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Today, I didn't mean to talk about tendinopathy so much in a short amount of time, but today we're going to talk about rotator cuff tendinopathies. And mainly because I think that this is something we see very often or maybe we think we see and maybe we don't always get it right but it's important to make sure that we have a good basic understanding of what the rotator cuff does and how we rule this out. Cause we know that special tests in the shoulder are not that great.
In this episode, we're going to cover the role of the rotator cuff and why it matters, who gets this, and what the imaging really tells us about this, how to assess it the best that we can, and then the best evidence based treatment strategies in physical therapy to date. So what is the rotator cuff? Very quickly Keep in mind, the rotator cuff is made up of four muscles. We have our supraspinatus, infraspinatus, teres minor, and subscapularis.
Which you might have learned the acronym SITS in PT school. SITS, like it just spells out the first letter of each muscle. With these muscles, you probably learned in PT school the supraspinatus does abduction in the first 15 degrees, infraspinatus, external rotation, teres minor, external rotation, subscapularis. But the really cool thing about the rotator cuff is that they all work together to basically stabilize the humeral head and the glenoid fossa during our movements.
Now, that seems very vague, so these muscles all work together to create this force couple where they basically suck the humeral head into the faucet to make it nice and secure. Anytime we move our arm away from our body. So it's plays a huge role.
In helping with shoulder elevation, rotation controlled movement during dynamic loading, throwing, lifting, reaching overhead, so we need to keep this in mind as well with our exercise prescription when they are trying to get back to things that involve quite a bit of co contractions and high level play essentially. So that is the rotator cuff. Now how does this beautiful design lead to pain?
And what I mean is rotator cuff tendinopathy, which Again, tendinopathy is an umbrella term for tendinitis and tendinosis. We usually see more tendinosis, which is from that overuse, aging, altered mechanics, and degeneration, rather than the acute inflammation. Yes, we know that other things can happen with rotator cuff dysfunction. It could be torn. It could have a fall or an acute injury, things like that, that can be at play, things other than overuse.
Another way to think about it is if we know that the threshold for The rotator cuff, and I know that's super vague, but if it's at a certain level, and what we're asking it to do is above that level, there's, that mismatch can often lead to pain, problems, loss of function, etc. Whether it's a huge acute injury, high velocity, or something that has happened over time for a long period of time that was not corrected for. Now, who gets rotator cuff tendinopathy?
The most common patient populations are going to be middle aged and older adults. To define that further, it's over the age of 40. We'll also see this, though, in athletes with repetitive overhead movements. Swimmers, baseball players, tennis players, and again, the overall, with time, not enough recovery, potentially poor programming, potentially poor sleep, etc. The rotator cuff was not given enough time to recover and has broken down over time.
We also see this in laborers with high repetition arm use, so workers in construction, painters, mechanics or sedentary individuals with poor shoulder mechanics because they're just not starting off with the biggest oomph in their gas tank. is what I'll say. They don't have maybe as much to work with versus someone who has been strengthening this area. In terms of your patient population, you'll probably have all sorts of patients come in with tears and imaging findings that freak them out.
But we know in our research, so Lewis et al. in 2015 found that up to 60 percent of asymptomatic adults over the age of 60 have rotator cuff tears on their MRI. Asymptomatic is the key word here. So it doesn't necessarily mean that they're screwed and we just shut them out of the door from PT. Cause a lot of times I've heard the rotator cuff described as almost like a blanket. If there's a hole in the blanket, it still works as a blanket, right?
So we treat the surrounding areas and a lot of people can do pretty well unless it's torn to the point where They're not responding well to physical therapy. So we know that structural damage does not always correlate to pain or function, and clinical symptoms and function limitations matter a lot more than imaging. Now, when We are trying to diagnose this we need to make sure that we're also ruling out other things.
So pain overhead, pain at night pain in the shoulder, there's so many symptoms that can overlap across different pathologies. But as always, I think low hanging fruit is screening out the joints above and below. So like for instance, shoulder pain, do they have something referring down from the neck? Are we ruling out the neck? Joint referral, nerve pain, et cetera.
And hopefully you'll be able to pick up in their subjective if it sounds like something neural or something with neck related movements or a neck related mechanism of injury in the shoulder itself, is it? Global pain, are they just losing motion? A postmenopausal woman or someone who has a history of type two diabetes, things like that, where we're maybe looking at frozen shoulder or have they had shoulder pain in the past that has been frozen shoulder?
Is there some sort of glenohumeral instability? AC joint pathology? Do they have something going on that's labral related, biceps and all that kind of stuff? I think. It can be overwhelming to think about all the things that are in the shoulder. So just try and dive into, is this a passive tissue issue? Is this a contractile tissue issue? Say that five times fast. And then be able to use your exam and your questioning to see What does this line up with more?
What seems to be the root of the problem? Will you find maybe other things reacting out of pain due to pain, inflammation, etc.? Probably, but what is the root problem here? There are all sorts of clinical tests that have been identified for rotator cuff tendinopathy. There's the painful arc test, where they have pain between 60 to 120 degrees abduction. So you're basically just checking their range of motion. External rotation resistance test okay, we're muscle testing now.
There's the Job's test or empty can test. I would maybe start with full Where you're raising their arm up 90 degrees from their side in the plane of scaption and then basically resisting them. Their thumb is pointing up for full can and then, You point their thumb downward for an empty can. You are essentially with the empty can making it a more provocative test for resisted supraspinatus testing. And then there's the near and Hawking Kinney Hawkins Kennedy test.
Again, essentially you're just trying to impinge the joint and see if it hurts. And then speeds test assesses biceps involvement. You can get quite a lot out of your exam by just remembering range of motion. Strain testing. Passive range of motion versus active range of motion, for instance. Is their passive more than their active? Helps us to, again, dive back into, is this a passive tissue issue or a active tissue issue? Is it something labral? That kind of stuff.
Now, imaging, of course, you can use ultrasound, MRI, x rays. X rays can be good to help identify if there's any calcific tendinopathy. Because if they've got some calcium deposits, then there are surgeries that can help to address that. MRIs can be helpful to see is there a full thickness tear. But again, your patient might come back in distress by all the things that are shown to be wrong in their shoulder.
So just maybe mentally prepare for them for that if they haven't had it already and are getting it. And then ultrasounds can be also effective for detecting tears and calcifications. The first line treatment for This condition is going to be exercise therapy, not injections, not surgery. This is supported by Le France and Le France et al in 2022. NSAIDs and pain modulation will only offer short term symptom relief. It's not gonna be a long term fix.
Yes, your patient might want this, might ask for it, but if it's a tendinopathy, a tendinosis, the tendon is going to need load to help it to. Build itself up to what we need it to do in that person's day to day. And everybody's gonna be a little bit different. That's why you should ask about what they're trying to get back to and all that kind of stuff. But also making sure that we're not doing nothing.
Cause a lot of times these people if it's been going on for a long time, they got shoulder pain maybe, they're frustrated, they can't do anything. They decide, I'm gonna wait two weeks and then I'll try again. And It's not any better. It might even be worse. How frustrating is that, right? If you're just trying to figure out, you're trying to live an active lifestyle as a patient and take care of your body and you just seem stuck.
Just help your patients understand that this is a long term condition but there is hope, right? And we use exercise, yay to help them. Whereas maybe exercise has been a negative experience in the past due to this pain.
So give them guidelines, give them, if they need pain rules or pain guides, or just need to be told it's okay as long as you, blah you give them an upper limit and a lower limit, and they'll probably feel a lot better about this condition, even if they don't physically feel better for a while. Communication is huge, right? But, I'm going to get off my soapbox. Let's actually go into treatment.
With our treatments, just like a lot of tendons, usually we're going to approach it from a phase based approach. If it is purely just active tissue that's involved there's not really any passive range of motion restrictions. A lot of times in our first phase we're just maybe starting off with isometrics. Depending on what's involved. So a lot of times we're zooming in on like our supraspinatus and infraspinatus tendons.
But we are trying to get those tendons to be able to just accept load and not freak out. So isometrics can be great because there are special receptors in those muscles and tendons. In them. that help them to basically dampen pain and inhibit our cortical and cause cortical inhibition, which AKA means we're taking their pain down. A lot of people just need some pain relief and they will thank you for it. So start with these pretty early.
They should not be feeling like they're trying to win some sort of reverse arm wrestling match. So if you see them grimacing or like grunting, please tell them, chill out a little bit. Again, give them restrictions on pain. Usually, a lot of people will do three to four out of ten or less, not more. And then keep in mind that there's a lot of other muscles beyond the rotator cuff that help with bracing your arm overhead or having good function of your shoulders.
So we have our parascapular muscles, the muscles that are around the scapula. If they're able to tolerate positions that load their lower traps, their serratus, their mid traps, things like that, then you can go ahead and get them engaged.
Usually a lot of times these patients are maybe not ready for positions that require them to have their arm overhead because a lot of times This also gets a lot of rotator cuff involvement, but if you are able to reposition in ways either where maybe they start with their arms down by their side and work their way up, or they're in positions that are not using gravity as much, then this can be really helpful to just go ahead and get started on that.
Especially if they've had pain for a while, they might not have been loading these muscles for a while so they're probably going to need a little bit of work to help support the rotator cuff muscle as needed. Muscle group as it is getting rehabbed and then once they are able to tolerate it, we move them into more strengthening.
So more dynamic exercises depending on their tolerance, like if they're not quite ready against gravity, we use things that help them like active assisted exercises, working to active range of motion. Then, hey, maybe they can handle the weight of their arm against gravity. Maybe we add weight or dumbbells or resistance bands. A lot of times in this strengthening phase, it feels a lot better for the shoulder to work, start working in more of a horizontal plane.
So like pushing and pulling motions rather than a vertical where we're pressing overhead or maybe pulling down, although. Sometimes that's a little, tends to be feeling a little better than the pressing. Rotator cuff strengthening. There's the classic like arm by your side, been at 90 degrees and you're just rotating out or walk, doing walkouts.
But there's all sorts of progressions where you can basically start working on rotational strengthening or things like that, that involve loading the rotator cuff, but maybe you're doing classic. Pressing motions or things like that. Like for instance, a looped band around the forearms that you have tension on and you're doing like a non weighted shoulder press, things like that. There's a lot of options instead of just staying at that end.
To help prepare your patient for whatever they need to do. Keep in mind, the needs of someone who is a swimmer might be a lot different than someone who's a construction worker or things like that. It's nice to be able to cater your treatment plan towards what they actually need the most of.
Long story short, if they are dealing with maybe loss of range of motion due to pain or secondary stiffness, manual therapy can definitely be a great adjunct PRPs injections still have limited evidence but can be reserved for like chronic cases. Think it's something to stay tuned on. PRP and then surgery. Yeah. If. That's typically going to be used for more full thickness tears or failed conservative management.
Arthroscopic, according to Katala et al. in 2017, arthroscopic decompression or subacromial decompression is not recommended. What you should take away from today is rotator cuff tendinopathy is a degenerative not inflammatory condition. Remember, we're talking about tendinosis, not tendinitis, which is an inflammatory condition. A lot of people have asymptomatic tears, so clinical presentation matters a lot more than imaging.
And we need to make sure that we are also ruling out other factors that could cause shoulder pain and not just leaning in on special tests, because we know that special tests in the shoulder are Not the best. Exercise therapy is going to be the most effective treatment, but progressive loading is key, so really narrowing in on your programming skills is going to be huge. And surgery should be a last resort for non responsive cases.
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