Scientific/Clinical Article| Volume 30, ISSUE 2, P125-135, April 2017

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Rehabilitation of symptomatic atraumatic degenerative rotator cuff tears: A clinical commentary on assessment and management


      Study Design

      Clinical Commentary.


      Atraumatic rotator cuff (RC) disease, is one of the most common cause of shoulder pain, which encompasses a continuum from tendinopathy to full thickness cuff tears. Extrinsic, intrinsic and environmental factors have been implicated in the pathophysiology of this disorder, affecting the clinical presentation of symptoms including pain and irritability. Successful rehabilitation of symptomatic atraumatic degenerative rotator cuff (SADRC) tears must address the underlying mechanisms causing dysfunction and correct modifiable factors.

      Purpose of the Study

      The purpose of this paper is to review the shoulder complex anatomy, introduce atraumatic degenerative RC pathology, differentiate between symptomatic and asymptomatic degenerative RC tears, propose an assessment and introduce the Rotator Cuff Protocol 1 (RCP1) designed by the clinical reasoning of one of the lead authors (LW) as a rehabilitation management approach for those clients who present with SADRC tears.


      N/A for clinical commentary.


      The ability to identify SADRC tears should consider shoulder anatomy, extrinsic, intrinsic and environmental factors, and the consideration for the natural history of atraumatic partial and full thickness tears in the general population. A thorough clinical history and examination, which includes shoulder symptom modification tests, allows the examiner to determine at what phase the patient may start their exercise program. The RCP1 is a program that has been used clinically by many therapists and clients over the years and research is underway to test this protocol in atraumatic rotator cuff disease including SADRC tears.

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        • Bunker T.
        Rotator cuff disease.
        Curr Orthop. 2002; 16: 223-233
        • Hermans J.
        • Luime J.J.
        • Meuffels D.E.
        • Reijman M.
        • Simel D.L.
        • Bierma-Zeinstra S.M.A.
        Does this patient with shoulder pain have rotator cuff disease? The rational clinical examination systematic review.
        JAMA. 2013; 310: 837-847
        • Kukkonen J.
        • Joukainen A.
        • Lehtinen J.
        • et al.
        Treatment of non-traumatic rotator cuff tears. A randomized controlled trial with one-year clinical results.
        Bone Joint J. 2014; 96: 75-81
        • Cook J.L.
        • Purdam C.R.
        Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy.
        Br J Sports Med. 2009; 43: 409-416
        • Cooper A.
        • Ali A.
        Rotator cuff tears.
        Surgery. 2013; 31: 168-171
        • Ainsworth R.A.
        • Lewis J.S.
        Exercise therapy for the conservative management of full thickness tears of the rotator cuff: A systematic review.
        Br J Sports Med. 2007; 41: 200-210
        • Hawkes D.H.
        • Alizadehkhaiyat O.
        • Kemp G.J.
        • Fisher A.C.
        • Roebuck M.M.
        • Frostick S.P.
        Shoulder muscle activation and coordination in patients with a massive rotator cuff tear: An electromyographic study.
        J Orthop Res. 2012; 30: 1140-1146
        • Kooijman M.
        • Swinkels I.
        • van Dijk C.
        • de Bakker D.
        • Veenhof C.
        Patients with shoulder syndromes in general and physiotherapy practice: An observational study.
        BMC Musculoskelet Disord. 2013; 14: 128
        • Yamamoto A.
        • Takagishi K.
        • Kobayashi T.
        • Shitara H.
        • Osawa T.
        Factors involved in the presence of symptoms associated with rotator cuff tears: A comparison of asymptomatic and symptomatic rotator cuff tears in the general population.
        J Shoulder Elbow Surg. 2011; 20: 1133-1137
        • Moosmayer S.
        • Lundt G.
        • Seljom U.
        • et al.
        Comparison between surgery and physiotherapy in the treatment of small and medium-sized tears of the rotator cuff: A randomized controlled study of 103 patients with one-year follow-up.
        J Bone Joint Surg Br. 2010; 92: 83-91
        • Kuhn J.E.
        • Dunn W.R.
        • Sanders R.
        • et al.
        Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: A multicenter prospective cohort study.
        J Shoulder Elbow Surg. 2013; 22: 1371-1379
        • Boettcher C.E.
        • Cathers I.
        • Ginn K.A.
        The role of shoulder muscles is task specific.
        J Sci Med Sport. 2010; 13: 651-656
        • Boettcher C.E.
        • Ginn K.A.
        • Cathers I.
        Standard maximum isometric voluntary contraction tests for normalizing shoulder muscle EMG.
        J Orthop Res. 2008; 26: 1591-1597
        • Burkhart S.S.
        • Nottage W.M.
        • Ogilvie-Harris D.J.
        • Kohn H.S.
        • Pachelli A.
        Partial repair of irreparable rotator cuff tears.
        Arthroscopy. 1994; 10: 363-370
        • Wickham J.
        • Pizzari T.
        • Stansfeld K.
        • Burnside A.
        • Watson L.
        Quantifying “normal” shoulder muscle activity during abduction.
        J Electromyogr Kinesiol. 2010; 20: 212-222
        • Wickham J.
        • Pizzari T.
        • Balster S.
        • Ganderton C.
        • Watson L.
        The variable roles of the upper and lower subscapularis during shoulder motion.
        Clin Biomech. 2014; 29: 885-891
        • Reinold M.M.
        • Escamilla R.
        • Wilk K.E.
        Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature.
        J Orthop Sports Phys Ther. 2009; 39: 105-117
        • Tardo D.T.
        • Halaki M.
        • Cathers I.
        • Ginn K.A.
        Rotator cuff muscles perform different functional roles during shoulder external rotation exercises.
        Clin Anat. 2013; 26: 236-243
        • Escamilla R.F.
        • Yamashiro K.
        • Paulos L.
        • Andrews J.R.
        Shoulder muscle activity and function in common shoulder rehabilitation exercises.
        Sports Med. 2009; 39: 663-685
        • Schachter A.K.
        • McHugh M.P.
        • Tyler T.F.
        • et al.
        Electromyographic activity of selected scapular stabilizers during glenohumeral internal and external rotation contractions.
        J Shoulder Elbow Surg. 2010; 19: 884-890
        • Wattanaprakornkul D.
        • Cathers I.
        • Halaki M.
        • Ginn K.A.
        The rotator cuff muscles have a direction specific recruitment pattern during shoulder flexion and extension exercises.
        J Sci Med Sport. 2011; 14: 376-382
        • Beaudreuil J.
        • Bardin T.
        • Orcel P.
        Editorial: Natural history or outcome with conservative treatment of degenerative rotator cuff tears.
        Joint Bone Spine. 2007; 74: 527-529
        • Hegedus E.J.
        • Cook C.
        • Brennan M.
        • Wyland D.
        • Garrisson J.C.
        • Driesner D.
        Vascularity and tendon pathology in the rotator cuff: A review of literature and implications for rehabilitation and surgery.
        Br J Sports Med. 2010; 44: 838-847
        • Nho S.J.
        • Yadav H.
        • Shindle M.K.
        • MacGillivray J.D.
        Rotator cuff degeneration: Etiology and pathogenesis.
        Am J Sports Med. 2008; 36: 987-993
        • Seitz L.A.
        • McClure P.W.
        • Finucane S.
        • Boardman III, N.D.
        • Michener L.A.
        Mechanisms of rotator cuff tendinopathy: Intrinsic, extrinsic, or both?.
        Clin Biomech. 2011; 26: 1-12
        • Via A.G.
        • De Cupis M.
        • Spoliti M.
        • Oliva F.
        Clinical and biological aspects of rotator cuff tears.
        Muscles Ligaments Tendons J. 2013; 3: 70-79
        • Yamamoto A.
        • Takagishi K.
        • Osawa T.
        • et al.
        Prevalence and risk factors of a rotator cuff tear in the general population.
        J Shoulder Elbow Surg. 2010; 19: 116-120
        • McCreesh K.
        • Lewis J.
        Continuum model of tendon pathology – where are we now?.
        Int J Exp Pathol. 2013; 94: 242-247
        • Scott A.
        • Docking S.
        • Vicenzino B.
        • et al.
        Sports and exercise-related tendinopathies: A review of selected topical issues by participants of the second International Scientific Tendinopathy Symposium (ISTS) Vancouver 2012.
        Br J Sports Med. 2013; 47: 536-544
        • Kaux J.-F.
        • Forthomme B.
        • Le Goff C.
        • Crielaard J.-M.
        • Croisier J.-L.
        Current opinions on tendinopathy.
        J Sci Med Sport. 2011; 10: 238-253
        • Michener L.A.
        Not all tendons are created equal: Implications for differing treatment approaches.
        J Orthop Sports Phys Ther. 2015; 45: 829-832
        • Drakos M.C.
        • Rudzki J.R.
        • Allen A.A.
        • Potter H.G.
        • Altchek D.W.
        Internal impingement of the shoulder in the overhead athlete.
        J Bone Joint Surg Am. 2009; 91: 2719-2728
        • Edelson G.
        • Teitz C.
        Internal impingement in the shoulder.
        J Shoulder Elbow Surg. 2000; 9: 308-315
        • Hughes P.C.
        • Green R.A.
        • Taylor N.F.
        Measurement of subacromial impingement of the rotator cuff.
        J Sci Med Sport. 2012; 15: 2-7
        • Hughes P.C.
        • Taylor N.F.
        • Green R.A.
        Most clinical tests cannot accurately diagnose rotator cuff pathology: A systematic review.
        Aust J Physiother. 2008; 54: 159-170
        • Mihata T.
        • Jun B.J.
        • Bui C.N.H.
        • et al.
        Effect of scapular orientation on shoulder internal impingement in a cadaveric model of the cocking phase of throwing.
        J Bone Joint Surg Am. 2012; 94: 1576-1583
        • Fessa C.K.
        • Peduto A.
        • Linklater J.
        • Tirman P.
        Posterosuperior glenoid internal impingement of the shoulder in the overhead athlete: Pathogenesis, clinical features and MR imaging findings.
        J Med Imaging Radiat Oncol. 2015; 59: 182-187
        • Kibler W.B.
        • Ludewig P.M.
        • McClure P.W.
        • Michener L.A.
        • Bak K.
        • Sciascia A.D.
        Clinical implications of scapular dyskinesis in shoulder injury: The 2013 consensus statement from the “scapular summit.”.
        Br J Sports Med. 2013; 47: 877-885
        • Kijima T.
        • Matsuki K.
        • Ochiai N.
        • et al.
        In vivo 3-dimensional analysis of scapular and glenohumeral kinematics: Comparison of symptomatic or asymptomatic shoulders with rotator cuff tears and healthy shoulders.
        J Shoulder Elbow Surg. 2015; 24: 1817-1826
        • Ohl X.
        • Hagemeister N.
        • Zhang C.
        • et al.
        3D scapular orientation on healthy and pathologic subjects using stereoradiographs during arm elevation.
        J Shoulder Elbow Surg. 2015; 24: 1827-1833
        • Ratcliffe E.
        • Pickering S.
        • McLean S.
        • Lewis J.S.
        Is there a relationship between subacromial impingement syndrome and scapular orientation? A systematic review.
        Br J Sports Med. 2014; 48: 1251-1256
        • Michener L.A.
        • Boardman N.D.
        • Pidcoe P.E.
        • Frith A.M.
        Scapular muscle tests in subjects with shoulder pain and functional loss: Reliability and construct validity.
        Phys Ther. 2005; 85: 1128-1138
        • Ludewig P.M.
        The association of scapular kinematics and glenohumeral joint pathologies.
        J Orthop Sports Phys Ther. 2009; 39: 90-104
        • McCreesh K.
        • Donnelly A.
        • Lewis J.
        Immediate response of the supraspinatus tendon to loading in roator cuff tendinopathy.
        Br J Sports Med. 2014; 48: A42-A43
        • Bigliani L.U.
        The morphology of the acromion and its relationship to rotator cuff tears.
        Orthop Trans. 1986; 10: 228
        • Bigliani L.
        • Ticker J.
        • Flatow E.L.
        • Soslowsky L.
        • Mow V.
        The relationship of acromial architecture to rotator cuff disease.
        Clin Sports Med. 1991; 10: 823-838
        • Henkus H.E.
        • de Witte P.B.
        • Nelissen R.G.
        • Brand R.
        • van Arkel E.R.
        Bursectomy compared with acromioplasty in the management of subacromial impingement syndrome.
        J Bone Joint Surg Br. 2009; 91: 504-510
        • Lewis J.S.
        • McCreesh K.M.
        • Roy J.-S.
        • Ginn K.A.
        Rotator cuff tendinopathy: Navigating the diagnosis-management conundrum.
        J Orthop Sports Phys Ther. 2015; 45: 923-937
        • Mackenzie T.A.
        • Herrington L.
        • Horlsey I.
        • Cools A.
        An evidence-based review of current perceptions with regard to the subacromial space in shoulder impingement syndromes: Is it important and what influences it?.
        Clin Biomech. 2015; 30: 641-648
        • Pandey V.
        • Vijayan D.
        • Tapashetti S.
        • et al.
        Does scapular morphology affect the integrity of the rotator cuff?.
        J Shoulder Elbow Surg. 2016; 25: 413-421
        • Sonnabend D.H.
        • Howlett C.R.
        • Young A.A.
        Histological evaluation of repair of the rotator cuff in a primate model.
        J Bone Joint Surg Br. 2010; 92: 586-594
        • Killian M.L.
        • Cavinatto L.
        • Galatz L.M.
        • Thomopoulos S.
        The role of mechanobiology in tendon healing.
        J Shoulder Elbow Surg. 2012; 21: 228-237
        • Baumgarten K.M.
        • Gerlach D.
        • Galatz L.M.
        • et al.
        Cigarette smoking increases the risk for rotator cuff tears.
        Clin Orthop Relat Res. 2009; 468: 1534-1541
        • Factor D.
        • Dale B.
        Current concepts of rotator cuff tendinopathy.
        Int J Sports Phys Ther. 2014; 9: 274-288
        • Harvie P.
        • Ostlere S.J.
        • Teh J.
        • et al.
        Genetic influences in the aetiology of tears of the rotator cuff.
        J Bone Joint Surg Br. 2004; 86: 696-700
        • Magnusson S.P.
        • Hansen M.
        • Langberg H.
        • et al.
        The adaptability of tendon to loading differs in men and women.
        Int J Exp Pathol. 2007; 88: 237-240
        • Passaretti D.
        • Candela V.
        • Venditto T.
        • Giannicola G.
        • Gumina S.
        Association between alcohol consumption and rotator cuff tear.
        Acta Orthop. 2016; 87: 165-168
        • Kelly B.T.
        • Williams R.J.
        • Cordasco F.A.
        • et al.
        Differential patterns of muscle activation in patients with symptomatic and asymptomatic rotator cuff tears.
        J Shoulder Elbow Surg. 2005; 14: 165-171
        • Schibany N.
        • Zehetgruber H.
        • Kainberger F.
        • et al.
        Rotator cuff tears in asymptomatic individuals: A clinical and ultrasonographic screening study.
        Eur J Radiol. 2004; 51: 263-268
        • Struyf F.
        • Cagnie B.
        • Cools A.
        • et al.
        Scapulothoracic muscle activity and recruitment timing in patients with shoulder impingement symptoms and glenohumeral instability.
        J Electromyogr Kinesiol. 2014; 24: 277-284
        • Kibler B.W.
        • Sciascia A.
        • Wilkes T.
        Scapular dyskinesis and its relation to shoulder injury.
        J Am Acad Orthop Surg. 2012; 20: 364-372
        • Brophy R.H.
        • Dunn W.R.
        • Kuhn J.E.
        • et al.
        Shoulder activity level is not associated with the severity of symptomatic, atraumatic rotator cuff tears in patients electing nonoperative treatment.
        Am J Sports Med. 2014; 42: 1150-1154
        • Smith L.
        • Xia Y.
        • Galatz L.M.
        • Genin G.M.
        • Thomopoulos S.
        Tissue-engineering strategies for the tendon/ligament-to-bone insertion.
        Connect Tissue Res. 2012; 53: 95-105
        • Bartolozzi A.
        • Andreychik D.
        • Ahmad S.
        Determinants of outcome in the treatment of rotator cuff disease.
        Clin Orthop. 1994; 308: 90-97
        • Chester R.
        • Shepstone L.
        • Daniell H.
        • Sweeting D.
        • Lewis J.
        • Jerosch-Herold C.
        Predicting response to physiotherapy treatment for musculoskeletal shoulder pain: A systematic review.
        BMC Musculoskelet Disord. 2013; 14: 203
        • Lewis J.
        Rotator cuff related shoulder pain: Assessment, management and uncertainties.
        Man Ther. 2016; 23: 57-68
        • Littlewood C.
        • Malliaras P.
        • Bateman M.
        • Stace R.
        • May S.
        • Walters S.
        The central nervous system–an additional consideration in “rotator cuff tendinopathy”and a potential basis for understanding response to loaded therapeutic exercise.
        Man Ther. 2013; 18: 468-472
        • Plinsinga M.L.
        • Brink M.S.
        • Vicenzino B.
        • van Wilgen P.
        Evidence of nervous system sensitization in commonly presenting and persistent painful tendinopathies: A systematic review.
        J Orthop Sports Phys Ther. 2015; 45: 864-875
        • Biederwolf N.
        A proposed evidence-based shoulder special testing examination algorithm: Clinical utility based on a systematic review of the literature.
        Int J Sports Phys Ther. 2013; 8: 427-440
        • Itoi E.
        • Minagawa H.
        • Yamamoto N.
        • Seki N.
        • Abe H.
        Are pain location and physical examinations are useful in locating a tear site of the rotator cuff?.
        Am J Sports Med. 2006; 34: 256-264
        • Litaker D.
        • Pioro M.
        • El Bilbeisi H.
        • Brems J.
        Returning to the bedside: Using the history and physical examination to identify rotator cuff tears.
        J Am Geriatr Soc. 2000; 48: 1633-1637
        • Hunt S.
        • Kwon Y.
        • Zuckerman J.
        The rotator interval: Anatomy, pathology, and strategies for treatment.
        J Am Acad Orthop Surg. 2007; 15: 218-227
        • Yang J.L.
        • Lu T.W.
        • Chou F.C.
        • Chang C.W.
        • Lin J.J.
        Secondary motions of the shoulder during arm elevation in patients with shoulder tightness.
        J Electromyogr Kinesiol. 2009; 19: 1035-1042
        • Park H.B.
        • Yokota A.
        • Gill H.S.
        • El Rassi G.
        • McFarland E.G.
        Diagnostic accuracy of clinical tests for the different degrees of subacromial, impingement syndrome.
        J Bone Joint Surg Am. 2005; 87: 1446-1455
        • Hegedus E.J.
        • Goode A.P.
        • Cook C.E.
        • et al.
        Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests.
        Br J Sports Med. 2012; 46: 964-978
        • Magarey M.E.
        • Jones M.A.
        Dynamic evaluation and early management of altered motor control around the shoulder complex.
        Man Ther. 2003; 8: 195-206
        • Vad V.B.
        • Warren R.F.
        • Altchek D.W.
        • O’Brien S.J.
        • Rose H.A.
        • Wickiewicz T.L.
        Negative prognostic factors in managing massive rotator cuff tears.
        Clin J Sport Med. 2002; 12: 151-157
        • Toprak U.
        • Ustuner E.
        • Ozer D.
        • et al.
        Palpation tests versus impingement tests in Neer stage I and II subacromial impingement syndrome.
        Knee Surg Sports Traumatol Arthrosc. 2013; 21: 424-429
        • Chopp J.N.
        • O’Neill J.M.
        • Hurley K.
        • Dickerson C.R.
        Superior humeral head migration occurs after a protocol designed to fatigue the rotator cuff: A radiographic analysis.
        J Shoulder Elbow Surg. 2010; 19: 1137-1144
        • McFarland E.G.
        • Garzon-Muvdi J.
        • Jia X.
        • Desai P.
        • Peterson S.A.
        Clinical and diagnostic tests for shoulder disorders: A critical review.
        Br J Sports Med. 2010; 44: 328-332
        • Gerber C.
        • Werner C.M.L.
        • Macy J.C.
        • Jacob H.A.C.
        • Nyffeler R.W.
        Effect of selective capsulorrhaphy on the passive range of motion of the glenohumeral joint.
        J Bone Joint Surg Am. 2003; 85: 48-55
        • Dinnes J.
        • Loveman E.
        • McIntyre L.
        • Waugh N.
        The effectiveness of diagnostic tests for the assessment of shoulder pain due to soft tissue disorders: A systematic review.
        Health Technol Assess. 2003; 7: 1-166
        • Domenech M.A.
        • Sizer P.S.
        • Dedrick G.S.
        • McGalliard M.K.
        • Brismee J.M.
        The deep neck flexor endurance test: Normative data scores in healthy adults.
        PM R. 2011; 3: 2-105
        • MacDermid J.C.
        • Silbernagel K.C.
        Outcome evaluation in tendinopathy: Foundations of assessment and a summary of selected measures.
        J Orthop Sports Phys Ther. 2015; 45: 950-964
        • Watson L.
        • Warby S.
        • Balster S.
        • Lenssen R.
        • Pizzari T.
        The treatment of multidirectional instability of the shoulder with a rehabilitation program: Part 1.
        Shoulder Elbow. 2016; 8: 271-278
        • Watson L.
        • Warby S.
        • Balster S.
        • Lenssen R.
        • Pizzari T.
        The treatment of multidirectional instability of the shoulder with a rehabilitation programme: Part 2.
        Shoulder Elbow. 2016; 9: 46-53
        • de Witte P.B.
        • Henseler J.F.
        • Nagels J.
        • Vliet Vlieland T.P.
        • Nelissen R.G.
        The western ontario rotator cuff index in rotator cuff disease patients. A comprehensive reliability and responsiveness validation study.
        Am J Sports Med. 2012; 40: 1611-1619
        • Hefford C.
        • Abbott J.H.
        • Arnold R.
        • Baxter G.D.
        The patient-specific functional scale: Validity, reliability, and responsiveness in patients with upper extremity musculoskeletal problems.
        J Orthop Sports Phys Ther. 2012; 42: 56-65
        • Horn K.K.
        • Jennings S.
        • Richardson G.
        • Van Vliet D.
        • Hefford C.
        • Abbott J.H.
        The patient-specific functional scale: Psychometrics, clinimetrics, and application as a clinical outcome measure.
        J Orthop Sports Phys Ther. 2012; 42: 30-42
        • Lewis J.S.
        Rotator cuff tendinopathy/subacromial impingement syndrome: Is it time for a new method of assessment?.
        Br J Sports Med. 2009; 43: 259-264
        • Juul-Kristensen B.
        • Hilt K.
        • Enoch F.
        • Remvig L.
        • Sjøgaard G.
        Scapular dyskinesis in trapezius myalgia and intraexaminer reproducibility of clinical tests.
        Physiother Theory Pract. 2011; 27: 492-502
        • Kibler W.B.
        • Sciascia A.
        • Dome D.
        Evaluation of apparent and absolute supraspinatus strength in patients with shoulder injury using the scapular retraction test.
        Am J Sports Med. 2006; 34: 1643-1647
        • Odom C.J.
        • Taylor A.B.
        • Hurd C.E.
        • Denegar C.R.
        Measurement of scapular asymmetry and assessment of shoulder dysfunction using the lateral scapular slide test: A reliability and validity study.
        Phys Ther. 2001; 81: 799-809
        • Struyf F.
        • Nijs J.
        • Baeyens J.-P.
        • Mottram S.
        • Meeusen R.
        Scapular positioning and movement in unimpaired shoulders, shoulder impingement syndrome, and glenohumeral instability.
        Scand J Med Sci Sports. 2011; 21: 352-358
        • Tate A.R.
        Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in overhead athletes.
        J Orthop Sports Phys Ther. 2008; 38: 4-11
        • Tate A.R.
        • McClure P.
        • Kareha S.
        • Irwin D.
        • Barbe M.F.
        A clinical method for identifying scapular dyskinesis, part 2: Validity.
        J Athl Train. 2009; 44: 165-173
        • Borstad J.D.
        • Ludewig P.M.
        The effect of long versus short pectoralis minor resting length on scapular kinematics in healthy individuals.
        J Orthop Sports Phys Ther. 2005; 35: 227-238
        • Roy J.-S.
        • Moffet H.
        • Hébert L.J.
        • Lirette R.
        Effect of motor control and strengthening exercises on shoulder function in persons with impingement syndrome: A single-subject study design.
        Man Ther. 2009; 14: 180-188
        • Cook J.L.
        • Purdam C.R.
        The challenge of managing tendinopathy in competing athletes.
        Br J Sports Med. 2014; 48: 506-509
        • Couppé C.
        • Svensson R.B.
        • Silbernagel K.G.
        • Langberg H.
        • Magnusson S.P.
        Eccentric or concentric exercises for the treatment of tendinopathies?.
        J Orthop Sports Phys Ther. 2015; 45: 853-863
        • Dideriksen K.
        Muscle and tendon connective tissue adaptation to unloading, exercise and NSAID.
        Connect Tissue Res. 2014; 55: 61-70
        • Voleti P.B.
        • Buckley M.R.
        • Soslowski L.J.
        Tendon healing: Repair and regeneration.
        Annu Rev Biomed Eng. 2012; 14: 47-71
        • Camargo P.R.
        • Alburquerque-Sendín F.
        • Salvini T.F.
        Eccentric training as a new approach for rotator cuff tendinopathy: Review and perspectives.
        World J Orthop. 2014; 5: 634-644
        • De Mey K.
        • Danneels L.A.
        • Cagnie B.
        • Huyghe L.
        • Seyns E.
        • Cools A.M.
        Conscious correction of scapular orientation in overhead athletes performing selected shoulder rehabilitation exercises: The effect on trapezius muscle activation measured by surface electromyography.
        J Orthop Sports Phys Ther. 2013; 43: 3-10
        • Ganderton C.
        • Pizzari T.
        A systematic literature review of the resistance exercises that promote maximal muscle activity of the rotator cuff in normal shoulders.
        Shoulder Elbow. 2013; 5: 120-135
        • Ekstrom R.A.
        • Donatelli R.A.
        • Soderberg G.L.
        Surface electromyographic analysis of exercises for the trapezius and serratus anterior muscles.
        J Orthop Sports Phys Ther. 2003; 33: 247-258
        • Pizzari T.
        • Wickham J.
        • Balster S.
        • Ganderton C.
        • Watson L.
        Modifying a shrug exercise can facilitate the upward rotator muscles of the scapula.
        Clin Biomech. 2014; 29: 201-205
        • Cricchio M.
        • Frazer C.
        Scapulothoracic and scapulohumeral exercises: A narrative review of electromyographic studies.
        J Hand Ther. 2011; 24: 322-333
        • Hughes P.C.
        • Green R.A.
        • Taylor N.F.
        Isolation of infraspinatus in clinical test positions.
        J Sci Med Sport. 2014; 17: 256-260
        • Kelly B.T.
        • Kardrmas W.R.
        • Speer K.P.
        The manual muscle examination for rotator cuff strength: An electromyographic investigation.
        Am J Sports Med. 1996; 24: 581-588
        • Marta S.M.A.
        • Pezarat-Correira P.L.C.
        • Fernandes O.J.S.M.
        • Carita A.I.
        • Cabri J.M.H.
        • de Moraes A.C.
        Electromyographic analysis of posterior deltoid, posterior rotator cuff and trapezius musculature in different shoulder exercises.
        Int Sport Med J. 2013; 14: 1-15
        • Cools A.M.
        • Dewitte V.
        • Lanszweert F.
        • et al.
        Rehabilitation of scapular muscle balance which exercises to prescribe?.
        Am J Sports Med. 2007; 35: 1744-1751
        • Decker M.J.
        • Hintermeister R.A.
        • Faber K.J.
        • Hawkins R.J.
        Serratus anterior muscle activity during selected rehabilitation exercises.
        Am J Sports Med. 1999; 27: 784-791
        • Warby S.A.
        • Ford J.J.
        • Hahne A.J.
        • Watson L.A.
        • Pizzari T.
        Comparison of two exercise rehabilitation programs for multidirectional instability of the glenohumeral joint: A randomised controlled trial.
        Am J Sports Med. 2017; (Publication pending)
      1. Warby SA, Ford JJ, Hahne AJ, Watson LA, Balster S, Lenssen R, Pizzari T. Effect of exercise-based management on multidirectional instability of the glenohumeral joint: a pilot randomised controlled trial protocol. BMJ Open. 2016; 6:e013083. 10.1136/bmjopen-2016-013083.

        • Barden J.M.
        • Balyk R.
        • Raso V.J.
        • Moreau M.
        • Bagnall K.
        Atypical shoulder muscle activation in multidirectional instability.
        Clin Neurophysiol. 2005; 116: 1846-1857
        • Kronberg M.
        • Németh G.
        • Broström L.A.
        Muscle activity and coordination in the normal shoulder.
        Clin Orthop Relat Res. 1990; 257: 76-85
        • Solem-Bertoft E.
        The influence of scapular retraction and protraction on the width of the subacromial space: An MRI study.
        Clin Orthop. 1993; 296: 99-103
        • Smith J.
        • Dietrich C.T.
        • Kotajarvi B.R.
        • Kaufman K.R.
        The effect of scapular protraction on isometric shoulder rotation strength in normal subjects.
        J Shoulder Elbow Surg. 2006; 15: 339-343
        • Park I.
        • Lee H.-J.
        • Kim S.-E.
        • Bae S.-H.
        • Byun C.-H.
        • Kim Y.-S.
        Which shoulder motions cause subacromial impingement? Evaluating the vertical displacement and peak strain of the coracoacromial ligament by ultrasound speckle tracking imaging.
        J Shoulder Elbow Surg. 2015; 24: 1801-1808
      2. World Health Organization. Towards a common language for functioning, disability and health: ICF. Available at: (Accessed on January 01, 2002).

        • Kirkley A.
        • Alvarez C.
        • Griffin C.
        The development and evaluation of a disease-specific quality-of-life questionnaire for disorders of the rotator cuff: The western ontario rotator cuff index.
        Clin J Sport Med. 2003; 13: 84-92
        • Roy J.S.
        • MacDermid J.C.
        • Woodhouse L.J.
        Measuring shoulder function: A systematic review of four questionnaires.
        Arthritis Care Res. 2009; 61: 623-632
        • Longo U.G.
        • Saris D.
        • Poolman R.W.
        • Berton A.
        • Denaro V.
        Instruments to assess patients with rotator cuff pathology: A systematic review of measurement properties.
        Knee Surg Sports Traumatol Arthrosc. 2012; 20: 1961-1970

      JHT Read for Credit

      Quiz: #485

      Record your answers on the Return Answer Form found on the tear-out coupon at the back of this issue or to complete online and use a credit card, go to There is only one best answer for each question.
      • #1.
        Once an accurate Dx has been established the ____________ must be determined before proper management can be undertaken
        • a.
        • b.
          mechanical etiology
        • c.
        • d.
          cost of care
      • #2.
        The primary intervention is
        • a.
          relief of pain
        • b.
          restoration of PROM
        • c.
          restoration of AROM
        • d.
          restoration of proper mechanics
      • #3.
        Current thinking identifies _____________ as the primary cause of SADRC
        • a.
          imbalance between the anterior and posterior portions of the rotator cuff
        • b.
        • c.
          intrinsic pathology
        • d.
          extrinsic pathology
      • #4.
        Loading of the cuff tendons, especially the supraspinatus, is felt to
        • a.
          correct mechanical defects of the shoulder girdle
        • b.
          enhance the physiology to support healing
        • c.
          increase the compression on the insertional region of the tendon
        • d.
          diminish the blood supply to the critical zone
      • #5.
        A primary purpose of the article is to introduce a management program, the RCP1
        • a.
        • b.
      When submitting to the HTCC for re-certification, please batch your JHT RFC certificates in groups of 3 or more to get full credit.