Rotator Cuff Tendinopathy
What is the Rotator Cuff?
The rotator cuff is a group of muscles and their tendons that stabilize the shoulder joint and allow motion of the arm. There are four rotator cuff muscles – the supraspinatus, infraspinatus, teres minor, and subscapularis. The supraspinatus tendon is the most commonly injured one because it sits below the acromion (the top outer edge of the scapula), making it especially vulnerable to impingement with overhead activity. The health of the rotator cuff is dependent on the appropriate function of adjacent structures including the scapula, acromioclavicular (AC) joint, and glenohumeral (shoulder) joint, which significantly impacts the dynamic motion of the shoulder. With dysfunction or poor mechanics of these structures, the rotator cuff becomes mechanically disadvantaged and thus more vulnerable to increased stress and strain leading to gradual breakdown of collagen fibers in the tendon, or in other words – tendinopathy.
What are the Risk Factors for Tendinopathy?
Studies have shown that 70% of all shoulder pain is related to the rotator cuff.1 The prevalence of rotator cuff tendinopathy increases with age, occurring in only 10% of patients under 20 years old, but in over 60% of the population over 80 years old.2 Tendinopathy is particularly associated with overuse, including repetitive overhead activities such as sports like swimming, tennis and golf, as well as weight lifting, manual labor, and just life! Anatomic variants predisposing to rotator cuff impingement, rotator cuff and scapular stabilizer muscle weakness, and poor scapular mechanics also underlie many cases of tendinopathy. Other risk factors for rotator cuff pathology include diabetes mellitus3 and obesity. Finally, genetics may also play a role in developing rotator cuff tendinopathy.4
Do I Have Rotator Cuff Tendinopathy?
Symptoms of rotator cuff tendinopathy include pain typically localized to the outer upper arm with difficulty raising the arm overhead and performing activities of daily living such as brushing hair or putting on a shirt. Pain is also typically significant with lying on the shoulder at night. A physical exam of the shoulder is essential in diagnosing pain from the rotator cuff. This includes observation for muscle atrophy and abnormal scapular position or movement; palpation for areas of tenderness; passive and active range of motion; tests of rotator cuff strength; and impingement tests designed to put temporary stress on the rotator cuff tendons in certain positions. A thorough exam also includes an evaluation of the cervical spine and neurological exam because the neck can cause referred pain to the shoulder such as with a cervical radiculopathy or “pinched nerve.”
Do I Need Imaging of my Rotator Cuff?
An X-ray will not show the muscles or tendons of the rotator cuff, however, it does show pathology affecting the bones and joints of the shoulder including anatomic variants of the acromion as well as arthritis affecting the AC and shoulder joints. A musculoskeletal ultrasound is useful in visualizing the rotator cuff, particularly in real time while the shoulder is in motion. An MRI provides a definitive diagnosis of rotator cuff tendinopathy while showing other soft-tissue structures in the shoulder such as the labrum and biceps tendon which can cause shoulder pain. It is important to note, however, that asymptomatic rotator cuff tendon tears are commonly seen on MRI.
How do I Heal my Rotator Cuff Pain Without Surgery?
Because rotator cuff tendinopathy is associated with overuse, it is important to undergo relative rest from aggravating activities including the avoidance of repetitive overhead motions. Modalities such as topical ice and heat can help temporarily improve chronic shoulder pain. Cryotherapy is additionally helpful in reducing acute swelling and inflammation as well as relieving pain, however, some research shows that cold may reduce the body’s natural inflammatory response which is necessary for healing tendon pathology.
Physical therapy is the primary treatment for rotator cuff tendinopathy. A therapy prescription includes manual therapy as well as exercises targeting shoulder mobility and rotator cuff strengthening. Eccentric strengthening, muscle contraction during the lengthening of a muscle, is particularly helpful in the rehabilitation of tendinopathy. In addition, exercises that focus on restoring scapular mobility and strengthening scapular stabilizing muscles also reduce stress through the shoulder and improve pain, mobility, strength, and function.
Acetaminophen (Tylenol) is a first-line medication for treating rotator cuff pain, however, it is important to be cautious and not take more than the recommended maximum daily limit due to its potential to cause liver damage. A short course (7-10 days) of nonsteroidal anti-inflammatory medications (NSAIDs) such as Ibuprofen or Aleve helps reduce acute pain related to rotator cuff disease.5 The use of NSAIDs, however, is controversial as they can disrupt the body’s natural healing response. In addition, NSAIDs are associated with GI side effects, cardiovascular problems, and kidney dysfunction, especially in the elderly patient population.6
A corticosteroid injection can be utilized for pain that persists despite an adequate trial of physical therapy, or for patients who cannot participate in physical therapy due to pain. Steroid, when injected into the subacromial bursa under ultrasound guidance, helps decrease inflammation-associated pain; studies have shown that such injections lead to a short-term improvement in pain and function in patients with rotator cuff tendinopathy.1,7,8,9,10 Notably use of this type of injection should be limited as there is a significant risk of tendon rupture with multiple steroid injections.10,11 Platelet Rich Plasma (PRP) is a type of regenerative therapy and has been proven to be an effective treatment for shoulder pain10 and a good alternative to steroid injections.7,11 An injection of PRP involves taking a small amount of the patient’s own blood, spinning it in a centrifuge machine to separate out the cellular components, and then injecting the platelet-rich portion into the tendon injury. The concentrated platelets contain growth factors that promote the body’s healing process and help to repair and rebuild damaged tissue thereby reducing pain. PRP has been found to reduce pain and improve function in patients with rotator cuff tendinopathy and tears.7,11
Schedule an Appointment Today
If you are having shoulder pain, please call to schedule an appointment at Desert Spine and Sports Physicians so that our team of highly trained Physical Medicine and Rehabilitation specialists can help diagnose and treat your issue. We offer appointments and in-office procedures at all of our Phoenix, Scottsdale, and Mesa locations. We look forward to helping you improve your function and decrease your pain.