doesn’t make this an active exercise, but assures these movements are generated by trunk motion (JOY L. LON, RAMIN A. RUBERTE THIELE, JACK G. SKENDZEL, JONGEUN JEON, RICHARD E. HUGHES, BRUCE S. MILLER, JAMES E. CARPENTER; Activation of the Shoulder Musculature During Pendulum Exercises and Light Activities; Journal of ortopaedic &amp;amp;amp;amp; sports physical therapy; april 2010; Volume 40; Number 4; 230-237; Level of evidence: 2B; Level of evidence 2B). The muscles must be completely relaxed. Do this exercise for about 3 minutes and move your arm about 10 to 20 cm in each direction. In addition, pendulum exercises can be initiated during this time. These can be done at home, twice a day (MARKUS WALTHER, ANDREAS WERNER, THERESA STAHLSCHMIDT, RAINER WOELFEL, FRANK GOHLKE; The subacromial impingement syndrome of the shoulder treated by conventional physiotherapy, self-training, and a shoulder brace: Results of a prospective, randomized study; J shoulder elbow surg; juli/augustus 2004; Volume 13; nummer 4; 417-423; Level of evidence: 1B; Level of evidence 1B).
<img src="/images/4/44/Pendelen.png" _fck_mw_filename="Pendelen.png" alt="" />
- Resistance training to increase the mobility
It is proven that resistance training can be used to increase mobility. It was also proved that improving strength was associated with an improvement of other factors, namely: muscle and bone mass, balance, and also mobility. Those factors are important in our daily life (E C RHODES1, A D MARTIN1, J E TAUNTON2, M DONNELLY3, J WARREN3, J ELLIOT3, ‘Effects of one year of resistance training on the relation between muscular strength and bone density in elderly women’, Br J Sports Med, 2000. http://bjsm.bmj.com/content/34/1/18.full#ref-7. (Level of evidence: 1B ); Level of evidence 1B). As such, resistance exercise training is a suitable means to increase muscle size, strength and mobility. The gains from this training are variable and will be better in younger than in older adults () MICAH J. DRUMMOND,* ROBIN L. MARCUS, AND PAUL C. LASTAYO, ‘Targeting Anabolic Impairment in Response to Resistance Exercise in Older Adults with Mobility Impairments: Potential Mechanisms and Rehabilitation Approaches’, J Aging Res, 2012 September 11. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3446726/. (Level of evidence: 5); Level of evidence 5).
You can start with strength training when the patient demonstrates adequate passive and active glenohumeral range of motion, absent of substitution patterns, with acceptable scapulothoracic kinematics
The patient progresses to isotonic and light closed chain stability exercises. The internal and external rotators are strengthened by utilizing said motions with the arm below shoulder height accompanied by elastic resistance and a towel roll placed between the arm and trunk to encourage proper technique, thereby minimizing substitution patterns.
For training the M. serratus anterior you perform the bear hug exercise. You stand with the back toward the wall, knees slightly bent, and the feet shoulder-width apart. You flex your elbows to 45°, the arms are abducted 60° out from the trunk, and the shoulder is internally rotated to 45°. The patient then performs horizontal adduction of both upper extremities, following an imaginary arc at approximately 60 degrees of elevation until they obtain maximum scapular protraction by touching their fists together as to mimic a hugging motion around a cylindrical object (Figure 8 A–B). Afterwards you return to starting position.
For strengthening the trapezius and rhomboid musculature you perform the sport row cord exercise.
You stand still and pull the cords till your forms 90° with your humerus, which directs downwards, and your radius and ulna, which directs forward.
Advanced training of the muscles
When you start with these exercises the remodeling phase is almost complete, and the rotator cuff tissue almost mature. The patient should be pain free with activities of daily living. In addition, the patient must not show dyskenisia when performing active motions at multiple angles.
Progressive strengthening of the posterior rotator cuff muscles, is accomplished by performing an exercise. You stand in a standing position, while performing external rotation of the shoulder at 45 degrees of abduction utilizing elastic resistance. By performing this exercise you ensure high levels of activation of the Teres Minor and the Infraspinatus. The supraspinatus muscle is optimally generated, by perfoming external rotation at 90° of abduction.
To strengthen the serratus anterior further, you perform an exercise standing, facing away facing away from the elastic resistance attachment with the hands held at shoulder width and chest height, holding onto the resistance band or cord. Next, the upper extremities are extended forward away from the body similar to a bench press motion at approximately 120°of a forward elevation followed by protraction of the scapula. In addition the push- up with a plus progression strengthens the serratus anterior even further. It begins with gradually increasing the gravity resistance. It starts by pressing against a wall , then an edge and eventually the floor.
Advanced rhythmic stabilization
The patient stabilizes their upper extremity in a position of 90° of external rotation and 90° of forward elevation in the scapular plane. Once in this position the patient must maintain this position against elastic oscillations with a rubber bar. Additionally, advanced closed chain stability exercises are performed in the quadruped position, while stepping on and off steps of various hights and angles. Propioceptive neuromuscular facilitation can be implemented to continue the progression of rhythmic stabilization.
c) Self-managed exercise program
This is a self-managed exercise program to address pain and disability associated with rotator cuff tendinopathy. There are several subdivisions in the program namely; week 0, week 3-4, week 6-8 and week10-12. Each subdivision has its own exercises and its own difficulties. It is important to follow the program correctly and to properly apply the exercises (LITTLEWOOD C, ASHTON J, CHANCE-LARSEN K, MAY S, STURROCK B: Exercise for rotator cuff tendinopathy: a systematic review, Physiotherapy in Press, juni 2012. Level of evidence: 1A; Level of evidence 1A, P M LUDEWIG, J D BORSTAD, Effects of a home exercise programme on shoulder pain and functional status in construction workers; ‘http://oem.bmj.com/content/60/11/841.full’, Occup Environ Med 2003, 14 november 2002.Level of evidence: 1B; Level of evidence 1B).
The exercises are prescribed by a physiotherapist but independently performed by the patient. It involves exercising the affected shoulder against gravity, a resistive therapeutic band or hand weight. It should be executed twice a day over 3 sets of 10 to 15 repetitions. This exercise can be uncomfortable for the patient but is prescribed to ensure the discomfort is manageable (LITTLEWOOD C., ASHTON J., MAWSON S., MAY S., WALTERS S.; A mixed methods study to evaluate the clinical and cost-effectiveness of a self-managed exercise programme versus usual physiotherapy for chronic rotator cuff disorders: protocol for the SELF study ‘http://www.biomedcentral.com/1471-2474/13/62’,30 April 2012, BMC Musculoskeletal Disorders 2012.Level of evidence: 1B; Level of evidence 1B).
Self-managed exercise program: (<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="10" />; Level of evidence 1B)
Week 0: Baseline assessment & start of treatment
Resisted isometric shoulder abduction (or lateral rotation or flexion etc) against a wall, or resisted shoulder abduction from 0°-30° using moderate resistance from Theraband.
Week 3-4: initial follow-up & progression
Resisted shoulder abduction from 80 to 120° using light weight, e.g. tin of food.
Week 6-8: Second follow-up & progression
Resisted shoulder abduction from 80 to 120° with progressively increasing repetition and weight, e.g heavy Theraband or dumbbell.
Week 10-12: Final follow-up & discharge
Final assessment to identify any non-resolved functional limitations and progress loaded exercises as required, e.g. press-up, pull-up.
Recent Related Research (from <a href="http://www.ncbi.nlm.nih.gov/pubmed/">Pubmed</a>)
<span class="fck_mw_references" _fck_mw_customtag="true" _fck_mw_tagname="references" />
24. DI GIACOMO G., POULIART N.,COSTANTINI A.,DE VITA A., Atlas of Functional Shoulder Anatomy, Springer, Italy, 2008, 232 p. (Level of Evidence 5)
25. Coghlan JA, Buchbinder R, Green S, Johnston RV, Bell SN. Surgery for rotator cuff disease. Cochrane Database Syst Rev 2008;(1):CD005619 (level of evidence 1A)
26. Buchbinder R, Green S, Youd JM. Corticosteroid injections for shoulder pain. Cochrane Database Syst Rev 2003; (1):CD004016. (level of evidence: 1A)
27. Lewis JS. Rotator cuff tendinopathy/subacromial impingement syndrome: is it time for a new method of assessment? Br J Sports Med 2009;43(4):259-64
28. CAROLYN M. SOMMERICH, JAMES D. MCGLOTHLINb & WILLIAM S. MARRAS. Occupational risk factors associated with soft tissue disorders of the shoulder: a review of recent investigations in the literature. Ergonomics 1993; 36(6): pages 697-717 (level of evidence 2A)
29. Gaida JE, Ashe MC, Bass SL, Cook JL. Is adiposity an under-recognised risk factor for tendinopathy? A systematic review. Arthr Care Res 2009; 61(6), pages 840–849
30. Abate M, Schiavone C, Salini V, Andia I. Occurrence of tendon pathologies in metabolic disorders. Rheumatology (Oxford). 2013 Apr;52(4):599-608. doi: 10.1093/rheumatology/kes395. Epub 2013 Jan 12.
31. Cohen R, William G (1998) Impingement syndrome and rotator cuff disease as repetitive motion disorder. Clin Orthop 351:95–100
32. Alessia Rabini, MD, PhD1, Diana B. Piazzini, MD1, (2012) Effects of Local Microwave Diathermy on Shoulder Pain and Function in Patients With Rotator Cuff Tendinopathy in Comparison to Subacromial Corticosteroid Injections: A Single-Blind Randomized Trial. Journal of Orthopaedic & Sports Physical Therapy Volume: 42, pages: 363-370 (level of evidence 1B)
33. Michael Scarpone, David Rabago, (2013) Effectiveness of platelet-rich plasma Injection for rotator cuff tendinopathy: a prospective Open-label study. Glob Adv Health Med. (level of evidence 1B)
34. Andrew Carr, Cushla Cooper, (2013) assessing platelet-rich plasma plus arthroscopic subacromial decompression in the treatment of rotator cuff tendinopathy. Biomed Central. (level of evidence 1B)
35. Chris Littlewood, Stephen May and Stephen Walters, (2013) Systematic Reviews of the Effectiveness of Conservative Interventions for Rotator Cuff Tendinopathy, review. (level of evidence 2A)
36. C. A. Speed, C. Richards, D. Nichols, S. Burnet, J. T. Wies, H. Humphreys, B. L. Hazleman, (2002). Extracorporeal shock-wave therapy for tendonitis of the rotator cuff, A DOUBLE-BLIND, RANDOMISED, CONTROLLED TRIAL. THE JOURNAL OF BONE AND JOINT SURGERY. (level of evidence 1B)
37. Nitin B. Jain, MD, MSPH1, Reginald Wilcox, PT, Jeffrey N. Katz, MD, MS, and Laurence D. Higgins, MD. Clinical Examination of the Rotator Cuf,manuscript, 5 january 2013. (level of evidence 5)
38. Cortney A Myer, Eric J Hegedus, Daniel Thomas Tarara, Daniel M Myer. A User's Guide to Performance of the Best Shoulder Physical Examination Tests, British Journal of Sports Medicine, 2013. (level of evidence 5)
39. Olivier A. van der Meijden, Paul Westgard, Zachary Chandler, Trevor R. Gaskill, Dirk Kokmeyer, Peter J. Millett; CLINICAL COMMENTARYREHABILITATION AFTER ARTHROSCOPIC ROTATOR CUFF REPAIR: CURRENT CONCEPTS REVIEW AND
EVIDENCEBASED GUIDELINES; April 2012 ( level of evidence 2A)
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