Management of rotator cuff tendinopathy

Jeremy Lewis PhD FCSP MMACP Consultant Physiotherapist, Central London Community Healthcare NHS Trust, London, UK; Professor of Musculoskeletal Research, Faculty of Education and Health Sciences, University of Limerick, Ireland; Reader in Physiotherapy, School of Health and Social Work, University of Hertfordshire, Hatfield, UK; Sonographer

Rotator cuff (RC) tendinopathy is characterised by shoulder pain and weakness most commonly experienced during shoulder external rotation and elevation. Assessment is complicated by the lack of diagnostic accuracy of the special orthopaedic tests and the poor correlation between structural changes identified on imaging and symptoms. Clinicians and people suffering with the symptoms of RC tendinopathy should derive considerable confidence that the outcomes achieved with an appropriately graduated exercise programme are equal to those achieved with surgery for RC tendinopathy, as well as atraumatic partial and full thickness RC tears. Education is an essential component of rehabilitation. Outcomes may also be enhanced by clinically sub-grouping RC tendinopathy presentations and directing treatment strategies according to the clinical presentation as against a generic “one size fits all” approach. There are substantial deficits in our knowledge regarding RC tendinopathy that need to be addressed to further improve clinical outcomes.

Learning outcomes has at least equivalent outcome to surgical intervention, with the added generalised benefits of exercise http://www.youtube. 1 Review a presented model for the assessment and com/watch?v=aUaInS6HIGo , a faster return to work and at a management of rotator cuff tendinopathy. lower cost than surgery. This evidence relates to those diagnosed 2 Consider consistent evidence supporting an with subacromial pain syndrome (Lewis 2011), rotator cuff exercise based approach for management that is tendinopathy (Holmgren et al 2012) and atraumatic partial and equivalent to surgical outcomes. full thickness rotator cuff tears (Kuhn et al 2013, Kukkonen et 3 Understand the consideration of staging rotator al 2014). Evidence also exists for significant benefit of exercise in those with massive inoperable RC tears when compared to cuff tendinopathy and lifestyle factors to enhance placebo treatment (Ainsworth et al 2009). This body of evidence clinical outcomes. conflicts with reports of a 750% increase in subacromial 4 Understand the need for agreement across the decompressions performed in the United Kingdom between 2001 health professions with respect to patient education, to 2010 (Judge et al 2014) and a 600% increase in arthroscopic and when discussing expectations and outcomes. RC repairs performed in the United States between 1996 to 2006 (Colvin et al 2012), and highlights the need for carefully thought- out care pathways for these conditions, determining thresholds for Introduction when other interventions, such as injection therapy and surgery Rotator cuff (RC) tendinopathy refers to the clinical presentation should be considered. of pain and weakness present in the shoulder and generally, but not exclusively, experienced during external rotation and The rotator cuff is commonly described as a group of muscles elevation, once other causes of symptoms have been excluded and tendons that are recruited equally and synchronously during (Lewis 2009). The true prevalence and incidence of symptomatic shoulder movement to stabilise the humeral head on to the RC tendinopathy remains undetermined due to the lack of scapula. This precept has been challenged. The supraspinatus and certainty between clinical symptoms and RC structural failure. infraspinatus are recruited at higher levels during shoulder flexion, Those clinically diagnosed with RC tendinopathy should have and concomitantly the subscapularis is recruited at higher levels considerable confidence that graduated and supervised exercise during extension. This varying pattern of recruitment was also

12 Articles • In Touch • Winter 2014 • No 149 shown not to be load dependent (Wattanaprakornkul et al 2011a). muscles were respectively reported to be equally activated The asynchronous action of the RC potentially may be used to during these procedures (Boettcher et al 2009), a finding that inform clinical exercise management. challenges the usefulness of these tests other than one of symptom reproduction. Imaging, most commonly ultrasound and It is important not to assume that observed structural failure in MRI, and the intra-operative visualisation of structural failure are the RC tendons is always symptomatic. Frost et al (1999) reported procedures commonly used as the gold standard comparators to that people with and without symptoms of RC tendinopathy determine the accuracy of the clinical tests (Michener et al 2009). demonstrated equivalent RC pathological changes. Asymptomatic However, the ability for observed structural failure to determine the professional baseball pitchers demonstrate substantial RC usefulness of clinical tests is substantially challenged, as multiple pathology in their pitching and catching shoulders (Miniaci et studies have demonstrated a poor relationship between imaging al 2002) and, more recently, ultrasound studies of men without and symptoms (Frost et al 1999; Sher et al 1995; Milgrom et al symptoms identified structural changes in 96% of those scanned 1998; Girish et al 2011). Further discussion, and the reasons including subacromial bursal thickening, supraspinatus tendinosis for this disparity, has been published (Lewis 2009, 2011) and and partial thickness tears, as well as labral pathology (Girish et al these data suggest that many people will undergo surgery on 2011). In most cases the onset of RC tendinopathy is associated tissues that may not be associated with the presenting symptoms. with increased load on the RC structures. Increased load is a very The diagnostic uncertainty of the clinical tests and imaging relative term varying between individuals, as well as within an procedures to confirm a diagnosis or identify which tissues are individual during periods of variations in activity level. Genetics responsible to the individual’s symptoms has prompted some to (Harvie et al 2004) and lifestyle (Dean & Söderlund In Press-a) use treatment direction tests to guide patient management. One are factors that may contribute to RC tendinopathy. such procedure, the Shoulder Symptom Modification Procedure (SSMP) (Lewis 2009), was developed to determine the influence Tendon pathology has been described as a continuum (Cook of thoracic and scapular posture as well as the relationship of & Purdam 2009; McCreesh & Lewis 2013; Lewis 2010), and the humeral head to the glenoid fossa on the patient’s symptoms. while loading is essential for tendon production, both chronic A diagnosis of RC tendinopathy is reached if these procedures under-load and unaccustomed overload may have a potential do not alleviate the individual’s symptoms. This type of approach detrimental impact on tendon health structurally. Loading may requires validation. therefore be subcategorised into adaptive load that results in the synthesis of healthy tendon, and mal-adaptive load that may be detrimental. As mentioned, lifestyle and other factors may also Management positively or negatively influence tendon quality and there may Once diagnosed it may be beneficial, clinically, to subcategorise be a threshold of complex factors that favours tendon production the presenting symptoms and offer management appropriate to or degradation. Reasons why some people experience pain as the stage of RC tendinopathy. Subgrouping has been advocated well as the source of the pain remain uncertain. Tendon, bursa, for those suffering from low back pain as a method of improving osteotendinous junction and musculotendinous junctions, clinical outcome (O’Sullivan 2005) and this may also benefit those capsular tissues and muscles, and their attendant nerve supply, with RC tendinopathy instead of a “one size fits all” approach. Figure are all potential sources of local pain. Central sensitisation (Paul 1 details a suggestion for the possible stages of RC tendinopathy. et al 2012; Coronado et al 2014) and cortical changes (Ngomo et al 2014) may also be involved and this may influence assessment findings and outcome. Corticospinal excitability of the infraspinatus muscle was found to be decreased on the affected side and this change was associated with pain duration but not intensity (Ngomo et al 2014). Assessment Special orthopaedic tests have been developed to clinically diagnose RC tendinopathy. However, narrative and systematic reviews (Lewis & Tennent 2007; Hegedus et al 2012; Hegedus & Lewis 2014) have challenged the certainty that these tests can diagnose RC tendinopathy with the clinical assurance required to inform clinical decision making. Needle EMG has demonstrated that during the full and empty can test the supraspinatus is activated. However, eight and nine other Figure 1: Model for the onset and management of RC tendinopathy

In Touch • Winter 2014 • No 149 • Articles 13 Research has already suggested that people who have failed RC Irritable RC tendinopathy tear repairs may be pain free and their outcome may not differ Irritable RC tendinopathy is characterised by combinations of significantly from those with an intact repair (Kim et al 2012, irritability, constant pain, night pain and an inability to reduce Slabaugh et al 2010). In addition, it is important to establish 24-hour pain. There may be concomitant subacromial bursal the role of placebo in these operative procedures. Moseley et involvement (Santavirta et al 1992). As with all stages of RC al (2002) reported that there was no difference in outcome tendinopathy, load management in the form of relative rest is the between arthroscopic lavage, arthroscopic debridement, and skin focal intervention and drives management. The aim of relative incision (placebo) in 180 people undergoing treatment for painful rest is to find a level of activity that does not increase, but rather osteoarthritis of the knee, and Sihvonen et al (2013) reported no initiates a reduction in 24-hour pain. difference between arthroscopic repair versus placebo surgery for people diagnosed with a painful degenerative tear of the medial Isometric exercises, most commonly in the direction of external meniscus. Similar research is required for both subacromial rotation, with a towel or pillow placed between the waist and decompression and RC repair surgery. elbow and performed sub-maximally and just at the onset of pain for up to 30 seconds (three repetitions) may help to reduce pain attributed to RC tendinopathy. Non-irritable RC tendinopathy When the irritability has settled, or if the individual presents There is limited evidence to support this recommendation with non-irritable symptoms, the rehabilitation programme is (Hoeger Bement et al 2008, Lemley et al 2014) and research is progressed. This should include scapular muscle exercises and a currently being conducted to investigate the clinical benefit of graduated programme of exercises for the RC and may include this anecdotal observation. The duration, intensity and number of combinations of flexion, extension, abduction and rotation. contractions may be varied according to the individual’s response. The posterior RC (supraspinatus, infraspinatus and teres minor) If contributing to a measure of symptomatic relief, this procedure have been shown to demonstrate increased activity during may be repeated throughout the day, anecdotally and on average flexion (Wattanaprakornkul et al 2011a, 2011b), possibly in an up to five times. If the symptoms settle, then a graduated exercise attempt to control anterior translation of the humeral head on programme may be introduced. In cases where the symptoms the glenoid fossa during flexion. Shoulder extension increases the are not settling, injection therapy may be considered. Although activation of subscapularis. External rotation should be graduated evidence is equivocal, injections that target the bursa may be to include unsupported rotation at 90 degrees of abduction. associated with a more effective clinical response (Henkus et al 2006). Progressing exercises to permit pain during the exercise sets may be relevant, as one study specifically permitted and recommended Following provocative fatiguing activity, people diagnosed with RC pain up to a level of 5 out of 10 (where 10 represented maximal tendinopathy demonstrate swelling in the supraspinatus tendon pain) during the exercise programme, provided that the pain and a reduction in the acromiohumeral distance (McCreesh had settled by the next exercise session (Holmgren et al 2012). et al 2014). The swelling may be driven by an increase in Activities that require rapid adjustments in balance, assessment tenocytes (Cook & Purdam 2009) and an increase in tendon and re-assessment of distance to target (where the individual water content. Both glucocorticoids and selected analgesics and / or target may be moving), such as playing tennis, baseball have been shown to reduce tenocyte proliferation (Carofino et and cricket, necessitate that the rehabilitation programme al 2012; Scherb et al 2009) and injection therapy embedded incorporates substantial sensory-motor training. It is also within RC tendon management, primarily when the presenting necessary for energy to be transferred from the lower limbs to the symptoms suggest irritability or an inability to cope with exercises shoulder, for example more than 50% of the effort involved in a due to substantial pain provocation, together with relative rest, tennis serve involves energy transfer (Kibler 1995). An important may be more appropriate at this stage than it would be in the part of shoulder assessment is an evaluation of lower limb and more degenerative stage where reduced tenocyte numbers are truck range of movement, strength and endurance relevant to the probable (Cook & Purdam 2009). individual’s sport or vocational activity. Any deficits identified need to be included in treatment planning and management. As discussed, surgery for subacromial impingement syndrome and RC tears has exponentially increased. Research has reported that, following subacromial decompression, non-manual workers Degenerative RC tendinopathy may take from nine days to six weeks to return to work, and for Ainsworth et al (2009) developed a dedicated rehabilitation manual workers this increases to between three to 12 weeks. programme for people with clinical symptoms in the presence of Driving is resumed between 13 to 29 days (McClelland et al massive inoperable rotator cuff tears. The programme progresses 2005; Charalambous et al 2010). It is conceivable that one of the from assisted to independent shoulder exercises, and typically benefits of surgery is an enforced period of relative rest followed starts in supine progressing to sitting and / or standing if possible. by a slow, careful and graduated rehabilitation programme which The programme is available online at www.bobbyainsworth.com/ may promote tendon homeostasis. Research comparing a slow index.html . A randomised clinical trial demonstrated significant incremental rehabilitation programme with and without surgery benefit over a placebo treatment at three and six months follow would be of benefit to understand this possible relationship. up (Ainsworth et al 2009).

14 Articles • In Touch • Winter 2014 • No 149 studies ranged from six to 19. This must be considered when Education offering patients appropriate and evidence based management. Appropriate patient education is an integral component of management. People suffering from RC tendinopathy need to appreciate that treatment requires the same respect as a bone Conclusion fracture. It would be inconceivable to run on a fractured femur RC tendinopathy is common and is frequently associated or hammer nails into walls with a fractured humerus. While with substantial pain and loss of function. A diagnosis of RC immobilisation is required for a fracture, it is not required for RC tendinopathy is often reached after exclusion of other causes of tendinopathy, but relative rest and a graduated rehabilitation shoulder pain. This is due to the lack of diagnostic accuracy of the programme is essential. Discussion focussing on how the individual clinical orthopaedic special tests and because structural failure would cope with work or sport with a recent fracture may help identified by imaging investigations does not always correlate identify solutions for activity modification with RC tendinopathy. with symptoms. Both clinicians and people suffering with the Lifestyle issues such as smoking, stress reduction, appropriate symptoms of RC tendinopathy should derive considerable nutrition and adequate sleep need to be addressed (Dean & confidence that the outcomes achieved with an appropriately Söderlund In Press-a, In Press-b) by the appropriate member graduated exercise programme are equal to those achieved of the healthcare team in a timely manner. The importance of with surgery for RC tendinopathy, and atraumatic partial and generalised musculoskeletal fitness needs to be emphasised. full thickness RC tears. Education is an essential component of Keeping a record of activity and responses, most notably the rehabilitation. Outcomes may also be enhanced by sub-grouping 24-hour response, will assist the patient and therapist to RC tendinopathy presentations and directing treatment strategies understand the type and amount of loads that are tolerated and according to the clinical presentation as against a generic will inform exercise and activity progression. For some individuals “one size fits all” approach. Outcomes may be further exercise tolerance for RC exercises may be limited to one set per enhanced by considering the influence of the musculoskeletal day, every three days. This does not imply that all components of chain on shoulder function as well as lifestyle influences. management would be equally reduced. There are substantial deficits in our knowledge regarding RC tendinopathy that need to be addressed to further improve Outcomes clinical outcomes. As mentioned, clinicians as well as people suffering RC tendinopathy should derive considerable confidence that an About the author exercise approach should achieve the same outcomes as surgical Dr Jeremy Lewis works in the NHS as well as at the Centre for management. Surgery has not demonstrated additional benefit Health & Human Performance ( www.chhp.com ), assessing and for RC tendinopathy at one, two or five-year follow up (Haahr et treating people with often complex shoulder problems. Jeremy al 2005; Haahr & Andersen 2006; Ketola et al 2009, 2013). One has trained as a sonographer (University of Leeds) and performs study has demonstrated that a graduated exercise programme ultrasound guided shoulder injections, (including hydro-distension substantially reduces the need for surgery for up to 80% of people procedures for frozen shoulder) as part of the rehabilitation who have already had failed non-surgical treatment (Holmgren et process if required and appropriate. He has an MSc (Manipulative al 2012). For people diagnosed with atraumatic partial thickness Physiotherapy), and Postgraduate Diplomas in Sports tears of the supraspinatus tendon involving less than 75% of the Physiotherapy (Curtin), and Biomechanics (Strathclyde). Jeremy tendon, a graduated physiotherapy exercise programme was as regularly lectures and teaches internationally on the shoulder beneficial as surgery involving acromioplasty, or acromioplasty (www.LondonShoulderClinic.com ). In addition to his own research, and RC repair (Kukkonen et al 2014). This finding suggests that he supervises PhD and MSc students. Jeremy is an associate attempting surgical repair of a RC tear may not improve outcome editor for the journals Shoulder & Elbow and Physiotherapy. He over a well-structured physiotherapy exercise programme. was a co-editor and author for Grieve’s Modern Musculoskeletal Physiotherapy (4th ed). Additionally, at two-year follow up, 75% of people diagnosed with an atraumatic full thickness tear and had undergone a graduated Contact details exercise programme did not require surgical intervention (Kuhn Website: www.LondonShoulderClinic.com et al 2013).The findings of these studies suggest that a carefully Email: [email protected] planned and graduated exercise programme should achieve the same outcomes as surgery for subacromial pain / impingement syndrome, RC tendinopathy (Holmgren et al 2012) partial References (Kukkonen et al 2014) and full thickness (Kuhn et al 2013) Ainsworth R, Lewis JS, Conboy V. A prospective randomized placebo atraumatic RC tears. controlled clinical trial of a rehabilitation programme for patients with a diagnosis of massive rotator cuff tears of the shoulder. Shoulder & Elbow Of importance and relevance to clinicians translating the findings 2009;1:55-60 of research to inform clinical practice, as well as department Boettcher CA, Ginn KA, Cathers I. The ‘empty can’ and ‘full can’ tests do not managers, clinical leads and health funding bodies, the number selectively activate supraspinatus. Journal Science and Medicine in Sport of treatments required to achieve the outcomes reported in these 2009;12:435-439

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