Probably is the answer to the question above. I cannot tell you how many rotator cuff tendinopathies I have treated since becoming a physical therapist. It really must be hundreds. It is a very common injury from all walks of life. I have treated everyone from collegiate swimmers to 85 year olds for rotator cuff tendinopathy. The good news is that almost all of them get better. Ready to learn more about this condition? Let’s start with anatomy.
The shoulder joint
The main shoulder joint is called the glenohumeral joint. It is a large and complex joint that is made when the humerus (upper arm bone) and the scapula (shoulder blade) come together. It is a ball and socket joint. However the ball is much bigger than the socket. Think of a golf ball on a tee. The golf ball is the head of the upper arm bone and the tee is the outside part of the shoulder blade.
This allows the shoulder to have the most movement of any joint in the body. However, it also has the least stability and this is what tends to get the shoulder joint in trouble.
The rotator cuff
The rotator cuff is a group of four muscles – supraspinatus, infraspinatus, teres minor, and subscapularis. These muscles attach to the scapula (the shoulder blade) and then travel to connect to the humeral head (the top of the arm bone). They work together to provide stability to the shoulder joint. Their main purpose is to keep the ball on the socket.
What is the difference between tendinopathy , tendinitis, and tendinosis?
Before delving into the rotator cuff tendinopathy, let’s review tendons. A tendon is the connective tissue that attaches the muscle to the bone. The area where the tendon connects to the bone is more susceptible to irritation and injury because of it’s limited blood supply.
Tendinopathy is a term used to encompass any issue with the tendon. This includes tendonitis and tendinosis. There is a difference between tendonitis and tendinosis. Many of the conditions that were previously thought to be tendonitis are actually tendinosis. However, because we do not necessarily know if the tendon has tendonitis or tendinosis, we refer to the condition as tendinopathy.
Tendons can get inflamed with a force that is too strong or quick. This tensile force on the tendon can cause micro-tears in the tendons. This is tendonitis. It is postulated that untreated tendonitis can become tendinosis. Tendonitis is an inflammatory condition and will respond to anti-inflammatory medication. It typically has a recovery period of 1-6 weeks. Tendinitis of the rotator cuff can be a result of direct trauma to the shoulder, a fall, or poor throwing mechanics in overhead sports.
Tendinosos is a degeneration of the tendon’s collagen proteins. This is hypothesized to occur after a period of untreated tendonitis. Collagen provides the tendon with durability and strength. Tendinosis is caused by chronic overload of the tendon without sufficient time to rest and heal. The tendon becomes enlarged and irritated. It does not have signs of acute inflammation and is not improved with anti-inflammatory medication such as ibuprofen. Early-stage tendinosis can heal within 6 to 10 weeks, but chronic stage can take 3 to 6 months. Tendinosis can lead to rotator cuff tears.
What causes rotator cuff tendinopathy?
There are several different causes of this condition. They can be broken down into intrinsic and extrinsic causes.
- Extrinsic – This causes tendinopathy by compressing the rotator cuff tendons.
- Anatomical variations – This includes variations in bone or muscle. For example, the acromion is a piece of bone that juts off of the shoulder blade. It sits right over top of the shoulder joint. It can be shaped in such a way that rotator cuff will rub against it repetitively which can cause irritation to the tendon.
- Bone spurs – These are bony growths on the bones of the shoulder joint which can cause irritation and compression to the rotator cuff tendons.
- Poor posture – This causes the humeral head to sit more forward in the joint and to migrate up when moving the shoulder in certain directions. This can cause compression the rotator cuff tendons by pressing them against the structures above the shoulder.
- Poor scapular stabilization strength – The scapular stabilizers are muscles that attach to the scapular and are very important in keeping the scapula in a stable position. If they are weak it will allow the humeral head to migrate up and impinge the rotator cuff tendons.
- Tight pectoral muscles – The pectoralis major and minor are muscles on the chest but also attach to the humerus. If they are tight it will cause the shoulder joint to sit more forward and lead to compression of the rotator cuff tendons with upward humeral head migration.
- Intrinsic – These factors lead to the breakdown of the rotator cuff tendons.
- Vascular changes – Anything that affects the blood supply to the tendons, can decrease the ability of the tendons to heal from repetitive stress or micro-tearing.
- Repetitive overloading of the tendon – This is chronically having the tendon and muscle do more than they are capable of doing. This will lead to micro-tears and then degeneration of collagen in the tendon. This can occur with overhead sports such as baseball, swimming, or tennis. It can also occur with occupations that require repetitive shoulder motions.
- Age – Tendons get weaker with age. This means that the risk of rotator cuff injuries increases as we age.
What are the symptoms of rotator cuff tendinopathy?
There are several symptoms associated with rotator cuff tendinopathy. These include:
- Dull pain in the area of the shoulder.
- Pain increases with reaching overhead and behind the back.
- It is common to have difficulty putting on bra, belt, or coat.
- Pain with sleeping on the affected side.
- Difficulty reaching above shoulder height especially out to the side of the body.
- Weakness in the affected shoulder.
Who gets rotator cuff tendinopathy?
Anyone can get rotator cuff tendinopathy. Shoulder disorders are extremely common and rotator cuff tendinopathy is the most common shoulder disorder. There are a few risk factors that do increase the chances of a person developing this condition. They include:
- Occupations that require repetitive or overhead arm movements.
- Being overweight or obese
- Metabolic disorders including diabetes
- Decreased flexibility in the shoulders and upper back
- Advancing age
- Certain sports
- Baseball
- Volleyball
- Swimming
- Tennis
- Track and field – Javelin and shot put
Who should I see?
- Physical therapy – This would be my first stop. Physical therapy can help decrease pain and inflammation with techniques including manual therapy and dry needling. PT can evaluate and address abnormal joint mobility, muscle weakness, and flexibility. With rotator cuff tendinopathy it is important to slowly increase the load on your tendons. Your PT can help you add appropriate exercises at the appropriate time without overloading these muscles. They can assess your shoulder positioning during work or sports to prevent the problem from happening again.
- Orthopedic physician – An orthopedist might be necessary if the condition is not responding to physical therapy or if a tear is suspected. Your physician can prescribe medication, give a steroid injection, or order imaging if needed.
What can I do?
- Relative rest – Resting the area to decrease further pain and damage from occurring is one of the best ways to treat rotator cuff tendinopathy. Basically, stay away from the activities that are causing pain. This gives the tendons time to rest and heal. If you keep doing what is causing the injury, it is not going to get better. This might include not participating in your sport or activity for a period or time. If you are not able to participate in your activity, then you can supplement with non-irritating activities such as biking, walking, or jogging while your tendon is healing.
- Ice – Ice can help decrease pain and swelling in the tendon. Ice the painful area for 15 to 20 minutes at a time. I would recommend using an ice pack several times per day if the pain is constant or is preventing you from participating in an activity. Ice immediately after activity.
- Posture – Having forward, rounded shoulders causes muscular imbalances in the shoulder. It stretches out the rotator cuff and scapular stabilizing muscles which are important for shoulder stabilization. It also shortens the pectoralis major, pectoralis minor, and biceps and causes them to get tight. Below is a video showing how to stretch the pecs and biceps and also how to use a wall to check your posture.
- Soft tissue mobilization – Soft tissue mobilization helps release the muscles around the shoulder and decrease the stress on the rotator cuff tendons. Use a massage ball or lacrosse ball to roll on the painful areas all around the shoulder. Spend a good 3 to 5 minutes rolling. Do not roll so hard that you bruise the area, but it should be a pretty painful sensation. Roll out the area no more than a few times a week. See the video below.
- Strengthen the rotator cuff and scapular stabilizers – I find that irritation of the rotator cuff tendons occurs because of weakness of the rotator cuff muscles and scapular stabilizers. These are the stabilizing muscles of the shoulder that allow the shoulder to reach and lift without injury or irritation. Using loop resistance bands and resistance bands can increase strength and difficulty.
In review
- The rotator cuff is a group of four muscles – supraspinatus, infraspinatus, teres minor, and subscapularis.
- They work together to provide stability to the shoulder joint.
- Their main purpose is to keep the ball on the socket.
- Tendinopathy of the rotator cuff tendons could be caused by acute or chronic irritation of the tendons.
- Tendinitis is more of an acute injury caused from direct trauma or performing an activity with poor shoulder mechanics for a brief period.
- Tendinopathy is a chronic irritation of the tendons that can eventually lead to tendon tears. This is typically from repetitive activities that are ongoing.
- There are many causes of rotator cuff tendinopathy.
- Extrinsic – This causes tendinopathy by compressing the rotator cuff tendons.
- Intrinsic – These factors lead to the breakdown of the rotator cuff tendons.
- Symptoms of rotator cuff tendinopathy include pain in the shoulder that increases with reaching overhead and behind the back.
- Anyone can get rotator cuff tendinopathy.
- It is the most common shoulder disorder.
- Physical therapy is excellent at treating this condition.
- An orthopedist would be needed if the condition is not responding to physical therapy or if a tear is suspected.
- There are things that you can do.
- Relative rest
- Ice
- Posture
- Soft tissue mobilization
- Rotator cuff and scapular strengthening
As always, If you have questions about the content of this post or any other musculoskeletal questions, please e-mail me.
Additional resources
https://www.choosept.com/guide/physical-therapy-guide-rotator-cuff-tendinitis