Journal of Australian Strength and Conditioning Rehabilitation of rotator cuff tendinopathy. J. Aust. Strength Cond. 22(6)46-54. 2014 © ASCA
Review of the Literature REHABILITATION OF ROTATOR CUFF TENDINOPATHY Omar W. Heyward BSc ESSAM AEP
A
BSTRACT The multifaceted nature of the shoulder joint requires in depth knowledge of the structures in the glenohumeral joint complex, and therefore a very specific intervention protocol for the rehabilitation of rotator cuff tendinopathy.
Initially scapular stability must be regained in order to then isolate rotator cuff weaknesses before introducing kinetic chain integration. The order of phases is important because each phase builds on the previous which in turn will lead to healthy function of the shoulder joint. The aim of this article is to educate coaches on the correct structure of rehabilitation protocols for rotator cuff tendinopathy to aid in the successful management of injured athletes. INTRODUCTION TO ROTATOR CUFF TENDINOPATHY Rotator cuff tendinopathy is a common cause of pain in the overhead athlete. Tendinopathy refers to tendon degeneration and deterioration, the mechanism of injury is complex and multifaceted in nature, and the exact cause could be due to a number of factors. When the rotator cuff tendons become irritated, the collagen fibres of the tendons lose structure and no longer run parallel with one another, thus weakening the tendons. If this injury is not managed appropriately the tendon degeneration could lead to impingement and ultimately to a rupture, requiring surgical repair. Rehabilitation of the shoulder joint provides many challenges for the athlete and Strength and Conditioning Coach alike. The complexities of the joint require a rehabilitation protocol that works functionally with the joint and incorporates the entire kinetic chain. In the rehabilitation of the shoulder the stabilisers must be initially trained in isolation to strengthen the weakened structures before integration can take place. Phase one of rotator cuff tendinopathy deals with scapular stabilisation as the base for rotator cuff work. Phase two strengthens specific rotator cuff musculature in isolation. The final phase of rehabilitation introduces full integration of the shoulder joint into the kinetic chain and further strengthens tendons with eccentric training. From here on the athlete can get introduced back to normal training with sport specific and plyometric-type exercises of progressive load based on the discretion of the Strength and Conditioning Coach. This article aims to educate the Strength and Conditioning Coach upon practical methods, protocol and reasoning behind the rehabilitation of the athlete suffering from rotator cuff tendinopathy. ROTATOR CUFF TENDINOPATHY The shoulder or glenohumeral joint is a very complex structure, classified as a ball and socket joint. The humeral head is relatively large as it sits in the shallow fossa; as a result there is minimal intrinsic stability within the joint. Therefore, stability of the joint heavily relies upon the integrity of the rotator cuff and scapulothoracic musculature in addition to the correct length-tension relationships of these muscles. The rotator cuff consists of four muscles: Supraspinatus, Infraspinatus, Teres Minor and Subscapularis (see Image 1 below). These muscles all arise from the scapula and attach to the humeral head. In doing so the tendons unite with the fibrous portion of the glenohumeral joint capsule, thus improving intrinsic stability. When healthy this musculotendinous unit acts to dynamically stabilise the humeral head in the small and shallow glenoid cavity. For the rotator cuff to work optimally the scapular stabilisers must be functioning properly to stabilise the humerus in the glenohumeral fossa. When the rotator cuff musculature are not working optimally in synchronised unison, tendinopathy may occur; this could be due to shoulder impingement syndrome. Shoulder impingement can be broken down to either primary or secondary impingement. Primary impingement has been reported as the compression of the rotator cuff between the anterior third of the acromion, coracoacromial ligament, coracoid or the acromioclavicular joint and the humeral head (1). This is usually due to inherent abnormalities in the associated structures. Secondary impingement refers to a decrease in subacromial space that has been caused by glenohumeral instability (2, 3). The subacromial space is where the supraspinatus runs and when this space is decreased the risk of impingement and associated tendinopathy is greatly increased.
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Figure 1 - The rotator cuff. REHABILITATION Phase 1 - Scapula Stability A collection of evidence demonstrates that patients with rotator cuff tendinopathy often suffer from scapular dyskinesis (4-6). Scapular dyskinesis can be defined as abnormal resting position of the scapula or an alteration in the mechanics of the scapula during dynamic movement; it may be the result of an innate response to injury of the shoulder. It is commonly associated with a decrease in upward rotation and posterior tilting with an increase in internal rotation and anterior tilt of the scapula (4-6). This dyskinesis can be a result of poor recruitment patterns of scapulothoracic musculature, weakness of the scapula stabilising muscles or flexibility issues. These changes have been documented by many authors and generally involve improper muscular activation patterns of the serratus anterior, middle and lower fibres of trapezius, hypertonic upper trapezius and levator scapulae, pectoralis minor tightness/ shortness, posterior glenohumeral soft tissue tightness and thoracic kyphosis (4, 6, 7). With the decrease in scapula upward rotation with arm abduction in rotator cuff tendinopathy, the subacromial space is compromised; this inherently increases the risk of supraspinatus impingement with abduction. Rehabilitation should therefore firstly focus on normalising scapular resting position. Once scapular positioning has been corrected the rotator cuff and other associated scapulothoracic muscles can be incorporated into the rehabilitation process without the risk of secondary impingement. This is of prime importance because the scapula is a base for the rotator cuff and all upper extremity motion. Therefore the initial goal of rehabilitation in the first phase is restoring stability and functionality to the scapula. This often means improving inflexibilities in the upper trapezius and pectoralis minor muscles via a combination of physical therapy and stretching protocols. These protocols should be used in conjunction with strengthening of the weakened scapular stabilisers, the lower trapezius and serratus anterior, before integrating any specific rotator cuff exercises. If rotator cuff exercises are started too early in the rehabilitation protocol, i.e. before the scapula position has been normalised, pain could be exacerbated (8). Scapula Stability Exercises 1. Scapula Setting The scapular setting exercise (9, 10) is utilized first to restore normal resting position of the scapula and retrain the lower trapezius. The exercise should be performed in the prone position as opposed to standing or seated to decrease upper trapezius activation. When in prone position the upper trapezius have a decreased role as a postural or stabilising muscle because they are no longer acting against gravity. Once the ideal position of the scapula has been found by the athlete, they must use low effort to maintain the isometric contraction so that global muscles (e.g rhomboids) do not dominate the movement. Research shows that optimal results are achieved by holding 10 second isometric contractions (11).
Figure 2 – Scapular setting.
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Journal of Australian Strength and Conditioning 2. Prone Extension Prone extension is a progression of the scapular setting exercise. It must only be commenced once the athlete has some competence with scapular setting and has built some endurance in the lower trapezius. Prone extension has been found to have optimal upper trapezius to middle trapezius activation ratios (12). The start position of the exercise is the same as the 'Scapular Setting' position with the arms externally rotated (i.e. palms facing down) to decrease the risk of subacromial impingement. The exercise is performed by extending at the shoulder joint so that the palms are raised a few centimetres above the ground. Since the purpose is to build endurance capacity of the associated musculature the exercise is performed for 10 to 15 repetitions.
Figure 3 – Prone extension. 3. Straight Arm Pull-down The straight arm pull-down is performed in a standing position. The upper trapezius can become hyperactive as a scapular stabiliser to hold the scapula, so it is important that the athlete sets their scapulae into normal resting position prior to commencing the movement. The exercise is performed on a cable machine with a revolving straight bar attached high. The start position is with palms facing down on the bar at shoulder height, with arms anterior to the body. Force is applied downwards upon the bar, bringing palms toward the body in the sagittal plane. It is important not to raise the hands higher than shoulder height in the eccentric phase to minimise upward rotation of the scapula. The role of this exercise is to further develop stability in the scapula in a more challenging position, that is, while standing. Again the aim is to develop muscular endurance so the exercise is performed for 10-15 repetitions. A common error during this exercise as a result of scapular dyskinesis in athletes suffering shoulder pathology is scapula protraction whilst performing the concentric phase of the exercise. This could cause additional impingement and is easily avoided by correcting technique. It is the duty of the Strength and Conditioning Coach to cue correctly so that this does not occur, i.e. instruct the athlete to keep their chest out and shoulders back.
Figure 4 – Straight arm pull-down. Volume 22 | Issue 4 | December 2014 48
Journal of Australian Strength and Conditioning Phase 2 – Rotator Cuff Isolation Rotator cuff endurance training must only commence once a solid foundation of scapular stability has been achieved. The focus of this phase is to strengthen the weakened rotator cuff musculature in isolation to a sufficient level to then be able to integrate them into more complex full kinetic chain movements. Recent research has shown that slow controlled rehabilitation exercises for the shoulder with an isometric contraction show favourable ratios of upper trapezius to lower trapezius activation (13). This emphasises the importance of performing all early stage rehabilitation exercises in a slow, controlled fashion with a static ‘hold’ at end range. This emphasises muscular endurance capacity to be able to sustain increased load for later stage rehabilitation. Rotator Cuff Exercises 1. Side Lying External Rotation Side lying external rotation has been shown to be an ideal position for correction of upper trapezius to lower trapezius muscle imbalances (13). This position of external rotation is also utilised first because of the decreased risk of subacromial impingement with movement. It has been shown that the exercise elicits favourable activation of infraspinatus, supraspinatus, teres minor and posterior deltoid (14) so it is an ideal exercise to start early in the rehabilitation protocol.
Figure 5 – Side lying external rotation. 2. Prone Horizontal Abduction This exercise is performed with external rotation (thumbs pointing up) at 90 degrees of abduction and has been shown to elicit high supraspinatus muscular activity levels (15, 16). When performing the exercise it is important to cue contraction of the posterior deltoid as opposed to squeezing the shoulder blades together. The reason for this is to try to eliminate global muscles (i.e. rhomboids) as the prime movers and to encourage supraspinatus, infraspinatus and teres minor to work synergistically with the posterior deltoid.
Figure 6 – Prone horizontal abduction.
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Journal of Australian Strength and Conditioning 3. Standing External Rotation Once some adaptation has begun to develop with side lying external rotation the next progression is to perform the exercise in a standing position with a cable machine or resistance bands. Standing external rotations are to be performed with supinated palms and a small rolled towel placed in the axilla. This position has been shown to increase infraspinatus activation (15) and subacromial space (17) thus decreasing the risk of impingement and therefore pain while performing the exercise. As the athlete increases endurance in the external rotators and have improved control of the scapula they can begin to abduct their arms. This must not be rushed and should be done carefully and with patience so that pain levels are not increased, especially the following day. The aim is to get to 90 degrees of abduction.
Figure 7 – Standing external rotation. 4. Standing Internal Rotation Standing internal rotation is also performed with supinated palms and with a towel placed in the axilla to decrease risk of impingement. This is used to engage the subscapularis. It is important to ensure correct posture during the exercise, especially when in full contraction so that the shoulder is not rolled forward, which will increase the risk of impingement. As with standing external rotation, standing internal rotations are to be slowly progressed with adding arm abduction up to 90 degrees.
Figure 8 – Standing internal rotation. 5. Scaption Scaption is performed standing in the ‘full can’ position. The athlete performs maximal elevation of the arms in the scapular plane, which is 30 degrees anterior of the frontal plane. The scapular plane places the supraspinatus in an ideal position for high levels of muscular activation, with minimal middle and posterior deltoid activity (18). Minimising deltoid activity in this phase is important to decrease sheer force. When performing scaption it is important to ensure shoulders do not elevate, activating upper trapezius, during the concentric phase.
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Figure 9 - Scaption Phase 3 – Integration Because the shoulder joint is stabilised multidirectional, rehabilitation should take this into consideration by exercising the joint as a functional and integrated unit. The final phase of rotator cuff tendinopathy rehabilitation involves kinetic chain integration and eccentric loading exercises to emulate the physical demands of the athletes sport. It is of the utmost importance to integrate the shoulder back into the kinetic chain to normalise muscle patterning and ensure a safe and full return to sport. Eccentric loading helps to strengthen the tendons by realigning the disorderly collagen fibres to run parallel with one another; it is in this form that tendons are at their strongest. Kinetic Chain Exercises 1. Reverse Flye The deltoid muscle is often neglected in shoulder rehabilitation programs, and in many protocols it does not get mentioned at all. The deltoid muscle has three distinct portions, the anterior, middle and posterior fibres. The muscle arises from the lateral third of the clavicle, the acromion, and the lateral spine of the scapula and inserts into the deltoid tuberosity of the medial lateral aspect of the humerus. The posterior fibres of the deltoid are of most interest to us in the later stages of rehabilitation of rotator cuff tendinopathy. The role of the posterior deltoid is to laterally rotate the arm, thus aiding in counteracting thoracic kyphosis, and increasing the subacromial space, both of which have been shown to be compromised in patients with shoulder pathology (19, 20). In posterior deltoid training, the athlete will benefit from co-contraction of external rotators of the glenohumeral joint.
Figure 10 – Reverse Flye
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Journal of Australian Strength and Conditioning 2. Drawing the Sword This exercise recruits all fibres of the deltoid, upper and middle trapezius as well as the rhomboids, gets the athlete more comfortable with the arm overhead, and dynamically recruits rotator cuff musculature as stabilizers. The start position is from standing with the working arm in internal rotation over the opposite hip. The movement involves arm elevation, abduction and external rotation moving diagonally across the body to the finish position with the arm elevated. Eccentric exercises should include scaption, external rotation and internal rotation. The exercise tempo should be for a 3 second eccentric phase with no concentric phase. For internal and external rotation on a cable machine, the athlete can assist with the opposite arm to get to the start position, so they don’t have to contract concentrically. For the scaption exercise the athlete should use the shoulder press to get to the start position.
Figure 11 – Drawing the sword. GUIDELINES FOR PROGRESSION This type of rehabilitation protocol aims to develop function shoulder strength and stability. The aforementioned phases of rehabilitation, while extremely important to do in sequence to build from basics to more advanced movements, are designed to overlap one another. The athlete and the Strength and Conditioning Coach must be flexible and patient with the rehabilitation process. A relatively minor, uncomplicated tendinopathy may be resolved within 8 weeks while a complicated injury could take over 6 months to rehabilitate. Table 1 outlines an example 12 week rotator cuff tendinopathy protocol to use as a guide and may be adapted as necessary. With respect to loading the exercises; light resistance should be used, especially in the early stage of rehabilitation. Once the athlete has gained proficiency with the exercises the resistance should be adapted to the maximal load the athlete handle for the target set and repetition ranges without compromising technique. CONCLUSION AND PRACTICAL IMPLICATIONS This article brings a practical approach of rotator cuff tendinopathy to the athlete and Strength and Conditioning Coach through proper structure and loading. Rehabilitation of the athlete suffering rotator cuff tendinopathy should be treated through a structured protocol; firstly developing scapular control, then strengthening rotator cuff deficiencies in isolation before integration of the shoulder into the kinetic chain.  It is of the utmost importance for exercises in the initial stage of rehabilitation to be performed in a slow and controlled fashion to promote muscular endurance  Rotator cuff isolation exercises should only be performed on a base of a stable scapula  Rotator cuff isolation work should only be used for the specific muscles that have been weakened or damaged to decrease the risk of creating muscular imbalances  Integration exercises of the rotator cuff into the full kinetic chain should be as sport specific as possible to ensure a safe and full return to sport Through application of these principles with appropriate loading and progression successful outcomes can be achieved.
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Journal of Australian Strength and Conditioning LIMITATIONS This protocol may not be ideal for each individual case of rotator cuff tendinopathy; it should be used as a guide only. The Strength and Conditioning Coach should work in liaison with qualified medical practitioners when developing a rotator cuff tendinopathy rehabilitation regimen. Treatment protocols should be specific to the athlete, their sport and their exact pathology. Table 1 - 12 Week rotator cuff tendinopathy rehabilitation protocol. Exercise Scapula Setting
Sets x Reps Frequency Tempo Prone Sets x Extension Reps Frequency Tempo Straight Sets x Arm Reps Pulldown Frequency Tempo Side Lying Sets x ER Reps Frequency Tempo Prone Sets x Horizontal Reps Abduction Frequency Tempo Standing Sets x ER Reps Frequency Tempo Standing Sets x IR Reps Frequency Tempo Scaption Sets x Reps Frequency Tempo Reverse Sets x Flye Reps Frequency Tempo Drawing Sets x the Sword Reps Frequency Tempo Eccentric Sets x ER Reps Frequency Tempo Eccentric Sets x IR Reps Frequency Tempo Eccentric Sets x Scaption Reps Frequency Tempo
W1 3*10
W2 3*10
W3 3*12
W4 3*12
W5 3*12
W6 3*15
W7 3*15
W8 3*15
W9
W10
4 2102 3*10
4 2102 3*10
4 2102 3*12
4 2102 3*12
3 2102 3*12
2 2102 3*15
1 2102 3*15
1 2102 3*15
4 232 3*10
4 232 3*10
4 232 3*12
4 232 3*12
3 232 3*12
2 232 3*15
1 232 3*15
1 232 3*15
4 232
4 232
4 232 3*10
4 232 3*12
3 232 3*12
2 232 3*15
1 232 2*15
1 232 1*15
1 232 3*10
2 232 3*10
3 232 3*12
3 232 3*12
2 232 3*15
1 232 3*15
3*12
3*12
1 232
2 232
3 232
3 232
3 232 3*12
3 232 3*15
2 232 3*15
1 232 3*12
2 232 3*15
3 232 3*12
3 232
W11
W12
3*10
3*12
1 232 3*15
1 232 3*10
2 232 3*12
3 232 3*15
3 232 3*15
1 232 3*10
1 232
2 232 3*10
3 232 3*12
2 232 3*15
1 232 3*15
3*18
3*18
3*20
1 222
1 222
2 222 3*10
3 222 3*12
3 222 3*12
3 222 3*15
3 222 3*15
1 222
2 222 2*10
3 222 2*12
3 222 3*12
3 222 3*15
2 023 2*12
3 023 3*12
3 023 3*12
3 023 3*15
2 023 2*12
3 023 2*15
3 023 3*12
3 023 3*15
2 023
3 023
3 023
3 023
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Journal of Australian Strength and Conditioning REFERENCES 1. Neer CS. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report. The Journal of Arm & Bone Surgery. 1972; 54: 41-50 2. Jobe, FW. and Kvitne, RS. Shoulder pain in the overhand or throwing athlete: The relationship of anterior instability and rotator cuff impingement. Orthapedic Reviews. 1989; 18:963-975 3. Paley KJ, Jobe FW, Pink MM, Kvitne RS, ElAttrache NS. Arthroscopic findings in the overhand throwing athlete: evidence for posterior internal impingement of the rotator cuff. Arthroscopy 2000; 16:35–40 4. Ludewig PM, Reynolds JF. The association of scapular kinematics and glenohumeral joint pathologies. The Journal of Orthopaedic & Sports Physical Therapy 2009; 39:90–104 5. McClure PW, Michener LA, Karduna AR. Shoulder function and 3dimensional scapular kinematics in people with and without shoulder impingement syndrome. Physical Therapy 2006; 86:1075–1090 6. Ludewig PM, Cook TM. Alterations in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement. Physical Therapy 2000; 80:276–291 7. Cools AM, Witvrouw EE, Declercq GA, Danneels LA, Cambier DC. Scapular muscle recruitment patterns: trapezius muscle latency with and without impingement symptoms. American Journal of Sports Medicine 2003; 31:542–549 8. Kilber, BW. Shoulder rehabilitation: principles and practice. Medicine and Science in Sport and Exercise. 1998 30(4):40-50 9. Mottram SL. Dynamic stability of the scapula. Manual Therapy 1997; 2:123–131 10. Mottram SL, Woledge RC, Morrissey D. Motion analysis study of a scapular orientation exercise and subjects’ ability to learn the exercise. Manual Therapy 2009; 14:13–18 11. Richardson CA, Jull GA. Muscle control – pain control. What exercises would you prescribe? Manual Therapy 1995; 1(1):1-9 12. Moseley J, Jobe F, Pink M, Perry J, Tibone J. EMG analysis of the scapular muscles during a shoulder rehabilitation program.
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