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Rotator Cuff Tendinitis

Shoulder pain is the third leading complaint of musculoskeletal pain. How to differentiate diagnosis, manage, and prevent recurrence in athletes.

This overview is part of a Chronic Overuse Injuries Primer. View the introduction.
 

History/Pathogenesis

Rotator cuff (RC) tendinitis is an injury that often occurs due to repetitive shoulder use (specifically overhead) in athletes and nonathletes of all ages. Although RC tendinitis is most often the result of repetitive overuse, it can also present as acute following a traumatic injury or in response to poor overhead biomechanics.

The RC is made up of a group of four muscles (supraspinatus, infraspinatus, teres minor, and subscapularis) responsible for stabilizing the shoulder joint, as well as allowing it to move. When this muscle group is repetitively overstrained, degeneration of the cuff musculature occurs in response to subacromial impingement, insufficient blood supply, and tensile overload. It is this degeneration that results in RC tendinitis, as well as tears in the rotator cuff if not given required attention upon the onset of symptoms.1-6

Prevalence/Epidemiology

At a prevalence rate of 67%, general shoulder pain (primarily shoulder impingement syndrome and/or RC pathologies) is the third leading complaint of musculoskeletal pain at physician office visits. Though all age groups are affected by RC pathologies, the incidence rates have shown to be age dependent. The prevalence rate in patients under 20 years old ranges from 5% to 10%, while it is typically over 60% in patients older than 80 years of age. Additionally, studies have shown that in working populations, the incidence of related symptoms may be as high as 14% to 18%.2,6-14

Image: istock (SARINYAPINNGAM)Physical exam for rotator cuff pai should include ruling out cervical spine dysfunction by checking cervical ROM and any radicular findings. Look for painful active range of motion (AROM), especially above 90° of forward elevation; and pain/weakness with shoulder flexors, abductors, internal rotators, and/or external rotators.

Signs/Symptoms

Shoulder pain with overhead activity; weakness in the shoulder musculature; numbness/paresthesia (usually between the lateral neck to the elbow); and night pain. In young patients, impingement is usually related to laxity caused by an instability, in those 25 to 40 years of age there is generally an overuse of the rotator cuff, and for those over 40, the impingement is generally caused by overloading the cuff muscles beyond their threshold.

High Risk Activities for Rotator Cuff Tendinitis

Activities involving repetitive overhead activity/athletic activities (reaching, pushing, or lifting), especially painting, tennis, baseball, swimming, volleyball, etc.

Related Conditions or Risk Factors

  • Older age
  • Anatomic variants that predispose impingement
  • Scapular instability
  • Instability/hypermobility of glenohumeral joint
  • Weakness of RC muscle or secondary supporting muscles (poor mechanics)
  • Dyskinesis
  • Problems in contralateral shoulder (compensation)
  • Diabetes mellitus
  • Rheumatoid arthritis
  • Hyperlipidemia
  • High BMI

There is preliminary evidence for genetic/familial predisposition to RC pathology, but further research is needed.

RCT is often seen in association with subacromial impingement syndrome.2,6,11,13-22

Physical Exam

Initially, clinicians must rule out cervical spine dysfunction by checking cervical ROM and any radicular findings. Look for painful active range of motion (AROM), especially above 90° of forward elevation; and pain/weakness with shoulder flexors, abductors, internal rotators, and/or external rotators. Frequently, one sees positive findings with impingement testing (Hawkins-Kennedy or Neer’s provocation testing). One may see scapular dyskinesis.

Diagnostic Tests

Conduct impingement testing (Hawkins-Kennedy or Neer’s provocation testing). If indicated, evaluate with baseline x-rays, MRI, musculoskeletal diagnostic U/S testing, or bone scan testing, or EMG/NCS testing.

Differential Diagnosis

  • Chronic bursitis-tendonitis with impingement
  • Adhesive capsulitis
  • Degenerative joint disease of the acromioclavicular or glenohumeral joint
  • Thoracic outlet syndrome
  • Cervical spondylosis
  • Pancoast tumor
  • Stress fracture

Prevention

The primary methods of preventing RC pathology involve rest, stretching, and strengthening. Excessive overhead activity should be avoided when possible and adequate rest for recovery between activity sessions is necessary. Strengthening of the rotator cuff muscle group has also shown to help prevent RC injuries. Weakness of this muscle group can lead to a great predisposition to impingement syndromes and likely RCT. Stretching may also provide potential benefit, as it can aid in healing and reduce tightness of the group, potentially increasing functional range of motion and overall function.2

Acute Treatment

NSAIDs; short course of oral prednisone (if can tolerate side effects); subacromial/intraarticular injection; physical modalities (eg, ice, ultrasound, iontophoresis, phonophoresis, topical anesthetic skin refrigerant, and electrical stimulation); relative rest (limit overhead work); and flexibility exercises to regain full ROM.

Image courtesy of the authorsInternal rotation stretch with stretch out strap, for rotator cuff tendonitis.

Long-Term Treatment/Rehab

Physical therapy should be the first method of treating RC tendonitis. Cortisone injections into the intra articular space are often utilized in combination with therapy, which aims to reduce symptoms and allow patients to tolerate the necessary range of motion progressions. Therapy should begin by focusing on obtaining full range of motion prior to strength progressions, so that the potential complications of adhesive capsulitis are minimized.

Upon gaining full range of motion, progressive resistance training may be implemented. Strengthening should employ full ROM and focus on restoring the balance of strength upon the individual four RC muscles, as well as the periscapular stabilizers.

As strength returns appropriately, progression may be made to gradual overhead activity at the therapist’s discretion. Additionally, further research is needed, but eccentric exercise implementation has shown promise when utilized for tendinopathy rehabilitation. When retraining the periscapular muscles and scapula-humeral rhythm, activity-specific exercises should be utilized to simulate the specific demands of the desired activity the patient will return to.

Surgical intervention should not be required unless RC tendonitis progresses into an actual tear that needs to be repaired. Even then, nonoperative treatment is typically utilized for 6 to 9 months before surgical referral. Regenerative medicine techniques are now on the forefront of research and for potential treatments, such as platelet-rich plasma and stem cell injection options, for chronic overuse musculoskeletal/sports injuries. These techniques should be considered on a case-by-case basis for RC tendinitis.1-2,23-29

Practical Takeaways 

  • Rotator cuff (RC) tendinitis is an injury that often occurs due to repetitive shoulder use (specifically overhead) in athletes and nonathletes of all ages.
  • At a prevalence rate of 67%, general shoulder pain (primarily shoulder impingement syndrome and/or RC pathologies) is the third leading complaint of musculoskeletal pain at physician office visits.
  • High risk activities for RC tendinitis are those involving repetitive overhead activity/athletic activities (reaching, pushing, or lifting),especially painting, tennis, baseball, swimming, volleyball, etc.
  • Acute treatment can include NSAIDs; short course of oral prednisone (if can tolerate side effects); subacromial/intraarticular injection; physical modalities (eg, ice, ultrasound, iontophoresis, phonophoresis, topical anesthetic skin refrigerant, and electrical stimulation); relative rest (limit overhead work); and flexibility exercises to regain full ROM.
  • Long-Term Treatment/Rehab begins with physical therapy. Cortisone injections into the intra articular space are often utilized in combination with therapy.
Additional chronic overuse injuries in this primer:
Last updated on: May 29, 2020
Continue Reading:
Carpal Tunnel Syndrome: Chronic Overuse and Clinical Management
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