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  journal of orthopaedic &  sports physical therapy | volume 45 | number 11 | november 2015 | 923 [   CLINICAL   COMMENTARY   ] 1 Department of Allied Health Professions and Midwifery, School of Health and Social Work, University of Hertfordshire, Hatfield, UK. 2 Therapy Services, St George's Hospital NHS Trust, London, UK. 3 Musculoskeletal Physiotherapy, Central London Community Healthcare NHS Trust, London, UK. 4 Centre for Health and Human Performance, London, UK. 5 Department of Clinical Therapies, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland. 6 Department of Rehabilitation, Faculty of Medicine, Laval University, Quebec City, Quebec, Canada. 7 Center for Interdisciplinary Research in Rehabilitation and Social Integration, Quebec City, Quebec, Canada. 8 Discipline of Biomedical Science, Sydney Medical School, University of Sydney, Sydney, Australia. Dr Lewis developed the shoulder symptom modification procedure and the shoulder fixation belt seen in Figure 6. The other authors certify that they have no affiliations with or financial involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed in the article. Address correspondence to Dr Jeremy Lewis, Department of Allied Health Professions and Midwifery, School of Health and Social Work, Wright Building, College Lane Campus, University of Hertfordshire, Hatfield AL10 9AB, Hertfordshire, UK. E-mail: jeremy.lewis@LondonShoulderClinic.com 󰁴  Copyright ©2015 Journal of Orthopaedic & Sports Physical Therapy ® R otator cuff (RC) tendinopathy refers to pain and weakness, most commonly experienced with movements of shoulder external rotation and elevation, as a consequence of excessive load on RC tissues. Excessive load is a relative term and will  vary within and between individuals as a consequence of changes in activity levels. Epidemiological data are difficult to determine due to a poor level of association between structural failure and symptoms, and uncertainty as to the cause and lo-cation of the symptoms. Rotator cuff tendinopathy is commonly referred to as subacromial impingement syndrome. However, the belief that acromial irrita-tion is the primary cause of symptoms may be erroneous. 14,67,68,91 The anterior (subscapularis) and posterior (ie, attaching to the posterior surface of the scapula  115 ; supraspina-tus, infraspinatus, and teres minor) RC muscles, respectively, provide internal and external rotation torque at the shoul-der. 11,27,96  The RC muscles also provide functional shoulder joint stability, with anterior and posterior RC muscles being recruited at significantly different activity levels, depending on the movement per-formed: shoulder flexion (greater poste-rior RC muscle activation) or shoulder extension (greater anterior RC muscle activation). 114,115  This suggests that coun-terbalancing humeral head translation resulting from shoulder flexor, extensor, and abductor muscle activity is an impor-tant function of the RC.The aim of this commentary is to pres-ent information related to the function of the RC, to discuss uncertainties related to pathoetiology and assessment, and to present strategies for management 󰁴 SYNOPSIS:  The hallmark characteristics of rotator cuff (RC) tendinopathy are pain and weak-ness, experienced most commonly during shoulder external rotation and elevation. Assessment is complicated by nonspecific clinical tests and the poor correlation between structural failure and symptoms. As such, diagnosis is best reached by exclusion of other potential sources of symptoms. Symptomatic incidence and prevalence data currently cannot be determined with confidence, primarily as a consequence of a lack of diagnostic accuracy, as well as the uncertainty as to the loca-tion of symptoms. People with symptoms of RC tendinopathy should derive considerable comfort from research that consistently demonstrates im-provement in symptoms with a well-structured and graduated exercise program. This improvement is equivalent to outcomes reported in surgical trials, with the additional generalized benefits of exercise, less sick leave, a faster return to work, and reduced costs to the health care system. This evidence covers the spectrum of conditions that include symptomatic RC tendinopathy and atraumatic partial- and full-thickness RC tears. The principles guiding exercise treatment for RC tendinopathy include relative rest, modification of painful activities, an exercise strategy that initially does not exacerbate pain, controlled reloading, and gradual progression from simple to complex shoulder movements. Evidence also exists for a specific exercise program being beneficial for people with massive inoperable tears of the RC. Education is an essential component of rehabilita-tion, and attention to lifestyle factors (smoking cessation, nutrition, stress, and sleep manage-ment) may enhance outcomes. Outcomes may also be enhanced by subgrouping RC tendinopathy presentations and directing treatment strate-gies according to the clinical presentation and the patient’s response to shoulder symptom modification procedures outlined herein. There are substantial deficits in our knowledge regarding RC tendinopathy that need to be addressed to further improve clinical outcomes. J Orthop Sports Phys Ther 2015;45(11):923-937. Epub    21 Sep 2015. doi:10.2519/jospt.2015.5941  󰁴 KEY WORDS:   infraspinatus, rotator cuff,  shoulder, supraspinatus JEREMY LEWIS,  PT, PhD 1-4  ã KAREN MCCREESH, PT, PhD 5 JEAN-SÉBASTIEN ROY, PT, PhD 6,7  ã KAREN GINN, PT, PhD 8 Rotator Cuff Tendinopathy: Navigating the Diagnosis- Management Conundrum    J  o  u  r  n  a   l  o   f   O  r   t   h  o  p  a  e   d   i  c   &    S  p  o  r   t  s   P   h  y  s   i  c  a   l   T   h  e  r  a  p  y   ®    D  o  w  n   l  o  a   d  e   d   f  r  o  m   w  w  w .   j  o  s  p   t .  o  r  g  a   t   V  r   i   j  e   U  n   i  v  e  r  s   i   t  e   i   t   A  m  s   t  e  r   d  a  m   o  n   N  o  v  e  m   b  e  r   1 ,   2   0   1   5 .   F  o  r  p  e  r  s  o  n  a   l  u  s  e  o  n   l  y .   N  o  o   t   h  e  r  u  s  e  s  w   i   t   h  o  u   t  p  e  r  m   i  s  s   i  o  n .    C  o  p  y  r   i  g   h   t   ©   2   0   1   5   J  o  u  r  n  a   l  o   f   O  r   t   h  o  p  a  e   d   i  c   &    S  p  o  r   t  s   P   h  y  s   i  c  a   l   T   h  e  r  a  p  y   ® .   A   l   l  r   i  g   h   t  s  r  e  s  e  r  v  e   d .  924  | november 2015 | volume 45 | number 11 | journal of orthopaedic &  sports physical therapy  [   CLINICAL   COMMENTARY   ]  based in part on a specific approach to shoulder symptom modification proce-dures (SSMPs) outlined herein. Emerg-ing research implicating the potential for central sensitization and cortical involve-ment is also discussed. Pathoetiology Neer 86,87   argued that 95% of RC pathol-ogy was caused by irritation from the overlying acromion, calling the condi-tion subacromial impingement syndrome and recommending acromioplasty in the event of failure of nonsurgical care. Sup-port for this pathoetiological model of RC tendinopathy is equivocal, 64  and recom-mendations to avoid the use of the term subacromial impingement syndrome  have been made. 68,91  The definitive cause of RC tendinopathy remains uncertain, as does the reason for the pain experienced  by people with this common condition. A poor level of association exists be-tween symptoms related to RC tendinop-athy and structural failure observed on imaging (ultrasound, magnetic resonance imaging [MRI]) or intraoperatively, 67,68  and uncertainty persists regarding the role of inflammation in the tendon and associated bursae. 23,82,95,113  Higher con-centrations of inflammatory substances have been reported in the subacromial  bursal tissue in people diagnosed with RC tendinopathy. However, this finding is not consistent, 99,113  and a definitive un-derstanding of the relationship between  bursal and tendon symptoms with re-spect to both causation and association remains elusive. 25 There is poor understanding of the source of the pain in RC tendinopathy, as subacromial bursectomy has been shown to be as effective as the combi-nation of subacromial bursectomy and acromioplasty. 49  Although this finding challenges the benefit of acromioplasty, this study, like other surgical studies, did not control for placebo 84,106  and the sub-stantial relative rest following surgery. 19,73  Therefore, there is no certainty that any derived benefit was due to either surgical procedure. 64 Proposed mechanisms of RC tendi-nopathy include intrinsic, extrinsic, or combined mechanisms. 65,104  Extrinsic or external mechanisms potentially involve attrition of the RC tendons from con-tact with structures such as the humeral head below and the coracoacromial arch above, 87   possibly due to poor function of the musculature responsible for control-ling the position of the humeral head sec-ondary to weakness, fatigue, pain-related inhibition, and structural incompetence. Diagnostic ultrasound is both a reliable and valid method to measure the sub-acromial space and the acromiohumeral distance. 74,76  Approximately 45% of peo-ple diagnosed with RC tendinopathy have a reduction in the subacromial space dur-ing elevation of the arm, which rehabili-tation has the potential to normalize. 100  Studies of the effect of RC muscle fatigue suggest that the size of the subacromial space is reduced following fatigue 21  and that recovery to normal is delayed in those with RC tendinopathy. 75  In addi-tion, electromyography studies in people  with RC tendinopathy have reported re-duced RC muscle activation, 31,85  as well as delayed onset of activation in muscles controlling position and movement of the scapula. 20 The evidence for the acromion being the principal cause of external irritation on the RC tendons has been challenged. 68   Variations described in acromial shape 8  may not be morphological but may in-stead develop over time, 90,116  or be a sec-ondary consequence of RC failure. 18,89  Deviations in posture from an idealized 54   yet unsubstantiated norm, and the con-comitant changes in scapular position, have been proposed as a potential mech-anism of external irritation on the RC tendons. 40  However, studies of scapular orientation in people with RC tendinopa-thy have reported conflicting findings, 93  consistent with investigations that sug-gest that posture in those with and with-out symptoms may not follow set clinical rules, 69  leading to the development of individualized postural-assessment protocols. 67  Intrinsic mechanisms relate to factors that directly influence tendon health and quality, including aging, 110  genetics, 109   vascular changes, 46  and altered load-ing. 66  Excessive tissue load remains the most substantial causative factor in the development of RC tendinopathy, as re-flected by the fact that RC tendinopathy occurs more frequently in the dominant limb 117   and in occupations 77   and sports  with high rates of upper-limb loading. 103  Underloading may also disrupt tendon homeostasis, 23  potentially resulting in a temporally earlier point of failure, when the tendon is subject to load. Lifestyle factors such as obesity, metabolic syn-drome, and smoking may increase the risk and detrimentally impact recovery of RC tendinopathy. 5,94 There is clear potential for interaction  between intrinsic and extrinsic mecha-nisms. McCreesh et al 75  have demon-strated that RC muscle fatigue leads to short-term decrease in acromiohumeral distance and swelling of the supraspi-natus tendon in people with RC tendi-nopathy. The enlarged tendon occupies more subacromial space, a phenomenon represented by the subacromial occupa-tion ratio (acromiohumeral distance-supraspinatus thickness), increasing the potential for compression 78  and the pos-sible development of secondary a cromial osteophytes. 16-18  This swelling, 75  com- bined with loss of humeral head control (superior migration), may lead to symp-toms clinically associated with subacro-mial impingement. As such, it would be appropriate to direct treatment to restore local homeostasis by reducing pain, im-proving the tendon’s capacity to sustain loading, and re-establishing humeral head control before considering surgical subacromial decompression, even in the presence of RC tendon tears and acromial osteophytes. 60,61,64,68 Central Sensitization and Cortical Changes The cause of local pain in tendinopathy remains elusive, and frequently the level of pain experienced varies substantially    J  o  u  r  n  a   l  o   f   O  r   t   h  o  p  a  e   d   i  c   &    S  p  o  r   t  s   P   h  y  s   i  c  a   l   T   h  e  r  a  p  y   ®    D  o  w  n   l  o  a   d  e   d   f  r  o  m   w  w  w .   j  o  s  p   t .  o  r  g  a   t   V  r   i   j  e   U  n   i  v  e  r  s   i   t  e   i   t   A  m  s   t  e  r   d  a  m   o  n   N  o  v  e  m   b  e  r   1 ,   2   0   1   5 .   F  o  r  p  e  r  s  o  n  a   l  u  s  e  o  n   l  y .   N  o  o   t   h  e  r  u  s  e  s  w   i   t   h  o  u   t  p  e  r  m   i  s  s   i  o  n .    C  o  p  y  r   i  g   h   t   ©   2   0   1   5   J  o  u  r  n  a   l  o   f   O  r   t   h  o  p  a  e   d   i  c   &    S  p  o  r   t  s   P   h  y  s   i  c  a   l   T   h  e  r  a  p  y   ® .   A   l   l  r   i  g   h   t  s  r  e  s  e  r  v  e   d .  journal of orthopaedic &  sports physical therapy | volume 45 | number 11 | november 2015 | 925 among individuals. Central sensitization could contribute to explain this dispar-ity, 41  and several studies have investigated its role in individuals with RC tendinop-athy. Gwilym et al 41  demonstrated that a significant proportion of individuals  with RC tendinopathy have pain radiat-ing down the arm and hyperalgesia to punctate (pinprick) stimulus of the skin. Furthermore, the presence of either hy-peralgesia or referred pain preoperatively is associated with a worse outcome from subacromial decompression 3 months af-ter surgery. 41  Two other studies compared pain thresholds between individuals with and without unilateral RC tendinopa-thy  24,92  and found hypersensitivity at local and remote sites bilaterally in the symp-tomatic population, suggesting central sensitization. These findings suggest that central sensitization is present in a pro-portion of people diagnosed with RC ten-dinopathy, and that the pain experienced may not always relate to local pathology. Another potential influence in the development or maintenance of pain is the presence of central motor alterations. Ngomo et al 88  have shown that individu-als with RC tendinopathy demonstrate decreased corticospinal excitability of the infraspinatus muscle on the affected side compared to their unaffected side. Furthermore, this interhemispheric asymmetry is associated with the dura-tion of pain, suggesting that the cortico-spinal excitability may decrease over time in the affected shoulder. 88  Corticospinal hyperexcitability at rest and hypoexcit-ability during voluntary activation have also been reported for the deltoid muscles in individuals with chronic full-thickness tears of the RC. 7   These altered muscle cortical representations show adaptive changes in the central nervous system as-sociated with RC tendinopathy and may contribute to the neuromuscular deficits associated with this disorder. Assessment  Assessment involves a number of sequen-tial and interrelated stages. Following the patient interview and careful screening for health-related systemic conditions, further information is gained from the completion of pain, quality-of-life, and disability questionnaires and measure-ments of impairments (active and passive ranges of movement, shoulder capsule ex-tensibility, and muscle function: strength and endurance). 13,45  As is easily understood from observ-ing sporting activities such as the tennis serve and pitching in baseball, as well as function during many vocational activi-ties, energy to complete many of them is transferred from the lower limbs, through the trunk, to the shoulder. 57,59,102,105  Pain,  weakness, and restricted range of move-ment in the lower limbs or trunk are ex-amples of deficits distal to the shoulder that have the potential to detrimentally impact shoulder function. Reduced en-ergy transfer to the shoulder could result in higher requirements at the shoulder itself, potentially leading to early fatigue of the RC muscles and a lower threshold at which tissue failure and/or shoulder symptoms may occur. Although the va-lidity of the whole-body screening that is relevant to every sport and vocation re-mains in its scientific infancy, the assess-ment of the influence of pain, restricted movement, instability, and weakness in the rest of the body should be con-sidered as an integral part of shoulder assessment. Assessment of impairment is typically followed by special orthopaedic tests designed to assess the structural integ-rity of the RC. Reproduction of pain and identifying weakness during these pro-cedures are considered clinically diag-nostic. However, multiple narrative and systematic reviews 45,47   have concluded that the capability of these tests to as-sess and implicate the RC as the source of symptoms cannot be achieved with the certainty and confidence required to meaningfully inform clinical decision making. 67,68  Tests have been described to individually assess the 4 RC muscles and their related tendons. 71  A fundamental requirement for a clinical procedure to implicate a structure would be the ability of the clinical test to assess that structure in isolation; the morphology of the RC muscle group, however, does not allow for this. Clark and Harryman 22  reported that the infraspinatus and supraspinatus fuse near their insertions and cannot be separated, and that the teres minor and infraspinatus merge inseparably just proximal to the musculotendinous junc-tion. The RC tendons are also confluent  with the capsule of the shoulder and the coracohumeral and glenohumeral liga-ments. Interweaving of the RC with the glenohumeral joint ligamentous and capsular tissues negates the possibility of isolated testing of individual structures. The inability to test shoulder muscles in isolation has been demonstrated in an in-tramuscular electromyography investiga-tion comparing the full- and empty-can tests, which are commonly used to test for supraspinatus pathology. During the full-can test, 8 other shoulder muscles  were found to be equally activated rela-tive to the supraspinatus, and during the empty-can test, 9 other shoulder muscles  were equally activated, 10  a finding that challenges the validity and clinical utility of these tests.Bursae function to reduce friction  between moving structures, and up to 12 bursae have been identified through-out the shoulder region. Bursae receive a rich sensory innervation from mechano-receptors and nociceptors 4  and have the potential to substantially contribute to shoulder pain. 28,29,39  Substance P is one of many substances identified in the shoul-der bursae that may stimulate free nerve endings and result in shoulder pain, 98,113   with higher concentrations of substance P in the subacromial bursa being associ-ated with higher levels of shoulder pain. 39   All shoulder special tests stretch and compress multiple structures, including the bursae, and, as such, it is unlikely that orthopaedic special tests can be used to isolate a single structure.Diagnostic ultrasound, MRI, and sur-gery have been used as reference stan-dards to validate clinical orthopaedic tests. An essential criterion for validity is    J  o  u  r  n  a   l  o   f   O  r   t   h  o  p  a  e   d   i  c   &    S  p  o  r   t  s   P   h  y  s   i  c  a   l   T   h  e  r  a  p  y   ®    D  o  w  n   l  o  a   d  e   d   f  r  o  m   w  w  w .   j  o  s  p   t .  o  r  g  a   t   V  r   i   j  e   U  n   i  v  e  r  s   i   t  e   i   t   A  m  s   t  e  r   d  a  m   o  n   N  o  v  e  m   b  e  r   1 ,   2   0   1   5 .   F  o  r  p  e  r  s  o  n  a   l  u  s  e  o  n   l  y .   N  o  o   t   h  e  r  u  s  e  s  w   i   t   h  o  u   t  p  e  r  m   i  s  s   i  o  n .    C  o  p  y  r   i  g   h   t   ©   2   0   1   5   J  o  u  r  n  a   l  o   f   O  r   t   h  o  p  a  e   d   i  c   &    S  p  o  r   t  s   P   h  y  s   i  c  a   l   T   h  e  r  a  p  y   ® .   A   l   l  r   i  g   h   t  s  r  e  s  e  r  v  e   d .  926  | november 2015 | volume 45 | number 11 | journal of orthopaedic &  sports physical therapy  [   CLINICAL   COMMENTARY   ] that structural failure, seen on imaging, is present in those with symptoms, and not present in those without. Of concern, the authors of several studies have reported the presence of substantial shoulder tis-sue structural abnormality in people  without shoulder symptoms. 35,38,81,83  In an MRI investigation, Frost et al 35  reported that 55% of people diagnosed with sub-acromial impingement syndrome had evidence of supraspinatus tendon pa-thology, compared with 52% in people  without symptoms, with the incidence increasing equally in both groups with advancing age. Asymptomatic partial- and full-thickness RC tears have been reported in 50% of people in their sev-enth decade and in 80% of people over 80 years of age. 81  In a separate study using MRI, a very high incidence of RC pathology (79% for the pitching shoulder and 86% for the catching shoulder) was reported in asymptomatic professional  baseball pitchers. 83  In a recent study, 96% of men without shoulder symptoms were reported to have some form of structural abnormality identified on ultrasound, including subacromial bursal thicken-ing, supraspinatus tendinosis, and su-praspinatus tears. 38  It is apparent that the presence of structural tissue failure in large numbers of people without symp-toms challenges the validity of imaging to identify the source of symptoms. This also includes intrasurgical observation of tissue failure, which has been considered  by some to be the gold standard compar-ator to determine the validity of clinical tests. 79  These data highlight the fact that many people undergo surgery on shoul-der tissue(s) that potentially may not be the cause of their symptoms. A consequence of the difficulty in de-riving a definitive structural diagnosis from clinical tests and imaging proce-dures has prompted some individuals to advocate treatment-direction (also known as treatment classification) tests to guide patient management. 112  One method, the SSMP, 67   systematically in- vestigates the influence of thoracic pos-ture, 3 planes of scapular posture (and combinations of scapular positioning), and humeral head position (using a bat-tery of tests) on shoulder symptoms. 67   In addition, the cervical and thoracic spinal regions are screened to determine their influence on symptoms. 67  Shoulder Symptom Modification Procedure The first stage of the SSMP is to iden-tify relevant (typically 1-3) aggravating movements, activities, or postures that reproduce symptoms. Then, as detailed in the APPENDIX , a systematic and step- wise algorithm is applied to the aggra- vating movements, activities, or postures to determine if the symptoms are altered and to what extent. It is difficult to state definitely what alteration in symptoms is clinically meaningful, and the SSMP relies on the patient to make that deter-mination. Patients report what is impor-tant to them, such as improvement in movement/function, less pain, reduced paresthesia, or a greater feeling of sta- bility. If an individual expresses that any component of the SSMP has resulted in a meaningful positive change, then the procedure used to produce that change is used to inform treatment. With respect to pain, anecdotally, patients frequently report improvement when they experi-ence a 30% reduction in symptoms, but this varies from individual to individual.The first procedures of the SSMP aim to determine the influence of increasing and decreasing the thoracic kyphosis on the presenting symptoms. For example, if shoulder abduction through a painful arc is identified as the main provocative movement, then the immediate influence of active thoracic extension and possi- bly flexion is assessed when performing shoulder abduction through that painful arc. For simple activities, thoracic exten-sion is achieved by asking the patient to place a finger on the sternum and use this as a guide to actively lift (extend) the thorax, and hold this position while repeating the movement of shoulder ab-duction ( FIGURE 1 ). For more demanding movements such as a push-up or a ten-nis or volleyball serve, or for prolonged activities such as a 400-m freestyle swim, athletic tape is used in an attempt to hold the thoracic spine into extension.If the thoracic maneuver reduces the symptoms by 100%, then the assessment is complete and treatment is initiated  with a combination of postural aware- A B FIGURE 1. Performing symptomatic shoulder flexion in natural posture (A). Repeating the same movement after performing active thoracic extension by asking the patient to place the fingers of the contralateral hand on the sternum and lift gently (B) before repeating the shoulder flexion movement.    J  o  u  r  n  a   l  o   f   O  r   t   h  o  p  a  e   d   i  c   &    S  p  o  r   t  s   P   h  y  s   i  c  a   l   T   h  e  r  a  p  y   ®    D  o  w  n   l  o  a   d  e   d   f  r  o  m   w  w  w .   j  o  s  p   t .  o  r  g  a   t   V  r   i   j  e   U  n   i  v  e  r  s   i   t  e   i   t   A  m  s   t  e  r   d  a  m   o  n   N  o  v  e  m   b  e  r   1 ,   2   0   1   5 .   F  o  r  p  e  r  s  o  n  a   l  u  s  e  o  n   l  y .   N  o  o   t   h  e  r  u  s  e  s  w   i   t   h  o  u   t  p  e  r  m   i  s  s   i  o  n .    C  o  p  y  r   i  g   h   t   ©   2   0   1   5   J  o  u  r  n  a   l  o   f   O  r   t   h  o  p  a  e   d   i  c   &    S  p  o  r   t  s   P   h  y  s   i  c  a   l   T   h  e  r  a  p  y   ® .   A   l   l  r   i  g   h   t  s  r  e  s  e  r  v  e   d .
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