Today, physical therapy is one of the most important components of conservative treatment despite limited evidence found in the literature about its efficacy. In a multicenter study, Kuhn et al. [33] investigated 452 patients with atraumatic full-thickness rotator cuff tears. These patients were treated with a conservative regimen receiving physical therapy with or without an intra-articular corticosteroid injection depending on the severity of the symptoms. At the final follow-up by telephone after 24 months, 30 % of the patients had elected to undergo surgery, most of the time within 6–12 weeks after diagnosis of the injury. Conservative treatment was effective in approximately 70 % of the patients. However, this study may not be suitable for athletes, especially overhead-throwing athletes, since pain reduction is not the most important factor but rather improvement of strength [33]. Several studies have shown that patients with clinical signs of rotator cuff tendinopathy also demonstrate kinematic alterations consistent with scapular dyskinesis [31, 41]. The importance of treating scapular dyskinesis during physical therapy sessions will be discussed later in this chapter.

Throwing motions should be evaluated and if necessary corrected particularly in overhead-throwing athletes. For this reason, it is important to know its phases and the main muscles involved in each phase (Fig. 7.2).

The supraspinatus muscle plays an important role in the late cocking phase. This muscle causes humeral abduction and contributes to the stability of the joint by drawing the humeral head towards the glenoid [22]. During the acceleration phase in unstable shoulders, the supraspinatus tendon is active as well and may help to stabilize the joint in these athletes [22].

The infraspinatus together with the teres minor muscle is responsible for external rotation of the shoulder during the late cocking and follow-through phase [22].

The subscapularis muscle acts as an internal rotator in the acceleration and follow-through phase, helping to carry the arm across the chest. While professional overhead players have the capacity to activate every rotator cuff muscle individually, the amateur players are not able to use every muscle exclusively [22]. This may lead to faster fatigue, eventually overuse and injury. When a rotator cuff tear is diagnosed, part of the training focus should be on the phase in which the damaged tendon is activated.

Although a change of position or change of sport might eliminate the cause of the tear and provide lasting relief, it is not desirable especially for high-level athletes and is therefore not feasible.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used for the management of pain and reduction of swelling in orthopedic patients. Despite their positive anti-inflammatory and pain-relieving effects, NSAIDs also have been reported to have a negative effect on rotator cuff tendon-to-bone healing in the animal model. In a study by Cohen et al. [11], Sprague–Dawley rats underwent acute rat rotator cuff reconstructions. Postoperatively, these rats either received a cyclooxygenase-2-specific NSAID (n = 60) or a nonselective NSAID (n = 60). The rats in the control group received no treatment (n = 60). The cyclooxygenase-2-specific as well as the nonselective NSAID group showed significantly decreased ultimate load to failure modes when compared to the control group at 2, 4, and 8 weeks. No differences were seen between the two NSAIDs used in this study suggesting that this inhibition of tendon-to-bone healing may be caused by cyclooxygenase-2 [11].

Similar results were reported in a smaller study where rats receiving daily intraperitoneal NSAID injections starting from postoperative day 11 after a rotator cuff repair displayed a significantly lower mean maximal load to failure at 21 days postoperatively when compared to the control group which received only saline injections and the group that received injections from postoperative day 1 to 11 [8]. No differences were found with respect to cellularity, vascularity, and collagen orientation though [8].

In a meta-analysis, Boudreault et al. [4] showed that even though only moderate grade evidence exists regarding the efficacy of NSAIDs for rotator cuff tendinopathy, these drugs are effective in reducing short-term pain but not in improving function. Furthermore, NSAIDs are as effective as corticosteroid injections for pain relief [4].

Extracorporeal shock wave therapy has been proposed as an alternative treatment for surgical rotator cuff reconstruction. Harniman et al. [27] concluded in a systematic review that there is moderate evidence showing no effect of low-energy ESWT (<0.2 mJ/mm²) in chronic non-calcific rotator cuff tendonitis and moderate evidence in support of high-energy ESWT (generally 0.2–0.4 mJ/mm²) for chronic calcific rotator cuff tendonitis. Similar results were published by Huisstede et al. in 2011 [28]. Due to the fact that significant methodological weaknesses were found in the two randomized controlled trials, further well-designed studies will be necessary to prove the benefit of extracorporeal shock wave therapy.

Iontophoresis is a process in which ions flow driven by an electric field. These molecules (e.g., drugs) have to have an electric charge or need to be linked to a charged molecule. The benefits of iontophoresis are controversial as a treatment for different musculoskeletal disorders in both in vitro and in vivo studies.

However, there are no studies investigating the impact of iontophoresis on rotator cuff pathologies. Thus, it is not possible to draw any conclusions on the efficacy of iontophoresis in the treatment of rotator cuff disease.

There is insufficient evidence to merit the use of ultrasound therapy in shoulder pathologies. Several authors have reported improving pain and quality of life in patients that were treated with ultrasound [1, 17, 36]; others have reported no differences in outcome [16, 35, 38, 42]. One big problem in ultrasound treatment is that there is no accepted standard method with respect to the frequency and treatment intensity. In the above-cited studies, the treatment intensity, frequency, and duration were not the same, making a comparison of the different studies difficult.

There is little literature that investigates the impact of transcutaneous electrical nerve stimulation (TENS) and pulsed electromagnetic field (PEMF) on rotator cuff pathologies.

Eyigor et al. [20] were able to show that intra-articular corticosteroid injections as well as TENS are efficient in the treatment of rotator cuff tendinitis. When compared, corticosteroid injections were slightly more efficacious than TENS with regard to pain relief, ROM, and disability in the first weeks [20].

PEMF has been shown to improve the short-term clinical outcomes in patients with therapy refractory rotator cuff tendinitis over a 4-week treatment period [2]. To our knowledge no other studies investigate the impact of PEMF on rotator cuff tears.

Especially in the treatment of pain, acupuncture has gained increasing attention. Unfortunately, there is lack of well carried out clinical studies in the literature that investigate the benefit of acupuncture for rotator cuff healing. The studies that exist show controversial results.

In a randomized clinical trial, Kleinhenz et al. [32] reported that acupuncture with penetration of the skin was more effective in improving the Constant–Murley Score than when performing placebo needling in patients with rotator cuff tendinopathy [32]. In a meta-analysis published in the Cochrane Library, the authors found no significant difference in short-term improvement associated with acupuncture when compared to placebo. This may be explained by type II error due to a rather small sample size of the two included trials [24].

There is only one randomized clinical study investigating the impact of manual therapy on rotator cuff disease [23]. The authors found an improved clinical outcome (pain relief, strength, and shoulder function) after 2 months in the group, where patients received manual therapy in combination with supervised shoulder exercises when compared to the group where only supervised shoulder exercises were performed.

The rehabilitation program of an athlete needs to be formulated by the physical therapist to the specific deficits and pathologies of every athlete. One of the main factors for successful rehabilitation is to understand the factors contributing to the rotator cuff disease.

Independent of the specific sport, the conservative treatment of a rotator cuff tear can be divided into four phases [5, 7]. In the first phase, the main objective is to control pain and inflammation. After this acute phase of about 2 weeks, the second phase begins, which focuses on achieving full range of motion, isometric and dynamic muscle strength, and neuromuscular function of the rotator cuff. It is also important not to provoke either apprehension or pain [5]. Generally, the exercises should be adapted to sport-specific movements of the shoulder. In throwers, for example, contractures of the posterior capsule are very common and should be addressed by therapy because they may lead to glenohumeral internal rotation deficit, displacement of the center of rotation, and an anterior tilt of the scapula [6, 30, 31]. Normally this phase takes about 4–6 weeks. The main goals of the third phase are to increase strength and joint stability throughout the kinetic chain, as well as gradually introducing sport-specific skills. This begins with plyometric training for throwers and sport-specific interval programs for all athletes. Finally, in phase four, the goal is the return to sports, with the ability to fully throw or strike and have the use of the upper extremity without symptoms or apprehension. Braun et al. [5] suggested starting the third phase within 3 months and return to competitive sports within 6 months; otherwise, a surgical intervention should be considered (Table 7.1).