{{first_name}}, did you see my announcement earlier this week?
Starting January 23rd, 2026, every issue of The Clinical Coach™ will contain at least a 1 CE credit. That being said, the format of this newsletter is changing some…
Be warned… the new format is long, but packed with gold.
Now, in order to obtain the CE credit at the end of the newsletter, you must be a TCC member.
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Now, let me introduce you to the new format for The Clinical Coach™
Clinical Topic: Rotator Cuff Tendinopathy
Learning Objectives: By the end of this newsletter, you will be able to:
Differentiate rotator cuff tendinopathy from subacromial impingement syndrome, adhesive capsulitis, and glenohumeral osteoarthritis using specific physical examination tests and clinical presentation patterns
Apply proper dry needling technique to infraspinatus, supraspinatus, and subscapularis muscles including patient positioning, anatomical landmarks, needle specifications, insertion depth, and angle.
THE CLINICAL PRESENTATION
A 48-year-old recreational female athlete presents to your office with a 4-month history of right shoulder pain. The pain is deep in the shoulder, radiates down the lateral arm to mid-biceps level, and significantly worsens with overhead activities. She reports difficulty sleeping on the affected side and states that reaching behind her back to fasten her bra is painful.
She's already tried 6 weeks of physical therapy focused on rotator cuff stretching exercises, which she reports made her pain worse. Her primary care physician prescribed NSAIDs and suggested rest from overhead activities. She rested for 3 weeks, and as expected from no activity, the pain improved slightly but returned as soon as she attempted to return to her normal gym routine.
She's frustrated, she's been compliant with all recommendations, yet her pain persists. "Why isn't this getting better?" She asks.
THE COMMON MISDIAGNOSIS
Most practitioners diagnose this presentation as "subacromial impingement syndrome" or "rotator cuff strain" and treatment focuses on reducing inflammation and strengthening the rotator cuff.
This misdiagnosis happens because the clinical presentations overlap significantly:
Pain with overhead activities
Lateral arm pain
Night pain
Painful arc during abduction
The typical treatment pathway looks like this: Neer's and Hawkins-Kennedy tests are positive → diagnosis of impingement → prescribe NSAIDs, ice, and generic rotator cuff exercises → patient doesn't improve → corticosteroid injection → temporary relief → pain returns → patient ends up in your office months later.
The consequence: Patients receive generic stretching and strengthening exercises for muscles that are already dysfunctional with trigger points. Stretching a muscle with active trigger points often exacerbates symptoms rather than improving them.
Red flags that should prompt different diagnosis:
Severe night pain unrelated to position → consider referred pain from cervical spine or serious pathology
Significant weakness out of proportion to pain → consider rotator cuff tear
Fever, unexplained weight loss, or progressive symptoms → consider infection or malignancy
Limited painful passive range of motion in all planes → consider adhesive capsulitis
THE PROPER DIFFERENTIAL DIAGNOSIS
I examine every shoulder the same way. Every time.
Active ROM. Passive ROM. Strength testing. Palpation.
This systematic approach allows me to differentiate between conditions that present similarly but require completely different treatment strategies.
Subjective Findings Consistent with Rotator Cuff Tendinopathy:
Chronic shoulder pain (typically >3 months duration)
Pain with specific aggravating activities: overhead reaching, lifting, repetitive shoulder use
Night pain, particularly when lying on the affected side
History of failed conservative treatment (rest, NSAIDs, physical therapy)
Patient reports shoulder feels "weak" or "doesn't work right" but can still perform activities with effort
Objective Examination Protocol:
Observation:
Assess posture: forward shoulder position, scapular asymmetry or winging
Observe for muscle atrophy: supraspinatus fossa, infraspinatus fossa, deltoid
Note any protective positioning or guarding
Active Range of Motion:
Flexion: Document degrees achieved and presence of painful arc
Abduction: Note painful arc typically occurring between 60-120 degrees (classic rotator cuff sign)
External rotation: Assess at 0° and 90° of abduction
Internal rotation: Document vertebral level reached (T7, T10, L1, etc.)
Document compensatory patterns: shoulder hiking, trunk lean, scapular winging
Passive Range of Motion:
Should be full or near-full in rotator cuff tendinopathy
If significantly limited (e.g., passive flexion <140°, passive external rotation <60°), consider adhesive capsulitis as primary diagnosis
Pain at end-range is acceptable; significant restriction indicates capsular involvement
Strength testing:
Painful but relatively strong (4/5) in resisted external rotation (infraspinatus/teres minor)
Painful but relatively strong in resisted abduction (supraspinatus)
Pain and possible weakness with resisted internal rotation (subscapularis)
Special tests:
Empty can test (Jobe's test): Positive for pain (sensitivity 89%, specificity 50% for supraspinatus pathology)
External rotation resistance test: Positive for pain (sensitivity 88%, specificity 59% for infraspinatus/teres minor)
Internal rotation resistance test (Lift-off test or Belly-press test): Positive for subscapularis involvement
Neer's and Hawkins-Kennedy: May be positive but lack specificity—don't rely on these alone
Palpation findings:
Tenderness over the greater tuberosity (supraspinatus/infraspinatus insertion)
Palpable hypersensitive points in the muscle bellies of infraspinatus (posterior shoulder), supraspinatus (superior to scapular spine), and subscapularis (anterior shoulder, palpated from axilla)
Trigger point referral patterns: infraspinatus refers to anterior shoulder and down lateral arm; subscapularis refers to posterior shoulder and down posterior arm
Differential Diagnosis Table:
Clinical Finding | RC Tendinopathy | Subacromial Impingement | Adhesive Capsulitis | RC Tear |
|---|---|---|---|---|
Passive ROM | Full | Full | Significantly limited all planes | Full or limited by pain |
Active ROM | Painful arc | Painful arc | Limited all planes | Weakness, possible arc |
Strength | 4/5, painful | 4-5/5, variable | 3-4/5, limited by stiffness | 2/5 or less |
Trigger Points | Present, significant | May be present | Present but secondary | Variable |
Night Pain | Yes | Yes | Severe | Moderate to severe |
Onset | Gradual | Gradual | May be sudden or gradual | Acute or chronic |
SOAP Note - Assessment section: "Rotator cuff tendinopathy, [right] shoulder, affecting infraspinatus and supraspinatus muscles. Clinical presentation consistent with chronic tendinosis with myofascial trigger point involvement. Differential diagnoses of subacromial impingement and adhesive capsulitis ruled out based on full passive ROM and specific muscle palpation findings."
THE CERTIFIED DRY NEEDLING PRACTITIONER APPROACH
The key muscles to target are: infraspinatus, supraspinatus, and subscapularis. These muscles develop trigger points that maintain abnormal tension on their tendons, preventing relaxation and recovery, and aggravating pain.
1. INFRASPINATUS
Why: Most commonly involved in rotator cuff tendinopathy; primary external rotator; trigger points refer pain to anterior shoulder and down lateral arm (patient's typical complaint area)
Identify the spine of the scapula
Palpate the infraspinatus fossa (the area below the scapular spine)
The muscle belly is approximately one-third of the distance from the scapular spine to the inferior angle of the scapula
Needle specifications: 40mm x 0.25mm (or 50mm for larger patients)
Technique:
Insert perpendicular to the skin surface
Aim toward the scapula (you should feel bony resistance at depth if you go too far)
Typical depth: 20-30mm depending on body habitus
The infraspinatus is thicker than most clinicians expect (2-3cm in many patients)
Wind the needle to elicit local twitch response, or apply e-stim for 10 minutes.
Expected response:
Local twitch response (visible muscle fasciculation)
Patient reports reproduction of familiar anterior shoulder and lateral arm pain
May report deep aching sensation in the muscle
Safety: Avoid Pneumothorax. Aim perpendicular to the scapula, do not angle medially which could risk pneumothorax. The scapula provides a bony backstop when you're at appropriate depth.
2. SUPRASPINATUS
Why: Initiates shoulder abduction; commonly involved in painful arc presentation; trigger points cause local pain in the shoulder
Identify the spine of the scapula
Palpate the supraspinatus fossa (the area above the scapular spine)
The muscle belly sits just superior to the scapular spine, running laterally toward the acromion
Needle specifications: 40mm x 0.25mm
Technique:
Palpate approximately 2-3cm medial to the acromion, just above the scapular spine
Insert perpendicular to the skin
Typical depth: 20-25mm
Aim toward the supraspinous fossa of the scapula
Expected response:
Local twitch response
Reproduction of shoulder pain, particularly in the region patients describe as "deep in the joint"
Safety: This muscle is more superficial than the infraspinatus. Avoid needling too far laterally near the acromion where the tendon is located—stay in the muscle belly.
3. SUBSCAPULARIS
Why: Primary internal rotator; often overlooked but frequently involved; trigger points refer to posterior shoulder; weakness here contributes to anterior instability and altered mechanics
Palpate the anterior axillary fold
Move medially along the anterior border of the scapula
The subscapularis sits between the rib cage (medially) and the scapula (laterally)
Needle specifications: 75-100mm x 0.30mm (needs longer needle due to depth)
Technique:
This is an advanced technique requiring precise palpation
Approach from the axilla, palpating the lateral border of the scapula
Insert just medial to the palpated scapular border, aiming posteriorly and slightly laterally toward the subscapular fossa
Typical depth: 50-100mm
You're passing through the latissimus dorsi and teres major to reach the subscapularis
Expected response:
Local twitch response (may be less dramatic than other RC muscles)
Posterior shoulder pain referral
Patient may report feeling it "deep inside the shoulder"
Safety: This is the most technically challenging of the three. Stay lateral to the rib cage to avoid pneumothorax risk. If uncertain about anatomy, refer to your Certified Dry Needling Video library or consult with your instructor. If uncertain about needling this muscle consider advanced training or skip this muscle initially.
Post-Needling:
Patients typically experience immediate improvement in active range of motion. The painful arc may reduce in severity or resolve temporarily. This creates a therapeutic window for your neuromuscular re-education.
Immediate interventions:
Gentle active range of motion in all planes (10-20 repetitions each direction)
Isometric external rotation holds (10 seconds x 10 repetitions)
Expected Post-Needling Soreness (24-48 hours):
Patient education is critical. Warn patients they will experience muscle soreness similar to post-workout delayed onset muscle soreness (DOMS). This is a type of therapeutic soreness indicating successful trigger point disruption.
Soreness management at home:
Ice/heat as needed for comfort
Gentle movement preferred over complete rest
Avoid aggressive stretching or loading during this period
Soreness should peak at 24 hours and resolve by 48-72 hours
SOAP Note - Plan section: "Trigger point dry needling performed to right infraspinatus (2 sites, 40mm needle, depth 25mm), supraspinatus (1 site, 40mm needle, depth 20mm), and subscapularis (1 site, 50mm needle, depth 45mm). Local twitch responses elicited at all sites. Patient tolerated procedure well. Post-needling soreness expected for 24-48 hours. Ice applied for 15 minutes post-treatment."
SOAP Note - Objective section (findings immediately post-needling): "Active shoulder flexion improved from 145° to 165° with reduced pain (VAS 6/10 to 3/10). Painful arc from 60-120° reduced to 80-100° and less intense. Patient reports subjective improvement in shoulder 'looseness' and reduced deep ache."
Note: Do not make up numbers if you are not truly measuring.
EXERCISE AND REHAB PROGRAMMING
Here's what I tell every patient after I needle their shoulder:
"The needling releases muscle tension. Your muscles are relaxed right now. It's like hitting the reset button between your brain and your muscles. Now we need to retrain them. If we don't reteach them what they need to do and help them rebuild their strength and conditioning, those trigger points will most likely come back. The needling is step one. The rehab is what makes it last."
Most patients nod. Some look skeptical. I get it. They've tried exercise before and it either didn’t work, or made them worse.
Why Dry Needling Alone Isn't Enough:
Trigger points reduce motor unit recruitment. When a muscle has active trigger points, it can't contract effectively—motor neurons are inhibited, muscle fibers don't activate fully, and strength output is reduced regardless of conscious effort.
Once trigger points are released through dry needling, the muscle still needs:
Neuromuscular re-education: Teaching the muscle to contract normally again
Progressive loading: Rebuilding strength and tissue capacity gradually
Motor control training: Restoring proper movement patterns and scapular mechanics
Without this three-phase approach, the underlying movement dysfunction persists, abnormal loading patterns return, and trigger points redevelop within weeks.
IMMEDIATE POST-NEEDLING (Same day after needling):
Goal: Neuromuscular re-education while the muscle is in a relaxed, receptive state
Gentle active ROM in all planes: 10 reps each direction (flexion, abduction, external rotation, internal rotation). Pain-free range only. This reinforces normal movement patterns.
Isometric external rotation holds: Standing with elbow at side, 90° elbow flexion, resistance band or towel providing light resistance. Hold 10 seconds, 10 reps. This activates infraspinatus/teres minor in a shortened range without loading the tendon excessively.
Scapular retraction/depression: Sitting or standing, consciously pull shoulder blades down and back, hold 5 seconds, 10 reps. This begins addressing scapular dyskinesis that often coexists. Substitute with DB shoulder shrugs for experience patients.
WEEKS 1-2 (Frequency: daily):
Goal: Pain reduction, ROM normalization, initiate low-load strengthening
Gentle Range of Motion: 3 × 15 reps, 2x/day. Front, side and rear lateral raises unweighted.
Isometric rotator cuff holds:
External rotation (as above)
Internal rotation (resistance band at belly button level, press into band, hold 10-15 sec)
Resisted Abduction (arm at side, press outward into wall or resistance, hold 20 sec)
3 sets of 10-20 second holds for each direction, 2x/day (am/pm preferably)
Scapular stabilization - wall slides: Standing against wall, arms in "W" position, slide arms up and down wall maintaining scapular contact. 2 sets of 15 reps, 2x/day.
Patient engagement strategy: Use a programming app to set up and deliver your patient’s home program with images/videos. Explain to them that these exercises "add on to" the benefits of their treatment by retraining proper muscle activation, building strength and conditioning. Set the expectation right from the start: 10 minutes daily, non-negotiable for success.
WEEKS 3-4 (Frequency: 3-4 days/week):
Goal: Progressive loading, eccentric emphasis, functional movement patterns
Continue active ROM and stretching: As needed for any remaining restrictions
Resistance band external rotation (standing): Elbow at side, 90° elbow flexion, rotate arm outward against band resistance. 3 sets of 15 reps. Emphasize 3-second eccentric (slow return to starting position).
Resistance band internal rotation (standing): Same position, rotate inward. 3 sets of 15 reps with 3-second eccentric.
Scaption with light weight (3-8 lbs): Arm at 30° forward of frontal plane, thumb up, raise arm to 90°. 3 sets of 15-20 reps. This targets supraspinatus in functional plane.
Prone horizontal abduction (T's and Y's): Lying prone on table or exercise ball, arms hanging down, raise arms into "T" position (90° abduction) or "Y" position (120° abduction). 3 sets of 12-15 reps. This strengthens infraspinatus, teres minor, and scapular stabilizers.
Push-up plus (modified on wall or knees): Standard push-up, but at top position, continue to "push" scapulae forward (protract). This activates serratus anterior. 3 sets of 10 reps.
WEEKS 5-8 (Frequency: 4-5 days/week with rest days):
Goal: Increased strength, return to functional activities, transition to maintenance
Increase resistance on all exercises: Progress from light to medium to heavy as tolerated without pain recurrence. Introduce dumbbells, barbells, machines.
Dumbbell external/internal rotation (side-lying): More challenging position. 3 sets of 15 reps with 8-10 lb dumbbell.
Overhead press variations: Start with light dumbbells (10-15 lbs), progress to 20-25 lbs as tolerated. 3 sets of 8-10 reps.
Rows (inverted or dumbbell): For posterior chain and scapular stabilizers. 3 sets of 15-20 reps.
Return to sport-specific or functional activities gradually: If patient is a swimmer, begin with 30% normal yardage. If recreational weight lifter, begin with 30% normal load. Progress by 10-20% per week as tolerated.
Modifications based on presentation:
If patient has significant scapular dyskinesis: Spend extra time on scapular stabilization exercises (weeks 1-4) before progressing to higher load rotator cuff work
If subscapularis is primary problem: Emphasize internal rotation strengthening and avoid excessive external rotation stretching
If patient is overhead athlete (volleyball, baseball, swimming): Include sport-specific exercises starting week 5-6, coordinate with sport coach if possible
If patient has been dealing with the pain longer than 6 months: Consider longer timeline in weeks 1-2 before loading, emphasize slow eccentric loading to stimulate brain remapping. Also consider a longer expected recovery timeline overall.
Expected timeline:
30-40% improvement by end of week 2
40-60% improvement by end of week 4
70-90% improvement by end of week 8
Return to activity by weeks 11-12
General Preparation/Wellness program by week 13-14
If patient plateaus or regresses, reassess for:
Compliance with home program
Recurrence of trigger points (may need additional dry needling session)
Underlying cervical spine contribution
Poor sleep or sleep positioning
Inadequate rest days (overtraining)
SOAP Note - Plan section (exercise prescription): "Home exercise program prescribed for rotator cuff strengthening and neuromuscular re-education: isometric external/internal rotation holds, scapular stabilization exercises, active ROM exercises. Patient instructed to perform [daily/weekly] [2x/3x/4x/day], then progress to [resistance exercises]. Written instructions and photos provided via [app]. Patient verbalized understanding. Follow-up in 2 weeks to assess progress and advance program."
CLINICAL PEARLS
Needle depth matters more than you think: The infraspinatus is often 2-3cm thick in average-sized adults. If you're only going 10-15mm deep, you're likely in the superficial tissue or upper trapezius, not reaching the actual infraspinatus trigger points. Don't be afraid to go deeper—use the scapula as your backstop.
The subscapularis is frequently overlooked: Many practitioners skip this muscle because it's harder to access. But in patients with chronic rotator cuff pain who aren't improving with infraspinatus/supraspinatus treatment alone, subscapularis is often the missing piece. Invest time learning this technique—it's worth it.
Distinguish between tendinitis and tendinosis: Acute tendinitis (true inflammation, <6 weeks duration) may benefit from rest and anti-inflammatories. Chronic tendinosis (degenerative changes, >3 months) won't improve with rest alone—it needs controlled loading. Most patients you see will have tendinosis, not tendinitis. Adjust your language and treatment accordingly.
Patient communication is crucial: Many patients have been told to "rest and avoid" for months. When you tell them they need to exercise (and that some discomfort during exercise is acceptable), it contradicts previous advice. Explain why loading is necessary for tendon healing. Use analogies: "Tendons are like rubber bands—if you never stretch them, they become brittle and weak. We need to progressively load yours to make it stronger."
Post-needling soreness is expected: Warn patients they'll be sore for 24-48 hours. This is therapeutic soreness, not injury. If you don't prepare them for this, they'll panic and think you made them worse. I tell patients: "You'll feel like you had a hard workout in that shoulder. It's temporary and means we reached the right structures."
Re-assess trigger points at follow-up: Even if pain has improved, re-palpate the muscles. If significant trigger points persist, consider additional needling session. Some patients need 2-3 sessions spaced 1-2 weeks apart for full trigger point resolution.
When to modify or refer:
If patient isn't improving by 30-40% after 3 weeks of needling + exercise, consider MRI to rule out full-thickness rotator cuff tear
If patient has profound weakness (1-2/5) on strength testing, this suggests tear rather than tendinopathy—refer for imaging
If trigger points resolve but pain persists, consider cervical spine as pain source
If patient has medical comorbidities (diabetes, autoimmune conditions) that impair healing, set more conservative timelines
SAMPLE CASE: Here you’ll get a sample case from patients who’ve completed care with my or one of my colleagues. Including presentation, examination, treatment and outcomes.
KEY TAKEAWAYS FOR YOUR PRACTICE
Differentiate rotator cuff tendinopathy from impingement and capsulitis using passive ROM (should be full in tendinopathy) and specific muscle palpation for trigger points
Don't rely on Neer's/Hawkins-Kennedy alone—they have poor specificity; use resisted muscle tests and palpation to identify specific involved muscles
Go deep enough with infraspinatus needling—2-3cm depth in most adults; use the scapula as your bony landmark and backstop
Subscapularis is often the missing piece in patients who don't fully respond to posterior rotator cuff treatment; master this technique for complete care
Combine dry needling with progressive loading—needling without exercise leads to temporary relief; exercise without needling is often too painful to perform correctly; together they create lasting results
Set realistic timelines—expect 30-40% improvement by week 3. Expect 80-90% by week 9-10; chronic tendinopathy won't resolve overnight, but it does get better with proper treatment and care.
I told you…
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Until next time!
In health and strength,
Dr. Kauffman