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Rotator cuff rehabilitation: current theories and

practice

Jeffrey D. Osborne, Ashok L. Gowda, Brett Wiater & J. Michael Wiater

To cite this article: Jeffrey D. Osborne, Ashok L. Gowda, Brett Wiater & J. Michael Wiater (2016)
Rotator cuff rehabilitation: current theories and practice, The Physician and Sportsmedicine, 44:1,
85-92, DOI: 10.1080/00913847.2016.1108883

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Published online: 07 Nov 2015.

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ISSN: 0091-3847 (print)

Phys Sportsmed, 2016; 44(1): 85–92

DOI: 10.1080/00913847.2016.1108883

CLINICAL FEATURE
REVIEW

Rotator cuff rehabilitation: current theories and practice

Jeffrey D. Osborne, Ashok L. Gowda, Brett Wiater, and J. Michael Wiater

Department of Orthopaedic Surgery, Beaumont Hospital, Royal Oak, MI, USA

Abstract Keywords
A fully functioning, painless shoulder joint is essential to maintain a healthy, normal quality Rotator cuff, Rotator cuff tear, Rotator cuff
of life. Disease of the rotator cuff tendons (RCTs) is a common issue that affects the repair, Physiotherapy, Rotator cuff
population, increasing with age, and can lead to significant disability and social and health rehabilitation, Management rotator cuff
costs. RCT injuries can affect younger, healthy patients and the elderly alike, and may be the
result of trauma or occur as a result of chronic degeneration. They can be acutely painful, History
limited to certain activities or completely asymptomatic and incidental findings. A wide Received 21 September 2015
variety of treatment options exists ranging from conservative local and systemic pain Accepted 13 October 2015
modalities, to surgical fixation. Regardless of management ultimately chosen, physiotherapy Published online 5 November 2015
of the RCT, rotator cuff muscles and surrounding shoulder girdle plays an essential role in
proper treatment. Length of treatment, types of therapy and timing may vary if therapy is
definitive care or part of a postoperative protocol. Allowing time for adequate RCT healing
must always be considered when implementing ROM and strengthening after surgery. With
current rehabilitation methods, patients with all spectrums of RCT pathology can improve
their function, pain and quality of life. This manuscript reviews current theories and practice
involving rehabilitation for RCT injuries.

Introduction review the rehabilitation and management options for those

with rotator cuff disease.
Rotator cuff pathology is the most common cause of shoulder
pain, and its prevalence increases with patients’ age.[1,2]
Rotator cuff tear presentation and prevalence
Rotator cuff tears have been shown to cause significant pain
and disability with decreased performance in activities of Rotator cuff pathology commonly presents as pain or
daily living (ADLs).[3,4] Disorders of the shoulder reduce weakness with flexion and internal or external rotation of
health-related quality of life, increase absenteeism from work the shoulder. Night pain and inability to perform ADLs is
and increase the use of healthcare resources.[4–6] Various also a frequent complaint. With bursal-sided partial thick-
treatment options exist for the management of rotator cuff ness rotator cuff tears, impingement may be elicited with
disease, including conservative and surgical. Conservative flexion and internal rotation of the arm. Rotator cuff tears
treatment includes activity modification, nonsteroidal can be acute, chronic or acute-on-chronic. Acute or trau-
anti-inflammatory drugs (NSAIDs), corticosteroid injections matic tears are less common and are suspected when a
(CSIs) and physiotherapy. Physiotherapy modalities include younger patient presents with pain and dysfunction after
manual therapy and exercise.[7] While these therapies do not an antecedent traumatic event. Chronic or atraumatic tears
treat specific pathology, they focus on correcting rotator cuff are more common and are likely the result of an age-related,
and scapular muscle weakness and dysfunction, tightening of degenerative process. These tears may be asymptomatic or
the posterior capsule and other soft tissues, and correcting may present as an insidious onset of symptoms in middle-
postural abnormalities that contribute to pain and dysfunc- aged to elderly adults. Recent studies have supported this
tion.[8] With surgical treatment, postoperative rehabilitation association by reporting an increasing incidence of rotator
similarly focuses on stiffness prevention and strengthening cuffs tears over the past 20 years with the aging popula-
rotator cuff and scapular musculature. Prior systemic reviews tion.[2,11]
evaluating rotator cuff therapy have concluded that further The prevalence of rotator cuff abnormalities has been
clinical trials are needed to establish an optimal treatment shown to increase substantially from 9.7% in patients under
protocol.[9,10] Here, based on the current literature, we 20 years of age to 62% in patients 80 years of age and older.

Correspondence: J Michael Wiater, MD, Residency Program Director, Director Shoulder Reconstruction Fellowship, Department of Orthopaedic Surgery,
Beaumont Hospital, 3535 W 13 Mile Rd #744, Royal Oak, MI 48073, USA. Tel: 248-551-0195, Fax: 248-551-5404. E-mail: [Link]@[Link]

© 2015 Taylor & Francis

86 J.D. Osborne et al. Phys Sportsmed, 2016; 44(1): 85–92

[12] Given the high prevalence of tears, it is probable that Rotator cuff tendinopathy and partial tears
atraumatic degenerative tears are often asymptomatic.
Rotator cuff tendinopathy is defined as a contractile pain and
Yamamoto et al found 65.4% of rotator cuff tears to be
dysfunction, and should be differentiated from subacromial
asymptomatic in a mountain village.[13]
impingement which is characterized by constant pain and
Rotator cuff tears are best imaged by MRI or ultrasound and
limitations to motion.[22,23] Tendinopathy is characterized
described by location, size and degree of retraction. Patte [14]
by pain in and around the RCTs, exacerbated by motion and
developed a classification system utilizing tear topography in
activity. Tendon thickening or disorganization can lead to
multiple planes. The description of tear retraction in the coronal
weakness or fatigue and further exacerbate symptoms.[24]
plane demonstrated good reproducibility. Davidson and
Partial thickness tears can be bursal or articular sided, and
Burkhart [15] developed a classification system describing
may result from a multitude of intrinsic or extrinsic factors
tear geometry on preoperative MRI. Though this provides
(Figure 1).[24]
prognostic indication, it lacks description of displacement,
Several studies have evaluated the effects of therapeutic
tendon quality or muscle atrophy. DeOrio and Cofield [16]
exercises compared to alternative interventions. Lombardi
described intraoperative tear findings ranging from small to
et al. [25] reported on 60 patients with an average age of
massive, but did not specify tendon involvement or tissue
55.5 years. Patients were randomized into two groups: one
quality. Though location and tear type are readily agreed
received no intervention and the other underwent therapy uti-
upon, Kuhn et al. [17] found poor interobserver reliability
lizing multi-pulley muscle-building equipment. This consisted
using current classification systems. Currently, no classification
of flexion, extension, medial and lateral rotation exercises at
system reliably includes tear size, shape, length, location,
50–70% of a 6 repetition maximum, twice weekly for 8 weeks.
tendon involvement, tissue quality and muscle atrophy.
At 2 months, those who received therapy had statistically sig-
nificant improvement in pain and function scores. Brox et al.
Treatment options [26] evaluated 80 patients with a mean age of 48 years assigned
to 3–6 months of supervised exercise including ROM and
Treatment of rotator cuff pathology is individualized based
strengthening in rotation, flexion, extension, abduction, adduc-
on a variety of patient-related factors, including activity level,
tion for 1 h daily versus 12 sessions of placebo laser and found
degree of impairment, comorbidities, patient expectations
improvements in pain and functional outcomes with therapeutic
and most importantly age. Tear characteristics, including
intervention. Dorrestijn et al. [27] evaluated surgical versus
severity of the tear (partial versus full thickness), location,
nonsurgical treatment in subacromial impingement syndrome.
size, amount of retraction and degree of muscle belly fatty
No difference in pain and shoulder function was found in four
atrophy are also significant factors. Treatment of rotator cuff
randomized control trials, though the methodological quality of
tendon (RCT) disease ranges from conservative options
included studies was medium to low.
(including exercise, electrotherapy, acupuncture, manual ther-
Concerns for healing in conservative management may
apy, injection therapy, taping) to surgical intervention. In
also involve factors outside of physiotherapy intervention.
general, the first-line treatment for chronic, atraumatic tears
Increasing age of patients has been linked to poorer tendon
is conservative. When a patient fails conservative treatment
healing environment and lower healing rates, though good
or presents with a traumatic injury, surgery is considered.
outcomes are still found in older patients being treated for
Rotator cuff repair has evolved over recent years with the use
rotator cuff tears.[28] The characteristics of the tear size and
of arthroscopic techniques that minimize surgical morbidity
tendon tissue can also affect both operative and nonoperative
and implants that allow for secure tendon to bone fixation.
treatments. As part of a conservative approach, NSAIDs are
Recently, the use of double-row repair has been shown to be
commonly used for pain control, but there is question of
effective in relieving pain and restoring function even in the
whether or not this may impede healing. In 2012, Chen and
case of massive, degenerative tears.[18,19] Despite the
Dragoo reviewed available animal studies and concluded
advances in surgical technique, not all tears are amenable to
NSAID use was not deleterious to soft tissue healing but
repair. Tear retraction to the level of the glenoid, fatty atrophy
may have an affect on bony healing.[29] In a rat model,
of the rotator cuff muscles and a narrowed acromial-humeral
Cohen et al. found significantly lower failure loads and
distance are all associated with high rate of retear and overall
decrease in collagen organization in rats treated with indo-
poorer clinical outcomes following attempted repair.[18,20]
Rehabilitation of the rotator cuff is imperative to the out-
come of both conservative and operative treatments. The
goals of treatment include pain relief, restoration of strength
and range of motion (ROM), and returning function to daily
activities. A comprehensive rotator cuff and shoulder girdle
rehabilitation program is available online via the American
Academy of Orthopaedic Surgery website [Link].
org, complete with images and instructions. The timing for
implementing a strengthening and stretching program and
exercises chosen should be based individually on the patient’s
injury and type of treatment chosen at the discretion of the
treating physician ([Link]/PDFs/Rehab_ Figure 1. (a) X-ray demonstrating a type II curved acromion and (b) T2
Shoulder_5.pdf).[21] MRI with evidence of partial thickness supraspinatus tearing.
DOI: 10.1080/00913847.2016.1108883 Rotator Cuff Rehabilitation 87

methacin or celecoxib versus controls.[30] However, in 2014, part of a conservative approach to tendinopathy and partial
Oak et al. demonstrated decreased inflammation, increased thickness tears. NSAID use is a viable option to reduce
fibrocartilage and increased load to failure in rats treated with pain and inflammation; however, their effect on tendon
licofelone (5-LOX, Cox-1, COX-2 inhibitor) when compared healing has yet to be definitely elucidated. Currently,
to control 14 days after undergoing supraspinatus repair.[31] there is not sufficient evidence advocating the use of
In a rat model, Chechik et al. suggested that the timing of CSIs as an adjunct to therapy as part of a rehabilitation
NSAID administration might be a factor. After rotator cuff protocol.
repair, rats treated with meloxicam during postoperative days
11–20 showed lower mean maximal load and stiffness at Full-thickness rotator cuff tear
3 weeks compared to rats treated on days 1–10. Of note, no
histological differences were noted between the two.[32] Nonoperative management for atraumatic, chronic rotator
Gumina et al. evaluated the effect of treating patients with cuff tears is often the first-line treatment (Figure 2).
rotator cuff tears with NSAIDs preoperatively and deter- Management options include analgesia, ultrasound and mas-
mined there was no effect on the histological inflammatory sage therapy, and both formal and home physical therapy
infiltrate at the tendon edge.[33] There appears to be no programs. The goals of treatment are to decrease pain,
literature involving human studies that can clearly advocate improve function and strength, and increase quality of life.
for or against NSAID use based on their potential effects on Multiple studies have shown improvement of pain, function
tendon healing. However, there is evidence for their effec- and strength scores with conservative management.[40–43]
tiveness in pain control and they continue to be commonly Physical therapy programs consisting of strengthening,
used for rotator cuff tears and in the setting of tendinitis or stretching and ROM exercises have been shown to be an
calcific tendinopathy to reduce inflammation.[34] In a meta- essential part of the conservative treatment plan. In a sys-
analysis, Boudreault et al. showed there was low to moderate tematic review, Ainsworth and Lewis [44] reported on the
evidence for oral NSAIDs to provide pain relief in rotator effectiveness of exercise therapy in the management of symp-
cuff tendinopathy.[35] Caution and proper patient education tomatic full-thickness rotator cuff tears. They included 10
regarding risks of gastrointestinal complications should studies consisting of 272 patients and determined a benefit
always be considered. with exercise programs as part of a conservative treatment
Subacromial CSIs are commonly used as part of the program. The degree of benefit or specific exercises and
conservative approach to rotator cuff tears and tendinopa- programs were not determined. Kijima et al. [41] reported
thy as well. There is controversy, however, over their 13-year follow-up of patients treated conservatively for MRI-
efficacy. In 2003, a Cochrane review by Buchbinder diagnosed rotator cuff tears. Treatment consisted of ROM
et al. determined that there was little evidence to guide and strengthening rehabilitation, anti-inflammatory and
treatment and that further trials were needed.[36] Two intra-articular steroid injections. At final follow-up, 88% of
years later, a meta-analysis by Arroll and Goodyear-Smith patients reported no to slight pain and 72% no disturbance of
showed significant improvement in shoulder pain after daily function. Kuhn et al. reported on 452 patients in the
subacromial CSI. They reported a duration of relief MOON shoulder group with average age of 62 years and
8–38 weeks and CSIs to be more beneficial than atraumatic full-thickness rotator cuff tears treated with daily
NSAIDs.[37] However, in a more recent meta-analysis by ROM and stretching and rotator cuff and scapula strengthen-
Boudreault et al., no significant difference was found ing three times a week for 6–12 weeks. At final follow-up,
between subacromial CSI and NSAIDs for pain improve- patient reported scores improved significantly at 6 and
ment.[35] In 2014, a systematic review by Koester et al. 12 weeks and nonoperative treatment was effective in 75%
reported that there is no clinical evidence to support the of patients at 2 years.[45] Mild muscle atrophy and scapular
efficacy of CSI for the treatment of rotator cuff tears. dyskinesis can be modifiable problems addressed in therapy
Their review of nine RCTs showed no significant clinical as well. Positioning of the scapula has been shown to affect
difference with CSIs versus controls. They did, however, rotator cuff muscle strength.[46] The scapula acts as a foun-
stress the importance of further, more standardized RCTs, dation for multiple shoulder muscles’ functions, and abnor-
as at present the studies lack validated, patient-oriented
outcome measures.[38] Despite the above reviews report-
ing very low complication rates with CSIs, their possible
effects on the rotator cuff and soft tissues must also be
considered. In a rat model, Maman et al. showed signifi-
cant decrease in load and stiffness in intact and injured rat
rotator cuffs after repeated CSI. Greater tuberosity volume
density was also decreased.[39] Although animal studies
do not directly translate to human outcomes, the potential
for harm with CSIs must be weighed against the little
evidence of their benefit when considering their use as
part of conservative management.
Figure 2. (a) X-ray demonstrating sclerosis at the insertion of the rotator
Physiotherapy, including ROM and strengthening of the
cuff tendons at the greater tuberosity insertion typical of a full-thickness
shoulder and surrounding musculature, has been shown to tear and (b) T2 MRI with evidence of full-thickness supraspinatus
be effective in reducing pain and improving function as tearing with mild retraction.
88 J.D. Osborne et al. Phys Sportsmed, 2016; 44(1): 85–92

mal alignment or balance in these may lead to impingement, and suture to bone fixation, minimizes suture abrasion, has
rotator cuff injury and other shoulder pathology. In patients good knot security and optimizes footprint coverage to ulti-
with scapular dyskinesis, integrated therapy regimens focused mately allow tendon to bone healing. Currently, this is
on establishing proper scapular positioning (post tilt, external achieved most often with preloaded suture anchor implants
rotation and upward elevation) and improving proximal core with double- or single-row repair.[57] Proponents of the
control should be implemented.[47] single-row fixation technique cite its decreased disruption
Several factors have been shown to contribute to the of the hypovascular zone of the tendon, thus limiting deleter-
efficacy of conservative management. These include gender, ious effects on healing. Proponents of the double-row repair
muscle atrophy of the supraspinatus and infraspinatus, and cite the increased tendon–bone contact area, higher fixation
scapular dyskinesis.[48] Tanaka et al. [49] found that pre- strength and decreased gapping with cyclic loading.[58,59]
served external ROM, a negative impingement sign, minimal To date, no significant clinical differences have been shown
supraspinatus atrophy and preserved supraspinatus musculo- between the two repair techniques, with the exception of
tendinous junction were significant predictors of successful improved strength when utilizing double row repair specifi-
nonoperative management. Successful outcomes with conser- cally in massive tears [58,60] (Figure 3).
vative treatment were seen in 87% of patients if three out of Physical therapy is an integral factor in the clinical success
the four above-mentioned criteria were met. of repair. Previous studies have demonstrated that both pas-
Operative versus nonoperative management has been eval- sive and active ROM and strengthening exercises lead to
uated in several studies. Moosmayer et al. [50] randomized decreased joint stiffness and increased strength.[61]
103 symptomatic patients with small- to medium-sized tears The timing of rehabilitation is important to balance pro-
to open surgical versus conservative management. At 1-year tection of repair integrity and healing with preventing stiff-
follow-up, both groups had improvements in constant and ness. Animal models have shown that healing of the RCT
ASES scores; however, the surgical group had a significantly progresses through three phases: inflammatory (7 days), pro-
greater increase in scores. The surgical group also saw a liferative (2–3 weeks), and maturation and remodeling (12–
significantly greater improvement in abduction ROM and 26 weeks).[62,63] Immobilization has been shown to be
pain improvement. MRI at 1 year’s time showed 76% intact associated with increased shoulder stiffness and transient
cuffs. Of the conservative group, 18% converted to surgical changes in quality of cortical and cancellous bone.[64] With
management after insufficient benefit from a minimum of 15 immobilization, fatty atrophy of RCT muscle belly has been
therapy sessions. This study suggests a benefit to early surgi- documented and correlated with poorer functional outcomes
cal intervention for complete tears; however, follow-up was and increased retear rates.[65] At the same time, clinical
limited to 1 year. In a systemic review, Seida et al. [51] studies have shown up to a 94% rate of retear in large or
included five level II and III studies and found significant massive tears.[66–68] With this in mind, varying rehabilita-
improvements regardless of intervention, but determined evi- tion protocols have been developed attempting to balance
dence too be limited to make formal conclusions regarding timing and integrity.[69]
the superiority of either treatment arm, surgical versus con- In general, an immobilization period of 4–6 weeks is
servative management. typically used to allow the tendon bone interface to progress
through the normal healing phases of inflammation, prolif-
eration and remodeling.[63] During this time, protocols vary
Rehabilitation after surgical repair
from limited passive motion at home to supervised passive
Rotator cuff repair, initially described by Codman in 1911, ROM or the continuous passive motion (CPM) device.[61]
utilized an open technique.[52] Surgical issues including After this initial 6-week period, most protocols recommend
postoperative pain, deltoid dysfunction and extended post- beginning more aggressive passive and active ROM culmi-
operative immobilization have caused this technique to fall nating in sport- or work-specific endurance and strengthen-
out of favor.[52,53] Open surgical repair is still an option for ing.[63,69] Ahmad et al. [70] found the incidence of cuff
massive chronic tears with poor tendon quality and soft tissue retears to be 29.1% in patients treated with arthroscopic
adhesions. rotator cuff repair. Poor postoperative compliance with sling
Mini-open rotator cuff repair was described using a del-
toid splitting approach to minimize trauma to the muscle.
Good to excellent results have been demonstrated in the
majority of patients, and are comparable to arthroscopic
repair.[54,55]
Most recently, arthroscopic rotator cuff repair has become
prevalent. This technique has a lower risk of stiffness, deltoid
injury and infections, and allows for earlier ROM.[56]
Arthroscopic repair has brought a multitude of tendon mobi-
lization and repair techniques into review. Side-to-side, trans-
osseous and suture anchor repair with double- or single-row
technique, and different anchor materials and suture have all
been implemented and studied. The chosen repair construct Figure 3. (a) X-ray demonstrating superior migration of the humeral
can be affected by the tear morphology and tendon quality head and (b) T2 MRI with evidence of a chronic retracted rotator cuff
and mobility. The ideal repair results in good suture to tendon tear.
DOI: 10.1080/00913847.2016.1108883 Rotator Cuff Rehabilitation 89

wear during the first 6 weeks and poor compliance with functional bracing. At 3 months, no statistically significant
complex motion or activity in the second 6-week period difference was found with Constant-Murley or pain scores
were found to be significant risk factors for retear. Kim between the home therapy group and conventional therapy.
et al. investigated the timing of retear after surgical repair. Heers et al. [80] evaluated 30 patients with ultrasound-docu-
As high as 26% of patients in their case series were found to mented rotator cuff tears treated with home exercises focusing
have retears in the first 3 months post surgery, while only on strengthening and ROM daily for 12 weeks and reported
6.6% in the period from 3 months to 1 year. They concluded improved ROM and constant scores. Krischak et al. [81] ran-
that retears infrequently occurred in the late postoperative domized 43 patients to home-based exercises twice daily or
period after demonstrating well-healed tendons.[71] In a pro- formal physical therapy for 8 weeks and found at final follow-
spective imaging study, Iannotti et al. showed significant risk up no difference in pain, ROM, maximum peak force and
for retears up to 26 weeks after surgery. In the 6–12-week functional scores. Patients with home-based therapy reported
postoperative period, 42% of retears occurred while half significantly higher perceived health status scores. Home-based
occurred between 12 and 26 weeks. Abduction strength was modalities for rotator cuff rehabilitation appear to be a viable
significantly decreased in shoulders with retear compared to option for patients with cost or time-demand issues unable to
healed, although no significant difference in outcome scores undergo traditional formal physical therapy.
were found at 1 year.[72] These studies suggest the impor-
tance of protecting the repair from significant stressing post-
Future direction
operatively for a period of 3–6 months, as this is the period of
greatest risk for retear. Despite the proven benefit of rehabilitation in decreasing
Different protocols of therapy with regard to activity level pain and improving strength and function in rotator cuff
during this postoperative period exist based on varying tears treated conservatively and operatively, tendon healing
degrees of aggressiveness. Keener et al. [73] compared out- remains an issue. Tear progression can limit the effective-
comes in 124 patients who underwent arthroscopic repair ness of conservative management, and retearing is a com-
randomized to immobilization or early ROM and found no mon issue in surgical repair patients. Due to this, aggressive
significant long-term clinical difference. A prospective study motion and strengthening after rotator cuff repair is often
by Cuff and Pupello [74] showed similar clinical results, with limited by the biology of tendon healing, and improvements
slight (91% vs. 85%) increased healing in the delayed motion may allow better strengthening, healing and decreased
group, though this was not statistically significant. Ross et al. retear rates. Thus, therapeutic modalities that modify or
[75] reviewed the effect of conservative versus aggressive improve the biologic environment of tendon healing are
postoperative rehab protocols. Conservative protocols were being studied as a possible alternative source to improve
defined as initially allowing limited ROM and not advocating results. Growth factors have been shown to affect tendon
early formal physical therapy. Aggressive protocols were healing, however, only in in vitro studies and animal mod-
defined as initially involving passive ROM under supervision els. No human studies specifically involving RCT repair
of a physical therapist or use of a CPM machine. After the have been studied. Also, an increase in local growth factors
initial period, both protocols began more aggressive ROM may ultimately cause a feedback inhibition leading to the
and strengthening. At short-term follow-up, the aggressive opposite effect than desired. Injection of mesenchymal stem
rehabilitation group showed a trend toward decreased pain, cells (MSCs) has been shown to be safe, however, further
improved ROM and increased rate of retear though this study into its effects on tendon healing are warranted. A
equalized with long-term follow-up. In a meta-analysis, multitude of delivery systems for these different factors are
Chang et al. [76] demonstrated improved early ROM with also being studied; however, no clear superior system has
forward flexion in the early ROM groups. A trend toward been identified to date.[82,83] Hernigou et al. have shown a
increased retear rates with early ROM was noted and was possible role for MSC augmentation. They compared 125
shown to be statistically significant when two trials that only patients with symptomatic rotator cuff tears to 75 controls
recruited small- to medium-sized tears were excluded. The and found the level of MSCs varied with a number of
authors cautioned that care is advised with early ROM pro- clinical factors, including duration and size of tear, and
grams in patients with large to massive tears. stage of fatty infiltration.[84] They concluded that there
might be a role for MSCs in biologic augmentation of
rotator cuff repairs. Ross et al. [85] evaluated granulocyte
Home-based modalities
colony-stimulating factor in a rat model where full-thick-
Home treatment regimens that can be taught to patients may ness rotator cuff tears were made and immediately repaired.
decrease medical costs and allow patients to rehabilitate at their Specimens were then randomized to 5 days of granulocyte
own convenience. Littlewood et al. [77] reported patients to be colony-stimulating factor or control. Granulocyte colony-
adherent to home therapy programs and to demonstrate stimulating factor–treated animals showed significant
improvements in pain and function when performing self-direc- increased cellularity composite scores at 12 and 19 days,
ted exercises. Ludewig and Borstad [78] reported on 67 tendi- though no significant MRI or mechanical differences were
nopathy patients assigned to five shoulder-strengthening noted. Platelet-rich plasma (PRP) is a whole blood fraction
exercises for 8–12 weeks or control and found home exercise containing several growth factors, which has been examined
to be effective in improving clinical function. Walther et al. to potentially improve RCT healing. Although the majority
[79] prospectively evaluated 60 patients randomized to guided of studies examining the efficacy of PRP in the treatment of
self-training programs, conventional physiotherapy or rotator cuff tears have failed to show substantial clinical
90 J.D. Osborne et al. Phys Sportsmed, 2016; 44(1): 85–92

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