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Journal of Back and Musculoskeletal Rehabilitation -1 (2019) 1–9 1

DOI 10.3233/BMR-181306
IOS Press

The effectiveness of trigger point treatment in

rotator cuff pathology: A randomized
controlled double-blind study
Yildiz Analay Akbabaa , Ebru Kaya Mutlua,∗ , Suleyman Altunb , Ezgi Turkmenc , Tansu Birincid
Derya Celika
a
Division of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Istanbul University-Cerrahpasa,
Istanbul, Turkey

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b
Clinics of Orthopedics and Traumatology, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul,
Turkey

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c
Department of Physiotherapy and Rehabilitation, Institute of Graduate Education, Istanbul
University-Cerrahpasa, Istanbul, Turkey

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d
Division of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Istanbul Medeniyet University,
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Istanbul, Turkey
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Abstract.
BACKGROUND: Studies have emphasized the importance of the presence of myofascial trigger points (MTrPs) in patients with
rotator cuff pathologies and the high frequency of MTrPs in rotator cuff muscles.
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OBJECTIVE: Evaluate the effectiveness of the treatment of active MTrPs in patients with rotator cuff pathologies.
METHODS: Fifty-three patients with rotator cuff tear were randomized into two groups. All patients received the same standard
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conservative treatment twice a week for 6 weeks. Patients in Group 1 additionally received ischemic compression (IC) of MTrPs.
Pain, range of motion (ROM), function, and anxiety and depression were assessed. MTrPs in rotator cuff muscles were assessed
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manually, and the number of MTrPs on the shoulder complex was counted.
RESULTS: There were no significant differences between the groups in terms of changes in resting/activity/night pain, ROM,
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function, or anxiety and depression (p > 0.05). Pain scores improved only in Group 1. However, the total number of MTrPs was
significantly decreased in Group 1 (p = 0.001).
CONCLUSION: A six-week course of IC helps treat active MTrPs. A standard conservative treatment program reduced pain and
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increased function; the addition of MTrP treatment did not improve clinical outcomes in patients with rotator cuff pathologies.

Keywords: Shoulder pain, trigger points, range of motion, rehabilitation

1 1. Introduction erative changes and trauma [1]. Symptoms of rotator 4

cuff tear mostly include pain, limited range of motion 5

2 Rotator cuff pathologies are a prevalent clinical is- (ROM), and dysfunction [2]. Rotator cuff tears may be 6

3 sue caused by many factors such as age-related degen- partial or full thickness. Partial rotator cuff tears may 7

be associated with shoulder pain and shoulder weak- 8

ness when the hand is raised above shoulder height 9

∗ Corresponding author: Ebru Kaya Mutlu, Saglık Bilimleri or reached behind the back of the body. On the other 10
Fakultesi, Fizyoterapi ve Rehabilitasyon, Istanbul Universitesi-
Cerrahpasa, 34740, Bakirkoy, Istanbul, Turkey. Tel.: +90 212
hand, full-thickness rotator cuff tears may be associ- 11

414 1500 40168; Fax: +90 212 414 1515; E-mail: fztebrukaya@ ated with intense shoulder pain and an inability to lift 12

hotmail.com. the arm away from the body [3]. 13

ISSN 1053-8127/19/$35.00
c 2019 – IOS Press and the authors. All rights reserved
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2 Y.A. Akbaba et al. / The effectiveness of trigger point treatment in rotator cuff pathology

14 Myofascial pain syndrome, which can be related treated at the clinical laboratory of the Physiother- 59

15 to rotator cuff problems, is a common condition that, apy Department of Istanbul University from May 2016 60

16 by definition, results from trigger points [4]. Myofas- through September 2017. Patients with ages between 61

17 cial trigger points (MTrPs) are specific tender spots 30 and 60 years were included if they had partial ro- 62

18 that produce symptoms known as myofascial pain [5]. tator cuff tears, MRI demonstration of a rotator cuff 63

19 MTrPs have been classified as active and latent trigger tear, positive results for a Hawkins-Kennedy test [12] 64

20 points by Simons et al. [6]. An active MTrP is always or positive results for an Empty Can test [13], at least 65

21 tender, avoids full lengthening of the muscle, weakens three trigger points in their shoulder complex, symp- 66

22 the muscle, and results in patient-recognized pain upon toms persisting for at least 3 months, and no radio- 67

23 compression [6]. Studies have emphasized the pres- graphic signs of glenoid or bone fracture. Patients were 68

24 ence of MTrPs in patients with rotator cuff patholo- excluded if they had a shoulder instability, an insuffi- 69

25 gies and the high frequency of MTrPs in rotator cuff cient response to non-operative management (includ- 70

26 muscles [7,8]. Suh et al. [9] reported that patients with ing local corticosteroid injection, non-steroidal anti- 71

27 rotator cuff pathologies are more prone to developing isnflammatory drugs, rest, and physiotherapy). Patients 72

28 MTrPs than shoulder without rotator cuff pathologies. were also excluded if they had inflammatory joint dis- 73

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29 The optimal treatment for symptomatic, non- eases, rheumatic diseases, frozen shoulders, massive 74

30 traumatic rotator cuff tear is unknown [10]. Standard rotator cuff tears, osteoarthritis of the humeral head, 75

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31 conservative treatments of rotator cuff tears are ROM thoracic outlet syndrome, prior surgery on the affected 76

exercises, stretching, strengthening, and mobilization; shoulder, or were unable to complete the question-

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32 77

33 treatment options for MTrPs include ischemic com- naires due to language problems or cognitive disorders.
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34 pression (IC), manual techniques, transverse friction

35 massage, spray and stretch, post-isometric relaxation, 2.3. Randomization and blinding 79

stretching, trigger point needling, and postural correc-

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37 tion [5,11]. However, no studies have investigated the The participants were randomly assigned to one of 80

38 effectiveness of trigger point treatment in addition to two intervention groups (ratio: 1:1) using “Research 81
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39 rotator cuff treatment [5]. We hypothesized that the Randomizer”, an online randomization web service 82

40 treatment of MTrPs would be more effective at reduc- (https://www.randomizer.org). Simple randomization 83

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41 ing pain as well as increasing function and ROM in procedures (computer-generated numbers) were uti- 84

42 patients with rotator cuff tears. The aim of this study lized, and sequentially numbered index cards contain- 85
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43 was to investigate the effectiveness of the treatment of ing the random assignments were prepared by an in- 86

44 active MTrPs in patients with rotator cuff tears. vestigator with no clinical involvement in the research. 87
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The index cards were folded and placed into sealed 88

envelopes. Two independent physiotherapists perform- 89

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45 2. Methods ing the interventions then opened each envelope and 90

divided the participants into the groups according to 91

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46 2.1. Study design the selected index card. Same physiotherapist carried 92

out all of the interventions of the one patient during 93

47 The clinical study was designed as a prospective, 12 sessions in the research clinic of the university. An- 94

48 randomized, double-blind study. The research proto- other physiotherapist, blinded to the allocation of the 95

49 col was devised according to the CONSORT guide- participants, conducted the evaluations before and af- 96

50 lines (see CONSORT checklist) and was confirmed by ter 6 weeks of treatment (assessor-blinded). The partic- 97

51 the Human Research Ethics Committee of Bakirkoy ipants remained blinded as to which group they were 98

52 Dr. Sadi Konuk Training and Research Hospital (IRB: in. 99

53 2015-281). The study was conducted in accordance

54 with the Declaration of Helsinki. Informed consent 2.4. Outcome measures 100

55 was provided by all patients prior to their enrollment.

All outcome measures were applied in the stated or- 101

56 2.2. Participants der in all patients. The Visual Analogue Scale (VAS); 102

each patient was asked about pain during periods 103

57 The participants were recruited from Bakirkoy of rest (VAS-rest), during activities of daily living 104

58 Dr. Sadi Konuk Training and Research Hospital and (VAS-activity), and at night during sleeping (VAS- 105
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Y.A. Akbaba et al. / The effectiveness of trigger point treatment in rotator cuff pathology 3

106 night) [14]. Pain-free active and passive shoulder for- age of the blood of an area in order to provide a resur- 155

107 ward flexion, abduction, and scapular plane external- gence of blood flow, which helps the affected tissue 156

108 internal rotation ROM were evaluated using a stan- heal after the pressure is released [6]. All of the par- 157

109 dard goniometer [14,15]. Function was assessed by the ticipants were instructed not to take any analgesic or 158

110 Disabilities of the Arm, Shoulder and Hand (DASH) anti-inflammatory medications during the study. 159

111 Questionnaire [16] and the American Shoulder and

112 Elbow Surgeons Standardized Shoulder Assessment 2.6. Sample size determination 160

113 (ASES) Form [16–18]. Anxiety and depression were The sample size and power analysis of the study 161
114 evaluated using the Hospital Anxiety and Depression were determined using PS power analysis. All of the 162
115 Scale (HADS), which was divided into Anxiety (HAD- patients were analyzed using intention-to-treat analy- 163
116 A) and Depression (HAD-D) subscales [19,20]. ses. Calculations were performed at a 95% confidence 164
117 Active MTrPs were examined in the scalene, levator interval and a power level of 95%. The DASH ques- 165
118 scapulae, upper trapezius, supraspinatus, infraspinatus, tionnaire exhibited a standard deviation (SD) of 13 166
119 teres major, latissimus dorsi, anterior-posterior del- points and a minimal clinically important difference of 167

120 toid, subscapularis, pectoralis major-minor, and biceps 15 points [21]. These parameters constituted at least 12 168

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121 brachii muscles. Active MTrPs diagnosis was done in samples per group. When a conservative drop rate was 169

122 agreement with the criteria described by Simons et added, 53 volunteers were included in the study. 170

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123 al. [6].
The VAS, ROM, DASH, ASES, and HAD scores, as 2.7. Data analysis 171

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124

125 well as all of the shoulder muscles with active MTrPs,

Data analyses were performed using the SPSS ver- 172
126 were assessed at baseline (first assessment) and after a
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sion 20.0 statistical software package (SPSS Inc., 173
127 six-week treatment (second assessment).
Chicago, IL). Statistical significance was set for all 174
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testing at P < 0.05. An independent samples t-test 175

128 2.5. Interventions and a chi-squared test were used to assess the base- 176
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line demographic data between the treatment groups 177

129 The patients were randomly divided into two groups. for continuous and categorical data, respectively. The 178
130 Patients in Group 1 received treatment of active MTrPs VAS, ROM, DASH, ASES, and HAD scores were an- 179
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131 in addition to standard conservative treatment pro- alyzed using a 2-by-2 mixed model analysis of vari- 180
132 gram; patients in Group 2 received only the stan- ance (ANOVA) with treatment group (Groups 1 and 2) 181
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133 dard conservative treatment program. All patients re- as the between-subject factor and time (before and af- 182

134 ceived the same standardized conservative treatment, ter treatment) as the within-subject factor. Intention-to- 183
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135 ergonomic recommends, and instructions to assume treat analysis was conducted with missing data, which 184

136 and maintain good posture. The conservative treatment were computed using regression equations. Pre- and 185
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137 was applied twice a week for 6 weeks (12 sessions) for post-treatment values within the groups were com- 186

138 both groups, and it was followed by cold application to pared using a paired sample t-test. 187

Additionally, treatment effects were directly com-

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139 the shoulder complex for 15 minutes. Patients in Group 188

140 1, in addition, received manual IC of active MTrPs. pared with reported minimum clinically important dif- 189

141 The outline of the rehabilitation program is provided ferences (MCIDs) in the literature. An established 190

142 in the Appendix. Patients were asked to perform gentle MCID for the VAS, DASH, and ASES has been sug- 191

143 static stretching and relaxation exercises at home two gested to be 2.14 cm, 10.2, and 6.4 points, respec- 192

144 times per day. tively [22–24]. Effect sizes (ESs) were determined by 193

145 The application of IC is described by Simons et calculating the differences in the means of the base- 194

146 al. [6]. This technique involves stretching a relaxed line and the follow-up data divided by the SD at the 195

147 muscle close to the point of discomfort. Initially, toler- baseline; an ES of 0.2, 0.5, and 0.8 was considered to 196

be small, moderate, and large, respectively, for intra- 197

148 ably painful (discomfort intensity level 7–8 out of 10)
group comparisons [25,26]. 198
149 and sustained pressure was directly applied on the ac-
150 tive MTrP using a thumb. The treatment is not helpful
151 if the patient tightens up his or her muscles and conse- 3. Results 199
152 quently protects the active MTrPs from pressure. The
153 compression was continued for 90 seconds. The aim of Fifty-three patients were eligible for this study. A 200

154 this compression is to intentionally increase the block- total of 46 patients (mean ± SD: 52.10 ± 10.38 201
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4 Y.A. Akbaba et al. / The effectiveness of trigger point treatment in rotator cuff pathology

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Fig. 1. Flow diagram of the study.

202 years; 26 females) satisfied all of the inclusion criteria. 8.62 months in Group 2 (p = 0.58). All of the base- 213

203 Five patients dropped out. Twenty patients in Group 1 line demographics were similar between groups (p > 214

204 (15 women) and 21 patients in Group 2 (11 women) 0.05). 215

205 were finally included in the analyses (Fig. 1). All of the Following the treatment, the groups did not ex- 216

206 patients received the allocated intervention. The mean hibit significant differences in their changes in rest- 217

207 age and body mass index of patients in Group 1 were ing/activity/night pain, ROM, function, or anxiety and 218

208 50.00 ± 11.23 years and 29.55 ± 5.03 kg/m2 , respec- depression (p > 0.05) (Tables 1–3). An intra-group as- 219

209 tively. The corresponding data for patients in Group 2 sessment revealed that VAS-rest (p = 0.02) and VAS- 220

210 were 54.10 ± 9.34 years and 29.37 ± 5.77 kg/m2 . The activity (p = 0.00) after 6 weeks improved in Group 1 221

211 average duration of symptoms at the time of enroll- (Table 1); there were no changes in rest/activity/night 222

212 ment was 10.33 ± 9.39 months in Group 1 and 8.36 ± pain in Group 2 (p > 0.05) (Table 1). Abduction and 223
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Y.A. Akbaba et al. / The effectiveness of trigger point treatment in rotator cuff pathology 5

Table 1
Comparison of pain within the group and between groups
Assessment Baseline After 6 weeks Effect P∗ P ∗∗
(cm) mean Mean Within-group score change size within-group between group
VAS-rest
Group 1 4.68 ± 2.47 3.47 ± 2.24 1.22 ± 2.10 0.48 0.02 0.21
Group 2 2.90 ± 2.97 3.00 ± 3.14 0.11 ± 1.65 0.03 0.77
VAS-activity
Group 1 7.75 ± 2.31 5.89 ± 2.72 1.89 ± 1.62 0.80 0.00 0.55
Group 2 6.71 ± 2.39 5.94 ± 3.35 0.77 ± 1.86 0.32 0.09
VAS-night
Group 1 6.90 ± 3.12 5.21 ± 3.89 1.73 ± 3.64 0.54 0.05 0.74
Group 2 6.67 ± 3.07 5.50 ± 3.18 0.50 ± 2.63 0.38 0.45
Abbreviations: VAS, visual analogue scale. Values are mean ± SD. ∗ Paired sample t-test. ∗∗ 2-by-2 mixed model analysis
of variance.

Table 2
Comparison of ROM within the group and between groups

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Assessment Group Baseline 6 weeks Effect P∗ P ∗∗
(◦ ) mean Mean Within-group score change size within-group between group

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Flexion ROM Group 1 139.65 ± 26.06 158.40 ± 20.76 18.75 ± 18.64 0.71 0.001 0.43
Group 2 137.62 ± 23.74 148.75 ± 24.18 10.25 ± 22.08 0.46 0.05

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Abduction Group 1 119.95 ± 43.81 151.35 ± 36.12 31.40 ± 36.30 0.71 0.001 0.59
ROM Group 2 116.95 ± 37.06 140.70 ± 39.13 22.20 ± 31.87 0.64 0.001
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External Group 1 50.70 ± 26.82 67.35 ± 22.29 16.65 ± 20.33 0.62 0.001 0.89
rotation ROM Group 2 54.52 ± 19.14 64.0 ± 17.66 8.25 ± 17.09 0.49 0.04
Internal Group 1 72.45 ± 22.36 81.65 ± 14.95 9.20 ± 16.64 0.41 0.02 0.41
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rotation ROM Group 2 69.29 ± 20.93 74.85 ± 20.97 5.30 ± 13.90 0.26 0.10
Abbreviations: ROM, Range of motion. Values are mean ± SD. ∗ Paired sample t-test. ∗∗ 2-by-2 mixed model analysis of variance.
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Table 3
Comparison level of function within the group and between groups
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Assessment Group Baseline 6 weeks Effect P∗ P ∗∗

mean Mean Within-group score change size within-group between group
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DASH Group 1 45.21 ± 19.94 29.66 ± 20.60 −15.55 ± 22.79 0.77 0.01 0.50
Group 2 48.43 ± 16.33 34.96 ± 24.75 −12.77 ± 21.54 0.82 0.01
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ASES Group 1 49.60 ± 19.47 70.26 ± 25.22 20.42 ± 30.97 1.06 0.01 0.72
Group 2 51.85 ± 17.11 63.66 ± 24.92 13.70 ± 20.93 0.69 0.01
HAD-A Group 1 9.43 ± 3.75 7.57 ± 4.99 −3.00 ± 4.50 0.49 0.69 0.14
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Group 2 8.55 ± 3.62 7.18 ± 4.33 −0.36 ± 1.74 0.37 0.50

HAD-D Group 1 10.5 ± 20.9 9.0 ± 5.85 −1.85 ± 4.09 0.07 0.27 0.86
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Group 2 10.9 ± 3.87 10.27 ± 5.42 −0.09 ± 2.30 0.16 0.89

Abbreviations: DASH, The Disability of the Arm, Shoulder and Hand Questionnaire Scores; ASES, The American Shoulder and Elbow Surgeons
Standardized Shoulder Assessment Form, HAD-A, The Hospital Anxiety and Depression Subscale-Anxiety; HAD-D, The Hospital Anxiety And
Depression Subscale-Depression. Values are mean ± SD. ∗ Paired Sample t-test. ∗∗ 2-by-2 mixed model analysis of variance.

224 external rotation ROM improved in both groups (Ta- scapulae, n = 14 (34.1%) in the upper trapezius, n = 235

225 ble 2); however, flexion and internal rotation ROM was 10 (24.4%) in the supraspinatus, n = 9 (22%) in the 236

226 increased only in Group 1 (p = 0.001 and p = 0.02, infraspinatus, n = 2 (4.9%) in the teres major, n = 1 237

227 respectively) (Table 2). The DASH and ASES scores (2.4%) in the latissimus dorsi, n = 14 (34.1%) in the 238

228 improved in both groups (p = 0.01); the HAD-A and anterior deltoid, n = 3 (7.3%) in the posterior deltoid, 239

229 HAD-D scores did not improve in either of the groups n = 10 (24.4%) in the subscapularis, n = 8 (19.5%) 240

230 (p > 0.05) (Table 3). The ESs of VAS, ROM, and in the pectoralis major, n = 7 (17.1%) in the pectoralis 241

231 ASES were larger in Group 1 compared with Group 2 minor and n = 8 (19.5%) in the biceps brachii mus- 242

232 (Tables 2 and 3). cles in both groups. The number of muscles with ac- 243

233 The number of active trigger points were n = 3 tive MTrPs was significantly lower in Group 1 than in 244

234 (7.3%) in the scalene, n = 6 (14.6%) in the levator Group 2 after 6 weeks (p = 0.001). The ES for active 245
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6 Y.A. Akbaba et al. / The effectiveness of trigger point treatment in rotator cuff pathology

Table 4
Comparison total number of active MTrPs within the group and between groups
Assessment Group Baseline 6 weeks Effect P∗ P ∗∗
mean Mean Within-group score change size within-group between group
Triger point (active) Group 1 4.30 ± 2.43 0.65 ± 1.30 0.65 ± 1.30 1.5 0.001 0.001
Group 2 3.23 ± 0.53 2.66 ± 1.01 0.52 ± 1.20 1.07 0.07
Values are mean ± SD. ∗ Paired sample t-test. ∗∗ 2-by-2 mixed model analysis of variance.

246 MTrPs after 6 weeks was 1.5, a large effect (Table 4). applied in addition to a standard conservative treat- 287

247 There was no adverse events or side effects in either ment program. Placebo compression or no intervention 288

248 intervention group after treatment. has been applied in studies that investigated the effec- 289

tiveness of MTrP treatment in pain related to shoulder 290

pathologies for comparison. Therefore, we could not 291

249 4. Discussion find any study to directly compare with our investiga- 292

tion. 293

250 Even though both groups improved in terms of pain, Hypotheses exist that the treatment of trigger points 294

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251 ROM, and function, there were no differences in pain, will increase joint motion by loosening the muscles 295

252 ROM and function between the groups. However, the involved in shoulder pathologies. However, no stud- 296

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253 ESs of VAS, ROM, and ASES were larger in patients ies have yet tested these hypotheses. Bron et al. [5] 297

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254 who received treatment of active MTrPs in addition to reported that a treatment consisting of manual com- 298

255 the standard conservative treatment program. Anxiety pression of MTrPs, manual stretching of muscles, and 299
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256 and depression level did not improve in either group. intermittent cold application with stretching did not 300

257 Rotator cuff tears can be treated with many differ- significantly change shoulder ROM in patients with 301
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258 ent methods such as exercise, mobilization, and elec- chronic shoulder pain compared with a control group. 302

259 trotherapy modalities [27–29]. Several studies have In our study, ROM improved in both groups whereas 303

noted the relevance of trigger points to shoulder flexion and internal rotation ROM only in patients re-
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260 304

261 pain [30]. such as impingement symptoms [31,32]. ceived IC technique. Furthermore, the ES of ROM was 305

262 A recent study reported that patients with shoul- larger in patients who received the IC technique than 306
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263 der pain derived from impingement symptoms had a in other patients. It is difficult to argue that this small 307

264 higher pain intensity, a larger number of MTrPs, and improvement in these patients is only due to trigger 308
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265 lower pressure pain threshold levels than healthy con- point treatment because the patients in our study also 309

trols [31]. The link between active MTrPs and symp- received stretching and strengthening exercises to gain
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266 310

267 toms of rotator cuff tears is not well known. Hains ROM. 311

268 et al. [7] studied the effectiveness of IC of MTrPs In studies investigating trigger point treatment in 312
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269 in shoulder muscles in patients with chronic shoul- shoulder pathologies, function was assessed using 313

270 der conditions compared with a placebo compression DASH and Shouder and Pain Disability Index (SPADI) 314
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271 group and a control group. In addition, Bron et al. [5] scores [22]. Studies that included 12 weeks of MTrP 315

272 pointed out that patients with non-traumatic shoulder treatment showed that DASH was significantly im- 316

273 pain had less pain after 12 sessions of treatment for proved compared with patients in the control group [5, 317

274 MTrPs than patients who did not receive any treat- 23]. However, the 7.7-point improvement did not attain 318

275 ment. According to these findings, clinically relevant the minimal clinically important difference of DASH, 319

276 improvements were achieved in 55% of patients with which is around 10 points [5,23]. Hains et al. [7] ap- 320

277 shoulder pain, and the number of muscles with ac- plied the IC to MTrPs in patients with chronic shoul- 321

278 tive MTrPs significantly decreased. Similarly, our pa- der pain over the course of 15 sessions. These authors 322

279 tients received 12 sessions of IC treatment, and im- found that patients in the treatment group exhibited a 323

280 provements in pain were significantly higher in pa- significant reduction in their SPADI scores compared 324

281 tients who received treatment of active MTrPs in ad- with patients in the control group. We used DASH and 325

282 dition to the standard conservative treatment program. ASES scores to evaluate the function of the patients. 326

283 However, we did not attain the minimal clinically im- Our results supported this literature for function pa- 327

284 portant difference of VAS, which has been reported to rameters following treatments for both groups. In addi- 328

285 be 2.17 points [22]. Because trigger points may be one tion, both groups attained the minimal clinical signif- 329

286 of the sources of shoulder pain, MTrP treatment was icance for the DASH and ASES scores. On the other 330
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Y.A. Akbaba et al. / The effectiveness of trigger point treatment in rotator cuff pathology 7

331 hand, the scores of one group were not superior to the could have provided a control for the condition’s natu- 382

332 other. ral healing process. Third, this study had a short-term 383

333 People who often experience stress or depression follow-up period. Fourth, pain intensity was assessed 384

334 may be more prone to develop MTrPs in their mus- by VAS rather than algometer. Besides, the change in 385

335 cles [33]. One theory maintains that such people stress inequivalence in the VAS-rest at baseline potentially 386

336 their muscles, leading to a form of repeated strain could inflate the results; however, the 2-by-2 mixed 387

337 that leaves their muscles susceptible to MTrPs [33]. model ANOVA controls for a baseline. Therefore, we 388

338 However, the relationship between psychological con- believe that our results are likely statistically robust. 389

339 ditions and MTrPs is not yet fully understood. Ce- Additional studies need to be conducted with larger pa- 390

340 lik and Nutlu [11] found that patients’ scores on the tient cohorts in order to confirm the effectiveness of 391

341 Beck Depression Inventory increased with the number active MTrP treatment in rotator cuff pathologies. 392

342 of latent MTrPs. These authors noted the possibility of

343 stress or depression management being a form of treat-
344 ment for latent MTrPs [11]. We investigated the anxi- 5. Conclusion 393
345 ety and depression level of patients with HAD scores.

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346 Patients who received the active MTrP treatment did A standard conservative treatment program increases 394
347 not differ in their HAD scores compared with patients function and ROM in patients with rotator cuff patholo- 395

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348 who were administered the standard conservative treat- gies. However, the addition of MTrP treatment to the 396
ment only. Furthermore, the anxiety and depression

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349
conservative program did not improve clinical out- 397
350 subscales were not improved in either group. The HAD
comes (resting/activity/night pain, ROM, function, and 398
351 is a measure of anxiety and depression in patients with
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anxiety and depression) in patients with rotator cuff 399
352 somatic disease [19,20]. However, the use of this scale
pathologies. Even so, the inclusion of trigger point 400
does not appear to be an appropriate choice for patients
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353
treatment in patients with rotator cuff pathologies may 401
354 with rotator cuff tears. We believe that using differ-
lead to results that are more positive in terms of pain 402
355 ent scales to assess anxiety and depression might affect
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management. Additionally, the treatment of MTrPs re- 403

356 these results eventually.
duces the total number of active MTrPs. 404
357 Our results indicated that a reduction in pain may
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358 be associated with a reduction in the number of trigger

359 points, which is one of the major goals of MTrP treat-
Conflict of interest
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405
360 ment [5]. Rotator cuff weakness results in upward mi-
361 gration of the humeral head. In addition, weakness of
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362 the serratus anterior and lower trapezius muscles lim- The authors have no conflict of interest to declare. 406

363 its scapular upward rotation and leads to compensatory

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364 activation of the upper trapezius muscle. Over the long

365 term, this situation sets the stage for fatigue, tightness, References 407
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366 and MTrPs in the upper trapezius muscle [34]. All

367 these mechanisms may lead to more trigger points in [1] Audigé L, Blum R, Müller AM, Flury M, Durchholz H. 408
Complications following arthroscopic rotator cuff tear re- 409
368 the upper trapezius muscle, as we found. The IC treat- pair: a systematic review of terms and definitions with fo- 410
369 ment led to a decrease in the number of MTrPs in the cus on shoulder stiffness. Orthop J Sports Med 2015; 3(6): 411

370 upper trapezius. However, this decrease was not statis- 2325967115587861. 412

371 tically significant [35]. [2] Kukkonen J, Kauko T, Virolainen P, Äärimaa V. The effect 413
of tear size on the treatment outcome of operatively treated 414
372 This study has several strengths. Besides being a rotator cuff tears. Knee Surg Sports Traumatol Arthrosc 2015; 415
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469 der and Elbow Surgeons Standardized Shoulder Assessment

470 Form, patient self-report section: reliability, validity, and re-
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471
472 [19] Zigmond AS, Snaith RP. The hospital anxiety and depression
473 scale. Acta Psychiatr Scand 1983; 67: 361-70.
1–7 days 533
474 [20] Aydemir Ö, Güvenir T, Küey L, Kültür S. Hastane anksiyete
475 ve depresyon ölçeği Türkçe formunun geçerlilik ve güvenilir- ROM: Active assistive ROM and wand exercise in 534

476 liği. Türk Psikiyatri Dergisi 1997; 8: 280-7. the supine position: 535
477 [21] Beaton DE, Katz JN, Fossel AH, Wright JG, Tarasuk V, Bom-
478 bardier C. Measuring the wole or the parts? J Hand Ther 2001; – Flexion 536

479 14: 128-42. – Abduction 537

480 [22] Michener LA, Snyder AR, Leggin BG. Responsiveness of the – Scapular adduction 538
481 numeric pain rating scale in patients with shoulder pain and – External rotation 539
482 the effect of surgical status. J Sport Rehabil 2011; 20: 115-28.
483 [23] Roy JS, MacDermid JC, Woodhouse LJ. Measuring shoulder – Internal rotation 540

484 function: a systematic review of four questionnaires. Arthritis Stretching (passive) exercises 541
485 Care Res 2009; 61: 623-32.
486 [24] Beaton DE, van Eerd D, Smith P, et al. Minimal change is sen- – Pectoralis minor muscle 542

487 sitive, less specific to recovery: a diagnostic testing approach – Upper trapezius muscle 543
488 to interpretability. J Clin Epidemiol 2011; 64: 487-96.
489 [25] de Vet HC, Terwee CB, Bouter LM. Current challenges in 7–14 days 544

490 clinimetrics. J Clin Epidemiol 2003; 56: 1137-41. – Continue with previous exercises 545
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546 – Wand exercises in the standing position 21–28 days 557

547 – External rotation in side-lying position – The exercises progressed increasing the repetition 558
548 – Pulley exercises (flexion and abduction) in sitting number 559
549 on a chair – External rotation with 0.5 kilograms in the side- 560
550 – Posterior capsule stretching lying position 561

551 14–21 days – Elevation on scapular position (90◦ ) 562

552 – Continue with previous exercises 28–35 days 563

553 – Distraction, traction, gliding exercises – Scapular adduction exercise in the prone-lying 564
554 – Middle/lower trapezius strengthening exercise position 565
555 with the elastic band
35–42 days 566
556 – Upper/lower trapezius self-stretching exercise
– Middle/lower trapezius strengthening exercise in 567

the prone-lying position 568

– Push-up exercise in the sitting position 569

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