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  • Writer's pictureDaniel Selin

Rotator cuff tendinopathy

Rotator cuff pain, shoulder, shoulder pain, joint pain, tendon pain, tendon issue, arm pain, degeneration, degenerative disease, pain during motion, aging, overuse, shoulder pain condition

Rotator cuff tendinopathy is the most common cause of shoulder pain. The prevalence of this condition significantly increases after the age of 40 and it tends to affect women slightly more often than men. Rotator cuff tendinopathy is characterized by pain in the shoulder and upper arm, which typically worsens in situations where the arm is lifted forward or to the side. Putting on a shirt or bra can often be difficult and painful and if the condition persists, pain may also occur at rest. This can lead to restless nights due to pain that prohibits sleep.

 

The rotator cuff

The rotator cuff refers to a structure that runs over the shoulder joint, consisting of the shoulder joint capsule and the four muscles that reinforce it. The primary function of the rotator cuff is to stabilize and support the shoulder joint during movement.


The muscles of the rotator cuff originate from the scapula and attach to the head of the humerus, forming a cuff between the humerus and the scapula. Above the rotator cuff of the shoulder lies a bursa, which covers and protects the tendons of the muscles from rubbing against the surrounding bone structures. The bursa can also become irritated in situations where there is an increase in friction or pressure in it, leading to discomfort and bursitis. Bursitis rehabilitation follows a similar protocol to that of rotator cuff tendinopathy since the underlying causes are often quite similar.

 

Etiology

The exact cause of rotator cuff tendinopathy often remains unclear, but the proposed mechanisms include both intrinsic, extrinsic, and combined factors.


Extrinsic factors include situations where the rotator cuff gets compressed between the humerus and the acromion (a bony part of the scapula, which acts as a roof in the shoulder joint). This leads to increased pressure and friction on the rotator cuff, which over time can result in discomfort.


Compression in itself can be caused by a combination of various factors, some of which are outlined below. Tissue compression can result from a pre-existing narrow space between the humerus and the acromion due to anatomical variations. Internal cartilage changes and thickening in the shoulder joint, swelling of the bursa, alterations in the humeroscapular kinematics, weakness or degeneration of the rotator cuff, reduced flexibility of the shoulder joint capsule, overloading, underuse, or abnormal functioning of the surrounding muscle structures can also result in compression of the rotator cuff structure.


Internal factors contributing to the development of rotator cuff tendinopathy may include biological changes, mechanical properties, morphology, or blood circulation-related alterations. Therefore, internal factors can affect tendon morphology and performance. Age, genetics, biomechanical challenges, overuse, and trauma are also internal factors that increase stress on the rotator cuff tendon structures.

 

Epidemiology

Shoulder pain and discomfort is very common. Approximately half of the population experiences shoulder pain at least once in their lifetime and for most, the pain is recurrent. Of all shoulder pain, pain that originates from the rotator cuff is the most common type.


Shoulder pain can easily become chronic, limiting daily activities and hobbies. The incidence of shoulder pain increases in individuals whose work or hobbies involve repetitive lifting of the upper arm above shoulder level. Such activities may include sports like volleyball, badminton, or javelin throwing as well as professions like painting or doing installation work.


The incidence of rotator cuff tendinopathy also increases with age due to degenerative changes in the shoulder joint. Initial symptoms are typically noticed after the age of 40, but shoulder problems and pain are quite common in individuals younger than this. Degenerative changes can also be observed in individuals much younger than 40, but these changes may not necessarily be painful. It is common for completely pain-free individuals to have degenerative changes in joints and tendon tissues without experiencing any pain. Therefore, the presence of degeneration in imaging findings should not necessarily be a cause for concern, regardless of the area being imaged.

 

Risk factors

Risk factors for rotator cuff tendinopathy are similar to those of other tendon-related issues and pain conditions. These risk factors can generally be categorized into several main groups. Here are some known risk factors for rotator cuff tendinopathy:


General Risk Factors:

  • Being overweight or obese

  • Metabolic disorders such as diabetes or having high cholesterol

  • Muscle dysfunction

  • Smoking

  • Disorders related to tendon flexibility and load-bearing capacity

  • Aging

  • Limitations in the range of motion in surrounding joints

  • Biomechanical challenges

Work and Activity-Related Risk Factors:

  • Static and ergonomically challenging work postures

  • Physically demanding work

  • Repetitive loading of the upper extremities

  • Having to work above shoulder level

  • Poor or insufficient recovery

  • Sports that place increased stress on the upper limbs

Psychological Factors:

  • Stress

  • Anxiety

  • Depression

  • Sleep-related challenges

Medical Conditions:

  • Rheumatoid arthritis and psoriatic arthritis

  • Thyroid disorders

  • Autoimmune diseases

It's important to note that while these risk factors may increase the likelihood of developing rotator cuff tendinopathy, the condition can also occur without any known risk factors. Additionally, addressing these risk factors through lifestyle changes or medical management may help reduce the risk or severity of the condition.

 

Symptoms

The typical symptom of rotator cuff tendinopathy is a dull, aching shoulder pain that radiates down the upper arm. This pain is often described as resembling toothache-like pain, which may not necessarily be excruciating in intensity but feels constant and disruptive to daily life.

Symptoms typically worsen in situations where the upper arm is raised above shoulder level. Lifting the arm to the side, in particular, exacerbates the pain in the shoulder and upper arm. In the early stages, the pain is usually moderate and occurs only in specific situations, but as the condition persists, the symptoms become more troublesome, and discomfort can also occur at rest.

Sleeping on the affected shoulder can provoke the pain and affect the quality of sleep, which can, in turn, worsen the symptoms. If left untreated for an extended period, the condition often leads to weakness in the muscles surrounding the shoulder. This is often due to avoidance behavior caused by pain, which over time weakens the muscles and can lead to muscular atrophy.

 

Treatment

The primary treatment of rotator cuff tendinopathy is conservative in nature. This treatment approach combines both pharmacological and non-pharmacological pain management methods, along with physical therapy. Exercise is used to improve the biomechanical properties of the upper limb, scapula, and chest, as well as to reduce increased stress on the affected tissues.


The goal of treatment is to alleviate pain and improve function and work capacity. This is achieved through a precise, progressive, and individualized exercise program, which often includes exercises to improve and maintain mobility, as well as manual therapy.

Medication commonly includes a combination of pain relievers and anti-inflammatory drugs. Possible inflammation can also be treated with cold therapy, which is often repeated several times a day.


Surgical procedures should only be considered if conservative treatment does not achieve the desired results or if the patient experiences severe pain that significantly impairs their functionality. The need for surgical intervention is not common and it is typically considered only if there is an underlying condition that impairs the prognosis of conservative treatment. Conservative treatment is often continued for an extended period, sometimes up to 6-12 months, before a decision about surgery is made.

 

Physiotherapy

The physical therapy begins with a thorough assessment upon which an individualized rehabilitation program can be developed. It is essential to differentiate and identify the underlying factors that may have contributed to the onset of the pain.

The goal of physical therapy is to reduce pain and possible swelling of the rotator cuff while normalizing shoulder mobility and strength. In the initial phase of the rehabilitation, the focus is on pain relief. It is important to modify one's activities so that the shoulder is not overloaded relative to its current load-bearing capacity. Soft tissue manipulation, joint mobilization, acupuncture and muscle exercises may be used in the early stages of rehabilitation to improve pain.

As pain diminishes, rehabilitation often shifts toward tissue strengthening and improving the kinematics of the shoulder and surrounding tissues. Progressive training aims to enhance the load-bearing capacity of the affected areas, reducing their susceptibility to future pain. Any range of motion restrictions can be addressed through a combination of manual therapy and mobility exercises.

When creating a rehabilitation plan, it's crucial to consider the individual's needs and preferences. The rehabilitation process is always tailored to the individual and can vary significantly depending on whether the person is, for example, an office worker whose shoulder bothers them at night or an athlete whose pain prevents them from continuing their profession.

 

Self care


  1. Rest and Load Modification: Give your shoulder adequate rest and avoid activities that exacerbate your pain too much. This often includes lifting your arms above shoulder level, repetitive lifting of heavy objects, or positions that apply increased pressure to the shoulder.

  2. Try Cold Therapy: Cold therapy can help alleviate pain and potential inflammation. You can use ice, cold packs or cold gel for this purpose.

  3. Pain Medication: Ibuprofen and paracetamol can relieve pain and potential inflammation. Always remember to follow the recommended dosage and consult a healthcare professional if you are unsure.

  4. Ergonomics: Strive to maintain a good posture to reduce strain on your shoulder. Avoid a slouched posture where the shoulders lean forward as this often increases the load on the shoulder joint and restricts the scapula's movement along the chest.

  5. Stretching: Try gentle, back and forth stretches to improve fluid circulation in the tissues surrounding the shoulder. However, avoid intense or prolonged stretching, as these can often worsen your pain.

  6. Shoulder Mobility Exercises: Aim to gradually restore any range of motion limitations by performing progressively challenging mobility exercises.

  7. Strength Training: Strengthening exercises develop the muscles in the area and improve stability. Start these exercises cautiously and gradually increase the load. Excessive training often increases tension and symptoms.

  8. Take Breaks: If you have a desk job or perform work that repeatedly stresses your shoulder, take regular breaks to change your posture and rest your shoulder. Stretching or light exercises during breaks can also be beneficial.

  9. Sleep Ergonomics: Find a comfortable sleeping position that doesn't worsen your pain. Using a pillow to support your arm and shoulder can help. Avoid sleeping on the affected shoulder.

  10. Consult a Physiotherapist: If your pain persists despite self-care measures or interferes with your daily activities, consult a physiotherapist for professional guidance.

Remember that these self-care measures should be adapted to your specific needs and circumstances, and it's essential to follow the guidance of a healthcare professional or physiotherapist for the most effective management of rotator cuff syndrome.










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