Shoulder pain coming from a rotator cuff tendinitis is one of the most common culprits we see at the practice – especially pain that’s been around for months or years. In many of these cases we find a history of rotator cuff impingement, but what does that mean and why doesn’t it just heal on it’s own?
An impingement in your shoulder is basically when the rotator cuff tendons get “pinched” on their way from your shoulder blade to your upper arm. This friction and strain on your rotator cuff causes a tendinitis (also known as tendinopathy or tendonitis), basically an inflamed tendon that swells up in a very confined space. This thickening of the tendon adds fuel to the fire. This loop keeps on going on and on. Usually with a little rest it gets better, but if you start loading it prematurely, you start up the cycle again.
A rotator cuff tendinitis is quite common in middle aged women, overhead sports people and the gardener or painter that does a lot of work above the level of their shoulder.
A Rotator cuff tendinitis is gets kickstarted with one event and after that your shoulder pain gradually becomes more intense. Unfortunately, we see a lot of people who ignore the pain for a long time, which in turn causes more pain and damage with longer recovery times.
Do not make the mistake of thinking that the problem will just go away. Rather call us for an assessment and diagnosis before you end up with irreversible damage to your shoulder muscles.
What is the Rotator Cuff?
The shoulder joint is a shallow ball-and-socket formation and the rotator cuff is made up of four muscles that keep the head of the humerus (“ball”) in the socket. This socket is part of your shoulder blade and is quite shallow, making it relatively unstable. The stability is improved by the labrum (a cartilage-like structure inside the joint) and the shoulder capsule (ligaments around the joint).
The four Rotator Cuff muscles are:
- Infraspinatus (biggest muscle on the back of your shoulder blade)
- Supraspinatus (above the small bony bridge of your shoulder blade)
- Subscapularis (on the inside of your shoulder blade)
- Teres minor (smaller muscle on the outside of the Infraspinatus muscle)
All four muscles originate on the shoulder blade, go through a small opening at the outer top part of your shoulder blade and attach to the upper arm bone (humerus).
What does the rotator cuff do?
The Rotator Cuff muscles have two different functions. The first one is working as a group to stabilize your shoulder joint, working like a washer inside a tap.
The second function is specific to each muscle.
- Infraspinatus: open the door movement; it rotates your shoulder to the outside.
- Supraspinatus: lifts your arm up to the side, like when you are nudging a friend.
- Subscapularis: downward action when throwing a ball; it rotates your shoulder to the inside.
- Teres minor: assists the Infraspinatus muscle and also holds the upper arm bone down when your arm moves to the side
Tennis, cricket and swimming use the Rotator Cuff muscles a lot as well as any over-head sports or activities. The Rotator Cuff muscles also play a big role in everyday activities like brushing your hair and tucking in your shirt. Simple things like reaching out of your car to get a parking ticket or reaching up to a cupboard to get a coffee mug, may become painful actions when you have a Rotator Cuff impingement or tendinitis.
How does Rotator Cuff tendinitis happen?
Healthy tendons are brilliant white in color and consist mostly out of collagen fibers, like the sinews you find when eating biltong. However, the blood supply and oxygen consumption of tendons and ligaments is 7.5 times lower than that of muscles. The fact that tendons have poor blood supply, means that tendons heal a lot slower after an injury.
Your rotator cuff tendons are under constant strain when you are upright, because gravity is always pulling your arm downwards. Any movement of your arm is made possible by your rotator cuff keeping the shoulder joint stable and in position. Think of a crane on a building site that’s attached to the top of a building with the long “arm”. If the crane isn’t attached properly and in the correct position, the arm that does the work will fail with any extra weight.
“Pinch” in your shoulder?
The most vulnerable part of your rotator cuff muscles is where the tendons run underneath the bone at the top of your shoulder. If your shoulder isn’t working the way it should this space becomes narrowed leading to rotator cuff impingement or pinching. Over time this pinch causes fraying of the tendon and what is called a rotator cuff tendinopathy or tendinitis.
The structure of a tendon changes if repetitive strain is continued. The network of collagen fibers in a tendon gets disrupted by micro-trauma caused by too much strain. This leads to hypercellular activity in the tendon, which is an excess production of collagen cells. So, in an attempt to heal, your body produces more new collagen cells. However, this leads to tendon thickening, loss of flexibility and ultimately weakening of the collagen structure. If the load isn’t reduced there is more and more damage to the tendon until it eventually fails. Like a rope grinding over a rock, it won’t last long.
Causes of Rotator Cuff tendinitis
Overload and overuse are the 2 leading causes for the cord like structure (Rotator Cuff tendon) to become inflamed. Incorrect biomechanics (the way your shoulder moves), fatigue or simply weakness are the factors that cause narrowing of small space at the top of your shoulder. This causes compression on the tendons and leads to pain and inflammation – in other words rotator cuff impingement.
Too much load or too many repetitions out of the blue overload your tendons, like swimming 100 laps or doing 100 burpees if you’re used to 50 or even something like hanging 10 loads of washing on the line. Sudden overload leads to minor tears in the muscles. This in turn causes swelling in the subacromial space (big word for the space between the shoulder blade at the top of your shoulder where the tendon goes through to the head of the humerus). Hence there will be less space for the tendons to move and shoulder movements will be painful.
Pitcher’s shoulder
Repetitive over-head throwing actions in ball sports causes the Rotator Cutt tendons to compress. Consequently this leads to pain and inflammation of the tendons.
Swimmer’s shoulder
Repetitive poor movements is another main cause of Rotator Cuff Tendinitis, for example in swimmers. As fatigue sets in with overtraining, the quality of movements will decrease and lead to pain and inflammation. The end result is Rotator Cuff tendinitis and possibly a Rotator Cuff tear if you don’t manage the training load on your shoulder.
Painter’s shoulder
Haven’t we all tried to paint our own house, whether that is the bathroom roof or the outside wall? The next morning you are very aware of your shoulders and neck being stiff and tight. Although it is not defined as a professional sport yet, it can still be the cause of your Rotator Cuff tendonitis. This time around it is a sudden overload of your Rotator Cuff muscles, seeing as you normally do not use the arm in that position, that will cause you to have pain and inflammation.
Symptoms of rotator cuff tendinitis
Why is my rotator cuff tendinitis not going away?
Think of your rotator cuff tendons as a rope that has to glide through a small opening. The smaller the opening the more friction there is on the rope for instance when your rotator cuff tendons are inflamed or if your shoulder muscles don’t work the way the should. This narrowing of the opening leads to rotator cuff impingement. As you use your shoulder the rotator cuff tendons still need to glide through this narrowed opening, resulting in fraying of the tendon. Consequently the tendon becomes weaker and can snap more easily.
Resting from the activities that hurt your shoulder will improve your pain as the inflammation settles, but as soon as you get back to your normal routine your rotator cuff tendinitis will just flare up again. This is where physiotherapy treatment can help you. We assess the biomechanics (movements) around your shoulder to find out why your rotator cuff is inflamed. Only then can we treat your rotator cuff tendinitis effectively and make sure it doesn’t get worse.
How bad is my rotator cuff tendinitis?
Reactive Tendinopathy
This is a non-inflammatory process caused by overload or severe compression – impingement – of the rotator cuff tendons. Your body responds by producing more cells, trying to make the tendon stronger, leading to thickening of the tendon. This thickening is why you feel stiffness in your shoulder, but it’s a different process to the normal stiffness you feel after exercise.
Tendon dysrepair
If you keep on overloading the tendon in the reactive tendinopathy phase, there will be worse breakdown of tissue leading to the production of more collagen and protein in your tendon. This causes the fibers to become disorganized and blood vessels and nerves grow where they shouldn’t normally be.
Degenerative tendinopathy
By the time you reach this stage of rotator cuff tendinitis the damage is irreversible. Extra vessels and lots of building proteins fill the tendon area, trying to rebuild the tendon and muscle tissue again and again. Eventually, at this end stage of the injury, it is often the point at which patients will turn to surgery because of the pain that kept on going for months and was not adequately addressed. Your body repeatedly tries to help you out, but too much load is added too soon and the natural healing process will now have caused more damage than good. Hence the tendon will be thick and swollen.
Diagnosis
Diagnosis
By performing muscle, nerve and structural tests we will be able to determine what is causing your the pain. We test the muscles and ligaments around your shoulder to give you an accurate diagnosis. Thereafter we will explain what the problem is, so that you will be confident to make an informed choice of the treatment options that are available to you. Discuss the way forward with your specific Physiotherapist seeing that they will know exactly what will be the best way to address your injury.
Sonar
Once our assessment is done, a sonar is helpful to confirm the amount of swelling and tissue damage of the muscle and the extent of the Rotator Cuff tendinitis.
X-rays
In the event of a traumatic injury like a fall, X-rays can be helpful to rule out a fracture of your arm or shoulder blade. They only show bony elements, therefore they will not be able to assist with the diagnosis of a Rotator Cuff tendinitis. The tests we do are very accurate and will be able to give a diagnosis without having to get X-rays done.
MRI
An MRI (Magnetic Resonance Imaging) uses very strong magnet and radio frequencies to create an image of the body. The inflamed Rotator Cuff tendons will be visible on the MRI. It is mostly referred for if another injury is suspected, especially for labral tears. It is very expensive and therefore only referred for when it will be necessary for further management of your shoulder tendonitis.
A big problem we see with rotator cuff tendinitis
Unfortunately a lot of people only go to their GP and get a prescription for pain killers and anti-inflammatory medication. This recipe is repeated at worst 2-3 times, having a negative effect on your stomach due to side effects of the medication. On top of that your rotator cuff symptoms come back soon after you stop taking the medication and get back into your normal routine. This continuous use will not enable the body to go through its own natural healing process and therefore the fibers cannot rebuild properly which weakens the tendons even more.
Another problem we see is that patients buy a sling to rest the shoulder. While this is useful for a couple of days, it puts your shoulder in exactly the position that we do not want shoulders. Keeping your arm in this position for days, weeks or months causes more muscle imbalances around your shoulder. When you eventually want to get rid of the sling, your muscles will be too weak to cope with the “extra” weight of your arm because it’s gotten used to the sling doing all the work. This means that we also have to correct our shoulder position as part of treatment, so the recovery period is longer than if you come to see us ASAP after the problem starts.
Physiotherapy treatment
Here are some ways and techniques that we use to treat your Rotator Cuff tendonitis:
- Electrotherapy like ultrasound and laser for pain management and to promote healing.
- Strapping and Taping to support and protect you from further injury or to stabilize your shoulder joint.
- Acupuncture or Dry Needling of the Rotator Cuff muscles to relieve muscle spasm.
- Massage, Soft tissue mobilization and muscle Stretches to lengthen the shortened muscles.
- Myofascial release of the Rotator Cuff muscles.
- Dynamic, static and ballistic stretches together with eccentric loading exercises to condition the muscle fibers.
- We will gradually progress your rehabilitation exercises to regain full function of your shoulder.
Phase 1: Decrease pain and rest
Your injured shoulder needs rest during this phase. During the first stage of rehabilitation our main goals are treating your severe pain and inflammation. We do this by using electrotherapy, soft tissue modalities like massage and dry needling and strapping/taping to protect your shoulder.
We will also give you a lot of information on what’s wrong with your shoulder, why it happened and what you can do about it.
Phase 2: Activate correct muscles for shoulder stability
When you have pain the small stabilising muscles in and around your shoulder are inhibited, so they don’t work as they should. This causes your shoulder to “learn” new habits and movements to compensate which means that other muscles are under more strain when they have to take over this stabilising function.
During this phase of rehabilitation we teach you how to activate these small stabilising muscles. Seeing that the stability muscles are not working the shoulder will often have a compensatory pattern already. The movements of this pattern will have to be broken down and your normal movement, that your arm moves without the shoulder blade being part of the movement, has to be re-established.
Phase 3: Correcting biomechanics
When you reach this stage of rehabilitation, you should know how to activate the small stabilising muscles around your shoulder. Now we will start correcting the coordinated movements of your arm, shoulder blade and upper back. The whole shoulder complex – collarbone, shoulder joint, shoulder blade, upper back and all the attached muscles – work together to let you do all sorts of complex movements with your arm like throwing, writing, getting dressed etc. With rotator cuff impingement, you lose some of this coordination due to pain or muscle imbalances.
During this phase we retrain the positioning and movements of your shoulder blade. Initially this will only involve small movements to make your aware of what your shoulder blade is doing. As you get used to where your shoulder is supposed to be we add arm movements to make the exercises more challenging.
Phase 4: Muscle strengthening
At this stage most of the pain of your rotator cuff tendinitis should have resolved. A lot of patients stop the rehab process at this point because there is no pain . The whole shoulder complex has to be strengthened again, otherwise your shoulder will flare up again as soon as your increase the load.
During this phase we will add specific exercises for strengthening of your rotator cuff muscles. This ensures that your shoulder will have enough stability for weight training, carrying heavy grocery bags or picking up your grandchildren.
Phase 5: Improving muscle endurance
At this stage you shouldn’t have pain with normal activities like washing your hair, driving or carrying groceries. Now we will start work on muscle endurance.
Rotator cuff tendinitis is an overuse injury, so the tendons can’t handle an increase in load and that’s where the problems start. By increasing muscle endurance we will make sure that your rotator cuff tendons can cope with extra load. This phase involves more repetitions of exercises and we will also be adding elastic resistance to keep the muscles under tension throughout the whole exercise.
Phase 6: Back to everyday heavier activities
This is the final stage of rehabilitation and our physiotherapist will still continue myofascial release, trigger point release and electrotherapy modalities as needed, but functional rehabilitation is the most important part of this phase.
We will start with more complex exercises involving your upper back, shoulder and whole arm to make sure that your rotator cuff symptoms don’t come back when you move furniture, pick up your children or go swimming.
How long will it take for my rotator cuff tendinitis to heal?
Treatment of rotator cuff tendinitis will depend on the severity of your injury. Due to the slow healing rate of tendons, physiotherapy treatment of rotator cuff impingement can take anywhere from 6 weeks to 3 months.
In the first few weeks of treatment we will need to see you twice a week until your pain is under control and we have started activation of the stabilising muscles around your shoulder. Thereafter we will see you once a week to monitor your progress and increase the intensity of your exercises. With each treatment we will guide you on what you should and should not do during that phase of rehabilitation.
If you’ve had the pain for months or years before coming to see us, don’t despair! The first few weeks of treatment will be similar to the less severe cases of shoulder tendonitis, but your process will take a bit longer. This is due to the compensations that your shoulder would have picked up over time, trying to get away from the pain.
At the end of rehabilitation we will clear your shoulder by stressing the rotator cuff muscles in different positions and with different loads to make sure that your shoulder can cope with the demands of everyday life and anything else you can throw at it.
Other medical treatments
- Your GP can prescribe pain medication or cortisone if necessary. This helps to get your pain under control, but it is still important to see your physiotherapist for rehabilitation. Without proper rehabilitation your problem will just come back after the medication has worn off.
- If your pain doesn’t resolve with non-surgical treatment, you will need to see an orthopaedic surgeon to find out about other options. In some cases the specialist will recommend surgery, but often with rotator cuff symptoms a cortisone injection into your shoulder will be the first choice.
- When your pain is severe a sling can be useful for 2-3 days to let your shoulder rest. However, the sling puts your arm in an awkward position that interferes with normal movements, so using a sling for more than a couple of days is a very bad idea.
Surgery for rotator cuff tendinitis
If your shoulder pain doesn’t respond to non-surgical treatment within 3 months, surgery might be the way to go for your problem. The operation will depend on the degree of your rotator cuff tendinopathy or if there is a tear present in your rotator cuff muscles.
The procedure is usually done arthroscopically (keyhole surgery), so the recovery time is faster than with a large incision. The surgeon will remove any bone spurs that could be causing further damage to the rotator cuff tendons and will also remove damaged, fibrotic (“dead”) parts of the tendon. If there are muscle tears present this will also be repaired during surgery.
After the operation you will have to wear a sling for 2-6 weeks (depending on the procedure) and physiotherapy after shoulder surgery is vital to get you back to top form. There is always a movement problem or weakness around the shoulders before the operation and this is why the rotator cuff injury happens in the first place. Surgery fixes the problem, but not the cause and you risk having the same problem again later on if you don’t sort out the original problem.
Also known as
Rotator cuff impingement
Supraspinatus tendinitis
Shoulder tendinitis
Shoulder impingement
What else could it be?
- Subacromial Bursitis – pressing over the outside area of your shoulder will increase your symptoms.
- Adhesive Capsulitis/ “Frozen shoulder” – you will notice that your shoulder is very stiff in all directions.
- Biceps tear or tendonitis – the front part of your shoulder will be painful.
- Rotator Cuff tear – you will have constant pain that doesn’t improve with movement.
- AC joint sprain/ degeneration – pain over the outside of the shoulder exactly where the collar bone meets the shoulder.
- Labrum tear – you will have a deep pain inside your shoulder and slight instability.
- Rotator cuff muscle strain – lifting your arm will be painful, but you won’t have pain when holding your arm still and supported.
