Physical Therapy
A number of physical therapy techniques have been used to treat RCT but no clinical trials exist to support use in rehabilitation. Initial physical therapy focuses on range of motion exercises to maintain mobility and prevent adhesive capsulitis, a common complication of RCT. The therapist then works on strengthening and stretching exercises to restore proper muscle activation and strength balance among the rotator cuff muscles. This is done using open kinetic chain exercises, therabands, muscle recruitment patterns, postural, and scapulohumeral kinesis techniques.
Preliminary studies have shown the benefit of eccentric exercise but further study is needed.39 Eccentric exercise focuses is the application of a load to create a muscle contraction during the lengthening of a muscle.39 Several studies suggest that eccentric exercise stimulates healing and provides effective rehabilitation of tendinopathy.39
Subacute Management
Partial tears or irreparable tears in elderly individuals are treated with conservative treatments. If no improvement is reached within 3 months or if patient cannot participate in physical therapy secondary to pain, other treatment options are considered. This includes local anesthetics, glucocorticoids,
PRP, or HA injections. The first injection attempted is a single, subacromial injection of lidocaine and steroid.40-42
There is no good evidence to suggest that glucocorticoid injections provide significant benefit but this is usually the next modality attempted.40-43 There are a few studies that show a small benefit, although, no difference has been reported when comparing to NSAIDs.41-43 A randomized controlled trial in Turkey found that, at 1-year follow-up, a PRP injection was found to be no more effective in improving quality of life, pain, disability, and shoulder range of motion than placebo in patients with chronic RCT who were treated with an exercise program.43 On the contrary, a study comparing subacromial sodium hyaluronate (HA) injections with rehabilitation showed an overall reduction in pain at weeks 2, 4, and 12 in the HA group, therefore, it may be a safe and effective treatment for patients suffering from RCT.44 Of note, this study was done in a middle-aged population without confounding rotator cuff pathology such as OA and glenohumeral instability. Physical therapy may play a pivotal role in the elderly population in whom these pathologies are common.
Another option is topical nitrate therapy. It is thought to cause local vasodilation, therefore, increasing blood flow to the damaged tendon.45 It is important to note that nitrates are contraindicated in patients with hypotension, anemia, allergy to nitrate therapy, ischemic heart disease, phosphodiesterase inhibitor therapy (e.g., Viagra), pregnancy, and angle-closure glaucoma.45 A common side effect of this treatment is headache.45
Chronic Treatment
An orthopedic referral is warranted when a patient fails conservative treatment for 6-9 months or when a tendon tear is suspected. Three common surgical interventions include debridement, acromioplasty to relieve impingement, and rotator cuff repair. These treatments are considered in active, highly functioning individuals.46 Medications, injections, and rehabilitation are preferred in the elderly in order to maintain strength, range of motion, and function.
Upcoming Research
Randomized control trial involving extracorporeal shock-wave therapy appear to provide minimal relief when treating calcific tendinopathy, which is more common in the elderly population.47
