Rotator cuff tendinopathy, as defined by Lewis et al. , is pain and weakness most commonly associated with external rotation and elevation of the shoulder due to overloading of the rotator cuff tissue. The etiology of rotator cuff tendinopathy is multifactorial And can be attributed to extrinsic and intrinsic mechanisms as well as environmental factors. Rotator cuff tendinopathy is not a homogeneous entity as the factors involved are varied in nature and thus require different therapeutic interventions to address these specific Consider mechanisms/factors.
Clinically Relevant Anatomy
The rotator cuff is the general name for a group of 4 different muscles and their tendons that provide strength and stability during movement of the shoulder. The muscle originates from the scapula and attaches to the head of the humerus, forming a cuff at the glenohumeral joint. skull to rotator cuff There is a bursa that covers and protects the muscles and tendons as they are in close contact with the surrounding bone.  The rotator cuff muscles include:
Originating from the scapula and inserting on the humerus Main function Supraspinatus muscle Supraspinous fossa greater tuberosity Upper articular surface abduction Infraspinatus Infraspinatus greater tuberosity middle articular surface external rotation Subscapular rotation Subscapular fossa Internal rotation of the lesser tubercle of the humeral neck
Up to 30% of the population experiences shoulder pain at some point in their lives, and up to 50% experience shoulder pain at least once a year. It can be said that shoulder diseases are extremely common. 54% of people with shoulder disease report symptoms are still present Appeared three years later.  Rotator cuff tendinopathy is considered the most common form of shoulder pain, affecting approximately 30% of the population.  People who participate in repetitive overhead activities have an increased incidence of shoulder pain, including repetitive Throwing sports such as baseball or volleyball Occupations such as painting or carpentry. The incidence of rotator cuff tendinopathy also increases with age, which needs to be considered when we talk about rotator cuff disease. The following conditions can be classified as rotator cuff terms Tendinopathy: Tendinitis Tendonitis or partial tear of the rotator cuff tendon should be ruled out: subacromial impingement syndrome, deltoid bursitis, frozen shoulder, and full-thickness tears .
Occupational Risk Factors:
Direct Load Bearing
Repetitive Arm Movements
Working with hands above shoulder height
Lack of Rest
Risk Factor for Tendinopathy:
Adiposity  
Metabolic Disorders: Nonfamilial Hypercholesterolemia Diabetes Mellitus 
Certain movements (repetitive arm movements) 
According to Lewis et al. , the exact cause of rotator cuff tendinopathy remains uncertain, but proposed mechanisms include intrinsic, extrinsic or combined factors, as shown in Figure 1 below.
Figure 1. Proposed mechanism of rotator cuff tendinopathy 
The extrinsic factor is caused by compression of the rotator cuff tendon on the side of the tendon bursa, encroaching on the subacromial space. This compression may be caused by anatomical variation of the subacromion – AC joint spur  of the scapula or humerus Kinematic posture abnormalities Rotator cuff and scapular muscle performance deficits Reduced extensibility and overuse of the pectoralis minor or posterior shoulder . There is also a unique extrinsic mechanism called an internal impact where the rear is compressed The tendon articular surface between the humeral head and glenoid, independent of subacromial space narrowing.  Muscle fatigue or weakness can lead to narrowing of the subacromial space, so rehabilitation can address this. 
Intrinsic factors leading to degradation of the rotator cuff tendon due to stretch or shear overload are changes in biomechanical properties, morphology and vascularity. Intrinsic factors thus have an influence on the morphology and performance of the tendon.   Age heredity and adverse Biomechanics  overuse and trauma  have also been considered as intrinsic factors, with increased tendon loading seen as the most important factor. 
Symptoms or features of rotator cuff tendinopathy are pain in the area of the quadriceps tendon of the rotator cuff, tenderness at the shoulder joint, with dull features, especially the crown of the head reaching the back of the back, lifting and sleeping on the affected side. more relevant Shoulder elevation and abduction cannot achieve upper arm abduction and forward flexion above 90°. ADL can cause considerable distress. The pain is not sudden, but gradually increases and lasts for a while. Associated with pain is your body getting weaker and weaker shoulder and can’t move.   There may also be localized swelling.
Shoulder pain is a common problem with many different causes, so it is important to determine the difference between rotator cuff tendinopathy and some of the following shoulder problems;
- Adhesive Capsulitis (Frozen Shoulder)
- Biceps Rupture
- Bicipital Tendinopathy
- Cervical Disc Disease
- Cervical Spondylosis
- Cervical Sprain and Strain
- Complex Regional Pain Syndromes
- Rheumatoid Arthritis
- Shoulder Pain in Hemiplegia
- Thoracic Outlet Syndrome (TOS)
Diagnosis is based on several aspects, such as the patient’s medical history. Additionally, the test will be used to implicate an isolated structure. Diagnosis of rotator cuff tendinopathy will be made based on response to clinical testing. Supporting tests, such as ultrasound x-rays Radioactive nucleotide isotope scanning Magnetic resonance imaging (MRI) Computed axial tomography (CT) Electromyography Nerve conduction Single photon emission computed tomography Diagnosis Analgesic injections and blood tests are sometimes used to enhance the diagnosis. 
Diagnostic ultrasound is considered the best tool for diagnosing rotator cuff tendinopathy  with partial thickness tears thickening the subacromial bursa and excluding full thickness tears . MRI scans can also be used to diagnose rotator cuff tendinopathy and partial rotator cuff tears. 
A visual analog scale was used to describe pain following palpation of the shoulder joint by a physical therapist. That’s not the only way you can use the Shoulder Pain and Disability Index (SPADI), too. Questionnaire to be filled out by the patient. 
Two clinical tests can be performed to evaluate for rotator cuff tendinopathy.  
The first is called the “empty can test”. With the patient standing, the shoulders are abducted 90°, adducted horizontally 30°, and complete end-range rotation. The therapist places both hands on the patient’s upper arm and provides downward pressure as the patient tries to maintain his position.
In the “Hawking test,” the patient stands with the shoulder abducted 90° and the forearm internally rotated. The presence of pain during exercise is a possible indicator of pathology.
In the modified Belly Press Test the patient stands or sits with arms flat on the stomach and elbows close to the body. The patient should bring the elbow forward and straighten the elbow. The final abdominal compression of the elbow should be measured with a goniometer. A stomach-press an anterior difference of 10° between the affected and unaffected side is suggestive of tendinopathy.
Treatments can be medical. But not all of it is firmly grounded in evidence. The use of non-steroidal anti-inflammatory drugs (NSAID’s) such as ibuprofen and aspirin can have pain reducing effects. The second option is a common corticosteroid injection administered as a treatment for arthritis. It has side effects such as hypersensitive skin at the injection site and skin discoloration. To give repeated injections will also facilitate the structure of the muscles. Medical examiners often prescribe immobilization. And the last one, too medical management is surgical treatment. Surgical results have been very good but will only be an option if conservative treatment has not worked.
Studies suggest that there may be no difference in pain between surgery and exercise regimens. There may be no difference between open surgery and arthroscopic surgery either but people may recover faster with arthroscopic surgery. Surgery can cause many complications including pain infection with difficulty in moving the shoulder postoperatively with damage to the shoulder tissue and the need for further surgery. These side effects have been shown to be independent of the type of surgery (open or laparoscopic). Effect of subacromial corticosteroid injection is supported by the available evidence although the effect may be small and short-lived. Also no better than an NSAID.Also the effect of localized microwave diathermy on disabled shoulder function and pain is equivalent to that of subacromial corticosteroid injections.Additionally, platelet-rich plasma injections also appear effective for significant improvements in pain function and pain outcomes.
Physical Therapy Management
Exercises for rotator cuff problems aim to reduce pain and swelling to allow for normal motion and ultimately strengthen the shoulder. Initially rest and ice are used for pain relief. It is very important for patients to avoid pain-inducing activities initially and symptoms. The physical therapist should guide the patient as to when to resume these activities.
The physical therapist can use techniques such as massage to condition the muscles for range of motion and strength exercises. It is important that the patient performs the exercises in sequence; first, stretching and range of motion exercises and then muscle-strengthening exercises. And a decreased shoulder internal rotation should be tested and extended posterior capsule if stiffness.
Kinesiotaping has been shown to impact the treatment of rotator cuff tendinopathy. But further research is needed.  .
Ultrasound percutaneous therapy for rotator cuff calcific tendinitis should be successful with short-term results. Improved function and decreased symptoms in mild to moderate calcification in young adults.
Exercise has been shown to be effective and helpful in improving shoulder arthritis compared to no treatment or placebo.
There is limited evidence from rotator cuff tendinopathy research to guide specific treatment protocols.
The following are suggestions to include in the preparation:
Kinetic chain exercises
Procedural errors and training correction  .
Scapulo-humeral rhythm and correction of glenohumeral instability .
Isometric exercises to reduce pain
Isometrics of pain relief have been demonstrated in patellar tendinopathy .
A small pilot study using isometric exercises for patients with rotator cuff tendinopathy. Patients performed external exercises and progressed from 3-5 times/day with 10-20 second holds for a week. The study showed a decrease in the VAS scale and noted that further research is needed in this area  .
- Isometric exercises will be more effective than isotonic exercises (eccentric and concentric) in improving pain and strength as well as providing faster gains in function.  .
Studies have shown that other interventions such as laser-and ultrasound therapy do not negate the effectiveness of treatment progression.
On the other hand the benefits of ESWT (Extracorporeal shock wave therapy) have been demonstrated in calcific tendonitis of the rotator cuff.
Stretching and range of motion exercises :
pendulum exercise: bend forward and hang shoulder height 90° from the body with arms fully extended
posterior capsule stretching: move your affected hand across your body and pull the affected arm closer to your body with your other hand.
- When symptoms allow (5-6 weeks) you can start strengthening exercises.
Level of evidence 5.
– scapular squeezes – external rotation exercises – internal rotation exercises – abduction exercises
Once the rehabilitation is complete it is important to strengthen the shoulder muscles to stay healthy and prevent injury. Most people with Rotator Cuff Tendinopathy see improvement after 6-12 weeks of rehabilitation.
Informational tips and tricksRotator Cuff Tendinopathy indicates a problem with your shoulder muscles. It can be caused by an excess of four nerves in that region or an inflammation of one of the nerves. Other causes of tendinopathy can be found in impingement of the bursa and calcification of the rotator cuff tendons.
Mobilization exercise with a caneAt the beginning of the training program patients are immobilized. For example, a cane can be used for actively assisted movement. It is important to perform the exercise within the pain limit.Start position: The patient lies on his his back with his knees bent on the table with the cane in both hands. He puts his hand that didn’t get it under the cane and his hand that touched it up. Exercise: The patient moves the cane with the free hand. He slowly brings his sore arm up and down and repeats exercise 25 again food. (Height and dementia).
Other techniques: external rotation and abductionWhen inverted in external position with the patient also lying on his back on the table with a cane in his hand. The wrist is bent at ninety degrees. As in the other exercise it is the unaffected arm that moves the other arm in an external rotation.
During the arrest the patient freely moves the rod as far away from the body as possible.
You can make this exercise more challenging by asking the patient to lie on a 45° support or to perform the exercise in a standing position.The frequency of each exercise is repetitions 2-3 per day per day.
Exercises without crutchesIn order to improve rotator cuff tendinopathy range of motion we can start with pendulum exercises. To do this, you need to stand on a table with your unacquired hand. The affected arm just hangs on and you let it hang. Then you can draw pictures manually so it swings like a pendulum. You can make small or large circles (clockwise or counterclockwise) you can move back and forth or from side to side. It is important for the patient not to make this a dynamic exercise but to assure that these movements are produced by the movement of the trunk. (LOE) (LOE) 5)The muscles should be completely relaxed. Do this exercise for about 3 minutes and move your arms about 10 to 20 inches in each direction. In addition, pendulum exercises can be started at this time. These can be done at home twice a day.(LOE 2B)
Resistance training to improve mobilityResistance training has been shown to be applicable to improve mobility. Improved strength was also shown to be associated with improvements in, among other things: musculoskeletal balance as well as mobility. Those things are important in our daily lives.(LOE 2B) As such, resistance exercise is an appropriate means of increasing large muscle strength and development. The benefits of this training vary and will be better in younger than older adults. (LOE 5)
Strength trainingStrength training can be initiated when the patient demonstrates adequate glenohumeral range of motion without substitution patterns with acceptable scapulothoracic kinematics
The patient progresses to isotonic and light closed chain stability exercises. The internal and external rotators are strengthened using described movements with the arm below shoulder height along with elastic resistance and a towel roll placed between the arm and trunk to encourage accordingly technique therefore provides substitution patterns.For training M. serratus anterior you do the bear hug exercise. You stand with your back to the wall with your knees slightly bent and your feet shoulder-width apart. You bend your elbows to 45° the hands are held 60° from the trunk and the shoulder is rotated to 45°. The patient then performs a horizontal rotation of both upper extremities following a simulated arc of approximately 60 degrees until maximum scapular protraction is achieved by bringing their elbows together as to imitate the embrace motion around a circular object. After that you return to the starting position.
To strengthen the trapezius and rhomboid muscles you do a sport row cord exercise.You stand up and pull the cord until you are aligned 90° with your humerus pointing down and your radius and ulna pointing forward.
Detailed training of the muscleWhen you start with these exercises the remodeling phase is almost complete and the rotator cuff tissue is almost mature. The patient should be pain free in activities of daily living. In addition, the patient should not exhibit dyskenisia during dynamic movements in many aspects.
The posterior rotator cuff muscles are progressively strengthened by performing exercises. You stand in position while externally rotating the shoulder in a 45-degree abduction using elastic resistance. By doing this exercise you ensure a higher level suggesting Teres Minor and Infraspinatus. The suraspinatus muscle is optimally generated by perfoming external rotation at 90° of abduction.To strengthen the serratus anterior further perform exercises standing facing away from the elastic resistance attachment and hands held shoulder width and chest height holding the resistance band or rope. The upper extremity is then extended forward away from the body similar to a bench press motion in approximately 120° of horizontal angle followed by retraction of the scapula. Plus, the push- up its plus progression strengthens the serratus anterior even further. It slowly increases gravity and starts. It begins by pressing against a wall then an edge and finally the floor.Advanced rhythmic stabilization
The patient stabilizes their upper extremity in a position of 90° external rotation and 90° anterior rotation in the scapular plane. Once in this position, the patient should hold this position against elastic oscillations with a rubber band. Also an advanced closed chain stability exercises are performed in a four-legged stance as they step on and off high steps and their sides. Proprioceptive neuromuscular facilitation can be used to further promote rhythmic stabilization.
Self-Managed Exercise Program This is a self-administered exercise program designed to address pain and disability associated with rotator cuff tendinopathy. There are several subdivisions in the program; Week 0, Weeks 3-4, Weeks 6-8 and Weeks 10-12. Each subdivision has its own exercises and its own difficulty. It is important to follow the plan correctly and apply the exercises correctly (LOE 1A)(LOE 1B) Exercises are prescribed by the physical therapist but performed independently by the patient. It involves exercising the affected shoulder with resistance against gravity Therapy bands or hand scales  ht. It should be performed twice a day in 3 sets of 10 to 15 repetitions. This movement may be uncomfortable for the patient, but regulations are in place to ensure this discomfort is manageable (LOE 1B)
Self-Administered Exercise Program: Week 0: Baseline Assessment and Treatment Begin with resisted isometric shoulder abduction (or lateral rotation or flexion, etc.) Week 3-4: Initial follow-up & progression Use light weights such as canned food from 80 to 120° against shoulder abduction. Weeks 6-8: Second follow-up and progression Resistance shoulder abduction from 80° to 120°, gradually increasing reps and weight, such as heavy Theraband or dumbbells. Weeks 10-12: Last visit and Discharge final assessment to identify any unresolved functional limitations and progress loading exercises as required, such as pull-ups and pull-ups.
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