Rotator cuff tendonitis (tendinopathy) is an overuse injury causing gradual onset pain in the shoulder. Here we explain the symptoms, causes, treatment and rehabilitation of rotator cuff tendonitis
- Shoulder pain which has developed gradually over a period of days or weeks. Often patients are unable to determine a specific point in time when the injury occurred.
- Your shoulder will be painful even at rest.
- Symptoms get worse if you lift your do a lot of overhead movements such as in racket sports or swimming.
- Pain is usually less likely with movements below shoulder height and it may become worse at night.
- Your shoulder is likely to be tender when pressing in on the affected tendon, which may also feel thickened.
- A creaking feeling called crepitus may be felt when moving your shoulder.
- An MRI scan can confirm the diagnosis and identify any tearing of the tendon.
What is rotator cuff tendonitis/tendinopathy?
There are four main muscles which rotate the upper arm (humerus) bone. These are the Supraspinatus, Infraspinatus, Subscapularis and Teres minor. Together they are known as the rotator cuff muscles.
Rotator cuff tendonitis (tendinopathy) is probably the most common cause of gradual onset shoulder pain and is inflammation of the tendons. Rotator cuff tendinopathy is probably a more accurate name for this injury. The ‘itis’ at the end of tendonitis refers to inflammation. The term tendinopathy includes ‘degeneration’ or wear and tear of the tendon as well.
Degeneration is more common in chronic injuries. Acute inflammation cells have been shown not to be present in long term injuries. Other similar terms include tenosynovitis which is degeneration of the sheath surrounding the tendon.
Overuse is the underlying cause. During thowing or overhead racket sports huge forces are involved in slowing the arm down. It is the rotator cuff muscles which do this. They work eccentrically, which means they contract whilst they are lenngthening.
This results in even larger stresses through the muscle. Few throwers or those involved in racket sports focus on training these muscles. The subscapularis is often injured by throwers and can be stubborn to treat.
Patients who have had a previous rotator cuff strain are more prone to developing tendonitis, especially if they didn’t rest or rehabilitate it properly.
If there has been any calcification (unwanted bone cells) in the tendon then treatment can be difficult. Extracorporeal shock wave therapy may help along with surgical removal through keyhole surgery could be indicated.
Other causes include:
- Working at a desk for long periods and using a mouse or keyboard can also contribute to overuse, particularly if you have poor posture.
- The tiny shoulder movements required to work with a computer mouse can add up over time.
- A hunched and rounded shoulder posture reduces the space in the joint through which the rotator cuff tendons pass.
- This can lead to the tendons rubbing on the underside of the acromion process at the top of the shoulder joint.
- Repeated friction leads to pain and degeneration. Thickening of the tendon can make the situation even worse and may lead to an impingement syndrome.
Treatment for rotator cuff tendonitis
Treatment for rotator cuff tendinopathy consists of two parts. The first priority is to treat the symptoms, reduce pain and inflammation in order to allow normal movement. The second aspect is to address the underlying causes and correct and correct them.
Rest – from activities which cause pain. The more you use the shoulder the longer it will take to heal and it may become chronic. Maintain fitness doing other activities such as running or cycling. Avoid any shoulder exercises or weight training and in particular, avoid the activities which caused the injury in the first place.
Apply ice or cold therapy to reduce pain and inflammation. Ice can be applied every hour for 10 minutes initially reducing to 15 minutes every 3-4 hours as required to reduce pain and inflammation.
Medication – a doctor may prescribe anti-inflammatory medication such as ibuprofen which may help in the early stages but less so long term. Ibuprofen should not be taken if you have asthma and your doctor will always check for contraindications before prescribing medication.
Electrotherapy – treatments such as ultrasound, interferential stimulation, laser or magnetic field therapy may be beneficial in reducing pain and inflammation.
Sports massage – may be used to relax tight muscles in the shoulder in general. If the injury is chronic and not responded to initial conservative treatment such as cold therapy as well as expected then cross friction massage may be applied to the tendon itself. This can break down any adhesion’s between the tendon and sheath surrounding it and reduce the injury to its acute stage to encourage correct healing.
Nitric oxide donor therapy – here is some evidence to suggest that nitrite oxide donor therapy patches applied to the shoulder can be successful. Glyceryl trinitrate patches of the correct dose (1.25mg/day) are applied to the shoulder for 24 hours at a time before being replaced.
Injections – a corticosteroid is injected into the shoulder at the subacromial space. This may reduce pain and inflammation to allow an exercise rehabilitation program to begin.
Correcting faults – a good therapist will help determine the cause of the injury whether that be poor technique or work-related repetitive overuse and identify strategies or changes to avoid the injury recurring. In particular poor posture and muscle imbalances can be corrected with exercises, taping and workspace evaluation.
Rotator cuff exercises
Once inflammation has reduced and you are pain-free, rotator cuff exercises are most important. The normal function of the shoulder should be restored and this involves releasing tension in tight muscles and strengthening weak ones.
It is usually the external rotator cuff muscles or the muscles which rotate the shoulder joint outwards which are weak, compared with the muscles which rotate the humerus inwards.
Scapulohumeral rhythm is the timing of how the shoulder blade moves with the shoulder joint. This is important for rehabilitation of all shoulder injuries along with stretching and strengthening of the muscles which rotate the shoulder outwards (lateral rotators).
See more detail on rotator cuff exercises.