Sports Medicine
Sports Injury Prevention & Rehabilitation

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Rotator Cuff Tendonitis

(Also known as Rotator Cuff Tendinitis, Rotator Cuff Tendinopathy, Supraspinatus Tendonitis, Supraspinatus Tendinitis, Supraspinatus Tendinopathy)
Note - Although recent research suggests that 'rotator cuff tendinopathy' is a more appropriate term to describe overuse injuries to the rotator cuff tendons, we will use the term 'rotator cuff tendonitis' in this document as it is more widely known.

What is rotator cuff tendonitis?
The rotator cuff is a group of muscles which originate from the shoulder blade and attach to the upper arm bone (humerus) via the rotator cuff tendons. Collectively, the rotator cuff act to provide stability to the shoulder joint and assist with elevation and rotation movements of the shoulder. The four muscles of the rotator cuff include:
  • Supraspinatus
  • Infraspinatus
  • Subscapularis
  • Teres Minor
During contraction of the rotator cuff muscles, tension is placed through the rotator cuff muscles and tendons. When this tension is excessive due to too much repetition or high force, damage to the rotator cuff tendon may occur. Rotator cuff tendonitis is a condition whereby there is damage, with subsequent inflammation and degeneration to one or more of the rotator cuff tendons. This is usually due to gradual wear and tear associated with overuse, however it may also occur traumatically due to a specific incident. The rotator cuff muscle that is most commonly affected in rotator cuff tendonitis is the supraspinatus.
Although this condition can occur at any age, it is commonly seen in patients between the ages of 40 and 60. Rotator cuff tendonitis is commonly seen in association with subacromial impingement or bursitis.

Causes of rotator cuff tendonitis
  • Rotator cuff tendonitis most commonly occurs due to repetitive or prolonged activities placing strain on the rotator cuff. This typically occurs due to excessive lifting, overhead activities, lying on the affected side or pushing and pulling.
  • Occasionally, rotator cuff tendonitis may occur suddenly due to a high force going through the rotator cuff tendons beyond what they can withstand. This may be due to heavy or awkward lifting, a fall onto an outstretched hand, heavy pushing or pulling, or a forceful throw. Rotator cuff tendonitis may also occur following a rotator cuff tear.
  • In athletes, rotator cuff tendonitis is commonly seen in throwing sports (such as football or baseball), swimming (particularly freestyle and butterfly), racquet sports (such as tennis), weight lifting or paddling sports (such as kayaking).

Signs and symptoms of rotator cuff tendonitis
The symptoms of rotator cuff tendonitis usually develop gradually over a period of time. Often, the pain associated with this condition is experienced as an ache that increases to a sharper pain or catching pain with certain activities.
  • In patients with minor rotator cuff tendonitis, little or no symptoms may be present. Some patients may experience pain on commencing activity that reduces as they warm up. These patients are usually able to continue sport or activity only to have an increase in pain, ache or stiffness upon resting later (particularly that night or the following morning). In severe or chronic cases the pain may be disabling, preventing the patient from performing further activity. Muscle wasting, weakness and night pain (regardless of position) may also be present.
  • Patients with rotator cuff tendonitis will usually experience pain or difficulty when lifting heavy objects (especially overhead). Pain may also increase when performing overhead activities, elevating the affected arm, during heavy pushing or pulling or when lying on the affected side.
  • Rotator cuff tendonitis usually presents as pain that is localized to the shoulder. Occasionally, pain may also be experienced in the upper arm, shoulder blade, upper back or neck. Tenderness on firmly pressing the tip of the shoulder (rotator cuff tendons) may also be present.
  • Rotator cuff tendonitis may also be seen in combination with shoulder instability (particularly in the younger athlete). In these instances, patients may experience 'clicking' or 'clunking' , an occasional sensation of the shoulder feeling 'out of place', pins and needles, numbness or a 'dead arm'.

Diagnosis of rotator cuff tendonitis
A thorough subjective and objective examination from a physician is usually sufficient to diagnose rotator cuff tendonitis. Further investigations such as an X-ray, Ultrasound or MRI scan may be required to assist with diagnosis and assess the severity of the condition.

Treatment for rotator cuff tendonitis
Most cases of rotator cuff tendonitis settle well with appropriate physical therapy. The success rate of treatment is largely dictated by patient compliance. One of the key components of treatment is that the patient rests sufficiently from any activity that increases their pain until they are symptom free. Activities which place large amounts of stress through the rotator cuff should be minimized, these include: overhead activities, throwing, heavy lifting, pushing or pulling and sleeping on the affected side. Resting from aggravating activities ensures that the body can begin the healing process in the absence of further tissue damage. Once the patient can perform these activities pain free, a gradual return to these activities is indicated provided there is no increase in symptoms.
  • Ignoring symptoms or adopting a 'no pain, no gain' attitude is likely to lead to the problem becoming chronic. Immediate, appropriate treatment in patients with rotator cuff tendonitis is essential to ensure a speedy recovery. Once the condition is chronic, healing slows significantly resulting in markedly increased recovery times and an increased likelihood of future recurrence.
  • Patients with rotator cuff tendonitis usually benefit from following RICE. RICE is beneficial in the initial phase of the injury (first 72 hours) or when inflammatory signs are present (i.e. morning pain or pain with rest). This primarily involves resting from aggravating activities (occasionally a sling may be required), regular icing and keeping the arm elevated (i.e. sleeping on the opposite side). Anti-inflammatory medication may also significantly hasten the healing process by reducing the pain and swelling associated with inflammation.
  • Patients with this condition should perform pain-free flexibility and strengthening exercises as part of their rehabilitation to ensure an optimal outcome. The treating physiotherapist can advise which exercises are most appropriate for the patient and when they should be commenced. Exercises to improve scapular stability and strength are a key component of the rehabilitation of rotator cuff tendonitis. Exercises to improve posture and upper back flexibility are also important, along with a graduated rotator cuff strengthening program (usually involving the use of Resistance Bands). If the rotator cuff is not adequately strengthened following injury, a poor outcome is likely.
  • In the final stages of rehabilitation, a gradual return to activity or sport is indicated as guided by the treating physical therapist provided there is no increase in symptoms.

Prognosis of rotator cuff tendonitis

With appropriate management and physical therapy, most minor cases of rotator cuff tendonitis that have not been present for long can usually recover within a few weeks. In chronic cases, recovery can be a lengthy process and may take 3-6 months or longer to achieve an optimal outcome.

Contributing factors to the development of rotator cuff tendonitis
There are several factors which can predispose patients to developing rotator cuff tendonitis. These need to be assessed and corrected with direction from a physical therapist. Some of these factors include:
  • shoulder instability
  • muscle weakness (especially the scapular stabilizers and rotator cuff muscles)
  • muscle tightness
  • joint stiffness (shoulder, AC joint, neck or upper back)
  • muscle imbalances
  • poor posture
  • excessive or inappropriate training or activity
  • abnormal biomechanics (eg. poor throwing technique or stroke technique with swimming)
  • inadequate warm-up
  • past history of shoulder injury

Physical therapy for rotator cuff tendonitis
Physical therapy treatment for rotator cuff tendonitis is vital to hasten the healing process, ensure an optimal outcome and reduce the likelihood of injury recurrence. Treatment may comprise:
  • soft tissue massage
  • electrotherapy (e.g. ultrasound)
  • joint mobilization (shoulder, AC joint, neck and upper back)
  • dry needling
  • ice or heat treatment
  • the use of a sling
  • progressive exercises to improve flexibility and strength (particularly the scapular stabilizers and rotator cuff muscles)
  • education
  • training and activity modification advice
  • technique correction
  • postural correction
  • anti-inflammatory advice
  • devising and monitoring a return to sport or activity plan

Other intervention for rotator cuff tendonitis
Despite appropriate management, some patients with rotator cuff tendonitis do not improve. When this occurs the treating therapist or doctor can advise on the best course of management. This may include further investigations (such as X-rays, ultrasound, CT scan or MRI), pharmaceutical intervention, corticosteroid injection (sometimes required in the case of secondary bursitis) or referral to appropriate medical authorities who can advise on any intervention that may be appropriate to improve the condition.