Systematic reviewExercise for rotator cuff tendinopathy: a systematic review
Introduction
Shoulder pain is a common problem with up to half of the population experiencing at least one episode per year [1]. The morbidity associated with shoulder pain is commonly encountered in primary care and physiotherapy [2] where pathology of the rotator cuff is thought to be the commonest cause [3]. The natural history of these disorders is not always favourable and the long-term outcome is frequently poor [4].
Systematic reviews have been undertaken which assess the effect of various interventions, including exercise, for problems relating to the rotator cuff [5], [6], [7], [8], [9], [10], [11], [12] but results have been mixed. One reason for this conflict might be the failure to define adequately the conditions being treated [13]. Studies refer to ‘subacromial impingement’ which, although a common diagnosis in clinical practice, is nothing more than an umbrella term used to describe a variety of conditions which present with varied signs and symptoms [14]. It is perhaps unsurprising that conflict arises when the effects of poorly defined interventions are evaluated in studies where the condition under treatment is also poorly defined.
As with low back pain, diagnostic sub-groups have been identified in the shoulder which when targeted with appropriate intervention might demonstrate superior outcomes [15]. One such diagnostic sub-group is rotator cuff tendinopathy, which would be termed contractile dysfunction in one classification system and has been recognised as a useful classification upon which to base treatment [4]. The signs and symptoms associated with rotator cuff tendinopathy have been reported to include symptom duration greater than three months, minimal resting pain, largely preserved range of shoulder motion and pain exacerbated through resisted testing [4]. This is in stark contrast to other presentations of ‘subacromial impingement’ which might include constant pain and marked limitation of motion [14]. With such varied clinical presentations, it seems sensible to suggest that the underlying pathology might also vary.
The pathology of rotator cuff tendinopathy has been shown to demonstrate similar pathological changes to tendon disorders in other areas of the body, e.g. the elbow, where loaded (against gravity or resistance) exercise has shown beneficial results [16]. Hence, it seems plausible that loaded exercise may also have a role to play in the management of these disorders.
No previous reviews have been identified that define this diagnostic sub-group as a focus for evaluation and considering that previous reviews have been guarded regarding the effectiveness of exercise in the treatment of ‘subacromial impingement’ there is justification to undertake a review with the aim of assessing the effectiveness of exercise in the management of rotator cuff tendinopathy.
Section snippets
Methods
This systematic review was carried out using a predetermined protocol in accordance with the PRISMA statement [17].
Study selection
Fig. 1 depicts the study selection process. The electronic search yielded a total of 2224 records which reduced to 1800 when the duplicates were removed. One additional source was retrieved through hand searching [31]. Two pilot studies were identified in this initial search [13], [32] and in the first instance [13] no further study had been conducted and in the second [32] a potentially relevant study was underway but further data was not available. No further studies were identified through
Discussion
This systematic review summarises the results of four studies that have evaluated the effect of exercise programmes, incorporating loaded exercise, for rotator cuff tendinopathy. It is suggested that both home and supervised exercise programmes might be more effective than no intervention or placebo and as effective as minimal comparators, e.g. functional brace, or active comparators, e.g. multimodal physiotherapy, surgery.
These findings are more optimistic than some previous reviews [8], [10],
Conclusions
The role of exercise in the treatment of rotator cuff tendinopathy is promising but due to the paucity of high quality research and limitations relating to lack of blinding, treatment comparisons and outcome measures employed further research is warranted to fully evaluate the likely benefit.
Conflict of interest
None.
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