Initial management of rotator cuff injuries includes relative rest, modification of painful activities, and an exercise program guided to regain motion and strength. Additionally a comprehensive treatment of rotator cuff injuries could incorporate a number of rehabilitation strategies based on patient-specific assessment findings including, but not limited to:
• Manual Therapy (nerve mobilization, soft tissue massage, triggerpoint, IASTM)
• Acupuncture (local, segmental and distal stimulation sites)
• Education on Psychosocial Factors (eg. BPS framework of pain, fear avoidance)
• Remedial Loading Programs (eg. static stretching, concentric, eccentric, isometric)
Managing Inflammation and Swelling
In some cases pathoamatomical explanations do not account for why pain persist (Wylie et al. 2016), which is why is it important to take into account patient-specific assessment findings.
In other cases pathological changes (eg. fibrosis, interstitial collagen deposition, and inflammatory cells) may be associated with sensorimotor declines (Fouda et al. 2017). So in addition using massage therapy to manage pain, prophylactic treatments may play a role in maintaining cellular organization and facilitating tissue repair by mediating differential cytokine production (Bove et al. 2016).
Maintaining and Restoring Range of Motion
If the goal is improving shoulder range of motion (ROM), a number of papers have demonstrated the effects of soft tissue mobilization or stretch training on improving internal rotation and horizontal adduction.
4 weeks of soft tissue mobilization had an affect on tissue stiffness, shoulder internal rotation and horizontal adduction in baseball players with posterior shoulder tightness (Yamauchi et al. 2016).
Modified cross body stretch and modified sleeper stretch leads to decreased the stiffness of the teres minor and infraspinatus (Umehara et al. 2017)
Instrumented manual therapy with self-stretching significantly reduces ROM deficits in baseball players (Bailey et al. 2017)
A 4-week treatment program of manual therapy or dry needling demonstrated a significant improvement in pain pressure threshold, muscle elasticity, and stiffness of neck and shoulder muscles (De Meulemeester et al. 2017).
A 8-week posterior shoulder stretching program significantly increased internal rotation and horizontal adduction ROM in university-level overhead athletes (Chepeha et al. 2017).
The Complex Clinical Picture of Musculoskeletal Pain
The responses to massage therapy are multifactorial - physiological and psychological factors interplay in a complex manner. A biopsychosocial framework is a practical approach for investigating the complex interplay between massage therapy and the experience of pain.
A treatment plan should be implemented based on patient-specific assessment findings and patient tolerance. I often treat this area while passively moving the arm through a wide range of motion. Gently stretching the muscles, neurovascular structures and investing fascia of:
• the rotator cuff
• teres major
• triceps brachii
• pectoral muscle group
• serratus anterior
• latissimus dorsi
More to Explore
Bachasson, D., Singh, A., Shah, S.B., Lane, J.G., Ward, S.R. (2015). The role of the peripheral and central nervous systems in rotator cuff disease. J Shoulder Elbow Surg.
Bailey, L.B., Shanley, E., Hawkins, R., Beattie, P.F., Fritz, S., Kwartowitz, D., Thigpen, C.A. (2015). Mechanisms of Shoulder Range of Motion Deficits in Asymptomatic Baseball Players. Am J Sports Med.
Bailey, L.B., Thigpen, C.A., Hawkins, R.J., Beattie, P.F., Shanley, E. (2017). Effectiveness of Manual Therapy and Stretching for Baseball Players With Shoulder Range of Motion Deficits. Sports Health.
Beard, D.J., Rees, J.L., Cook, J.A., ... Carr, A.J. (2017). Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial. Lancet. (OPEN ACCESS)
Berrueta, L., Muskaj, I., Olenich, S., Butler, T., Badger, G. J., Colas, R. A., . . . Langevin, H. M. (2016). Stretching Impacts Inflammation Resolution in Connective Tissue. Journal of Cellular Physiology.
Bove, G., Harris, M., Zhao, H., & Barbe, M. (2016). Manual therapy as an effective treatment for fibrosis in a rat model of upper extremity overuse injury. Journal of the Neurological Sciences. (OPEN ACCESS)
Cholok, D., Lee, E., Lisiecki, J., Agarwal, S., Loder, S., Ranganathan, K., Qureshi, A.T., Davis, T.A., Levi, B. (2017). Traumatic muscle fibrosis: From pathway to prevention. J Trauma Acute Care Surg. (OPEN ACCESS)
Cucchi, D., Marmotti, A., ... de Girolamo, L. (2017). Risk Factors for Shoulder Stiffness: Current Concepts. Joints. (OPEN ACCESS)
De Meulemeester, K.E., Castelein, B., ... Cagnie, B. (2017). Comparing Trigger Point Dry Needling and Manual Pressure Technique for the Management of Myofascial Neck/Shoulder Pain: A Randomized Clinical Trial. J Manipulative Physiol Ther.
Desjardins-Charbonneau, A., Roy, J.S., ... J.C., Desmeules, F. (2015). The efficacy of manual therapy for rotator cuff tendinopathy: a systematic review and meta-analysis. J Orthop Sports Phys Ther.
Eljabu, W., Klinger, H.M., von Knoch, M. (2015). The natural history of rotator cuff tears: a systematic review. Arch Orthop Trauma Surg.
Fisher, P., Zhao, Y., Rico, M., Massicotte, V., Wade, C., Litvin, J., . . . Barbe, M. (2015). Increased CCN2, substance P and tissue fibrosis are associated with sensorimotor declines in a rat model of repetitive overuse injury. Journal of Cell Communication and Signaling. (OPEN ACCESS)
Flynn, L.S., Wright, T.W., King, J.J. (2018). Quadrilateral space syndrome: a review. J Shoulder Elbow Surg.
Fouda, M.B., Thankam, F.G., Dilisio, M.F., Agrawal, D.K. (2017). Alterations in tendon microenvironment in response to mechanical load: potential molecular targets for treatment strategies. Am J Transl Res. (OPEN ACCESS)
Gigliotti, D., Leiter, J.R., Macek, B., Davidson, M.J., MacDonald, P.B., Anderson, J.E. (2015). Atrophy, inducible satellite cell activation, and possible denervation of supraspinatus muscle in injured human rotator-cuff muscle. Am J Physiol Cell Physiol. (OPEN ACCESS)
Gigliotti, D., Leiter, J.R., ... Anderson, J.E. (2016). Altered Satellite Cell Responsiveness and Denervation Implicated in Progression of Rotator-Cuff Injury. PLoS One. (OPEN ACCESS)
Gigliotti, D., Xu, M.C., Davidson, M.J., Macdonald, P.B., Leiter, J.R., Anderson, J.E. (2017). Fibrosis, low vascularity, and fewer slow fibers after rotator-cuff injury. Muscle Nerve.
Girish, G., Lobo, L.G., ... Jamadar, D.A. (2011). Ultrasound of the shoulder: asymptomatic findings in men. AJR Am J Roentgenol.
Gismervik, S.Ø., Drogset, J.O., Granviken, F., Rø, M., Leivseth, G. (2017). Physical examination tests of the shoulder: a systematic review and meta-analysis of diagnostic test performance. BMC Musculoskelet Disord.
Gordon, C., Andrasik, F., Schleip, R., Birbaumer, N., & Rea, M. (2016). Myofascial triggerpoint release (MTR) for treating chronic shoulder pain: A novel approach. Journal of Bodywork and Movement Therapies.
Gray, M., Wallace, A., Aldridge, S. (2016). Assessment of shoulder pain for non-specialists. BMJ.
Hawk, C., Minkalis, A.L., ... Bhalerao, S. (2017). Systematic Review of Nondrug, Nonsurgical Treatment of Shoulder Conditions. J Manipulative Physiol Ther.
Hegedus, E.J., Cook, C., Lewis, J., Wright, A., Park, J.Y. (2015). Combining orthopedic special tests to improve diagnosis of shoulder pathology. Phys Ther Sport.
Hegedus, E.J., Wright, A.A., Cook, C. (2017). Orthopaedic special tests and diagnostic accuracy studies: house wine served in very cheap containers. Br J Sports Med.
Hermans, J., Luime, J. J., Meuffels, D. E., Reijman, M., Simel, D. L., & Bierma-Zeinstra, S. M. (2013). Does This Patient With Shoulder Pain Have Rotator Cuff Disease? JAMA. (OPEN ACCESS)
Horsley, I., Herrington, L., Hoyle, R., Prescott, E., Bellamy, N. (2016). Do changes in hand grip strength correlate with shoulder rotator cuff function? Shoulder Elbow.
Itoi, E., Arce, G., Bain, G.I., ... Yoo, Y.S. (2016). Shoulder Stiffness: Current Concepts and Concerns. Arthroscopy.
Jain, N. B., Wilcox, R. B., Katz, J. N., & Higgins, L. D. (2013). Clinical Examination of the Rotator Cuff. Pm&r.
Kuhn, J.E., Dunn, W.R., Sanders, R., ... Wright, R.W. (2013). Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: a multicenter prospective cohort study. J Shoulder Elbow Surg. (OPEN ACCESS)
Leong, H. T., Hug, F., & Fu, S. N. (2016). Increased Upper Trapezius Muscle Stiffness in Overhead Athletes with Rotator Cuff Tendinopathy. PLOS ONE. (OPEN ACCESS)
Lewis, J., McCreesh, K., Roy, J.S., Ginn, K. (2015). Rotator Cuff Tendinopathy: Navigating the Diagnosis-Management Conundrum. J Orthop Sports Phys Ther.
Lewis, J. (2016). Rotator cuff related shoulder pain: Assessment, management and uncertainties. Man Ther.
Lewis, J.S., McCreesh, K., Barratt, E., Hegedus, E.J., Sim, J. (2016). Inter-rater reliability of the Shoulder Symptom Modification Procedure in people with shoulder pain. BMJ Open Sport Exerc Med. (OPEN ACCESS)
Littlewood, C., Malliaras, P., Bateman, M., Stace, R., May, S., & Walters, S. (2013). The central nervous system – An additional consideration in ‘rotator cuff tendinopathy’ and a potential basis for understanding response to loaded therapeutic exercise. Manual Therapy.
Littlewood, C., Bateman, M., Brown, K., Bury, J., Mawson, S., May, S., Walters, S.J. (2016). A self-managed single exercise programme versus usual physiotherapy treatment for rotator cuff tendinopathy: a randomised controlled trial (the SELF study). Clin Rehabil.
Miller, B.F., Hamilton, K.L., ... Butterfield, T.A., Dupont-Versteegden, E.E. (2017). Enhanced skeletal muscle regrowth and remodelling in massaged and contralateral non-massaged hind limb. J Physiol.
Nordez, A., Gross, R., ... Hug, F. (2017). Non-Muscular Structures Can Limit the Maximal Joint Range of Motion during Stretching. Sports Med.
Page, M. J., Green, S., Mcbain, B., . . . Buchbinder, R. (2016). Manual therapy and exercise for rotator cuff disease. Cochrane Database of Systematic Reviews.
Pintucci, M., Simis, M., Imamura, M., Pratelli E, ... Battistella, L.R. (2017). Successful treatment of rotator cuff tear using Fascial Manipulation(®) in a stroke patient. J Bodyw Mov Ther.
Salamh, P.A., Kolber, M.J., Hegedus, E.J., Cook, C.E. (2017). The efficacy of stretching exercises to reduce posterior shoulder tightness acutely in the postoperative population: a single blinded randomized controlled trial. Physiother Theory Pract.
Somerville, L. E., Willits, K., Johnson, A. M., Litchfield, R., Lebel, M., Moro, J., & Bryant, D. (2014). Clinical Assessment of Physical Examination Maneuvers for Rotator Cuff Lesions. The American Journal of Sports Medicine.
Struyf, F., Tate, A., Kuppens, K., Feijen, S., Michener, L.A. (2017). Musculoskeletal dysfunctions associated with swimmers' shoulder. Br J Sports Med.
Teunis, T., Lubberts, B., Reilly, B.T., Ring, D. (2014). A systematic review and pooled analysis of the prevalence of rotator cuff disease with increasing age. J Shoulder Elbow Surg.
Thomopoulos, S., Parks, W.C., Rifkin, D.B., ... (2015). Mechanisms of tendon injury and repair. J Orthop Res.
Umehara, J., Nakamura, M., Fujita, K., Kusano, K., Nishishita, S., Araki, K., Tanaka, H., Yanase, K., Ichihashi, N. (2017). Shoulder horizontal abduction stretching effectively increases shear elastic modulus of pectoralis minor muscle. J Shoulder Elbow Surg.
Umehara, J., Hasegawa, S., . . . Ichihashi, N. (2017). Effect of scapular stabilization during cross-body stretch on the hardness of infraspinatus, teres minor, and deltoid muscles: An ultrasonic shear wave elastography study. Manual Therapy.
Vickers, A.J., Vertosick, E.A., Lewith, G., ... Linde, K. (2017). Acupuncture for Chronic Pain: Update of an Individual Patient Data Meta-Analysis. The Journal of Pain.
Weiss, L.J., Wang, D., Hendel, M., Buzzerio, P., Rodeo, S.A. (2018). Management of Rotator Cuff Injuries in the Elite Athlete. Curr Rev Musculoskelet Med.
Wylie, J.D., Suter, T., Potter, M.Q., Granger, E.K., Tashjian, R.Z. (2016). Mental Health Has a Stronger Association with Patient-Reported Shoulder Pain and Function Than Tear Size in Patients with Full-Thickness Rotator Cuff Tears. J Bone Joint Surg Am.
Yamauchi, T., Hasegawa, S., . . . Ichihashi, N. (2016). Effects of two stretching methods on shoulder range of motion and muscle stiffness in baseball players with posterior shoulder tightness: A randomized controlled trial. Journal of Shoulder and Elbow Surgery.