Rotator Cuff Pain

What is rotator cuff pain?

Rotator cuff pain is a common cause of shoulder pain seen in patients for all ages. It describes a spectrum of conditions that effect the rotator cuff tendons such as tears, tendinopathy and calcific tendinitis. These can occur after a fall, a sporting injury or can begin for no obvious reason. The prevalence of rotator cuff pain increases with age.

Most rotator cuff pain will resolve with modification of activity and a course of physiotherapy. If the pain does not improve and is waking you at night an ultrasound guided steroid injection is very effective for rotator cuff pain. There are a few injection options depending on the type of rotator cuff issue you are suffering from, these include steroid, platelet rich plasma (PRP) and barbotage & lavage procedure.

What are the symptoms of rotator cuff pain?

The symptoms of rotator cuff pain are:

Pain on the outside of the upper arm. Pain can spread to the front of the shoulder (even into the chest) and the back of the shoulder into the shoulder blade.
Pain is aggravated by lifting the arm to the side and above head height particularly if a weight is in the hand
Weakness in the shoulder particularly with lowering the arm from an overhead position.

If this sounds like your pain, read on…

What other conditions can mimic rotator cuff pain?

If this does not sound like your pain there are other conditions that can mimic the pain of rotator cuff pain such as:

Rotator cuff pain vs frozen shoulder?

Rotator cuff pain and frozen shoulder both cause significant pain in the shoulder, however, frozen shoulder is also associated with significant stiffness, aswell as the pain. Frozen shoulder is also a progressive condition i.e., the pain gets worse overtime for no apparent reason. Frozen shoulder effects those aged 40-60 years old, whereas rotator cuff pain can affect people of all ages.

The anatomy

The rotator cuff is made up of four muscles in the shoulder. These are; supraspinatus, infraspinatus, subscapularis and teres minor. These muscles attach to the ‘ball’ of the shoulder joint, known as the humeral head, via their tendons. These tendons help to lift and rotate your arm allowing pain free, smooth movement and they achieve this by keeping the ‘ball’ in the centre of the shoulder joint. The most commonly injured rotator cuff tendon is the supraspinatus.

Rotator cuff pain can be a very painful and debilitating condition. It can prevent patients from carrying out simple daily activities such as reaching up, lifting their arm and dressing/undressing. It is also commonly aggravated by overhead activities such as playing tennis and gym weight exercises.

The bursa (see image below), specifically the sub-acromial bursa is located above the rotator cuff. If the bursa is inflamed, which often occurs with rotator cuff issues, it is known as a bursitis. The bursal tissue is very sensitive and can often become painful when inflamed.

What are the symptoms of rotator cuff pain?

Symptoms vary between patients to and are they are not exclusive to rotator cuff pain. It is important to differentiate rotator cuff pain from other shoulder condition such as frozen shoulder and osteoarthritis.

Classic signs and symptoms of rotator cuff pain

1. Pain on the outside of the upper arm. Pain can also refer to the front of the shoulder (even into the chest) and the back of the shoulder into the shoulder blade.

2. Pain is aggravated by lifting the arm to the side and above head height. It can also be painful reaching backwards and moving your hand behind your back.

3. Weakness in the shoulder particularly with lowering the arm from an overhead position.

4. Pain at night especially if you lie on the affected side.

What causes rotator cuff pain?

Rotator cuff pain is further classified according to the type of rotator cuff injury. This information is gained by carrying out a diagnostic ultrasound.

At Complete every patient has a diagnostic ultrasound scan (at no extra charge) performed prior to an injection, to ensure the correct diagnosis.

Rotator cuff tendinitis/tendinopathy: This is when the rotator cuff tendons become swollen and painful due to overuse and/or age. It is normally associated with a concurrent sub-acromial impingement and associated bursitis. The bursa is a thin sac that sits on top of the rotator cuff tendons (see image above).
Rotator cuff tear: This is when the tendon has a tear. This can occur over a period of time or with a sudden incident such as a fall. These tears can be a full or partial tear of the tendon.
Calcific tendinopathy (also known as calcific tendinitis): This is when there are bony deposits (known as calcification) in the rotator cuff tendon. It can cause acute, severe pain and a significant reduction in movement. The exact cause is unknown but can be related to some metabolic diseases such as abnormal thyroid and diabetic conditions.

How do you diagnose rotator cuff pain?

The diagnosis of rotator cuff pain is a “clinical diagnosis” which means that your physiotherapist can diagnose it during your initial assessment. However, to establish if you have a tendinopathy, a bursitis, a tear or calcification within the tendon a diagnostic ultrasound has to be carried out. It is not possible to ascertain this information without an ultrasound scan.

At Complete all of our clinicians are dual-trained sonographers and will perform a diagnostic ultrasound scan on your initial appointment.

What injection is effective for rotator cuff pain?

The most effective injection for your shoulder pain depends on your specific diagnosis.

1. Injection options for rotator cuff tendinopathy/tendinitis

The most common ultrasound guided injection we carry out for rotator cuff tendinopathy is a steroid injection. Steroid (also known as corticosteroid) injections for rotator cuff pain are extremely effective, when the pain is not improving and particularly if the pain is waking the patient up at night. Steroid is a strong anti-inflammatory that can provide fast, effective pain relief.

Injections are particularly useful if patients are struggling to engage with a programme of physiotherapy due to high levels of pain. The injection provides a “window of opportunity” for you to carry out physiotherapy with significantly less pain.

It is important to note that the steroid does not go into the rotator cuff tendon itself, which is potentially detrimental to the tendon. The injection targets the inflammation of the overlying bursa (known as a sub-acromial bursitis). It is very common when you have rotator cuff pain that the subacromial bursa is also inflamed. The bursa is a very pain sensitive structure and therefore injecting into this structure, normally provides excellent pain relief.

At Complete all our injections are carried out using ultrasound guidance, to ensure we target the bursa and not the tendon. The bursa is approximately 2-4mm, so without ultrasound guidance it is not possible to target the bursa alone. Research has shown performing a ultrasound guided injection improves outcomes in shoulder pain when compared to unguided injections (Aly et al, 2015, Eustace et al, 1997,Finnoff et al, 2015).

2. Injection options for rotator cuff tears

The optimal management for rotator cuff tears depends on several factors, these include:

- Your Age
- The Size and location of tear (determined on the ultrasound scan)
- Your required demands on your shoulder i.e. what activities you want to get back to

There are two main injection options for rotator cuff tears:

1. Ultrasound guided steroid injection

The first option is a steroid injection into the subacromial bursa (similar to tendinopathy option). This provides a painfree window for you to engage in a course of physiotherapy. Exercise based treatment following a rotator cuff tear is essential to restore full strength and movement in the shoulder. However, it is not uncommon that patients struggle to perform physiotherapy exercises due to high pain levels and so the combination of treatment (injection and physiotherapy rehabilitation) works very well.

This combination is very successful in a significant percentage of our patients and often avoids the requirement for surgery.

2. Plasma Rich Injections (PRP)

The second option for a rotator cuff tear is Plasma Rich Platelet (PRP) injections. PRP injections are a novel injection technique which aims to encourage new healing of the tendon (Schneider et al, 2018). These injections are most effective in younger patients who have had a specific injury/incident that resulted in the tearing of the rotator cuff such as a fall or lifting weights in the gym.

It is most effective when carried out as soon as possible after the injury. It must be combined with a comprehensive physiotherapy programme. Three PRP injections are carried out over a six-week period, with one injection every two weeks.

3. What are the options for calcific tendinopathy/tendinitis?

If the rotator cuff pain is due to calcium/bony deposits in a rotator cuff tendon then there are three potential options:

1. Shockwave Therapy (this is not an injection): Shockwave is an effective treatment modality for calcific tendinopathy (Cacchio et al, 2016). Delivers acoustic energy into to the calcific areas to encourage breakdown and reabsorption. You will require a minimum of three sessions, once per week for three weeks.

2. Steroid Injection: An ultrasound guided steroid injection into the subacromial bursa can be very effective at reducing the pain associated with the calcific tendinopathy/tendinitis.

3. Barbotage/Lavage: This procedure is carried out using ultrasound guidance and extracts the calcium/bony deposits from the tendon using a needle. Traditionally removing the calcium did require a surgical procedure. This treatment is very effective and often avoids the need for surgery.

How many steroid injections can you have for rotator cuff pain?

A majority of our patients only require one injection. The role of the injection is to provide a window of opportunity to allow you to engage in a physiotherapy program to restore full range of movement and strength in the shoulder.

We always try and limit the number of injections we carry out on our patients, however on occasion, having more than one injection is sometimes required to achieve adequate pain relief.

If you would like to discuss your injury before booking in for an injection, then please call 02074823875 or email info@complete-physio.co.uk and one of our expert clinicians will call you back.