The Best (and Worst) Treatment for Rotator Cuff Tendinopathy

Pain. Limited range of motion. Weakness. Stiffness. There are a few diagnoses of the shoulder that could harvest these symptoms, one of the most common being rotator cuff tendinopathy. This common overuse and/or degenerative injury stems from muscle imbalances that overload the shoulder and break down its supporting structures. But before we even get into the best (and worst) treatment of this condition, let’s analyze the elemental knowledge that you can use to set up a baseline with your patients. Never forget: patient education is a critical component of rehabilitation compliance. They more they know, the more they understand why you’re prescribing the treatment!

Starting Rehabilitation with Patient Education

A tendinopathy is defined as “an overuse condition that manifests itself as pain in and around tendons and happens when the body fails to regenerate properly. This painful condition is associated with tendon disorganization and thickening that reduces its physical properties, which causes the tendon to fatigue, further exacerbating the painful condition with ultimate failure” (Factor, Dale 2014).

Therefore, the best way to heal a tendinopathy is to mend and rebuild the tendons. This is an important reiteration when dealing with rotator cuff tendinopathy. While you already learned this in school (right?!?), it might be helpful to teach your patients that, while the rotator cuff is spoken about as one entity within the body, it’s actually compiled of multiple muscles and tendons that each play a role in movement and stability:

• Supraspinatus (abduction)
• Infraspinatus (external rotation)
• Teres minor (external rotation)
• Subscapularis (internal rotation)

Causes of Rotator Tendinopathy

What’s causing all of the pain and suffering in the shoulder you’re treating? Get up close and personal with your patient’s pain and classify the cause to not only given them better rehab protocol, but to help him or her better avoid the origin in the future (if possible):

• Intrinsic: Stems from aging, overuse and degeneration
• Extrinsic: Stems from volatile anatomic factors that cause conditions like subacromial impingement syndrome

By addressing and educating your patients about these musculoskeletal fundamentals, you will both be better qualified to start treatment.

Why Exercise can be the Best and Worst Treatment for Rotator Cuff Tendinopathy

Todd Ellenbecker DPT, MS, SCS, OCS, CSCS has been treating shoulder injuries throughout his entire career. After traveling with professional tennis players for many years, he understands that movement can make or break an injury if it’s not utilized appropriately.

“That’s often times what people do; they think ‘oh my shoulder is hurt, therefore I should start doing some weight lifting and exercises,’” said Ellenbecker. “Oftentimes, they either do overhead lifts or traditional fitness-type exercises, or they use heavy loads. Both of those overload the shoulder and oftentimes make people worse.”

So if haphazardly lifting weights doesn’t cut it, the opposite must also be true. Research shows that strengthening the muscles and tendons that constitute the rotator cuff can be a safe, proven and recommended rehabilitative method. All you have to do is choose exercises that put the shoulder in the correct position, move the muscles and tendons in the correct direction and yield high levels of muscle activity without putting the shoulder in stress. Super easy, right?!

Dr. Ellenbecker suggests you trust and utilize existing EMG data. “EMG actually tells us how high the level is that these muscles contract at, and so if we use an exercise or movement pattern were the muscle is very, very active, we’re then going to stimulate the muscle so that we can get a strengthening response,” he said.

We’ve rounded up a few summaries of this data below to get you started:

EMG-Proven Rotator Cuff Tendinopathy Rehabilitation Exercises

• Significantly greater activity of the infraspinatus (21%) was found during external rotation oscillation (performed using a TheraBand Flexbar and red TheraBand Elastic Resistance Band at 100% elongation with the shoulder in 20° of abduction in the scapular plane) (Ellenbecker et al. 2012).


• Activity of the infraspinatus was also at 21% during the upper extremity band walks exercise (performed at 60° to 90° arc of elevation in three unilateral steps with three repetitions at bi-acromial width position against a wall, subjects positioned 12 to 18 inches away from the wall) (Ellenbecker et al. 2012).


• Normalized peak and average infraspinatus muscle activity ranged between 73% and 102% and between 28% and 52%, respectively, during prone external rotation and reverse catch external rotation using a handheld medicine ball (performed with the glenohumeral joint in abduction at 90°) (Ellenbecker et al. 2015).


• Pendant external rotation and prone external rotation exercises are more valid than the "can" and prone elevation exercises for supraspinatus strengthening (Boettcher et al. 2009).


• The push-up plus and diagonal exercises are superior to traditional internal rotator exercises for activating both functional portions of the subscapularis muscle. The progressive continuum of exercises for the subscapularis is:


• Forward punch → Internal rotation at 0° → internal rotation at 45° → internal rotation at 90° → dynamic hug → diagonal → push-up plus (Decker et al. 2003).

Want more exercises approved by Dr. Ellenbecker? Check out his five favorite picks for rotator cuff tendinopathy in this week’s featured Injury Management Series! Grab a TheraBand CLX Elastic Resistance Band, CLX Door Anchor and FlexBar and learn how to better serve your patients in pain.

Hear from Dr. Ellenbecker himself while you check out the full playlist of his exercises.

Sources:

Boettcher CE et al. 2009 . Which is the optimal exercise to strengthen supraspinatus? Med Sci Sports Exerc. 41(11):1979-83.

Decker MJ et al 2003. Subscapularis muscle activity during selected rehabilitation exercises. Am J Sports Med 31(1):126-134

Ellenbecker TS et al. 2012. Analysis of rotator cuff and scapular muscle activation during elastic resistance, external rotation oscillation, and band walk exercises (abstract). J Orthop Sports Phys Ther 42(1):A42

Ellenbecker TS, et al. 2015. Muscular activation during plyometric exercises in 90 of glenohumeral joint abduction Sports Health 7(1):75-9

Factor, D and Dale, B. 2014 Current Concepts of Rotator Cuff Tendinopathy. Int J Sports Phys Ther. Apr; 9(2): 274–288