What is rotator cuff tendonitis?

Rotator cuff tendonitis is a condition characterized by damage, inflammation and degeneration of one or more of the rotator cuff tendons.   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 4 muscles of the rotator cuff include:  
  • Supraspinatus
  • Infraspinatus
  • Subscapularis
  • Teres Minor
  There may be several structures are involved in the process of injury largely due to their approximation but also to their vulnerability during arm elevation, a movement that may cause an impingement if not performed with sound biomechanics. Tendonitis, bursitis, strains and tears make up the differential diagnosis that go along with rotator cuff tendonitis as we know it.  
  • Tendinitis. Tendons in your rotator cuff can become inflamed due to overuse or overload, especially if you're an athlete who performs a lot of overhead activities, such as in tennis or racquetball.
  • Bursitis. The fluid-filled sac (bursa) between your shoulder joint and rotator cuff tendons can become irritated and inflamed.
  • Strain or tear. Left untreated, tendinitis can weaken a tendon and lead to chronic tendon degeneration or to a tendon tear. Stress from overuse also can cause a shoulder tendon or muscle to tear.
  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, or their an imbalance in muscle strength cause an impingement phenomena, damage to the rotator cuff tendons may occur.   Rotator cuff tendinitis 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 this condition is the supraspinatus.   Although this condition can occur at any age, it is commonly seen in patients between the ages of 40 and 60.  

What are the common 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:  
  • Impingement syndrome of the structures affected due to imbalances in strength, structure and or function
  • Normal wear and tear. Increasingly after age 40, normal wear and tear on your rotator cuff can cause a breakdown of fibrous protein (collagen) in the cuff's tendons and muscles. This makes them more prone to degeneration and injury. With age, you may also develop calcium deposits within the cuff or arthritic bone spurs that can pinch or irritate your rotator cuff.
  • Falling. Using your arm to break a fall or falling on your arm can bruise or tear a rotator cuff tendon or muscle.
  • Lifting. Lifting an object that's too heavy or doing so improperly — especially overhead — can strain or tear your tendons or muscles. Likewise, pulling something, such as a high-poundage archery bow, may cause an injury.
  • Excessive lifting and especially the repetitive strain of overhead movements such as paining, blow drying hair, overhead military press exercises
  • Sleeping on the affected side especially with your arm overhead
  • Heavy pushing or pulling. When the rotator cuff is not strong enough to stabilize the shoulder during pushing and pulling such as starting a hand gas machine or performing push ups
  • Poor posture. When you slouch your neck and shoulders forward, the space where the rotator cuff muscles reside can become smaller. In particular a forward head posture where the shoulders are protracted and held in an anterior internal rotation. This can allow a muscle or tendon to become pinched under your shoulder bones (including your collarbone), especially during overhead activities, such as throwing.
  • Repetitive stress in less than optimal posture such as performing lat pull downs with your head too far forward and shoulders rounded forward
  • A forceful throw is perhaps the most common athletic injury and this may occur at leisure as well, skipping rocks on the water or throwing snow balls etc.
  • Sports. In athletes, rotator cuff tendonitis is commonly seen in throwing sports (such as cricket or baseball), swimming (particularly freestyle and butterfly), racquet sports (such as tennis), weight lifting or paddling sports (such as kayaking).
   

What are the signs and symptoms of rotator cuff tendonitis?

The most common symptom is pain. You may experience it when you reach up to comb your hair, bend your arm back to put on a jacket or carry something heavy. Lying on the affected shoulder also can be painful. The symptoms of rotator cuff tendinitis usually develop gradually over a period of time. Often, the pain associated with this condition is experienced as an ache in the shoulder that increases to a sharper pain or catching pain with certain activities. Occasionally, pain may also be experienced in the upper arm, shoulder blade, upper back or neck.   In patients with minor rotator cuff tendinitis, 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 tendinitis will usually experience pain or difficulty when lifting heavy objects (especially overhead). Pain may also increase when performing overhead activities, elevating the affected arm, using the arm in front of the body, during heavy pushing or pulling or when lying on the affected side. Tenderness on firmly pressing the tip of the shoulder (rotator cuff tendons) may also be present.   Rotator cuff tendinitis 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'.

   

What are the underlying factors associated with rotator cuff tendonitis?

There are several factors which can predispose patients to developing this condition. These need to be assessed and corrected with direction from a physiotherapist. Some of these factors include:  
  • shoulder instability
  • muscle weakness (especially the scapular stabilizers and rotator cuff muscles)
  • muscle tightness (especially the pectoralis major, minor and upper traps, scalenes)
  • joint stiffness (shoulder, AC joint, neck or upper back)
  • muscle imbalances (typically an imbalances where the front muscles are stronger than the back)
  • poor posture (all of the muscle and joint compensations that go along with FHP)
  • excessive or inappropriate training or activity
  • inadequate recovery periods from sport or activity
  • abnormal biomechanics (e.g. poor throwing technique or stroke technique with swimming)
  • inadequate warm-up
  • past history of shoulder injury
  • certain bone anatomy, or degenerative bony spurring, on the acromion
   

What are the risk factors of Rotator cuff injury?

  • Age. As you get older, your risk of a rotator cuff injury increases. Rotator cuff tears are most common in people older than 40.
  • Being an athlete. Athletes who regularly use repetitive motions, such as baseball pitchers, archers and tennis players, have a greater risk of having a rotator cuff injury.
  • Working in the construction trades. Carpenters and painters, who also use repetitive motions, have an increased risk of injury.
  • Having poor posture. A forward-shoulder posture can cause a muscle or tendon to become irritated and inflamed when you throw or perform overhead activities.
  • Having weak shoulder muscles. This risk factor can be decreased or eliminated with shoulder-strengthening exercises, especially for the less commonly strengthened muscles on the back of the shoulder and around the shoulder blades.
 

What is the prognosis of rotator cuff tendonitis?

Treatments and drugs

Most of the time, treatment for rotator cuff injuries involves exercise therapy. Your doctor or a physiotherapist will talk with you about specific exercises designed to help heal your injury, improve the flexibility of your rotator cuff and shoulder muscles, and provide balanced shoulder muscle strength. Depending on the severity of your injury, physiotherapy may take from several weeks to several months to reach maximum effectiveness.    

How can physiotherapy and massage therapy help rotator cuff tendonitis?

A thorough subjective and objective examination from a physiotherapist is usually sufficient to diagnose rotator cuff tendonitis. An investigative ultrasound and X-ray are most commonly used to confirm diagnosis and assess the severity of the condition. In some cases, an MRI may also be performed to rule out other pathologies and assist with diagnosis.   Physiotherapy treatment is important to hasten the healing process and ensure an optimal recovery. If severe, gentle exercises are usually prescribed by the physiotherapist to encourage healing, mobility and strength. We start with isometric strengthening exercises and active assisted range of motion exercises. It is common for patients to start these exercises even as early as day one or two after a traumatic rotator cuff injury such as from a fall etc. Eventually, over the coming days, this progress of isometrics and range of motion will improve and almost on a daily basis can be increased in intensity (force) and volume (reps and sets) to gain full function of the shoulder. Low Intensity Laser Therapy and massage therapy can promote healing and increase circulation to great the optimal environment for best recovery.

   

Manual Physiotherapy and Massage Therapy

Manual therapy becomes more important during the chronic cases of rotator cuff tendinitis as these are more complex due to compensations that create instability, imbalances, neck and upper back dysfunction, joint disease and pain referral processes as well as the typically patterns of rotator cuff weakness found in acute cases.  Physiotherapy begins with an examination and assessment of shoulder joint mobility, neck and upper thoracic joint movements, scar tissue adhesions in the rotator cuff tendons, muscle tightness, strength and stability in the various muscles affecting shoulder blade movement. Joint mobilization to the facet and rib joints of the upper thoracic joints help improve overhead arm movements and restrictions in these joints are common a result of forward-head posture. In the middle-age and older population especially, stiffness in the ball and socket joint of the shoulder can be present and mobilized with gliding motions by your physiotherapist. Manual friction techniques performed on scar adhesions within a degenerative cuff tendon may be helpful to reduce the risk of tendon impingement underneath the shoulder blade and collar bone.  Low Intensity Laser Therapy may also improve this scar health and reduce mechanic stresses of impingement.   In the final stages of rehabilitation for patients with a rotator cuff problem, a gradual return to activity can occur as guided by the physiotherapist provided there is no increase in symptoms. With appropriate management and physiotherapy, most minor cases of rotator cuff tendinitis, those have not been present for long; can usually recover within a few weeks. Some clear up even without therapy when acute; however the risk of having a weak cuff is fairly high.   In chronic cases, recovery can be a lengthy process and may take 3-6 months or longer to achieve an optimal outcome.

   

Rehabilitation

Keeping your rotator cuff and scapular stabilizer muscles strong is the most important curative and preventative measure for rotator cuff injury. Think of your rotator cuff as you do your core muscles, they are essentially the core stabilizers to the shoulder. Without rotator cuff stability, you are at risk to your neck, shoulder and upper back.  If you've had a rotator cuff injury in the past, daily shoulder stretches and a shoulder-strengthening program are essential, if you have not, your physiotherapist will perform this test during your functional movement screen. Especially important is a program of strength exercise to promote balanced strength about the shoulder. Most people exercise the front muscles of the chest, shoulder and upper arm, but it is equally important to strengthen the muscles in the back of the shoulder and around the shoulder blade. Experience tells us that there are only a few very specific ways to strengthen the rotator cuff muscle group, a movement pattern that is somewhat clinical in nature and not performed in the gym setting often. Dumbbell resistance is the key, in side lying with the elbow at 90 degrees and the arm adducted resting on your side. The movement pattern is pure external rotation thru approximately 100 degrees of motion. Perform this exercise with a challenging weight that results in fatigue under12 repetitions for best results.  Your physiotherapist can advise when it is appropriate to begin these initial exercises and eventually progress to the intermediate, advanced and other exercises. As a general rule, the addition of exercises or progression to more advanced exercises should take place provided there is no increase in symptoms.   The neck and upper back and scapula should also be assessed for joint restrictions and soft tissue restrictions and strength imbalances. These can be corrected by physiotherapy and by an individualized postural exercise training program. Refer to this section for complete details.  

How can exercise and physical development help after rotator cuff tendonitis?

The Kinetic Chain

Our body functions best and with minimal stress when it is in optimal alignment and posture. Proper structural correction is achieved with proper footwear and support. With an optimal base, and with proper pelvis and spinal alignment and posture, the upper extremities can function with optimal mechanics.  Proper neck and back posture in essential in tendonitis of the shoulder and elbow and this requires skill development and neuromuscular training and is the science of motor learning. The kinetic chain is a integrated functional unit of systems that work interdependently to allow structural and functional efficiency. It is made of the soft tissue system (muscle, ligament, tendon, and fascia), the Neural system ( peripheral nervous system of nerves and the central nervous system or brain), and the Articular system (joints). If any of these systems do not work efficiently, compensations and adaptations may occur in the other systems. A dysfunction in the kinetic chain leads to decreased performance and predictable patterns of injury.  Imbalances may result from postural stress, a pattern of overload, repetitive movement, a lack of core stability, and a lack of neuromuscular efficiency. All functional movement patterns of the upper body, involve deceleration, stabilization and acceleration, which occur at every joint in the kinetic chain and in all planes of motion at varying speeds.   Optimum posture and alignment provides optimal structural and functional efficiency to the kinetic chain. If one component is out of alignment, it creates predictable patterns of tissue overload and dysfunction, leads to decreased neuromuscular control and initiates the cumulative injury cycle. Muscle imbalance leads to abnormal neuromuscular control leads to overloaded tissue and tissue fatigue which leads to inflammation and eventually leads to tissue trauma or injury. The most common patterns of compensation in the upper body is the Forward Head Pattern and this pattern can occur in isolation or in concert with a pronation pattern or the equivalent in the lower body.  These two patterns are the focus of our screen examination and our subsequent corrective preventative exercise plan. Identification of biomechanical imbalances in a way that is specifically related to the multi planner movements and that involves acceleration, deceleration, stabilization and occurs at multiple speeds in those specific body positions and posture activities of daily living.  Assessment of the muscular system (functional anatomy) the articular system (functional biomechanics) and the neural system (motor behavior) becomes important in the prevention and treatment of overuse injuries and repetitive strains. In order to live a healthy and active lifestyle, one has to train their body the way it moves during daily functional movements.

   

Exercise Training and Physical Development

Spinal alignment and stability and posturing is the most important physical training that you can do to prevent and maintain good shoulder and elbow mechanics and reduce abnormal stresses on the tendons and muscles of the upper extremity. As for Tennis Elbow itself, often strength training will cause more tightness and subsequently overload the tendon and make it worse. This overuse injury does well with soft tissue techniques and laser techniques and by decreasing inflammation first, strengthening movements may then be possible.   Everyone should strive to develop their bodies so that they can live a long and healthy life. This is especially important after you have suffered an injury or are unable to be as active while you were rehabilitating. All of our staff have a combination of health sciences and sports sciences training, having dual training in both kinesiology and physiotherapy and allowing us to provide a biomechanical focus at healthfx. We focus on:  
  • Biomechanics of human movement
  • Posture and alignment (static and dynamic)
  • Ergonomics and workplace
  • Functional movement screens and analysis to identify individual muscle imbalances
  We start with a functional movement screen that looks at some of the essential movement skills for daily living and also for an activity based lifestyle. This information in addition to our previous orthopaedic assessment findings will allow us to develop a personal improvement plan just for you. This plan will have specific goals, be measurable, will call you to action, will be realistic, and will be time sensitive so that you will see progress and we will monitor and support your success from a medically based standpoint and from a sports science stand point.    

How can low intensity laser therapy help with rotator cuff tendonitis?

Low Intensity Laser Therapy (LILT) is the use of monochromatic light. Meditech Bioflex has been producing this technology for 20 years and has an extensive in house clinical lab.   The light source is placed in contact with the skin allowing the photon energy to penetrate tissue, where it interacts with various intracellular biomolecules resulting in the restoration of normal cell morphology and function. This process also enhances the body's natural healing propensities.   Low Intensity Laser Therapy does not heat or cut tissue. Unlike many pharmacological treatments that mask pain or only address the symptoms of the disease, Laser Therapy treats the underlying condition or pathology to promote healing. The technology utilizes superluminous laser diodes to irradiate diseased or traumatized tissue with photons. These particles of energy are selectively absorbed by the cell membrane and intracellular molecules, resulting in the initiation of a cascade of complex physiological reactions, leading to the restoration of normal cell structure and function.   The process is curative and therefore results in the elimination of symptoms including pain. In addition, it enhances the body’s immune system response and facilitates natural healing. The therapy is completely safe and has no adverse side effects. The technology is highly effective in the treatment of musculoskeletal conditions, arthritis, sports injuries, wound healing and a wide range of dermatological conditions. Whiplash injury typically involves injury to muscles, ligaments, and joints and typically involve several levels and a more wide spread area of injury due to the force full nature of the injury. Muscles of the neck, although short, cross over several joints and so the discomfort is generally more global initially. Laser therapy directed by multiple diodes are able to reach these tissues.    

Physiological effects of Low Intensity Laser Therapy

With LILT there is an increased production and release of:  
  • Endorphins which - natural analgesics
  • Cortisol – a precursor of cortisone
  • Growth hormone – instrumental in tissue repair
  • ATP – improves and regulates cellular metabolism
  • An increase in protein synthesis – collagen, DNA, fibroblasts
  • A facilitated venous and lymphatic flow
  • Increased angiogenesis – the elevation of oxygen saturation
  • Enhanced immune response
  These responses are some of the many processes that accelerate cellular regeneration (cartilage, epithelium) and restore normal cell morphology and function. Treatments are typically 25 minutes to over 1 hour depending on the condition and area being treated   The most popular technical / clinical information requested is available on the Meditech website under Laser Reports. You may visit the Meditech website research section directly for detailed abstracts, case profiles and articles on a variety of topics relating to the use of low intensity laser therapy in the treatment of various medical conditions.  

What life style and self-care measures can you do for yourself to relieve rotator cuff tendonitis?

A minor injury often heals on its own, with proper care. If you think you've injured your rotator cuff, try these steps:  
  • Rest your shoulder. If you have any symptoms, stop doing what caused the pain and try to avoid painful movements. Limit heavy lifting or overhead activity until your shoulder pain subsides.
  • Keep your muscles strong. This is the most important preventative measure for rotator cuff injury. Think of your rotator cuff as you do your core muscles, they are essentially the core stabilizers to the shoulder. Without rotator cuff stability, you are at risk to your neck, shoulder and upper back.  If you've had a rotator cuff injury in the past, daily shoulder stretches and a shoulder-strengthening program are essential, if you have not, your physiotherapist will perform this test during your functional movement screen. Especially important is a program of strength exercise to promote balanced strength about the shoulder. Most people exercise the front muscles of the chest, shoulder and upper arm, but it is equally important to strengthen the muscles in the back of the shoulder and around the shoulder blade.
  • Apply ice and heat. Putting ice on your shoulder helps reduce inflammation and pain. Use a cold pack, a bag of frozen vegetables or a towel filled with ice cubes for 15 to 20 minutes at a time. Do this every couple of hours the first day or two. After about two or three days, when the pain and inflammation have improved, hot packs or a heating pad may help relax tightened and sore muscles.
  • Doctor and Physiotherapist. See your doctor for pain relief and your physiotherapist to treat the underlying causes. Over-the-counter (OTC) nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen (Advil, Motrin, others) or naproxen (Aleve), may help reduce pain. Acetaminophen (Tylenol, others) also may help relieve pain.
   

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