Reviewed by Kirsten Hales, SPT

Introduction

Rotator cuff tendonitis (RTC) is a common musculoskeletal condition, often associated with shoulder pain and dysfunction resulting from repetitive motion, aging, or poor posture. Conservative management strategies such as rest, physical therapy, and anti-inflammatory medications, are frequently used. However, the role of resistance exercise (RE) in alleviating pain and improving function in RTC tendonitis is still under investigation. The article “Effect of Resistance Exercise on Pain and Function in Rotator Cuff Tendonitis,” aims to provide insight into the effectiveness of resistance training in addressing pain and functional limitations in individuals with RTC tendonitis.

Methods

This systematic review and meta-analysis included data from 10 randomized controlled trials (RCTs) involving 552 patients diagnosed with RTC tendonitis. The different studies assessed the effects of RE programs on pain reduction, functional improvement, and overall quality of life in patients with chronic shoulder pain related to RTC injuries. Key outcomes analyzed were pain intensity (measured via the VAS) and functional improvement (assessed with the SPADI, and DASH).

Results

The systemic review revealed several key findings:

• Pain Reduction: Participants who engaged in RE programs demonstrated significant reductions in shoulder pain compared to control groups. Pain intensity scores improved by 35-45% after 6-12 weeks of resistance training.
• Functional Improvement: Functional outcomes, as measured by SPADI and DASH scores, showed that resistance exercise resulted in a 20-30% improvement in shoulder strength and ROM.
• Exercise Protocols: The studies varied in terms of the exercise duration (ranging from 6 to 12 weeks) and frequency (2-3 sessions per week). The most effective programs incorporated moderate to high-intensity exercises targeting both the rotator cuff muscles and scapular stabilizers.
• Long-Term Outcomes: While RE yielded immediate improvements in pain and function, the authors noted that the  long-term benefits were less clear. Follow-up data at 3 to 6 months showed some sustained improvements in strength and function, but not all patients maintained pain relief after completing the exercise programs.

Discussion

The authors concluded that RE can be effective in short-term interventions for reducing pain and improving function in patients with RTC tendonitis. By strengthening the muscles around the shoulder joint, RE can help stabilize the joint, reduce strain on the tendons, and promote healing. Additionally, resistance training may enhance neuromuscular control and proprioception, which play a critical role in preventing re-injury and improving overall shoulder function.

However, the review also highlighted several limitations. The diversification of the exercise protocols (such as variations in type, intensity, and duration) across studies makes it difficult to determine the most optimal approach for all patients. The absence of high-quality, long-term data leaves the question of long-term benefits unresolved.

Conclusion

The review concludes that RE is a promising intervention for managing pain and improving function in individuals with RTC tendonitis. Based on the article, clinicians are encouraged to incorporate RE into rehabilitation programs, particularly for patients with chronic shoulder pain. They are also encouraged to combine it with other conservative treatment strategies. In my clinical experience as a student PT, I have observed that incorporating RE into treatment plans for patients with RTC tendonitis can significantly improve pain and function in the short term and the long term. While I have witnessed the benefits of RE  firsthand, the variability in protocols highlights the need for individualized and carefully tailored programs to meet each patient’s needs. This approach ensures that treatment is not only effective but also adaptable to the unique challenges and goals of each patient. However, similar to the authors’ conclusions, further research is necessary to establish standardized protocols and determine the long-term efficacy of RE in managing RTC tendonitis.

Reference:

https://www.schoudernetwerk.nl/wp-content/uploads/2021/06/SR.TypeExerciseinRCRSPpatients.Nauntonetal.Pedro_.ClinRehab.2020.pdf

Reviewed by Tyler Tice, PT, DPT, OCS, ATC

Introduction

Extracorporeal Shockwave Therapy (ESWT) has gained traction as a non-invasive treatment for musculoskeletal disorders, including tendinopathies. Initially developed for kidney stone treatment, ESWT is now used in orthopedic cases for conditions such as plantar fasciitis, rotator cuff tendinopathy, elbow tendinopathy, and Achilles tendinopathy. This modality promotes tissue repair through neovascularization and the release of growth factors, offering a safer alternative to surgical procedures. This study evaluated the efficacy of ESWT in reducing pain, improving functionality, and enhancing quality of life for tendinopathy patients.

Materials and Methods

A total of 384 patients with diagnosed tendinopathies participated, with 326 receiving ESWT and 58 assigned to a control group. The study targeted four types of tendinopathies: elbow, plantar fasciitis, Achilles, and rotator cuff. The shockwave therapy was administered using the STORZ MEDICAL Master Pulse MP200 device. Treatment parameters varied by tendinopathy to ensure optimal outcomes. For elbow tendinopathy, the initial session involved a frequency of 21 Hz, a pressure of 1.8 bar and 2,000 shocks for analgesia, followed by subsequent sessions at 15 Hz, 1.6 bar, and 1,500 shocks for therapeutic purposes. Plantar fasciitis was treated with an initial frequency of 21 Hz, pressure of 1.6 bar, and 1,500 shocks, followed by subsequent sessions at 15 Hz, 1.8 bar, and 2,500 shocks. Achilles tendinopathy treatment included an initial session at 21 Hz, 1.8 bar, and 2,000 shocks, with subsequent sessions at 15 Hz, 2.0 bar, and 3,000 shocks. Rotator cuff tendinopathy involved an initial session at 21 Hz, 1.8 bar, and 2,000 shocks, followed by sessions at 15 Hz, 1.8 bar, and 1,500 shocks. Most participants underwent three to four treatment sessions, spaced at regular intervals.

Results

The findings demonstrated that ESWT significantly reduced pain, improved functionality, and enhanced quality of life across all tendinopathy types. For elbow tendinopathy, pain scores decreased from 1.99 pre-treatment to 0.10 immediately post-treatment and 0.01 at the four-week follow-up. Similar improvements were observed for plantar fasciitis, with pain scores dropping from 2.52 pre-treatment to 0.06 post-treatment and 0.00 at follow-up. Achilles tendinopathy showed reductions from 2.35 pre-treatment to 0.11 post-treatment and 0.00 at follow-up, while rotator cuff tendinopathy pain scores declined from 2.80 pre-treatment to 0.18 post-treatment and 0.01 at follow-up. Functionality and quality of life metrics followed the same trend, with significant improvements observed in all ESWT-treated groups compared to the control groups.

Discussion

ESWT demonstrated efficacy in alleviating pain, restoring functionality, and enhancing quality of life in patients with tendinopathies. The underlying mechanisms include increased vascularization, growth factor release, and modulation of pain perception.

Conclusion

Extracorporeal shockwave therapy is a safe, effective, and non-invasive option for managing chronic tendinopathies, particularly in patients unresponsive to conventional treatments. It delivers substantial improvements in pain, functionality, and quality of life with minimal risks. ESWT is a practical outpatient intervention that can significantly enhance recovery outcomes for musculoskeletal conditions.

Implications for Physical Therapy

Physical therapists can integrate ESWT into rehabilitation programs for tendinopathy patients, either as a standalone treatment or in conjunction with conventional methods. For example:

• Plantar Fasciitis: Pairing ESWT with plantar fascia stretching and strengthening protocols can expedite recovery.
• Rotator Cuff Tendinopathy: Using ESWT alongside scapular stabilization and rotator cuff exercises can restore shoulder function more effectively.
• Achilles Tendinopathy: Incorporating ESWT with eccentric loading exercises can address both pain and tendon remodeling.

Dedes V, Stergioulas A, Kipreos G, Dede AM, Mitseas A, Panoutsopoulos GI. Effectiveness and Safety of Shockwave Therapy in Tendinopathies. Mater Sociomed. 2018;30(2):131-146. doi:10.5455/msm.2018.30.141-146

Reviewed by Tyler Tice, PT, DPT, OCS, ATC

Introduction

Low back pain (LBP) is the leading cause of disability worldwide, affecting a significant portion of the population. With an aging demographic, the prevalence of LBP is expected to increase, negatively impacting physical and psychosocial health. Historically, treatment approaches for LBP focused on pathoanatomical principles, but clinical guidelines now advocate classification-based systems for improved outcomes. The McKenzie Method of Mechanical Diagnosis and Therapy (MDT) is a classification system designed to group patients into categories—derangement, dysfunction, postural syndrome, or “other”—to tailor treatment strategies. A hallmark of MDT is identifying a directional preference, where repeated movements or sustained positions improve symptoms, often leading to centralization of pain. This meta-analysis aimed to evaluate the efficacy of MDT in reducing pain and disability in patients with acute and chronic LBP compared to other interventions.

Methods

Eligible studies required therapists trained in MDT, and only interventions classifying patients prior to treatment were included. Comparator groups involved typical physical therapy interventions such as manual therapy, exercise, and education. Data were extracted from six databases and included 17 studies. Outcomes measured pain and disability using standardized scales. Subgroup analyses were conducted for acute (<12 weeks) and chronic (>12 weeks) LBP.

Results

For acute LBP, four studies compared MDT to other interventions, including manual therapy, exercise, and education. There were no significant differences in pain or disability between MDT and comparators. However, MDT showed a significantly greater pain reduction compared to manual therapy combined with exercise. For chronic LBP, seven studies revealed significant reductions in pain and disability with MDT compared to other interventions. MDT outperformed exercise alone in improving disability but not pain and showed no superiority over combined manual therapy and exercise or education alone. Heterogeneity in comparator interventions influenced outcomes, and the evidence quality ranged from moderate to high.

Discussion

MDT demonstrated moderate effectiveness in managing chronic LBP, particularly for improving disability outcomes. The directional preference and classification approach underpinning MDT appear to enhance treatment precision, addressing patient-specific movement dysfunctions. However, MDT’s benefits for acute LBP were less pronounced, likely due to the transient nature of acute symptoms and the potential for spontaneous recovery. The findings highlight the importance of patient classification and the application of directional preference exercises, which align with MDT’s core principles. Despite its strengths, the analysis noted variability in outcomes due to differences in study design and comparator interventions.

Conclusion

MDT is an effective treatment strategy for chronic LBP, particularly in reducing disability, with outcomes superior to exercise alone. While it may not outperform other interventions for acute LBP, MDT offers a structured approach to managing both acute and chronic conditions. The findings support MDT’s role in clinical practice, particularly for patients with persistent symptoms requiring tailored rehabilitation strategies.

Contributions to Physical Therapy

The McKenzie Method provides a valuable framework for treating LBP in physical therapy settings. Its classification-based approach enables therapists to deliver individualized care, focusing on directional preference exercises that centralize pain and improve functionality. For chronic LBP, MDT offers significant advantages in disability reduction, making it a suitable option for long-term management. Physical therapists can integrate MDT with other rehabilitation techniques, such as manual therapy or stabilization exercises, to optimize outcomes. Additionally, the method’s emphasis on patient education and self-management aligns with contemporary rehabilitation goals, empowering patients to take an active role in their recovery. This holistic approach can enhance adherence, reduce recurrence rates, and improve overall quality of life for individuals with LBP.

1. Lam OT, Strenger DM, Chan-Fee M, Pham PT, Preuss RA, Robbins SM. Effectiveness of the McKenzie Method of Mechanical Diagnosis and Therapy for Treating Low Back Pain: Literature Review With Meta-analysis. Journal of Orthopaedic & Sports Physical Therapy. 2018;48(6):476-490. doi:10.2519/jospt.2018.7562

Reviewed by Tyler Tice, PT, DPT, OCS, ATC

Introduction

The gluteal muscles, particularly the gluteus medius and gluteus maximus, play a critical role in stabilizing the pelvis and controlling hip movement during functional activities. Weakness in these muscles is often linked to lower extremity pathologies such as tibial stress fractures, low back pain, iliotibial band friction syndrome, and patellofemoral pain. The study examines muscle activation during various rehabilitation exercises to determine which exercises most effectively recruit these muscles. By quantifying activation as a percentage of maximal voluntary isometric contraction (%MVIC), the study provides guidance on selecting exercises for progressive rehabilitation of the gluteal musculature. Exercises producing greater than 70%MVIC are deemed sufficient to promote strength adaptation, based on prior research.

Methods

The study involved 26 healthy subjects who participated in a single testing session. Electromyographic (EMG) electrodes were placed on the dominant gluteus medius and maximus muscles. Maximal voluntary isometric contraction (MVIC) was established through standardized manual muscle testing positions. Participants performed 18 exercises, with surface EMG data collected to assess muscle activity. Exercises were selected to include both weight-bearing and non-weight-bearing tasks, some using unstable surfaces for additional challenge. These exercises included sidelying abduction, single-limb squat, front plank with hip extension, clamshell variations, and side planks with abduction. Exercises were randomized to mitigate fatigue effects, with rest periods provided between trials. EMG data were analyzed using a root-mean-square algorithm and normalized to %MVIC.

Results

Key findings indicate that several exercises effectively activate the gluteal muscles. For the gluteus medius, the top exercises included side plank abduction with the dominant leg on the bottom (103%MVIC), side plank abduction with the dominant leg on top (89%MVIC), single-limb squat (82%MVIC), clamshell progression 4 (77%MVIC), and front plank with hip extension (75%MVIC). For the gluteus maximus, the highest activation was observed during front plank with hip extension (106%MVIC), gluteal squeeze (81%MVIC), side plank abduction with the dominant leg on top (73%MVIC), side plank abduction with the dominant leg on the bottom (71%MVIC), and single-limb squat (71%MVIC). Exercises exceeding 70%MVIC for both muscles included front plank with hip extension, side plank abduction variations, and single-limb squat. These results provide rank-ordered recommendations for gluteal strengthening, emphasizing exercises that require high levels of stability and muscle coordination.

Discussion

The findings align with prior research but offer a unique cross-comparison of gluteal muscle activation across multiple exercises. Exercises requiring stabilization, such as planks and single-limb squats, generally elicited higher activation levels. Differences in muscle recruitment between studies were attributed to variations in technique and external support. Notably, exercises like side planks with abduction and front planks with hip extension demonstrated co-contraction of core musculature, which likely enhanced gluteal recruitment. Practical applications of these findings include tailoring exercise selection to a patient’s functional capacity, with simpler tasks like clamshells used initially and more complex exercises introduced progressively.

Conclusion

This study identifies effective exercises for strengthening the gluteus medius and maximus, providing valuable insights for rehabilitation protocols. High %MVIC values observed during certain exercises support their use in targeted strengthening programs. Clinicians can use these findings to design progressive exercise programs, ensuring optimal muscle recruitment and functional outcomes.

Contributions to Physical Therapy

Gluteal muscle strengthening is essential in managing various lower extremity and low back pathologies. Exercises like front planks with hip extension and side planks with abduction not only target the gluteal muscles but also engage the core, enhancing overall stability and functional movement patterns. These exercises can be used to address muscle weakness, improve pelvic control, and reduce compensatory movement patterns. By incorporating these high-activation exercises into rehabilitation protocols, therapists can promote efficient recovery and prevent injury recurrence, ultimately enhancing patient outcomes.

1. Boren K, Conrey C, Le Coguic J, Paprocki L, Voight M, Robinson TK. ELECTROMYOGRAPHIC ANALYSIS OF GLUTEUS MEDIUS AND GLUTEUS MAXIMUS DURING REHABILITATION EXERCISES. Int J Sports Phys Ther. 2011;6(3):206-223. Accessed December 22, 2024. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3201064/

Reviewed by Tyler Tice, PT, DPT, OCS, ATC

Introduction:

Running is one of the most popular forms of physical activity. However, the popularity of running is accompanied by a high prevalence of overuse injuries. Most injuries occur in the lower extremities, with a substantial proportion affecting the foot. These injuries are often linked to biomechanical factors such as impact loading, plantar pressure, and repetitive stress, particularly on the metatarsals and soft tissues of the foot. To address these issues, research has explored biomechanical modifications, such as cadence manipulation, as a strategy to reduce injury risk. Increasing cadence has been shown to decrease step length and ground reaction forces, potentially mitigating the forces implicated in injury development. This study specifically evaluates the effects of cadence manipulation on plantar loading in healthy runners, focusing on how these changes could influence injury prevention and management.

Methods:

Thirty-eight healthy recreational runners participated in this study. Participants met inclusion criteria requiring a minimum running distance of 12.87 km per week and no musculoskeletal injuries in the prior six months. Plantar loading data were collected during treadmill running at participants’ preferred pace under three cadence conditions: preferred, 5% increased, and 5% decreased. Each trial was randomized to minimize fatigue effects, with data collected for 30 strides per condition.

Plantar loading variables analyzed included:

• Contact Time (CT): The duration of foot contact with the ground.
• Peak Force (PF): Maximum force exerted during a foot strike.
• Force Time Integral (FTI): Total force exerted over the contact period.
• Peak Pressure (PP): Maximum pressure exerted on the plantar surface.
• Pressure Time Integral (PTI): Total pressure applied over time.

These variables were measured for the total foot and four specific regions: heel, medial metatarsal, central metatarsal, and lateral metatarsal.

Results:

The study found that cadence manipulation significantly influenced plantar loading patterns:

1. Increased Cadence (+5%):
   • Decreased CT, PF, and PTI for the total foot and all foot regions.
   • Reduced heel loading, including lower pressure and force variables.
   • Lower metatarsal loading across medial, central, and lateral regions.
2. Decreased Cadence (-5%):
   • Increased CT and higher PF and PTI values in the heel and metatarsal regions.
   • Elevated total foot loading, with more pronounced force and pressure variables.

Discussion:

The results underscore the biomechanical benefits of increasing cadence during running. A faster cadence reduces plantar loading by decreasing contact time and ground reaction forces. Notably, this study refuted the hypothesis that increased cadence would elevate metatarsal loads; instead, all regions of the foot experienced reduced loading. These effects may be attributed to reduced vertical oscillation of the body’s center of mass and a decreased foot inclination angle at initial contact.

From a clinical perspective, cadence manipulation presents a promising strategy for reducing the risk of overuse injuries, such as plantar fasciitis, Achilles tendinopathy, and metatarsal stress fractures. By lowering repetitive loads on vulnerable foot structures, a 5% increase in cadence can mitigate the cumulative stress associated with long-distance running.

Conclusion:

This study highlights the potential of cadence manipulation as an effective tool for injury prevention and rehabilitation in runners. A modest 5% increase in cadence reduces plantar loading across all foot regions, suggesting that cadence training could be integrated into physical therapy protocols for managing running-related injuries. Given the small but meaningful biomechanical changes observed, cadence adjustments should be considered alongside other therapeutic interventions, such as strength training and gait retraining, to optimize treatment outcomes.

Implications for Physical Therapy:

The findings of this study have direct applications in physical therapy practice. For patients recovering from lower extremity injuries or seeking to prevent future injuries, cadence training offers an evidence-based intervention to reduce plantar stress and improve running mechanics. Physical therapists can use tools like metronomes or wearable devices to guide patients in cadence adjustments, ensuring gradual and sustainable changes in running form. Furthermore, cadence manipulation can complement traditional rehabilitation approaches, such as strengthening exercises for the intrinsic foot muscles and addressing biomechanical deficits in the kinetic chain. By incorporating cadence training into a comprehensive rehabilitation program, therapists can enhance patient outcomes, reduce injury recurrence, and promote safe, efficient running mechanics. This approach aligns with the growing emphasis on personalized and biomechanically informed physical therapy interventions.

1. Wellenkotter J, Kernozek T, Meardon S, Suchomel T. The Effects of Running Cadence Manipulation on Plantar Loading in Healthy Runners. International journal of sports medicine. 2014;35. doi:10.1055/s-0033-1363236