Causes And Treatment of Rotator Cuff Tendinopathy:

Rotator cuff tendinopathy is a common cause of shoulder pain and impingement in athletes. In this condition, the rotator cuff tendons become swollen and hyper cellular, the collagen matrix is disorganized and the tendon weaker. Studies in running rats and in human swimmers suggest the major determinant of the onset of tendinopathy is the volume (e.g. distance swum, time running) of work. Apoptosis (programmed cell death) and associated pathways are increased in overuse tendinopathy and may play a role in the pathogenesis of tendinopathy.

Clinical Features

The athlete with rotator cuff tendinopathy complains of pain with overhead activity such as throwing, swimming and overhead shots in racquet sports. Activities undertaken at less than 90 degree of abduction are usually pain-free. There may also be a history of associated symptoms of instability, such as recurrent subluxation or episodes of dead arm.

On examination, there may be tenderness over the supraspinatus tendon proximal to or at its insertion into the greater tuberosity of the humerus. Active movement may reveal a painful arc on abduction between approximately 70 degree and 120 degree. Internal rotation is commonly reduced. The most accurate method to clinically assess rotator cuff strength is to measure developed resistance when the scapula is stabilized in a retracted position.

For the athlete with rotator cuff tendinopathy, symptoms can be reproduced with impingement tests, as well as pain at the extremes of passive flexion. Pain will also occur with resisted contraction of the supraspinatus, which is best performed with resisted upward movement with the shoulder joint in 90 degree of abduction, 30 degree of horizontal flexion and internal rotation .The investigation of choice in rotator cuff tendinopathy is MRI. These examinations may also demonstrate the presence of a partial tear of the rotator cuff.

Treatment of Rotator Cuff Tendinopathy

The treatment of rotator cuff tendinopathy should be considered in two parts.

• The first part is to treat the tendinopathy itself. The patient should avoid the aggravating activity and apply ice locally.
• There is no level 2 evidence to support NSAIDs, ultrasound interferential stimulation, laser, magnetic field therapy or local massage.
• There is level 2 evidence to support nitric oxide donor therapy (glyceryl trinitrate [GTN] patches applied locally at 1.25 mg/day) and for a single corticosteroid injection.
• Glyceryl trinitrate patches come in varying doses: a 0.5 mg patch should outcomes occurred at three to six months, so patients need to have this explained.
• A corticosteroid injection into the subacromial space may reduce the athlete’s symptoms sufficiently to allow commencement of an appropriate rehabilitation program.
• It has been reported that the second part of the treatment of rotator cuff tendinopathy should be the correction of associated abnormalities.
• These include glenohumeral instability, muscle weakness or in coordination, soft tissue tightness, impaired scapulohumeral rhythm and training errors.
• Impaired scapulohumeral rhythm may predispose to rotator cuff tendinopathy and must be assessed and treated.
• The treatment of scapulohumeral rhythm abnormalities is considered.
• Decreased rotator cuff strength or an imbalance between the internal and external rotators of the shoulder also predisposes to the development of rotator cuff tendinopathy.
• Treatment involves strengthening of the external rotators as they are usually relatively weak compared with the internal rotators.
• An exercise program to strengthen the rotator cuff muscles is described.
• Posterior capsular tightness is commonly associated with decreased internal rotation and reduced rotator cuff strength.
• Stretching of the posterior capsule is helpful. Instability is a common cause of rotator cuff tendinopathy and must be considered in any patient who presents with symptoms typical of rotator cuff tendon problems.
• If the presence of instability is not recognized, rotator cuff tendinopathy is likely to recur upon return to sport.
• While it is possible that correction of any of these disorders may improve tendinopathy, there is no level 2 evidence to support any particular rehabilitation strategy or regimen for managing supraspinatus tendinopathy.
• This provides fertile ground for novel clinical research trials.
• Tightness and focal muscle thickening of the rotator cuff muscle hems may also predispose to the development of rotator cuff tendinopathy.
• These changes reduce the ability of the musculotendinous complex to elongate and absorb shock. They may also alter biomechanics by reducing the full range of motion and impairing scapular control.
• These soft tissue abnormalities should be corrected. Abnormalities along the kinetic chain must be identified and corrected.
• Technique faults, for example, in throwing or swimming, should be corrected with the aid of a coach. Training errors need to be corrected.
• Overuse should be avoided.