What is Shoulder Tendinopathy? (aliases: tendinitis, tendonitis, rotator cuff tear) Because inflammation is not always present in tendon injuries, especially chronic tendon injuries, the term shoulder tendinopathy is used to describe the full spectrum of shoulder tendon injuries. If your shoulder's rotator cuff tendons are specifically injured it may be described as a rotator cuff tendinopathy. Rotator cuff tendinopathies can also be described based upon the specific tendon that is injured. These can include supraspinatus tendinopathy, subscapularis tendinopathy or infraspinatus tendinopathy. While not a true rotator cuff tendon, the long head of biceps is commonly associated with rotator cuff injuries and will be described as bicipital tendinopathy. Calcific tendinopathy is a subsection of all these rotator cuff tendinopathies where calcium (bone) has formed within the tendon. What is Shoulder Tendonitis? Shoulder tendonitis (or tendinitis) is an inflammation injury to the tendons of your shoulder's rotator cuff. Inflammation is normally present in the acute phase of tendon injury and is a normal component of the natural tendon healing process. Until a few years ago, shoulder tendonitis was the common term used to describe shoulder tendinopathy. But, in reality, tendonitis is only present in a small percentage of shoulder tendinopathy patients. What Causes Shoulder Tendinopathy? The most common cause of shoulder tendinopathy is repeated microtrauma to the rotator cuff tendons rather than a specific one-off trauma. Rotator Cuff Impingement, where your rotator cuff tendon impacts against the acromion bone, should not occur during normal shoulder function. However, when repeated shoulder impingement occurs, your rotator cuff tendon becomes inflamed and swollen via friction and compression. Shoulder bursitis commonly occurs in combination with rotator cuff tendinopathy or rotator cuff impingement. What are the Symptoms of Shoulder Tendinopathy? Shoulder tendinopathy commonly has the following symptoms: Shoulder clicking and/or an arc of shoulder pain when your arm is about shoulder height. Pain when lying on the sore shoulder or lifting with a straight arm. Shoulder pain or clicking when you move your hand behind your back or head. Shoulder and upper arm pain (potentially as far as your elbow). As your shoulder tendonitis deteriorates, your shoulder pain may even be present at rest. How is Shoulder Tendinopathy Diagnosed? Your physiotherapist or doctor may suspect shoulder tendinopathy based on your symptom history and some clinical tests. An ultrasound scan is a preferred method of investigating shoulder tendinopathy and associated injuries such as shoulder bursitis or other tendinopathies. shoulder tendonitis X-rays do not identify shoulder tendinopathy but can be useful to identify if bone spur encroachment (see picture) into the subacromial space that may cause your rotator cuff tendinopathy. What the Prognosis for Shoulder Tendinopathy? Shoulder tendinopathy can be a progressive disorder that often co-exists with shoulder bursitis or bicipital tendonitis and can deteriorate into calcific tendonitis or rotator cuff tears. They can require surgery with neglect or poor treatment. The good news is that most shoulder tendinopathy is reversible and very successfully treated. Due to shoulder impingement being a primary cause of your shoulder tendinopathy it is vital to thoroughly assess how your shoulder is moving and correct your shoulder biomechanics to prevent future shoulder impingement episodes and subsequent rotator cuff tendinopathies. A shoulder physiotherapist is high-qualified in shoulder assessment and biomechanical correction. For more advice, please consult your physiotherapist or a doctor with an interest in shoulder rehabilitation. What is the Best Treatment for Shoulder Tendinopathy? While every shoulder tendinopathy patient's treatment will vary depending upon the assessment and concomitant problems, researchers have concluded that there are essentially 7 stages that need to be covered to effectively rehabilitate shoulder tendinopathy and prevent recurrence. These are: Phase 1 - Early Injury Protection: Pain Relief & Anti-inflammatory Tips As with most soft tissue injuries the initial treatment is Rest, Ice, and Support. In the early phase, you’ll most likely be unable to fully lift your arm or sleep comfortably. Our first aim is to provide you with some active rest from pain-provoking postures and movements. This means that you should stop doing the movement or activity that provoked the shoulder pain in the first place and avoid doing anything that causes shoulder pain. Ice is a simple and effective modality to reduce your pain and swelling. Please apply for 20-30 minutes each 2 to 4 hours during the initial phase or when you notice that your injury is warm or hot. Anti-inflammatory medication (if tolerated) and natural substances eg arnica may help reduce your pain and swelling. However, it is best to avoid anti-inflammatory drugs during the initial 48 to 72 hours when they may encourage additional bleeding. Most people can tolerate paracetamol as a pain reducing medication. To support and protect your tendon injury, you may need to wear a sling or have your shoulder taped to provide pain relief. In some cases, it may mean that you need to sleep relatively upright or with pillow support. Your physiotherapist will guide you. Your physiotherapist will guide you and utilise a range of pain relieving techniques including joint mobilisations, massage, acupuncture or dry needling to assist you during this pain-full phase. Phase 2: Regain Full Range of Motion If you protect your injured shoulder tendons appropriately the injured tissues will heal. Inflammed structures eg (tendonitis, bursitis) will settle when protected from additional damage. Shoulder tendonitis may take several weeks to heal while we await Mother Nature to form and mature the new scar tissue, which takes at least six weeks. During this time period, you should be aiming to optimally remold your scar tissue to prevent a poorly formed scar that may become lumpy or potentially re-tear in the future. It is important to lengthen and orientate your healing scar tissue via joint mobilisations, massage, muscle stretches, and light active-assisted and active exercises. Physiotherapist-assisted joint mobilisations may improve your range of motion quicker and, in the long-term, improve your functional outcome. In most cases, you will also have developed short or long-term protective tightness of your joint capsule (usually posterior) and some compensatory muscles. These structures need to be stretched to allow normal movement. Signs that you have full soft tissue extensibility includes being able to move your shoulder through a full range of motion: hand behind head, hand behind back, stop sign position and across your chest to touch your opposite shoulder blade. In the early stage, this may need to be passively (by someone else) eg your physiotherapist. As you improve you will be able to do this under your own muscle power. Your physiotherapist will guide you. Phase 3: Restore Scapular Control Your shoulder blade (scapula) is the base of your shoulder and arm movements. Your shoulder blade has a vital role as the main dynamically stable base plate that attaches your arm to your chest wall. Normal shoulder blade-shoulder movement - known as scapulohumeral rhythm - is required for a pain-free and powerful shoulder function. Researchers have identified poor scapulo-humeral rhythm as a major cause of rotator cuff impingement. Any deficiencies will be an important component of your rehabilitation. Your physiotherapist is an expert in the assessment and correction of your scapulohumeral rhythm. They will be able to help you to correct your normal shoulder motion and provide you with scapular stabilisation exercises if necessary. Phase 4: Restore Normal Neck-Scapulo-Thoracic-Shoulder Function Your neck and upper back (thoracic spine) are very important in the rehabilitation of shoulder pain and injury. Neck or spine dysfunction can not only refer pain directly to your shoulder, but it can affect a nerve’s electrical energy supplying your muscles cause weakness. Painful spinal structures from poor posture or injury don’t provide your shoulder or scapular muscles with a solid pain-free base to act upon. In most cases, especially chronic shoulders, some treatment directed at your neck or upper back will be required to ease your pain, improve your shoulder movement and stop pain or injury returning. Your physiotherapist will assess your neck and thoracic spine and provide you with the necessary treatment as required. Phase 5: Restore Rotator Cuff Strength and Function Your rotator cuff is the most critical group of shoulder control and stability muscles. Among other roles, your rotator cuff maintains “centralisation” of your shoulder joint. In other words, it keeps the shoulder ball centred over the small glenoid socket. This prevents impingement and dislocation injuries. Your rotator cuff also provides the subtle glides and slides off your shoulder’s ball joint on the glenoid socket to allow full shoulder movement. It may seem odd that you don’t attempt to restore the strength of your rotator cuff until a later stage in the rehabilitation. However, if a tendon structure is injured we need to provide nature with an opportunity to undertake primary healing before we load the structures with resistance exercises. Having said that, researchers have discovered the importance of strengthening the rotator cuff muscles in a successful shoulder tendonitis rehabilitation program. Your rotator cuff exercises need to be progressed in both load and position to accommodate for your specifically injured rotator cuff tendon(s) and whether or not you have a secondary condition such as bursitis. Your physiotherapist will prescribe the most appropriate rotator cuff strengthening exercises for you. Phase 6: Restore High Speed, Power, Proprioception & Agility If your shoulder tendonitis has been caused by sport it is usually during high-speed activities, which place enormous forces on your body (contractile and non-contractile), or repetitive actions. In order to prevent a recurrence as you return to your sport, your physiotherapist will guide you through exercises to address these important components of rehabilitation to both prevent a recurrence and improve your sporting performance. Depending on what your sport or lifestyle entails, a speed, agility, proprioception and power program will be customised to prepares you for light sport-specific training. Phase 7: Return to Sport or Work Depending on the demands of your chosen sport or your job, you will require specific sport-specific or work-specific exercises and a progressed training regime to enable a safe and injury-free return to your chosen sport or employment. Sports that involve overhead arm positions such as racquet sports, throwing, bowling or swimming have high incidences of shoulder tendonitis. Your technique should ideally be assessed by your shoulder physiotherapist and/or sports coach. Your physiotherapist will discuss your goals, time frames and training schedules with you to optimise you for a complete return to sport or work. Work-related injuries will often require a discussion between your doctor, rehabilitation counsellor or employer. The perfect outcome will have you performing at full speed, power, agility and function with the added knowledge that a thorough rehabilitation program has minimised your chance of future injury. For more specific advice about your shoulder tendinopathy, please contact your physiotherapist.