What are the specific aims of supervised physical therapy for rotator cuff tendinopathy?

(Put another way,  what would you tell a patient who asks, “you are just sending me for some exercises – why can I not just do them at home?”)

 

The goal of physical therapy in treating all musculoskeletal conditions (rotator cuff tendinopathy included**) is, in general, to limit symptoms and restore function.

 

Typically, rotator cuff tendinopathy affects the supraspinatus tendon. To encourage its recovery, this tendon must be allowed to rest. However, complete rest likely will lead to a significant loss of range of motion (a “frozen shoulder”).  Thus, passive motion exercises may be helpful.

Figure 1: The left shoulder can be externally rotated passively by the therapist, especially if the scapula is stabilized. This motion can be performed solo by the patient using a stick while lying supine—ideally, after instruction, demonstration, and supervision


Also, it is possible to rest the supraspinatus all the while using the arm, if the other cuff muscles are strengthened. Specifically, the supraspinatus can rest if the other three rotator cuff muscles (subscapularis, infraspinatus, and teres minor) compensate and do the work of the entire cuff. Recall that the main job of the rotator cuff is to hold the humeral head in place and serve as a soft tissue socket. To give the supraspinatus the rest it needs, strengthening the other muscles is critical. For many patients, this requires teaching as to which muscles need to be strengthened, and instruction on how to do so without activation of the muscle in need of rest.

 

A good strengthening program for the subscapularis, infraspinatus, and teres minor can be devised by the physical therapist. For example, the subscapularis can be isolated and strengthened with internal shoulder rotation exercises, optimally with the arm held closely at the side (Figure 2).  Attention to technique and feedback from the physical therapist is the major benefit of supervised therapy. (If the arm is not held closely at the side, the pectoralis muscle will do too much of the work of internal rotation.)

Figure 2: internal rotation to isolate the subscapularis


Some of physical therapy exercises can be done by the patient at home, and patients are usually encouraged to continue them between visits and after formal sessions are completed. Nonetheless, some patients cannot do this due to lack of equipment, motivation, knowledge, or assistance. Thus, at a minimum, patients typically attend at least a few sessions with a physical therapist to learn the movements before they begin doing them independently.

 

A therapist may also apply passive modalities (ice, heat, and massage), monitor progress, provide encouragement, and confirm the diagnosis.

 

In short, a patient hopefully will transition to a “home program,” without supervision, but there are specific goals that may be best attained with supervision and instruction, at least initially.

 

 

** for a more comprehensive review of the pathophysiology of rotator cuff tendinopathy, see https://orthopaedia.com/page/Disorders-of-the-Rotator-Cuff