Physical Therapy Management Of Rotator Cuff Tendinitis


Rotator cuff tendinitis in overuse injury identified as the second stage of rotator cuff disease and results from mechanical wear on the tendon.1 The condition is marked by pain with palpation, movement, and stretching and plays a supporting role in the development of subacromial impingement syndrome due to the inflammatory process occurring in the subacromial space.3,6 Early identification of the signs of stage 1 (edema and hemorrhage) rotator cuff disease is important in preventing the progression and further degeneration and possible rupture of the inflamed tendon(s).2

Guide to Physical Therapy Practice5

▪ Pattern 4B: Impaired posture.
▪ Pattern 4D: Impaired joint mobility, motor function, muscle performance, and range of motion associated with connective tissue dysfunction.
▪ Pattern 4E: Impaired joint mobility, motor function, muscle performance, and range of motion associated with localized inflammation.

A great plethora of verbosity can be found here:
Goal is to address the individual impairments to decrease pain, improve ROM, maximize strength, and optimize posture.3,5,6

Treatment by Phase3,6

1. Protection Phase (Acute Phase)

Control Inflammation, Reduce Pain, and Promote Healing

  • Ice – compress or ice massage
  • Manual therapy: Cross frictions – low intensity
  • NSAIDs
  • Active Rest of involved limb from repetitive and/or aggravating motions

Retain Mobility

  • PROM, AAROM, ROM in pain free range
  • Joint Mobilization Techniques
    • Inferior glides in scapular plane
    • Anterior glides in scapular plane
    • Posterior glides in scapular plane
  • Codman’s pendulums – promote pain-inhibiting grade II joint distraction and oscillations

Retain Muscle Strength

Multi-angle, submaximal isometrics of all involved and surrounding musculature
  • External and Internal Rotators
  • Biceps
  • Triceps
  • Deltoid
  • Scapular Stabilizers
    • Rhomboids
    • Trapezius
    • Serratus anterior
    • Latissimus dorsi
    • Pectoralis major

Promote Neuromuscular Control

  • PNF training
    • Muscle setting
    • Rhythmic initiation
    • Position sense
    • Kinesthetic awareness
  • Protected Stabilization Exercise
    • Functional training of scapular muscles
    • Functional training rotator cuff muscles
    • Functional training of biceps brachii muscle


  • Cryotherapy - Ice
  • TENS
  • High Voltage Galvanic Stimulation
  • US
  • Phonophoresis
  • Iontophoresis
  • Taping

Patient Education and Goals

  • Posture
    • Awareness
    • Correction techniques
    • Mirrors for positional feedback
    • Tactile cues
    • Repetition and reminders
  • Address environmental or habitual patterns that evoke symptoms
  • Educate concerning body mechanics and pathology
  • Educate about recovery and need to work toward common goals
  • Safety
    • Avoid overheard activities such as reaching and lifting

Home Exercise Program (HEP)

  • Submaximal isometrics as per above
  • Self-massage
  • Ice massage
  • Posture
    • Chin tucks
    • Scapular alignment (shoulder rolls)
  • Early motion exercises
    • Supine wand exercise (AAROM): External rotation, elbow at side or slightly abducted, forearm supinated to a thumb-up position
    • Seated external rotation AARM with cane anchored on floor: “gear shift” patterns
    • Closed chain weight bearing through hands on high table: bear weight through hands while shifting side to side

Guidelines for Progression to Recovery Phase

  • Decreased pain and/or symptoms
  • Increased ROM
  • Painful arc in abduction only
  • Improved muscular function

2. Controlled Motion Phase (Recovery Phase)

Continue Patient Education

  • Posture
  • Avoidance of irritation
  • HEP progression (detailed below)
  • Self –administered soft tissue mobilization techniques
    • Massage
    • Isometrics


  • Continue as per above as needed
  • Combine with movement to improve joint tracking
  • Posteriolateral glide with active elevation in scapular plane

Promote Muscle Strength and Balance of Shoulder Girdle Muscles

  • Stretch shortened musculature – manual stretching
    • Pectoralis major and minor
    • Latissimus dorsi
    • Teres major
    • Subscapularis
    • Levator scaplulae
  • Strengthen scapular stabilizers
    • Serratus anterior
    • Lower trapezius
    • Rhomboids
  • Strengthen rotator cuff muscles
    • Supraspinatus
    • Infraspinatus
    • Teres minor
    • Subscapularis

Develop muscular stabilization and endurance

  • Open chain exercises
    • PNF techniques (video)
      • diagonal patterns, supine
      • rhythmic initiation, side lying
      • rhythmic stabilization, side lying
      • Scapular isometrics/isotonics
        • Elevation/depression
        • Upward/downward rotation
    • Isotonic exercise – low weight, high repetition using dumbbells
      • Side lying
        • External rotation
        • Internal rotation
      • Prone
        • Shoulder extension
        • Rows
        • Chin tucks for postural training
      • Standing
        • Forward flexion to 900
        • Abduction to 900
        • Scaption to 900
        • Rows
        • Wall or table push-ups
        • Lat pull-downs
  • Closed chain exercises
    • PNF techniques (video)
      • Prone prop on elbows
      • Quadruped
      • Observe closely for scapular winging
    • Modified push-up positions
      • Hands on wall
      • Hands on high table, low table, or mat
      • Observe closely for scapular winging
    • Endurance training
        • Upper body ergometer
      • Progressively increase time of PNF techniques and other isometric exercises to reach stabilization time of 3 minutes.

Progress Home Exercise Program

  • based on safe and effective execution of exercise
  • adapt therapeutic exercises above to equipment at home
    • wall push-ups
    • wall walking
    • reverse corner push-out with horizontally abducted shoulders – push through elbows to apply resistance to scapular stabilizer muscles
    • ER/IR with weight (soup can, cuff weight, etc…)
  • Self-stretching
    • Pectoralis major
    • Levator scapulae
    • Latissimus dorsi
  • Shoulder and Capsular stretches to enhance
    • Posterior shoulder adduction
    • External rotation
    • Internal rotation, standing and side lying
    • Abduction and elevation
    • Extension

Guidelines for Progression to Maintenance Phase

  • Full ROM with 0/10 pain on VAS
  • Involved arm MMT test strength of 70% of contralateral arm strength
  • Improved muscular strength, power, and control
  • Improved muscular endurance

3. Return to Function Phase (Maintenance Phase)

  • Increase muscular endurance
    • Repetitive loading of the defined pattern for 3-5 minutes
    • Develop quick motor responses to imposed stresses
      • Progressively increase the speed of the action
      • Plyometric training
  • Progress functional training
    • Emphasis on timing and sequence
      • Confirm proper scapulothoracic kinematics
      • Evaluate posture
      • Assure quality of movement
      • Address compensations
    • Eccentric training progressed to maximum load
    • Specifically target desired functional activity
      • Controlled movement
      • Progress to acceleration and deceleration of the movement
    • Patient involvement in evaluation of quality of performed task
      • Safety, posture, symptoms, ease of execution, etc…
      • Role of patient increases as part of education and move toward full independence and discharge.
  • Prevent injury
    • Patient education
      • Prior to work or exercise: Massage techniques for warm-up followed by isometrics, full ROM, and then stretching
      • Take breaks from repetitive activity
        • Develop with patient a plan for alternating stressful activities with relieving ones
      • Maintain proper postural alignment
        • Adaptations for work environment
        • Safe mechanics
      • Develop plan for strength and conditioning
        • For activities patient wishes to engage in for which the patient is not presently conditioned for safe management of the task.

Evidence on Modalities and Other Treatments4,7

Ultrasound, electrotherapy, and low energy laser are common modalities used in the treatment of rotator cuff tendinitis; however, current evidence indicates that their effects are no better than exercise alone or from that of placebo in reducing pain.
Similarly, corticosteroid injects have demonstrated limited improvement over placebo and no benefit over NSAID administration, however, research suggests that ultrasound-guided corticosteroid injection may prove a better option.
Kinesio Tape is yet another often-utilized modality that yet again fails to demonstrate efficacy in reducing pain or enhancing function.
Short wave diathermy has proved effective in reducing pain and improving function compared to ultrasound or home exercise.
Manual therapy techniques provide the greatest degree of decrease in pain and restoration of function.
Deep transverse frictions have a long history of use in the physical therapy profession, yet even recent literature remains unclear as to its long-term effect on pain and function.



  1. Neer CS. Impingement lesions. Clin Orthop. 1983;173:70–7
  2. Fongemie AE, et al. Management of shoulder impingement syndrome and rotator cuff tears. Am Fam Physician. 1998 Feb 15;57(4):667-674.
  3. Kisner C, Colby L. Therapeutic Exercise: Foundations & Techniques, 5th Ed. Philadelphia: F.A. Davis Company; 2007.
  4. Valena PA, Foxworth J. Evidence supporting the use of physical modalities in the treatment of upper extremity musculoskeletal conditions. Curr Opin Rheumatol. 2010 Mar. 22(2):194-204.
  5. American Physical Therapy Association. Guide to physical therapist practice. 2nd edition. American Physical Therapy Association. Phys Ther. 2001;81(1):9-746.
  6. Chang WK. Shoulder impingement syndrome. Phys Med Rehabil Clin N Am. 2004. 15:493–510
  7. Brosseau L, et al. Deep transverse friction massage for treating tendinitis. Cochrane Database Syst Rev. 2002;(4):CD003528.
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