Are Your Athletes with Rotator Cuff Tendinopathy Receiving the Best Treatment?
With approximately half of collegiate pitchers reporting a pitching-related arm injury in their careers and the prevalence of shoulder pain in competitive swimmers of 40-91%, rehab professionals will regularly encounter rotator cuff tendinopathy in their clinics. Commonly, athletes are diagnosed with the umbrella term subacromial impingement, but just like the nebulous diagnosis of low back pain, it’s a fugazi.
Rotator cuff tendinopathy is a more specific condition that can be defined as an overuse condition that manifests itself as pain and occurs when the body fails to regenerate properly. Neer believed rotator cuff failure is a process starting with tendinitis, then progressing to tendinosis with degeneration and partial thickness tears, and finally resulting in full thickness tears. Three general regions of rotator cuff tendinopathy should be considered and include the bursal sided, articular sided, and mid-substance regions.
Some authors have defined the signs and symptoms of rotator cuff tendinopathy to include symptom duration greater than three months, minimal resting pain, largely preserved range of shoulder motion, and pain exacerbated through resisted testing.
Causes of Rotator Cuff Tendinopathy
The causes are always multi-variate, but a good clinical review divided the causes into intrinsic and extrinsic mechanisms. They defined intrinsic mechanisms to include age, altered biology, microvascular blood supply, degeneration, tendon overload, and overuse trauma. Extrinsic mechanisms included anatomic variables such as acromial shape, osteophyte formation, and scapular dyskinesis.
MRI and ultrasound have comparably high accuracy for finding rotator cuff tears (>90%) with clinical tests (78.3% sensitivity) having moderate accuracy. It should be noted that in MRI studies examining asymptomatic athletes, abnormal tendons were found in 86% of professional baseball pitchers, 46% of elite adolescent tennis players, and 40% of elite overhead athletes.
To confirm a diagnosis of rotator cuff tendinopathy in the clinic, the literature recommends a combination of 3 positive of 5 tests (Neer, Hawkins-Kennedy, painful arc, empty can, and external rotation resistance).
Treatment for Rotator Cuff Tendinopathy
After a tendon injury, full maturation can take up to 24 months. Tendon healing can be divided into 3 phases: Inflammatory Phase (1 week), Repairing Phase (3-6 weeks), and Remodeling Phase (6+ weeks). These timelines will be important to consider when planning your treatment.
Meta-analysis studies of corticosteroid injections for rotator cuff tendinitis has shown it to be effective for up to 9 months, but this did not specifically examine the athletic population. How the patient is injected matters as well. Ultrasound guidance injections improves the accuracy, which could help to improve outcomes. Also, bursal-sided rotator cuff tears should receive a subacromial injection whereas intra-articular injections provide greater pain relief for articular sided rotator cuff injections.
Theoretically, platelet-rich plasma (PRP) injections have the potential to improve pain and recovery, but there is currently only limited clinical support in the literature.
Exercise to Treat Rotator Cuff Tendinopathy
Exercise has been shown to be effective to address pain and dysfunction in patients with rotator cuff tendinopathy. However, no agreement has been established on the prescribed volume of exercises.
A 2015 systematic review looked to answer this question. Though the studies examined were limited, some recommendations can be noted. It was not clear whether pain production or avoidance should be required during exercise as studies found positive outcomes with both. In general, higher reps and sets appear to be associated with superior improvements. And finally, there was no agreement on optimal frequency per week. In summary, the most effective programs included resistance exercises with higher rep/set schemes for a minimal of 12 weeks.
Clinicians seem to prescribe more exercises for shoulder pain than any other condition. This may have potentially been a product of the popularity of the decades old Thrower’s Ten Exercise Program which is essentially a shotgun approach. A recent 2016 randomized controlled trial looked at the effectiveness of prescribing a single exercise vs. “usual physio care” which included exercise, stabilization drills, stretching, and joint mobilizations in the treatment of rotator cuff tendinopathy. After 3 months, both groups had similar improvements in outcomes measures.
A Case for Including Eccentric Training
Eccentric training has already been shown to be effective in treating tendinopathy of the Achilles and patellar tendons. Histological changes in supraspinatous tendinosis have been found to have similarities with lower extremity tendinosis conditions. However, limited research has examined its effectiveness for rotator cuff tendinopathy.
Jonsson et al and Bernhardsson et al noted improvements in outcomes using eccentric training in patients with rotator cuff tendinopathies, but these studies had no control groups. Maenhout et al did produce a study using a control and found there was no difference using eccentric training compared to traditional rotator cuff therapy.
But consider for a moment the fiber makeup of the rotator cuff musculature which is about a 50/50 ratio of Type I and Type II fibers. If Type II fibers are more susceptible to damage during eccentric movements (i.e. pitching a baseball) and eccentric strength training has been shown to predominantly stress the Type II fibers, shouldn’t this kind of training be included into our rehab to develop resiliency?
A Phased Approach for Rehab
Just like in our article to address patellar tendinopathy, rotator cuff tendinopathy should have a similar approach.
Phase 1: Isometrics
Isometrics for rotator cuff tendinopathy have been shown to have analgesic effects. In a small 2016 pilot study comparing a week-long trial of isometrics vs. icing, both groups had improvements, but the isometric group had better VAS improvements. Their protocol consisted of external rotation isometrics 3-5x/day holding for 10-20 seconds at a time. The subjects were asked to gradually build to about 50% of their max force over 5 seconds. Up to 2/10 pain was allowed with a minute rest between sets.
Phase 2: Isotonics
You should begin isotonic training once it is tolerable (<4/10 pain). Because the above 2015 systematic review demonstrated good outcomes with higher volume training to treat rotator cuff tendinopathy, we can borrow the recommended training regimen for patellar tendinopathy. This program details a 3-4x15RM progressing to a 6RM performed 3x/week with a 3 second concentric with 4 second eccentric. The athlete should continue with isometric training on the off days.
Phase 3: Progressive Plyometrics
A 2015 IJSPT article does a great job of outlining the progressions for upper extremity plyometric training. Phase 2 isotonic training should still be continued during Phases 3 and 4.
My Rehab Expert has another article we recommend checking out when looking at shoulder ROM as well as rotator cuff and scapular strength standards to meet before clearing an athlete back to sport.
Phase 4: Return to Sport
The athlete can then begin a progressive return to sport program. A good JOSPT article lays out progressions for baseball, tennis, and golf athletes. Below are other sample programs available to the public.
Simply put, tendons only respond to load and this is where clinicians can be calculated and progressive. But you need to also consider the entire athlete, whether that means hip strength and ROM, thoracic mobility, scapular/glenohumeral force coupling, etc. as well as understanding that progress is rarely linear. Providing good education and laying out a plan at the start of treatment will always get you the best buy in from your athletes, no matter how perfect your exercises.
To find rehab professional near you who specialize in overhead athletes, explore our directory.