Rotator Cuff Tendinopathy

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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.
(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].

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.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]

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.

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)

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.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]

Examination

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.

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 (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.

b) Exercises
-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; 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; 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).

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.

References

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