#040 – 10 Articles on Rotator Cuff Related Shoulder Pain in 2021

Rotator Cuff Related Shoulder Pain is an umbrella term, that encompasses several pathoanatomical terms that are difficult to differentially diagnose, including; subacromial pain syndrome, rotator cuff tendinopathy, and symptomatic rotator cuff tears.

Below is a summary of 10 articles on Rotator Cuff Related Shoulder pain.

1 – Group-based exercise, individually supervised exercise and home-based exercise have similar clinical effects and cost-effectiveness in people with subacromial pain

Multicenter, three-arm, randomized controlled trial with concealed allocation and intention-to-treat analysis. (Open Access).

🎯Aim

• Investigate the effects of group-based exercise, individual exercise and home-based exercise on clinical outcomes and costs in patients with subacromial pain.

🩹Interventions

Intervention details here

Group-based exercise rehabilitation (GE): 57 Participant at 6 months follow-up

• A maximum of 12 group sessions are held over a period of 8 weeks, The aim is for two group sessions to be held weekly, and home training to be done 1-2 times per week for the first four weeks. Afterwards, group exercise sessions are held once a week, while home training is increased to 2-3 times a week.
• The duration of the group training sessions is 45-60 minutes per session, and the home training can be completed in 15-20 minutes per session.

Individual exercise rehabilitation (IE): 62 Paticipants at 6 months follow-up

• A maximum of 12 individual sessions over a period of 8 weeks.
• The aim is to have supervised training 1-2 times per week and corresponding home training for the first 4 weeks, depending on each individual’s needs. After this, the supervised training can be reduced to once per week, while the home training is increased to 2-3 times per week. In this way the citizen gradually becomes increasingly responsible for his/her own training.
• The duration of individual sessions is 30-45 minutes per session, and the home training can be completed in 15-20 minutes per session.

Home exercise rehabilitation (HE): 62 Paticipants at 6 months follow-up

• A maximum of 5 consultations over a period of 8 weeks, in addition to the first examination/assessment. The aim is to follow up on the exercise program approx every two weeks. Maximum 4 follow-ups
• The expected consultation time is 30 min. per appointment, and the home training can be completed in 15-20 min. per session.

📊Results

• No clear differences in clinical outcomes between three modes of delivery of physiotherapy commonly used for exercise rehabilitation among people with subacromial pain.
• Overall cost differences between group-based exercise and one-to-one exercise were not noticeable, whereas the home-based supervised exercise intervention produced the lowest total costs.
• In conclusion, the results of this study show that alternative modes of delivery, such as group, or minimally supervised exercise interventions, provide equivalent outcomes to more individualized one-to-one physiotherapy sessions, but home exercise interventions may produce the lowest societal costs.

2 – Effects of 12 Weeks of Progressive Early Active Exercise Therapy After Surgical Rotator Cuff Repair

12 Weeks and 1-Year Results From the CUT-N-MOVE Randomized Controlled Trial (Restricted Access)

🎯Aim

• To evaluate whether there was a superior effect of 12 weeks of progressive active exercise therapy on shoulder function, pain, and quality of life compared with usual care.

🧪Methods

• Progressive active exercise therapy for 41 participants.
• Usual care (UC), limited passive exercise therapy for 41 participants.
• Primery outcome measure: Western Ontario Rotator Cuff Index (WORC)
• Secondery outcome measures: Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire score, pain, range of motion, and strength.

📊Results

• Both groups showed significant improvements over time in all outcomes.
• At 12 weeks, there was no significant difference between the groups in the change in the WORC score from baseline.
• No between-group difference for the secondary outcomes including the WORC score at 1 year and the DASH score, pain, range of motion, and strength at 12 weeks and 1 year.
• Adverse events: 13 retears (16%) at 1-year follow-up: 6 in the PR group and 7 in the UC group.

⏩Conclusion

• Progressive exercise did not result in superior patient-reported and objective outcomes compared with usual care at either short- or long-term follow-up (12 weeks and 1 year).

3 – Definition of the terms “acute” and “traumatic” in rotator cuff injuries

A systematic review and call for standardization in nomenclature. (Open Access)

🤔Why

• There is no consensus throughout the literature of the terms “acute” and “traumatic” used in the classification of rotator cuff tears.
• The aim was to provide a detailed systematic review of the definitions used in the literature and present a suggestion for a standardization in nomenclature based on the findings.

📊Results

• 46 Stuides, 28 studies defining only the term “traumatic”, and 18 studies defining both terms, “acute” and “traumatic”.
• Diagnostics used: 31 studies used MRI, 6 studies used ultrasound, Three studies reported that either MRI or ultrasound was adequate for evaluation of an RCT, 3 studies used X-rays.
• 10 studies, using a period of a minimum of two up to a maximum of 6 weeks as time span for an acute RCT, and eight studies determining a time span from 2 to 6 months for their definition of “acute”.
• Traumatic lesion of the rotator cuff, all included studies required a sudden onset of symptoms following a patient-reported trauma to the shoulder
• For traumatic injuries, only 20% of the selected studies described a specific and adequate injury mechanism in combination with adequate imaging

⏩Conclusion

• The term “acute” should be reserved for RCT showing muscle edema, wavelike appearance of the central part of the torn tendon, and joint effusion, which typically requires adequate imaging within 2 weeks from trauma.
• Repair of acute tears should occur within 8 weeks from trauma to benefit from possibly superior biological healing capacities.
• The term “traumatic” should be used for a sudden onset of symptoms in a previously asymptomatic patient, triggered by an adequate trauma, e.g., a fall on the retroverted arm with an axial cranioventral force or a traumatic shoulder dislocation.

4 – Effectiveness of conservative therapy in tendinopathy-related shoulder pain

A systematic review of randomized controlled trials (Restricted Access)

🎯Aim

• Investigate the efficacy of conservative therapy on pain and function in people with tendinopathy-related shoulder pain.

📊Results

Data from 5 RCTs including 637 participants.

• Extracorporeal shock-wave therapy (ESWT) was effective on pain at short-term ≤3 months when compared with control.
• Laser therapy and ESWT were not effective on pain and function at short-term, respectively.
• No trials investigated medium- or long-term effects, and quality of the evidence ranged from low to very low quality.

⏩Conclusion

• Low to very-low quality evidence supporting NSAIDs, ESWT and rESWT on pain at short-term for people with tendinopathy-related shoulder pain.

5 – Spinal Manipulation and Electrical Dry Needling in Patients With Subacromial Pain Syndrome

A Multicenter Randomized Clinical Trial (Open Access)

🎯Aim

• To compare the effects of spinal thrust manipulation and electrical dry needling (TMEDN group) to those of non-thrust peripheral joint/soft tissue mobilization, exercise, and interferential current (NTMEX group) on pain and disability in patients with subacromial pain syndrome (SAPS).

🩹Intervention

12 sessions, 2/week for 6-weeks.

Spinal thrust manipulation and electrical dry needling (TMEDN) group: 72 Participants

• Thrust manipulation directed primarily to the lower cervical (C4-C6), cervicothoracic (C7-T3), mid-thoracic (T4-T9), and upper-rib (1–3) articulations.
• 12 sessions of electrical dry needling for 20 minutes, using a standardized protocol of 8 obligatory points targeting intramuscular trigger points, musculotendinous junctions, teno-osseous attachments, and/or peri-articular tissue in the anterolateral subacromial, posterolateral subacromial, lateral brachium, and scapular regions. More details here

Non-thrust peripheral joint/soft tissue mobilization, exercise, and interferential current (NTMEX) group: 73 Participants

• Non-thrust peripheral mobilization (preferably grade III or IV) to the glenohumeral joint, acromioclavicular joint, and peri-scapular region, as well as range-of-motion/stretching and strengthening exercises commonly used in patients with SAPS.
• Grade III or IV joint mobilizations were preferentially used to reduce hypomobility of the posterior capsule and surrounding tissue, improve glenohumeral arthrokinematics, and reduce symptoms.
• Exercises and stretching were initially taught, supervised, and gradually progressed by the treating therapist, in conjunction with the stretching exercises and “phase 1” strengthening. In addition, this group also received 8 to 15 minutes of soft tissue mobilization targeting the posterior and anterolateral shoulder region.
• The treatment ended with 15 to 20 minutes of IFC, using 4 pads surrounding the subacromial space region. Specific interventions are provided.
• More details here

📊Results

• 10 sessions of thrust manipulation to the cervicothoracic spine/upper-rib articulations and electrical dry needling (TMEDN) resulted in greater improvements in shoulder pain intensity, shoulder-related disability, and medication intake in comparison to NTMEX.
• For disability (SPADI), effect sizes were moderate and large at 4 weeks and 3 months, respectively, in favor of the TMEDN group.
• The between-group difference for change in shoulder pain intensity at 3 months, as measured by the NPRS, was also large and exceeded the reported minimal clinically important difference (MCID) for shoulder pain.
• For disability (SPADI), the point estimate for the between-group difference at 3 months (17.9 points) exceeded the respective MCID in patients with shoulder pain.
• For every 2 patients treated with TMEDN, 1 additional patient with SAPS achieved clinically important reductions in disability and “moderate” to “large” changes in self-perceived improvement ratings at 3 months.

⏩Conclusion

• Patients with SAPS who received cervicothoracic/upper-rib thrust manipulation and electrical dry needling experienced greater improvements in shoulder pain, disability, and medication intake compared to patients who received peripheral joint/soft tissue non-thrust mobilization, exercise, and interferential electrotherapy.

6 – Exercise-Based Muscle Development Programmes and Their Effectiveness in the Functional Recovery of Rotator Cuff Tendinopathy

A Systematic Review (Open Access)

🎯Aim

• Analyze and compare the effectiveness of different intervention modalities-based exclusively on physical exercise muscle-development programs to improve shoulder pain and function in RC tendinopathy.

📊Results

8 papers including 409 adult participants.

• Concentric vs. eccentric training:
  • There were no significant differences when using exercise programs with concentric or eccentric contractions for the improvement of shoulder pain, function, ROM, and strength. Based on one RCT (n = 34) with a low risk of bias (PEDro scale).
  • There were no statistically significant differences between groups for improvement of shoulder pain and function, and no clinically relevant differences were found in the primary variable “Shoulder Pain and Disabilities Index” (SPADI). Based on one RCT (n = 120) with low risk of bias.
• Exercises with vs. without co-activation of glenohumeral musculature:
  • There were no statistically significant differences between groups for shoulder pain, function, and acromiohumeral distance (AHD). Based on one RCT (n = 42) with low risk of bias.
• Exercises with pain vs. without pain:
  • Both exercise methodologies were seen to significantly improve shoulder pain, function, and ROM without differences between them. Based on one RCT (n = 22) with a low risk of bias.
• Eccentric training vs. conventional therapeutic exercises:
  • Based on 2 RCTs (n = 36) and (n = 48) with low risk of bias (PEDro scale), different results were found. While the first study found that both exercise methodologies improved shoulder pain and function significantly without finding differences between them, the second showed statistically and clinically relevant differences for pain and function using an eccentric exercise program.
• Exercises with vs. without high eccentric load:
  • It was argued that both methodologies significantly improved pain, function, and strength, but no differences were found between them. Based on one RCT (n = 61) with a low risk of bias.
• Supervised exercises vs. exercises at home:
  • There were no statistically significant differences between the two methodologies for the improvement of pain and function. No participant reported a full recovery after treatment. Based on one RCT (n = 46) with low risk of bias.

⏩Conclusion

• All exercise programs were effective in RC tendinopathy, improving pain and shoulder function.
• No solid results were obtained when the interventions were compared due to their heterogeneity.
• Patients perception assessment tools were the most widely used.
• Amount of load applied should be considered.

7 – Limitation of the external glenohumeral joint rotation is associated with subacromial impingement syndrome, especially pain

🕵️‍♀️Why

Internal/external glenohumeral rotation is important for shoulder function. However, because it is difficult to measure the glenohumeral joint rotation angle physically, the relationship between this angle and the clinical symptoms of subacromial impingement syndrome is still largely unknown.

Therefore, this study used advanced cine-magnetic resonance imaging techniques to understand this relation

🤔How

1. 100 shoulders with subacromial impingement syndrome.
2. Participants underwent cine-magnetic resonance imaging (MRI) during axial rotation with the arm adducted.
3. During imaging, patients rotated their shoulder from maximum internal rotation to maximum external rotation over 10 seconds and then to maximum internal rotation over 10 seconds.
4. The rotation angles were then evaluated using a series of axial images.
5. The Constant–Murley (Constant) and UCLA scores for each participant were determined, and the correlation between the scores and rotational angles was assessed.
6. Participants were divided into three groups according to the Constant pain score, and the rotational angles of each group were compared.
7. Rotational angles were also compared between shoulders with and without night pain.

📊Results

• Glenohumeral ER with the arm adducted was significantly restricted in the shoulders with SIS and proportional to the decrease in clinical scores.
• Shoulders in the severe pain group showed significantly smaller ER angles than those in the mild and moderate pain groups.
• SIS patients with night pain had smaller ER angles of the shoulder joint compared to the ER angles of those without night pain.
• limitation of ER in shoulders in the adducted position, especially glenohumeral ER, can be a therapeutic target for SIS-related pain.
• ER limitation, but not IR limitation, was strongly associated with poor functional scores, especially pain scores.

⏩Conclusion

• External rotational limitation of the glenohumeral joint is associated with pain induced by rotator cuff dysfunction.
• The results suggest that night pain can be effectively reduced using therapeutic interventions that target external rotational dysfunction.

8 – Self-reported management among people with rotator cuff related shoulder pain

An observational study (Restricted Access)

🎯Aim

• Investigate self-reported management among people with rotator cuff related shoulder pain (RCRSP) and their beliefs towards management.

📊Results

• 120 Participant in this cross-sectional survey.
• Most people had tried exercise (99/120, 82.5%) but only one in five people reported exercise was helpful, and one in six reported it was unhelpful or made their symptoms worse.
• Approximately a third of the cohort reported not receiving activity modification advice (34.2%, 41/120), those that did, received inconsistent information.
• People with both traumatic (imaging 31/43, 72.1%; injections 13/24, 54.2%, surgery 8/21, 38.1%) and atraumatic onset pain (imaging 43/77, 55.8%; injections 31/51, 60.8%, surgery 4/19, 21.1%) had similarly high rates of intervention prior to trialling conservative management.
• Patient beliefs in regards to management showed trends towards interventionalist care.

⏩Conclusion

• Regardless of traumatic onset, some people have interventions such as imaging, injections, and surgery prior to trying exercise.
• Patient reported management of RCRSP is often inconsistent with guideline recommended management.

9 – Conservative versus surgical management for patients with rotator cuff tears

A systematic review and META-analysis. (Open Access)

🎯Aim

• Compare conservative versus surgical management for patients with full-thickness RC tear in terms of clinical and structural outcomes at 1 and 2 years of follow-up.

📊Results

• 6 studies including 237 participants in the conservative group, and 231 participants in the surgical group.
• No statistical difference between groups at 12 and 24 months according to the Constant-Murley score (CMS).
• Quantitative synthesis showed better results in favor of the surgical group in terms of VAS pain score one year after surgery.

⏩Conclusion

• At a 2-year follow-up, shoulder function evaluated in terms of CMS was not significantly improved.

10 – Motor Control Exercises Compared to Strengthening Exercises for Upper and Lower Extremity Musculoskeletal Disorders

A Systematic Review With Meta-Analyses of Randomized Controlled Trials. (Restricted Access)

This study included conditions other than RCT-related shoulder pain, but the results are valuable.

🎯Aim

• The purpose of this review was to compare the efficacy of motor control exercises (MCE) to strengthening exercises for adults with upper or lower extremity musculoskeletal disorders (MSKDs).

📊Results

21 study including 1244 participant (all conditions)

Excluding Knee OA and in the short-term:

• Motor control exercise leads to greater pain and disability reductions than strengthening exercises in the short term; these differences might be clinically important.

⏩Conclusion

• These results suggest that motor control exercise could be prioritized over strengthening exercises for adults with rotator cuff-related shoulder pain, shoulder instability, hip-related groin pain, or patellofemoral pain syndrome.

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References: each article title is a link.