Overview

The shoulder is one of the most mobile joints in the body and allows us to get involved with a large range of activities, including playing tennis, basketball or swimming. Even if you aren’t sporty, we use our shoulders for a large number of everyday tasks, such as reaching a high shelf, giving someone a hug, or even just shrugging our shoulders. It can be extremely frustrating to suffer from a shoulder injury that limits the ability to perform these everyday tasks. 

The rotator cuff is a term used to describe the four muscles that surround and support the shoulder joint through these movements. Rotator cuff tendinitis is inflammation of the tendons which connect these muscles to the bone.This results in worsening pain in the shoulder that can limit the range of movement. To understand more about the symptoms, risk factors, diagnosis and treatment of tendinitis, please continue reading.

Introduction

Shoulder pain is a common problem, with up to 67% of individuals predicted to be affected over their lifetime.¹ Rotator cuff disorders are the prime cause of shoulder pain and include rotator cuff tendinitis, tears and bursitis. Rotator cuff tendinitis is inflammation of the tendons that can occur due to excessive use or injury. Risk factors for rotator cuff disease include increased age, occupational stress on the shoulder, overhead sports and the presence of other health conditions, such as diabetes.^2,3 Rotator cuff tendinitis causes pain on rest, which often worsens at night and on specific movements. It can commonly be diagnosed by a GP with a thorough history and clinical examination. Sometimes it may be necessary to get an ultrasound scan of the affected area to get a clearer picture of the damage. Treatment will usually consist of pain relief, physiotherapy and joint injections. Surgery can also be used in severe cases to repair the injured tendon.

Shoulder anatomy

What is the rotator cuff?

The shoulder is one of the most mobile joints in the body, with its clever ‘ball-and-socket’ mechanism, which allows for a large range of movement. However, this joint type is particularly susceptible to instability and therefore injury. The rotator cuff is a term used to describe the muscles that surround and support the shoulder joint to prevent dislocation. There are four muscles which make up the rotator cuff; these are called the subscapularis, supraspinatus, infraspinatus and teres minor. Each muscle has a slightly different function for movement of the shoulder, but collectively allow for us to rotate the arm in and out (internal and external rotation), raise the arm to the side (abduction) and return the arm back to the body (adduction). The diagram below shows where each of these muscles sits in relation to the shoulder joint.

What is tendinitis?

Tendons are tissues that connect the muscle to the bone, allowing for movement of the shoulder. When these tendons are damaged through overuse or ageing, they can become inflamed, known as ‘tendinitis’. Tendinitis presents as pain in the shoulder, and these symptoms are discussed further below.  

Risk factors

Rotator cuff injuries affect a large proportion of the population; however, certain individuals are at increased risk. Risk factors include: 

• Age - As we age, our tendons can become less elastic and are increasingly susceptible to damage with activity. As a result, rotator cuff disorders are more common in those over 50²
• Manual jobs- Jobs involving arm movement above head height or lots of repetitive movement are more likely to get rotator cuff tendinitis, for example, painters. This is because frequent movement above the head can increase the pressure, which can irritate the tendons²
• Overhead sports- Research has shown that athletes who perform in sports requiring overhead use of the arms, such as swimming and volleyball, are at increased risk of shoulder injuries. For example, up to 38% of swimmers develop a shoulder injury within a year³
• Diabetes and high cholesterol - Some research has shown people with these conditions are at increased risk of rotator cuff disease due to inflammation and weakening of the tendons^2,4

To try and reduce risk factors, it may be beneficial to:

• Warm up before sporting activities³
• Increasing load on the shoulder gradually² 
• Complete strengthening exercises to improve shoulder stability
• Maintain a healthy lifestyle to help blood sugar levels²

Symptoms

The most common symptom of rotator cuff tendinitis is pain, which may be associated with swelling. The pain is typically:

• Located on the outer upper element of the shoulder
• Worse on movement, particularly when raising the arm
• Worse at night and may disturb sleep
• Develops gradually

Exact symptoms can vary from person to person and are likely to overlap with other shoulder conditions. However, symptoms that may alert to another condition may include:

• Pain in multiple joints
• A lump in the area
• Sudden onset of pain 
• A high temperature
• Pain secondary to a traumatic cause

These symptoms may point towards other conditions such as a tear, arthritis or an infection.

Diagnosis

Clinical examination

Rotator cuff tendinitis can often be diagnosed in general practice with a discussion on the timeframe and nature of the symptoms. A clinical examination of the shoulder and neck will also be beneficial and involves looking, feeling and moving the shoulder to see which results in the most pain. Shoulder movements include raising the arm above the head, twisting the arm outwards and reaching behind the back. In rotator cuff problems, the pain is often worse when the arm is lifted between 60° to 120°, often described as the ‘painful arc’.⁵ At this level of elevation, the inflamed tendon gets compressed by the bone, also known as impingement.

I think an image of a painful arc would be useful here

Imaging

Imaging may be required if the pain is severe, not improving or if there was a traumatic injury to the shoulder. An X-ray can be useful to see a bony injury and rule out other shoulder conditions, such as arthritis. An ultrasound scan or magnetic resonance imaging (MRI) may be used to give a more detailed view of the damage to the rotator cuff. 

Differential diagnosis

These tests allow healthcare professionals to identify the cause of the shoulder pain and guide the correct treatment. The symptoms of rotator cuff tendinitis can often be confused with other shoulder conditions, including:

• Rotator cuff tear
• Bursitis
• Fractures
• Frozen shoulder
• Arthritis
• Dislocation

Treatment

Most cases of rotator cuff tendinitis can be managed conservatively with appropriate pain relief, physiotherapy and lifestyle modification. 

Rest

Initially, it may be necessary to rest from some of the activities that trigger shoulder pain until the pain is better controlled. Ice may be beneficial after an injury, whereas heat may be more beneficial for helping with chronic pain. A gradual increase in activity is encouraged as the individual feels able to tolerate.⁶

Pain relief

Pain relief is an important part of treatment to ensure the individual is able to go about their daily activities. There are lots of different types of medications that can be used for joint pain, such as paracetamol, ibuprofen, naproxen and codeine. It is important to discuss the best pain medication with a healthcare professional to ensure it can be taken safely alongside other medical conditions. For example, ibuprofen and naproxen may be avoided in those with severe heart failure or kidney problems.⁷ These medications can also cause side effects such as stomach ulcers if taken in the long term, and so another medication may need to be prescribed to protect the stomach.

Physiotherapy

A physiotherapist will be able to guide individuals on how to stretch and strengthen the muscles of the shoulder. A range of exercises can be completed at home and may involve swinging the arms and monitoring subsequent pain levels. If there is a high level of pain, the exercise may need to be adjusted or stopped with further guidance. The effects of physiotherapy will be observed over 6 weeks or so and, if successful, can be extended until the shoulder pain resolves. If the pain is not better after this time, other treatment options may be discussed.

Electrotherapy may be used as a physiotherapy intervention to help reduce pain. These methods include therapeutic ultrasound and transcutaneous electrical nerve stimulation (TENS). There is only low-quality evidence to suggest these may have additional benefits.⁸ 

Joint injections

Steroid injection can be used to help improve pain and allow an increase in activity. Steroid injections are given directly into the joint space and can often be performed in some GP practices. Up to 2 steroid injections can be given, with at least a 6-week gap between the injections. These injections may not be suitable for all individuals, and there are also potential side effects, including worse pain and tendon rupture.¹ 

Surgery

Surgery is reserved for cases where physiotherapy and joint injections have been unsuccessful. This is because studies have shown exercise can be as effective as surgery for tendinitis.⁹ Surgical techniques are usually performed by an arthroscopic technique, which involves small incisions to allow a camera and surgical instruments to be inserted. This can allow surgeons to see the damage to the tendon and treat it accordingly. Much like any other surgery, there is a risk of infection, nerve damage or damage to blood vessels. Additionally, it must be considered that a general or local anaesthetic can also have side effects such as vomiting, dizziness and confusion. Physiotherapy will be required following the surgery to assist in regaining strength and range of movement in the shoulder. 

Summary

Rotator cuff tendinitis can be an extremely frustrating condition, causing pain even on basic tasks. Despite shoulder problems being common across the population, rotator cuff injuries are more common in older individuals and those who have a large amount of repetitive overhead activity through work or sport. Tendonitis will often present with gradually worsening shoulder pain that is worse on lifting the arm through the ‘painful arc’. If left untreated, tendonitis can become chronic and result in a larger rotator cuff tear.

Rotator cuff problems can often be diagnosed on clinical examinations, which involve a healthcare professional looking, feeling and moving the joint. Sometimes, further scans such as ultrasound and MRI may be necessary to confirm the specific diagnosis. There are a variety of treatments for rotator cuff tendinitis, including pain control, physiotherapy and joint injections. If this does not show improvement, it may be necessary to have surgery. Length of recovery can depend on the severity of the tendinitis, but most patients will improve with conservative management.

FAQs

Is rotator cuff tendinitis the same as a rotator cuff tear? 

Tendinitis is inflammation of the tendon, whereas a tear is the complete disruption of the tendon that connects the muscle to the bone. Tendinitis can lead to a tear if there is insufficient treatment and repeated strain on the tendon.

How does rotator cuff tendinitis feel?

Rotator cuff tendinitis causes pain in the shoulder and may be associated with some swelling. The pain can be worse on raising the arm and at night. The pain may start mild and get worse with time.

How do you fix rotator cuff tendinitis?

Treatment will depend on the individual, but will usually consist of pain relief and physiotherapy. Joint injections or surgery may be recommended if the pain is severe and not improving. 

Can I continue exercising with rotator cuff tendinitis?

Rest is initially encouraged in the short term to allow the shoulder time to heal. A gradual increase in exercise, alongside physiotherapy exercises and pain relief, can help strengthen the shoulder and relieve pain.

How long does rotator cuff tendonitis take to heal?

The length of treatment for rotator cuff tendonitis can vary depending on the severity of the injury. Usually, symptoms will improve with 6 weeks of physiotherapy, but longer courses may be necessary. Sometimes, it can take months for symptoms to resolve, and further treatment may be required, such as surgery.