Rotator Cuff Tendinopathy

Original Editors - Miguel Gonzalez-Rodriguez as part of the Vrije_Universiteit_Brussel_Evidence-based_Practice_Project evidence based practice project.

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Definition/Description

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.

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.

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.
( Level: 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 movement.

Epidemiology /Etiology

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.

Characteristics/Clinical Presentation

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.

Differential Diagnosis

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.

Diagnostic Procedures

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.

Outcome Measures

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.

Examination

Two clinical test can be performed to assess Rotator Cuff tendinopathy

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.

Medical Management

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.

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.

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.

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

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 rehabilitation