Can You Just Shrug that shoulder pain Off?

What is Rotator Cuff Tendinopathy? 

Tendons are designed to be elastic, capable of absorbing and releasing force. When the force overcomes the elasticity of the tendon, it can cause micro tearing and damage to the cells that form the muscle. The tendon will try to thicken and overcome this stress in what is called a reactive phase. If this tendon thickens too much, the tiny fibres that make up the tendon will become disorganised, meaning this ability to absorb force is diminished [1]. 

The Rotator Cuff (RC) consists of four muscles (supraspinatus, infraspinatus, subscapularis, teres minor) all of which attach at the scapula (shoulder blade) and facilitate movement at the shoulder. A bursa (fluid filled sac that enables smooth movement of muscle) also sits under the acromion, a bone of the scapula. 

The impaired force absorption of the tendons that comprise the RC can occur for two main reasons, intrinsic (occurring inside the tendon), or extrinsic (external factors that impact the tendon) [2]. Examples of intrinsic causes include ageing, overuse and overload as well as poor blood supply. An example of extrinsic factors is shoulder joint shape abnormalities that ‘pinch’ the tendon as well as the bursa and hinder its action as movement occurs [3]. 

RC tendinopathy can also occur due to decreased strength/fatigue of the muscles that surround the RC, those that are important for controlling normal movement of the shoulder joint. In this case the abnormal muscle movements put increased load on the RC muscles and mean they are more likely to be compressed on the bony structures that make up the shoulder [4]. 

Risk factors for the condition include previous shoulder injury and other conditions such as osteoarthritis, hypertension and diabetes [5,6]. 

Common populations impacted include occupations that require repeated overhead activities as well as heavy manual labour workers; high psychological demand at work can also increase the chances [7]. Sporting populations include weightlifters and swimmers. Women, and people over 50 are more likely to have RC tendinopathy [5]. 

Symptoms 

People with RC tendinopathy will likely have symptoms that developed gradually but could have also started suddenly. It is often described as a dull ache radiating from the outer arm to below or above the shoulder tip. Pain is common during overhead activities such as reaching from a high shelf or behind the back, throwing, lifting and lying on the painful side [8]. You may also experience some swelling in the area. 

Growing weakness with movement and shoulder clicking when your arm is at shoulder height is also common. The following images depict some of the movements in which you may be experiencing pain and weakness [9]: 

Often, avoiding heavy lifting and repetitive overhead movements/exercises will limit the symptoms. Ice and non-steroidal anti-inflammatory (NSAIDs) drugs such as ibuprofen can reduce inflammation, swelling and pain [9]. 

It may be common to experience pain during the night which interferes with sleep. Sleeping on your shoulder or arm can impinge the tendons further and you might wake up with shoulder aches. The amount of pain you experience throughout the day will depend on the activities you perform with your shoulder [4]. 

Prognosis 

Roughly 50% of RC tendinopathy cases resolve in 8-12 weeks, but up to 40% will be symptomatic and unresolved for over a year. Recurring symptoms are common, (40-50%) of people, likely due to incomplete rehabilitation [10,11]. 

The evidence remains unclear whether your sex, age or occupational demands will impact your recovery (prognosis) [8,10]. However, high quality studies do indicate that poorer recovery is associated with high baseline disability/pain and previous episodes of shoulder pain, so early rehabilitation is best [8]. 

Treatment 

Complete rest is not recommended even though it will have an immediate reduction in pain. When you return to normal activity, the pain will increase because the tendon has unloaded [12]. A tendon is like a bucket and the load from activity is the water. If you strengthen the tendon, the bucket gets bigger and can hold more water. If you rest, the bucket gets smaller and can hold less water which causes pain [13]. 

The physio will want to know about all recent activity, and importantly whether you have had changes or commenced new activities just before you noticed shoulder pain [12]. 

Icing can help increase the amount of space between the arm and the acromion, which will reduce pinching and relieve pain [14]. Soft tissue massage of the triceps and back of your shoulder can help relieve pain. Your GP can prescribe you NSAIDs (e.g voltaren) which may provide a short-term (7-14 days) analgesic effect [12]. 

Mobilisations can help create space under the acromion. This will involve the therapist pushing your shoulder down the bed or holding it down whilst you lift your arm above your head. 

Strengthening exercises help improve pain and function [12]. Level of intensity to start with should be found using the ‘Goldilocks approach’ [15]. Isometrics (muscle contraction with no limb movement) can also have a pain-relieving effect. This will consist of keeping your arm in non-painful ranges and pushing your elbow against a wall. Once you can successfully hold isometric exercises for 3 rounds of 45-60sec then isotonics (exercises through full range) may be introduced utilising therabands [4]. These motor control exercises will help your scapula sit in its correct position whilst performing activities [16]. 

You may be feeling anxious about moving your shoulder [15,17], but 3 out of 10 pain is okay [15]. If pain increases the next day, contact your physio before continuing [15]. 

Stretching of the RC tendons is not advised as it can worsen compression and provoke pain [18], however the physio may prescribe stretches for the back of your shoulder. 

So don’t just shrug that shoulder pain off! Do your exercise program well as shown in this video (Figure 7), then there should be no need for surgery as research shows exercise therapy has equivalent outcomes [12]. 

References: 

1. Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. Br J Sports Med. 2009; 43;409-16 . DOI: 10.1136/bjsm.2008.051193 
2. Factor D, Dale B, Current concepts of rotator cuff tendinopathy, Int J Sports Phys Ther. 2014;9(2):274–88.Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4004132 
3. Seitz A.L, McClure P.W, Finucane, S, Boardman N.D, Michener, L.A. Mechanisms of rotator cuff tendinopathy: Intrinsic, extrinsic, or both? Clin. Biomech. 2011;26: 1–12. DOI: 10.1016/j.clinbiomech.2010.08.001 

4. Lewis J, McCreesh K, Roy JS, Ginn K. Rotator cuff tendinopathy: navigating the diagnosis-management conundrum. J ORTHOP SPORTS PHYS THER. 2015;45(11);923-37. DOI: 10.2519/jospt.2015.5941 
5. Leong HT, Chuen Fu S, He X, Han Oh J, Yamamoto N, Yung SH. Risk factors for rotator cuff tendinopathy: a systematic review and meta-analysis.
   J. Rehabil. Med. 2019;51(9);627-37. DOI: 10.2340/16501977-2598 
6. Applegate KA,Thiese MS, Merryweather AS, et al. Association between cardiovascular disease risk factors and rotator cuff tendinopathy: a cross- sectional study. J Occup Environ Med. 2017;9(2);154-160. DOI: 10.1097/JOM.0000000000000929 
7. Wong WK, Li MY, Yung PS, Leong HT. The effect of psychological factors on pain, function, and quality of life in patients with rotator cuff tendinopathy: A systematic review. Musculoskelet. Sci.. 2020; 47;102173. DOI: 10.1016/j.msksp.2020.102173 
8. Littlewood C, May S, Walters S. Epidemiology of Rotator Cuff Tendinopathy: A Systematic Review. Shoulder Elbow. 2013;5(4):256–65. DOI: 10.1111/sae.12028 
9. Brukner P, Khan K, Cook J, Cools A, Crossley K, Hutchinson M, et al. EBOOK BRUKNER & KHAN’S CLINICAL SPORTS MEDICINE: INJURIES, VOL. 1. (5th Edition). McGraw-Hill Education Australia; 2017 
10. Hopman K, Krahe L, Lukersmith S, McColl A.R, Vine K. Clinical Practice Guidelines for the Management of Rotator Cuff Syndtome in the Workplace. The university of New South Wales, Syndey. 2013. Available online at http://rcs.med.unsw.edu.au/rotatorcuffsyndromeguidelines 
11. Mitchell C, Adebajo A, Hay E, Carr A. Shoulder pain: diagnosis and management in primary care BMJ 2005; 331 :1124 doi:10.1136/bmj.331.7525.112 

12. Cardoso TB, Izzari T, Kinsella R, Hope D, Cook JL. Current trends in tendinopathy management. Best Pract Res Clin Rheumatol. 2019;33(1):122- 140. DOI: 10.1016/j.berh.2019.02.001 
13. Gaida, J. Tendinopathy Basic Principles and Management, NMI, 2019 September; University of Canberra. 
14. Parle PJ, Riddiford-Harland DL, Howitt CD, Lewis JS. Acute rotator cuff tendinopathy: does ice, low load isometric exercise, or a combination of the two produce an analgaesic effect?. Br J Sports Med; 2017;51(3):208–9. DOI: 10.1136/bjsports-2016-096107 
15. Mest, J. Emerging Concepts in Tendinopathy and Application to Clinical Practice. APA, 2021 June; University of Canberra. 
16. Kinsella R, Cowan SM, Watson L, Pizzari T. A comparison of isometric, isotonic concentric and isotonic eccentric exercises in the physiotherapy management of subacromial pain syndrome/rotator cuff tendinopathy: study protocol for a pilot randomised controlled trial. Pilot Feasibility Stud. 2017;3:45. DOI:10.1186/s40814-017-0190-3 
17. Mallows A, Debenham J, Walker T, Littlewood C. Association of psychological variables and outcome in tendinopathy: a systematic review. Br J Sports Med. 2017;51(9):743-748. DOI:10.1136/bjsports-2016-096154 
18. Cook JL. Ten treatments to avoid in patients with lower limb tendon pain. Br J Sports Med. 2018;52:882. DOI: 10.1136/bjsports-2018-099045