Rotator Cuff Tendinopathy
1. Introduction
This condition commonly presents with pain at the front, back or side of the shoulder and/or upper arm region. Tendinopathy of the rotator cuff tendon may also be termed ‘impingement syndrome’, ‘subacromial pain syndrome’ or ‘rotator cuff related pain’ as we often cannot distinguish one singular structure associated with the pain, and so these alternative terms refer to the region or nature in which pain is referred.
For a long time, we referred to tendinopathies as ‘tendinitis’. This was because we believed there was a lot of inflammation involved in the condition leading to treatments such as steroid injections and strong anti-inflammatory medication (such as diclofenac or naproxen). However, our understanding of tendon related pain has improved and we now know that tendon degeneration, as opposed to inflammation, is the primary factor in most tendinopathies.
Frequently Asked Questions
- Rotator cuff tendinopathy refers to pain and weakness, most commonly experienced with movements of shoulder rotation and lifting, as a consequence of excessive load on the rotator cuff tissues.
- Rotator cuff tendinopathy is a relatively common condition.
- The prevalence of shoulder complaints in the UK is estimated to be 14% (1).
- Rotator cuff problems account for up to 70% – 85% (2).
- No.
- With the right rehabilitation approach rotator cuff tendinopathies generally recover well.
- Rotator cuff tendinopathies are not linked to other serious pathology.
- Common age is normally 35 to 75 years old (4).
- Repetitive, unaccustomed, sustained or increased use of the shoulder (particularly above head) during occupation or activity (8).
- People who are obese.
- Reduced muscle strength.
- Smokers.
- Reduced joint range of motion.
- People who suffer from diabetes (9, 10).
- Pain on the front and side of the upper arm.
- Pain raising the arm from the side.
- Pain with lifting/picking things up.
- Often presented with a well-maintained movement in the shoulder.
- Difficulty laying on the affected shoulder – can disturb sleep.
- Modify your activity.
- Progressive and appropriate loading of the tendon has been shown to be one of the most effective treatments.
- Advice by a qualified physiotherapist will be helpful in most cases.
- Take simple painkillers/anti-inflammatories if you can do so.
- Improving lifestyle choices, such as sleep hygiene, healthy weight, quitting smoking, increasing muscle strength and physical activity.
- Most cases see improvements within 3-6 months.
- Persisting symptoms and recurrence can present, with estimates of 14% of patients still seeking advice after 3 years (3).
We recommend consulting a musculoskeletal physiotherapist to ensure exercises are best suited to your recovery. If you are carrying out an exercise regime without consulting a healthcare professional, you do so at your own risk.
2. Signs and Symptoms
- Pain localised to the front, back and side of the shoulder and/or upper arm.
- Pain often when elevating the arm, e.g. to reaching into a cupboard.
- Pain when washing your hair or fastening your bra/garments (hand behind back/head motion).
- Lifting/picking up heavier objects.
- Pain often when lying on this shoulder/arm at night.
3. Causes
The tendon function is to transmit muscle force to the bone and they are normally very tolerant to the load. Sudden increase of activity/load is the most common cause; however, it can also come on gradually with no clear cause. This is because many factors influence the condition.
Repetitive movements and prolonged arm elevation (such as working in construction and hairdressing) (8) are associated with a higher risk of shoulder disorders. Consequently, ergonomic adjustments should be considered.
4. Risk Factors
This is not an exhaustive list. These factors could increase the likelihood of someone developing rotator cuff tendinopathy (9, 10). It does not mean everyone with these risk factors will develop symptoms.
- Increased weight or obesity.
- Decreased muscle strength.
- Smoking.
- Decreased joint range of motion.
- Diabetes.
5. Prevalence
The prevalence of shoulder complaints in the UK is estimated to be 14% (1) and rotator cuff disorders account for up to 70% – 85% (2), with 1%–2% of adults consulting their GP annually regarding new onset shoulder pain (3).
Shoulder pain is the third most common musculoskeletal presentation in primary care after back and knee pain. Rotator cuff pain is very common in people aged between 35-75 years old (4).
6. Assessment & Diagnosis
The diagnosis is based on history and examination carried out by our experienced physiotherapists who see this condition on a regular basis due to its high prevalence in shoulder pain. Further investigation is not normally needed due to the high likelihood of finding elements not linked to your symptoms on scans unless there is a very acute onset as a result of a traumatic event or the condition is not responding accordingly to what is expected by the treatment.
7. Self-Management
Relative rest from the painful activities can be helpful initially to allow the pain to settle, alongside analgesics (paracetamol) and anti-inflammatories (NSAIDs such as ibuprofen – contraindicated if you have a history of gastrointestinal bleeding, ischaemic heart disease or renal problems). Physiotherapy and graded exercise progression are normally key (4, 5). Consider a short period of time off work (for example 1 week), if the job duties appear to be directly relevant to the shoulder symptoms.
8. Rehabilitation
The treatment aim is to achieve symptom free shoulder movement and function. Expect ups and downs and setbacks during the rehabilitation.
Below are three rehabilitation programmes created by our specialist physiotherapists targeted at addressing rotator cuff tendinopathies. In some instances, a one-to-one assessment is appropriate to individually tailor targeted rehabilitation. However, these programmes provide an excellent starting point as well as clearly highlighting exercise progression.
9. Rotator Cuff Tendinopathy
Rehabilitation Plans
Our team of expert musculoskeletal physiotherapist have created rehabilitation plans to enable people to manage their condition. If you have any questions or concerns about a condition, we recommend you book an consultation with one of our clinicians.
What Is the Pain Scale?
The pain scale or what some physios would call the Visual Analogue Scale (VAS), is a scale that is used to try and understand the level of pain that someone is in. The scale is intended as something that you would rate yourself on a scale of 0-10 with 0 = no pain, 10 = worst pain imaginable. You can learn more about what is pain and the pain scale here.
Exercises aim to stimulate the recovery of the rotator cuff tendons and to reduce the level of pain. This should not exceed any more than 4/10 on your perceived pain scale.
- 0
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- 910
If pain is manageable, or the early rehabilitation plan is going well, more active movements are included and repetitions and resistance need to be gradually increased. This should not exceed any more than 4/10 on your perceived pain scale.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
Generally, this will involve increasing the load, speed and stability to prepare your full return to previous levels and will normally involve pushing, pulling, carrying, lifting and throwing exercises, depending on your needs. This should not exceed any more than 4/10 on your perceived pain scale.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
10. Return to Sport / Normal life
For patients wanting to achieve a high level of function or return to sport, we would encourage a consultation with a physiotherapist as you will likely require further progression beyond the advanced rehabilitation stage.
As part of a comprehensive treatment approach, your musculoskeletal physiotherapist may also use a variety of other pain-relieving treatments to support symptom relief and recovery. Whilst recovering, you might benefit from further assessment to ensure you are making progress and to establish the appropriate progression of treatment. Ongoing support and advice will allow you to self-manage and prevent future reoccurrence.
11. Other Treatment Options
The suggestions for non-surgical management include a minimal number of exercises prescribed to challenge the functional deficit of the patient over a minimum 12-week period. Imaging can aid to exclude serious pathology or if the patient does not respond to treatment as expected, but is not key for the management of the injury. Steroid injections would not be considered a first-line intervention unless pain is severe and preventing sleep and engagement with the exercises (6).
12. Links for Further Reading
References
- Urwin M, Symmons D, Allison T, et al. (1998). Estimating the burden of musculoskeletal disorders in the community: the comparative prevalence of symptoms at different anatomical sites, and the relation to social deprivation. Ann Rheum Dis; 557, 649–55. 3.
- Mitchell C, Adebajo A, Hay E and Carr A. (2005). Shoulder pain: diagnosis and management in primary care. BMJ; 331, 1124–8.
- Artus M, Holt T A and Rees J. (2014) .The painful shoulder: an update on assessment, treatment, and referral. BJGP; 64 (626), e593-e595.
- Kulkarni R et al .(2015). BESS/BOA Patient Care Pathway Subacromial Shoulder pain. Shoulder & Elbow. 7(2) 135-143.
- Green S, Buchbinder R, Hetrick S; (2003). Physiotherapy interventions for shoulder pain.
- Mohamadi A, Chan J, Chen N et al. (2017). Corticosteroid injections give small and transient pain relief in rotator cuff tendinosis: A meta-analysis. Clinical Orthopaedics and Related Research.475, 232-243.
- Page, MJ, Green, S, McBain, B, et al. (2016). Manual therapy and exercise for rotator cuff disease. Cochrane Database Syst Rev. DOI: 10.1002/14651858.CD012224.
- Littlewood, C, Bateman, M, Connor, C, et al. (2019). Physiotherapists’ recommendations for examination and treatment of rotator cuff related shoulder pain: a consensus exercise. Physiother Pract Res. 40, 87–94.
- Svendsen et al. (2004). Work related shoulder disorders: quantitative exposure-response relations with reference to arm posture. Occup Environ Med. 61: 844-853.
- Dean & Sonderland. (2015). Lifestyle and MSK Conditions. Grieve MSK Physiotherapy.
- Franceschi et al. (2014). Obesity as a risk factor for tendinopathy. A SR. Int Journal of Endocrinology.
- Lewis J. (2016). Rotator cuff related shoulder pain: Assessment, management and uncertainties. Manual Therapy, Elsevier. 23, 57-68.
- Jafari et al. (2017). Pain & Respiration: A SR. Pain 158 (6), 995-1006.
- Fermin et al. (2016). The effect of contralateral exercise on patient pain and range of motion. Journal of Sport Rehabilitation.
Other Conditions in
Shoulders
Whiplash Disorders
An injury which typically occurs following a road traffic collision, often affecting the soft tissues of the neck.
Thoracic Outlet Syndrome
A condition presenting with pain in the arm as a result of compression of structures around the neck/shoulder.
Shoulder Osteoarthritis (OA)
Age and activity related changes to the joints of the shoulder which can lead to pain and stiffness.
Shoulder Impingement
Shoulder impingement is an umbrella term used to describe a variety of conditions that can cause pain in the shoulder.
Shoulder Dislocation
An injury in which your upper arm bone ‘pops out’ of the cup-shaped socket of your shoulder blade.
Frozen Shoulder
An insidious (no clear cause), painful/stiff condition of the shoulder persisting for more than 3 months.
Calcific Tendinopathy
A rare condition causing pain and loss of free movement in tendons and joints.
Biceps Tendinopathy
A tendon-related issue affecting the long bicep tenon at the front of the shoulder.
Benign Joint Hypermobility Syndrome
Common age related changes to the structure of the knee joint which may be associated with pain, stiffness and loss of function.
Acute Torticollis
Sometimes referred to as “wry neck”, this is a condition causing muscle spasms and associated neck pain.
Acromioclavicular Joint Injury
Injury to a small joint at the end of the collar bone (clavicle)/top of your shoulder.