Rotator Cuff Tendinopathy

This condition commonly presents with pain at the front, back or side of the shoulder and/or upper arm region. Tendinopathy of the rotator cuff tendon may also be termed ‘impingement syndrome’, ‘subacromial pain syndrome’ or ‘rotator cuff related pain’ as we often cannot distinguish one singular structure associated with the pain, and so these alternative terms refer to the region or nature in which pain is referred.

For a long time, we referred to tendinopathies as ‘tendinitis’. This was because we believed there was a lot of inflammation involved in the condition leading to treatments such as steroid injections and strong anti-inflammatory medication (such as diclofenac or naproxen). However, our understanding of tendon related pain has improved and we now know that tendon degeneration, as opposed to inflammation, is the primary factor in most tendinopathies.

The tendon function is to transmit muscle force to the bone and they are normally very tolerant to the load. Sudden increase of activity/load is the most common cause; however, it can also come on gradually with no clear cause. This is because many factors influence the condition.

Repetitive movements and prolonged arm elevation (such as working in construction and hairdressing) ⁽⁸⁾ are associated with a higher risk of shoulder disorders. Consequently, ergonomic adjustments should be considered.

The prevalence of shoulder complaints in the UK is estimated to be 14% ⁽¹⁾ and rotator cuff disorders account for up to 70% – 85% ⁽²⁾, with 1%–2% of adults consulting their GP annually regarding new onset shoulder pain ⁽³⁾.

Shoulder pain is the third most common musculoskeletal presentation in primary care after back and knee pain. Rotator cuff pain is very common in people aged between 35-75 years old ⁽⁴⁾.

The diagnosis is based on history and examination carried out by our experienced physiotherapists who see this condition on a regular basis due to its high prevalence in shoulder pain. Further investigation is not normally needed due to the high likelihood of finding elements not linked to your symptoms on scans unless there is a very acute onset as a result of a traumatic event or the condition is not responding accordingly to what is expected by the treatment.

Relative rest from the painful activities can be helpful initially to allow the pain to settle, alongside analgesics (paracetamol) and anti-inflammatories (NSAIDs such as ibuprofen – contraindicated if you have a history of gastrointestinal bleeding, ischaemic heart disease or renal problems). Physiotherapy and graded exercise progression are normally key ^{(4, 5)}. Consider a short period of time off work (for example 1 week), if the job duties appear to be directly relevant to the shoulder symptoms.

For patients wanting to achieve a high level of function or return to sport, we would encourage a consultation with a physiotherapist as you will likely require further progression beyond the advanced rehabilitation stage.

As part of a comprehensive treatment approach, your musculoskeletal physiotherapist may also use a variety of other pain-relieving treatments to support symptom relief and recovery. Whilst recovering you might benefit from further assessment to ensure you are making progress and to establish the appropriate progression of treatment. Ongoing support and advice will allow you to self-manage and prevent future reoccurrence.

The suggestions for non-surgical management include a minimal number of exercises prescribed to challenge the functional deficit of the patient over a minimum 12-week period. Imaging can aid to exclude serious pathology or if the patient does not respond to treatment as expected, but is not key for the management of the injury. Steroid injections would not be considered a first-line intervention unless pain is severe and preventing sleep and engagement with the exercises ⁽⁶⁾.

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