Ep 216: Latest clinical recommendations for rotator cuff tendinopathy, with Dr François Desmeules

[00:00:04] Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality research to quality practice. I'm Claire Ardern, the Editor-in-Chief of the Journal of Orthopaedic and Sports Physical Therapy. It's great to have you listening today.

[00:00:22] I think we all appreciate the value of a trustworthy clinical practice guideline for helping us feel confident when making decisions in practice. Today, I'm joined by Professor François Desmeules from the School of Rehabilitation at the University of Montreal in Canada. He led an international team of shoulder experts who have synthesized and summarized all the latest evidence on diagnosing and non-surgically managing rotator cuff tendinopathy.

[00:00:47] And they've made sense of the evidence for us all in the musculoskeletal rehabilitation community in a new guideline, with recommendations covering assessment, treatment and prognosis, including return to sport. Okay, let's jump into it. Professor François Desmeules, welcome to JOSPT Insights. Thank you, Claire. Happy to be here. I'm really happy to have you join me on the podcast today, François, because there is a brand new CPG about shoulders that you're going to tell us about.

[00:01:16] So please give us the latest on this very impressive clinical practice guideline. Yeah, well, you know, we're very excited to have this CPG published in JOSPT. You know, it's a clinical practice guideline on the overall care of rotator cuff tendinopathy and it covers the diagnosis, the non-circle care. So that includes medical care and also includes rehabilitation intervention and also the return to sport for athletes.

[00:01:46] So it's a very thorough CPG that covers a lot of things. So we're really pleased that we can get this out there to clinicians for them to hopefully improve their care and hopefully improve the outcomes of their patients. Absolutely. And I think the comprehensive nature of it is so impressive. There's something here that can help guide me and we'll get into some of those particular recommendations for different clinical populations.

[00:02:11] I think it's also important to mention here, as you say, that this guideline, different to some of the other clinical practice guidelines people may read, is much broader. So let's talk a little bit about the breadth of the CPG. We have a section about, you know, the initial diagnosis and that includes also indication for imaging. And we have a section with the non-surgical care, including medical intervention. So that would include, you know, medication and also injections.

[00:02:40] And obviously we're in JOSPT and I'm a physio. And, you know, part of the CPG is also aimed at clinicians, physiotherapists to know what to do with their patient in terms of exercise, education and other modalities. And finally, you know, there's a section also about return to sport. Who was involved in creating the CPG?

[00:03:02] We're a group of international experts on shoulder disorder and not only physiotherapists, but researchers and clinicians. And we also have, you know, physicians that are part of this CPG. So Martin Lamontagne, Dr. Kim also is part of this. So one or two big surgeons also and a physiatrist are part of our CPG.

[00:03:24] And obviously a group of clinicians and researchers, namely, you know, my two important colleagues, Jean-Sébastien Waugh at Laval University and also Laurie Mitchener at USC. There's a whole group of researchers that are involved in this CPG. And at some points, you know, we're basing our CPG on evidence from previous work from our team where we also consulted, you know, other clinicians.

[00:03:52] And we had a Delphi study to have consensus on some of the recommendations that we've included in this CPG. And finally, patients were also involved into the final publication of our CPG, making sure that all the recommendations that we have in this CPG, you know, are relevant to them and make sense for the overall care of their problems. That's great.

[00:04:47] The patient themselves in deciding what is the most important next step for me with my shoulder pain, in this case, with my shoulder pain. Let's get into the key messages for clinicians because I think that's what's going to interest our listeners most today. You mentioned there's some new updates in diagnosis. So let's start there and talk a bit about diagnosing rotator cuff tendinopathy.

[00:05:10] One thing that's interesting in terms of looking at the recommendation in terms of the initial diagnosis is one part, one component of our CPG is that we have recommendation, but we also have decision tree that were developed for the initial diagnosis. So it takes a step-by-step approach in terms of what needs to be assessed when we're suspecting a rotator cuff tendinopathy.

[00:05:33] And some of the take-home messages are, you know, I'm going to go with the simple ones and the obvious one, but obviously making sure to be systematic about excluding red flags, but also in terms of being systematic in terms of identifying any yellow flags that could impede rehabilitation with this patient are important.

[00:05:51] But the overall, you know, we can, through a rigorous assessment, and I'm not necessarily going to go into the details of, you know, what we do in terms of clinical assessment, the MSK examination. But if we do this in a systematic way, we're able to make a valid diagnosis of rotator cuff tendinopathy. And that in the majority of cases, we don't need any imaging to confirm such a diagnosis.

[00:06:21] Imaging could be useful further down the line with patients that do not have a good outcome. But, you know, imaging shouldn't be done systematically when we're suspecting just a rotator cuff tendinopathy. And, you know, and we know that it is still an issue in our healthcare systems, you know, the over-reliance on imaging for the diagnosis.

[00:06:42] It might not be that common in the physiotherapy profession, but we know very much so that, you know, in the primary care, that there's an overuse of imaging. And often patients with just a rotator cuff tendinopathy are getting an X-ray or getting an MRI. And, you know, it's not required if you're making a good valid MSK assessment and clinical examination.

[00:07:06] You're able to make that diagnosis and move on with, you know, a valid treatment plan for these patients based on your original assessment, clinical assessment. That's a really important message. And if folks go to the show notes for today's episode, they'll find links to the CPG to get to that step-by-step guidance on exactly how to structure the clinical assessment. And as you say, a guideline gives you guardrails. It's not a recipe that you must follow to the absolute letter.

[00:07:35] So it's going to look different for different people in different healthcare settings, depending on where in the patient's history or the course of the rotator cuff issue you're seeing people. So I would really encourage people to adapt the CPG to their local context. Next, let's move beyond diagnosing the rotator cuff tendinopathy, Francois, and talk about education.

[00:07:58] One of our recommendations, obviously, is to make sure that, and as part of our treatment plan, you know, we do have a patient-centered and specialized education of the patient, you know. And specific to rotator cuff tendinopathy, the evidence isn't that great in terms of, you know, there's a lack of evidence. It's quite scarce, actually, in terms of, you know, how good education is to treat rotator cuff tendinopathy. But we do have some evidence showing that education can be quite effective.

[00:08:27] And just given alone to some of our patients that do have rotator cuff tendinopathy, we do see good outcomes just when giving them, like, simple education that would include a reassurance that would get them, you know, information in terms of the pain physiology and activities to avoid and ways to promote, you know, healthy living.

[00:08:49] And we base this on the overall literature based on MSK, but also on a specific study that our group has done in the past, a randomized controlled trial published a few years back in BGSM, where we chowned that education was as effective as an exercise program, strengthening exercise program, and a motor control program. So, big message here.

[00:09:13] And we're hoping that, you know, we'll have really, really good evidence further down the line about this. Our recommendation was straight C, but, you know, we're hoping that, you know, in the future, you know, we'll get higher grade evidence to support such an important component of our treatments. So, watch this space, the evidence underlying education is developing, and we expect that it may change in the future.

[00:09:42] Yeah. Let's move to the exercise therapy component of a rehabilitation program. What are the key messages for clinicians to take away when it comes to designing an exercise therapy program? Well, the good news is that there's many ways to design an exercise program to treat pain and reduce disability and roto-coft endopathy. So, not surprisingly, you know, we have a recommendation.

[00:10:08] Exercise is a core component part of our treatment plan when we're treating these patients, right? So, it's grade A level evidence. If you look closely at, you know, what sort of exercise should we be giving to these patients, you know, the literature is actually quite clear at the moment that there's many ways that we can give, deliver these intervention programs. And then we'll be able to reduce pain and improve disability in these patients.

[00:10:37] So, it could either be strengthening exercises. It can be scapular-focused exercises. It can be eccentric exercises. It could be motor control exercises. And it could be sometimes, you know, we've got a bit of evidence showing that, you know, it's just a more broad general exercise program can be effective in reducing pain and reducing disability.

[00:11:00] Based on several systematic treatment analysis, this is our assessment of the evidence at the moment for exercise for the roto-coft endopathy. There might be a bit more benefit of using motor control exercises. It's not a huge advantage in terms of using that specific type of exercises in terms of improving pain and disability.

[00:11:23] And our hypothesis looking at this, you know, other researchers can certainly agree on this, is that it might not be the motor control part of such exercises. That's the important, you know, factor making it maybe a bit better than other exercises. It might just be that it's more gradual, you know, we're taking into account, you know, pain reduction while they're doing movements in terms of that.

[00:11:51] So, that could be one of the hypotheses related to the fact that we might see a bit more benefits of using these sort of exercises.

[00:11:59] But bottom line, as long as you're using exercises, you know, from different types of programs that have been reported in the literature, it looks like everyone's going to, all our patients are going to at least, you know, see some benefits of strengthening exercises, motor control, you know, more general exercises or something more focused. What a liberating message.

[00:12:23] That's great to know that, you know, as a clinician, you, and again, this comes back to what we talked about with shared decision making and a truly patient-centered approach to care, is that you've got many different options. Many roads lead to Rome, I guess, is the saying. And then it gives you options to discuss with the person with whom you're working and figure out what's going to work best for you. What's the best way for us to work together to help manage this rotator cuff endopathy problem that you've got?

[00:12:53] Yeah, for sure. You know, patient-centered care, you know, and making sure that we're addressing, you know, the preferences of our patient throughout the rehabilitation, you know, it makes sense for sure. Now, you mentioned there's return to sport in this CPG. What are the key things for people to keep in mind when they're supporting people to get back to that higher level of function? So specific to sport, you know, we have a few recommendations.

[00:13:20] So not a lot of literature out there specific to erotic of tendopathy. But, you know, we do have three recommendations related to elite and recreational athletes in terms of, you know, how do we address return to sport with this population? And obviously, we need to consider, you know, the athlete's capacity and load tolerance specific to their sport.

[00:13:43] And we need to also be able to assess reliably these patients in terms of their function and their capacity in sport. And you could be using, you know, specific outcome tools. Obviously, there are questionnaires out there and there's some also tests that you could be doing. Not clear if there's any of these tests that are better than others specific to this population.

[00:14:08] But you need to be able to assess, you know, the readiness of our patient in a systematic way. And then that information can guide you to a better return to sport and better outcomes in terms of the sports class patient for these patients, for sure. Great. And again, a really nice framework starting point.

[00:14:28] And I'll encourage people to go to the CPG and apply it in their specific context, which is, again, exactly how CPGs are intended for us to use them. Now, I think one other really important thing for us to discuss is what happens when things are not improving? And particularly, when is it the right time to refer on to medical colleagues, surgical colleagues? It's certainly something that's difficult to answer.

[00:14:56] And is there really good, hard evidence that show that, you know, we should be sending on patient on to seeing specialists at this point in time? There's not, you know, it's very difficult. You know, there are prognostic factors that we can look into. But in terms of timely management and moving on to another colleague and stuff like that, it's difficult to assess.

[00:15:19] Through our CPG, you know, we've again done a decision tree in terms of the overall treatment plan and patient timeline. And it's a step-by-step approach.

[00:15:31] So what we've done is actually through a consensus, if you look at the decision tree, you can see that, you know, if the patient doesn't improve significantly in terms of pain and disability, and it's within 12 weeks of good rehabilitation, patient-centered care, then some other stuff should be going on in terms of this patient.

[00:15:55] So imaging could be required and also a reference to a medical specialist for further assessment and treatment. It's not per se part of our CPG, but it's clear from our previous work and from the literature that we're sending him on to an orthopedic surgeon. It's not because we think that, you know, they would benefit from a surgical intervention.

[00:16:21] So subacromial decompression is not recommended anymore for this population. So it needs to be clear that if you're sending him on to see an MSK specialist, it's because they need further assessment and they need other sort of conservative treatment. But we're not thinking about surgery for this population anymore, even though they're becoming chronic and they've got severe pain and disability. Really important message.

[00:16:46] And thanks for the reminder about orthopedic surgery in particular, the subacromial decompression. That's a really important message to get out there. The other thing I think to touch on here is injections. So what are the key recommendations about injection therapy? Part of our CPG is that we looked at the evidence for, you know, for corticosteroid injections mainly. We can talk a bit more about the other types of injections.

[00:17:13] But let's talk first about corticosteroid injections, you know. So there is benefits from corticosteroid injections in terms of reducing pain and disability in the short term. But our decision tree is framed that, you know, it shouldn't be like a first-line treatment with patient, you know. So that needs to be clear. It might not be very common in our physiotherapy world that patient gets systematically injections.

[00:17:38] But, you know, in some jurisdiction, you know, injections are, you know, our first-line treatment often for this population. So it looks like, you know, it shouldn't be. It shouldn't be part of the initial treatment of the patient. If they've got severe pain and it's ongoing and there's, I mean, the pain is not going away with other rehabilitation intervention and function is problematic, then, you know, an injection is a good thing.

[00:18:07] But again, you know, one and then maybe a second one, preferably under ultrasound guidance. It shouldn't exceed two injections because we know that, you know, repeated injections into tendons, you know, there's data out there showing that in the long term, you know, they'll have a worse outcome because of that. That message to avoid too many corticosteroid injections into the tendon is really important.

[00:18:38] Now, Francois, you mentioned other types of injection therapies. Just briefly, what are the injections that people might need to keep in mind or might see in clinical practice? As, as for corticosteroid injection, you know, it shouldn't be a first-line treatment, but there is a bit of evidence supporting the use of PRP injections. Also, yellow ionic acid.

[00:19:02] The evidence out there is higher level, but there's some studies showing better benefit in terms of reducing pain and also improving function with these patients. They could be something that you could consider with a patient not faring well down the line after applying other higher level evidence intervention. Let's bring this back to the rehabilitation clinician's wheelhouse. We talked about exercise therapy.

[00:19:30] What are some of the other, if you like, adjuncts to an exercise therapy program that you would suggest people might consider? And maybe what are the things people should really avoid? Manual therapy can be an adjunct to treating these patients with exercise. It shouldn't be the only thing that's given to these patients. So we got to actually a level B in terms of using manual therapy.

[00:19:55] And there are again, you know, like for exercise, you know, how do you define that and what sort of manual therapy? So it can be very broad. So is there any specific types of intervention that can be done to improve the pain and function of our patient? It's not clear. Usually, you know, it'll be manual therapy either aimed at the shoulder, but it also could be at the neck, you know, and we do see a bit of benefit of using usually a combination of that.

[00:20:23] And in terms of other intervention that rehabilitation professional physiotherapists can use, you know, there's a bit of evidence supporting the use of taping, you know, and also acupuncture or dry needling. So most of the evidence out there is related to acupuncture, but there's a bit of specific to dry needling. But we do see a bit of benefit of using that. But again, as an adjunct, not, you know, as the main component of our intervention with these patients.

[00:20:52] And obviously, ergonomic adaptation, you know, multimodal intervention, you know, that would include that, you know, we do see benefits in terms of doing that with workers. So that's the other thing that, you know, that can be relevant. And in terms of things that we shouldn't be doing in 2025, you know, I mean, there are no evidence or there are evidence against the use of ultrasound, therapeutic ultrasound, and also electrical currents, whatever forms they are.

[00:21:20] I mean, we shouldn't be using that because, you know, there's no benefits for a patient. A fantastic summary, Francois, you and the team have done a power of work putting this clinical practice guideline together for the musculoskeletal rehabilitation community. I want to say a big thank you to all of you for doing all of that work. And Professor Francois Desmouls, thank you for joining me on JOSPT Insights today. Thanks for having me.

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