Rotator Cuff Tendinopathy

Hello and welcome back to the ThreeSpires Physiotherapy blog where we take a look at all things physiotherapy and health related. In this blog we are going to look at a common source of shoulder pain: rotator cuff tendinopathy.

In general, when we are looking at a new condition in our physiotherapy blog I begin by defining exactly what the condition is. Now, for rotator cuff tendinopathy it is easier firstly to have a think about the structures involved and then consider what is going on inside the shoulder that might be causing pain.

What is the Rotator Cuff?

As ever with physiotherapy, before we start considering how the Rotator Cuff gets injured and causes shoulder pain, we first need to know a bit of anatomy (it is really helpful for understanding what is going on if you have an idea of the structures in the shoulder that might be causing pain). The Rotator Cuff is in fact not just one muscle or tendon but is actually a group of 4 muscles and tendons that provide a large amount of shoulder stability and yes, they are important in rotating the shoulder joint. The four muscles that form the rotator cuff are: Supraspinatus, Infraspinatus, Teres Minor and Subscapularis. Without going into vast detail these four muscles kind of act as guy lines that tension and secure the head of the humerus (ball) to the socket of the shoulder blade and they also do internal and external rotation of the shoulder. In fact they are used and active in pretty much any shoulder movement that you can think of.

The tendons of each of the 4 rotator cuff muscles (Supraspinatus, Infraspinatus, Teres Minor and Subscapularis) all insert directly into the ball part of the shoulder joint and also merge with the capsule that surrounds the joint. As with all tendons they do not contract (that is the job of the muscles) and they simply transfer the tension from the muscles to the bones. The four tendons of the rotator cuff muscles are all made of collagen and have much lower blood flow than the muscles themselves. This means that they will have a tendency to heal and repair slowly (much more slowly than most people think).

What is a Tendinopathy?

Okay, so hopefully you now have a reasonable notion of what the rotator cuff is and what its basic role is in shoulder movement. Now we need to examine the word tendinopathy and see what this means. The word tendinopathy infers that although there is pain and damage to the tendon there is no actual inflammation. You may read elsewhere about tendonitis which means that there is inflammation of the tendon but most research seems to suggest that this is not an inflammatory condition and is instead a general injury caused mostly by overload.

What is Rotator Cuff Tendinopathy?

Phew, I think that should do for anatomy and terminology and we now need to begin examining exactly what rotator cuff tendinopathy is. So, rotator cuff tendinopathy is usually thought of as an injury to one (or several) of the rotator cuff tendons in the shoulder which is felt in the joint and often on the outside of the upper arm. In general, there will have been some form of overload of the tendons but in older people it can simply be that the tendons have degenerated and worn.

What are the Symptoms of Rotator Cuff Tendinopathy?

Generally, the symptoms of rotator cuff tendinopathy are:

• Pain (can be sharp) in the front or back of the joint and pain down the upper arm on lifting the arm out to the side, above the head or behind the back..
• Lying and sleeping on the shoulder will often cause pain.
• Unless very aggravated there will generally be not much pain at rest or at night.  

It is important point to note that these could be the symptoms of quite a few other conditions and not just rotator cuff tendinopathy and it is important that you get it confirmed by a professional (such as a physiotherapist.

What Causes Rotator Cuff Tendinopathy?

In the reasonably young (under 60yrs) rotator cuff tendinopathy is almost always an overuse injury which means that the person involved has been using it more than it could cope with. Often the person will remember an event or incident where they lifted something and felt pain but sometimes it can come on slowly over time with too much heavy or repetitive lifting. In an older population (over 60) the primary cause of the tendinopathy can be degeneration and wear and tear of the tendons rather than a specific overload.

Some common causes of rotator cuff tendinopathy are:

• Lifting too heavy a weight in the gym – generally this will be an overhead movement such as a shoulder press.
• Too much repetitive overhead work. This could be something like doing a lot of painting in the house or window cleaning. Even if you are used to doing a lot of stuff like this it could be that you have simply done a little bit more than you are used to and this has irritated the shoulder.
• A new exercise regime such as playing tennis or badminton that involves using the shoulder in a way to which you are not accustomed and in an overhead position.
• Swimming: possibly you have recently taken up swimming or have increased the amount of swimming you are doing which has irritated the rotator cuff tendons.

 

Who is at Risk of Getting Rotator Cuff Tendinopathy?

Almost anyone can develop rotator cuff tendinopathy but there are some risk factors that make some people more prone to overloading the tendons of the rotator cuff and developing rotator cuff tendinopathy:

• Men: Males are in general slightly more at risk of developing shoulder pain due to in general doing more exercise, heavy lifting and having more physical jobs.
• Age: unfortunately, as you get older the tendons in your shoulder become more prone to wear and tear and this can lead to rotator cuff tendinopathy.
• Anyone beginning a new exercise regime: this can include taking up swimming, climbing, tennis, badminton, squash or going the gym. In the early days the tendons in the shoulder take time to adapt and may get irritated if overloaded.

 

How is Rotator Cuff Tendinopathy Diagnosed?

Usually, rotator cuff tendinopathy will be diagnosed through a combination of the symptoms of the patient and a physical assessment by a physiotherapist. Mostly there will not be a need for investigations and imaging such as an ultrasound scan or MRI. Sometimes patients will initially go to their GP with shoulder pain and then be referred on to a physiotherapist. As with most injuries It is best to get an early diagnosis of your rotator cuff tendinopathy as this allows the best management and treatment plan to be devised. Delaying a diagnosis and letting things worsen will only lengthen the rehab process needed for your rotator cuff tendinopathy.

Treating Rotator Cuff Tendinopathy

The best treatment for rotator cuff tendinopathy will depend upon the exact nature of your symptoms:

1. Rest: yes, unfortunately initially at least it is important to have a period of rest to let symptoms and pain settle down. This mainly means stopping doing the specific activity or movement that has been irritating your shoulder tendons. You don’t need to rest for ever rather just enough to let things settle down a bit.
2. Exercises: for rotator cuff tendinopathy getting the right exercises that target the rotator cuff and slowly allow you to build up strength is essential.
3. Activity Modification: often one of the best approaches is to try to modify or alter some of the activities that are causing you pain. This is especially important if part of your work is irritating your shoulder e.g. if you are a painter. Examples of this could be reducing the amount of overhead work by using a step ladder if you are a painter. This can sometimes take a bit of trial and error and will involve you discussing this with your physiotherapist.
4. Other Treatments: a corticosteroid injection can sometimes be helpful if despite rest and specific exercises you cannot get your pain under control. Surgery is nowadays seen as very much a last resort.

Specific Rotator Cuff Tendinopathy Exercises

Unfortunately, without an actual assessment by a physiotherapist it is difficult to detail specific exercises for rotator cuff tendinopathy as the exercises will depend upon pain levels, the movements that aggravate the tendons and the specific part of the rotator cuff involved. I think the main point to note is that they should slowly and progressive build up in terms of intensity.

Are My Rotator Cuff Tendinopathy Exercises Meant to Hurt?

Pain is a difficult issue and it takes a bit of judgement to decide upon what is acceptable and what is not. It can be difficult when first starting rehab but needs some thinking about when trying to decide which exercises are best and what level to start with.

The short answer to the question above is that yes, a certain level of pain will be okay when doing rotator cuff rehab but you will have to be wary about the level of pain and your symptoms worsening after the exercise. As the exercises are designed to provoke and strengthen your rotator cuff tendons it is likely that they will be uncomfortable but importantly they should not make it worse afterwards or in the night after. In general, my advice to patients with rotator cuff tendinopathy is that exercises can be a bit uncomfortable but they should not be getting pain exceeding 2-3/10 on a pain scale and more importantly they should not feel worse afterwards. So, I would always prefer patients to take it easy on the exercises for the first few sessions so that they get an idea of how their rotator cuff is going to react to the exercises.

 

How Long Will It Take for My Rotator Cuff Tendinopathy to Heal?

This is one of two questions that most patients have when they have shoulder pain (the other is: what is wrong with my shoulder?) The answer to this question will depend upon several factors: firstly, the level of pain in your tendon, for example is it 1-2/10 or is it 10/10? Secondly, how long your symptoms have been going on for e.g. have they just started or is this something that has been going on for a year? Clearly, If you see someone early and don’t let the pain in your shoulder become too severe then your recovery is likely to be much quicker. A reasonable timeframe if caught early enough would be 8 – 12 weeks before you will be fully fit again but obviously this very much depends upon the stage that your tendon is at.

 

What Exercises or Activities Should I Avoid for my Rotator Cuff Tendinopathy?

There are not really any specific exercises that you must avoid rather it is a case of avoiding irritating your shoulder too much.

 

How Can ThreeSpires Physiotherapy Help with My Rotator Cuff Tendinopathy?

Physiotherapy is extremely helpful if you have developed rotator cuff tendinopathy and one of our physiotherapists will be able to help with:

1. Assessment & Diagnosis of Rotator Cuff Tendinopathy: this as mentioned earlier is a vital part of healing your tendinopathy and the sooner you have an assessment the sooner you will know what you are dealing with. Our physiotherapists will be able to comprehensively assess your rotator cuff tendinopathy and make a diagnosis.
2. Load Management Plan: once a diagnosis of rotator cuff tendinopathy has been made it is vital that you get a clear and comprehensive plan to reduce the load and irritation on your tendon and begin healing and recovering. Your physiotherapist will be able to identify which stage your rotator cuff tendons are at and what the appropriate load will be to promote recovery.
3. Exercises for Rotator Cuff Tendinopathy: your physiotherapist will be able to determine which are the most appropriate exercises for your rotator cuff tendinopathy and will be able to prescribe the optimum number and frequency to promote recovery.
4. Treatment for Rotator Cuff Tendinopathy: In conjunction with load management and exercises your physio will be able to use soft tissue and hands on techniques to treat any areas that have become overloaded and tight.

Okay, I hope that you have found this article about rotator cuff tendinopathy helpful, over the next few months we will be doing a series of further articles about other tendinopathies and the best exercises and some of the latest research surrounding tendinopathies. Should you or anyone you know have developed rotator cuff tendinopathy please get in touch and one of our physios would be happy to help.