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 and bursitis included included) is, in general, to strengthen the surrounding muscles, decrease inflammation, and restore function.

Typically, rotator cuff tendinopathy and bursitis affectsthe supraspinatus tendon and subacromial bursa. Treatment includes decreasinginflammation while maintaining range of motion to prevent a secondary “frozenshoulder” from occurring.

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, once the bursitis is treated (with an oral NSAID or a sub-acromial cortisone injection, for example) physical therapy can help strengthen the cuff.

Although some patients will demonstrate “weakness” solely because of pain induced inhibition (a point inferred from the normal strength demonstrated nearly instantly after the injection of an anesthetic), a strengthening program is usually indicated.

For many patients, a good strengthening program requires instruction on proper technique. 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, for example, the pectoralis muscle will do too much of the work of internal rotation.

Figure 2: internal rotation to isolate the subscapularis

Some physical therapy exercises can be done by the patient at home, of course. Nonetheless, it is imperative that a baseline stretching program is demonstrated to the patient (and, ideally, a friend or family member), to teach safe movement of the patient’s shoulder through the full range of motion.

In addition, some patients cannot participate fully in a home program because of a lack of equipment, motivation, knowledge, or assistance. These patients will need supervised treatment.

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.

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

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