Patient education: Rotator cuff tendinitis and tear (Beyond the Basics)

ROTATOR CUFF INJURY OVERVIEW — Tendons are tough bands of tissue that connect muscles to bones. Repetitive activities and overuse can injure tendons and lead to pain and impaired function. This is called tendinitis or tendinopathy. Although the most common cause of tendinitis is overuse, it can also be caused by other conditions.

Tendinitis is a common problem more likely to occur as people age. Tendinitis (or tendinopathy, as it is often called) is also more prevalent in people who routinely perform activities that require repetitive movement that increase stress on susceptible tendons. Rotator cuff disease is the most common cause of shoulder pain, particularly in people over age 30. Treatment focuses on resting the injured tendon to allow healing, decreasing inflammation, and correcting imbalances that caused stress on the injured area. In most people, tendinitis resolves with treatment. In some cases, it goes away without treatment.

Tendinitis can affect many different tendons in the body. Other types of tendon injury are discussed separately. (See "Patient education: Biceps tendinitis or tendinopathy (Beyond the Basics)" and "Patient education: Elbow tendinopathy (tennis and golf elbow) (Beyond the Basics)".)

WHAT IS THE ROTATOR CUFF? — The rotator cuff is composed of four muscles, each of which has a tendon that attaches to the upper arm bone (the humerus):

●Supraspinatus

●Infraspinatus

●Teres minor

●Subscapularis

These tendons form a cuff around the head of the humerus (figure 1A-C). These tendons attach to the front and side of the humerus and the greater and lesser tubercles (part of the upper humerus). The muscles associated with these tendons are located in the upper back, where they are attached to the shoulder blade (scapula).

There are four rotator cuff muscles that work together through co-contractions to control and stabilize the humeral head (the ball portion of the ball and socket) as you move your arm. Each muscle works independently. The most important and most vulnerable component of the rotator cuff is the supraspinatus tendon, which is essential for lifting the arm. The infraspinatus and teres minor rotate the arm outward, while the subscapularis rotates the arm inward.

Rotator cuff tendinitis — Rotator cuff tendinitis (or tendinopathy) occurs when the tendons are injured, usually as a result of repetitive overhead reaching, pushing, or lifting with outstretched arms. Athletes who perform overhead activity, such as swimming, tennis, throwing, golf, weightlifting, volleyball, and gymnastics, are also at risk. Tendinitis is usually treated with relative rest (avoiding aggravating activities), ice, antiinflammatory drugs, and physical therapy. (See 'Rotator cuff injury treatment' below.)

Rotator cuff tear — The rotator cuff tendon(s) may be torn as a result of injury, chronic tendinopathy, or a combination of both. Typically, the injury is caused by a fall, direct blow, or a rapid use of force (pulling on a starter cable, for instance).

The first task when treating a torn rotator cuff is to identify the major factors that contributed to the injury. This is done by taking a careful history and performing a biomechanical assessment and physical examination. Based on the results, an individualized treatment plan is designed. Interventions may include:

●Ergonomic adjustments (eg, placing monitors, keyboards, and chairs at appropriate heights)

●Postural retraining – Education and training to improve sitting, sleeping, and standing postures

●Mobility/flexibility interventions – Exercises for the thoracic spine, scapulothoracic joint, glenohumeral joint, and cervical spine as needed to improve shoulder mechanics

●Strengthening and stability exercises to restore balance and coordination to the shoulder complex

●Treatment of any underlying pathological tissue with manual therapy or other modalities (may include: cross friction massage, instrument-assisted soft tissue mobilization [IASTM], taping, ice/heat, nonsteroidal antiinflammatory drugs [NSAIDs], injection, dry needling)

Conservative treatment is adequate in the large majority of people, although younger people with a medium- to large-sized tear, particularly affecting the dominant arm, may be candidates for surgical repair. Surgery may also be recommended for older people who have significant pain related to a rotator cuff tear. (See 'Surgical repair of rotator cuff tears' below.)

People with small- to medium-sized tears usually improve with physical therapy exercises, stopping painful activities, and, in some cases, injection of a steroid. If shoulder strength and function do not improve after completing three to six months of physical therapy, surgical repair may be considered.

ROTATOR CUFF INJURY SYMPTOMS

Tendinitis — People with rotator cuff tendinitis typically complain of shoulder pain at the tip of the shoulder and the upper, outer arm. Specialists often refer to tendinitis as tendinopathy or tendinosis. Tendons subjected to overuse may be appropriately called tendinitis initially but with chronic overuse evolve to a painful tendinopathy or tendinosis lacking inflammation. The pain is often aggravated by reaching, pushing, pulling, lifting, positioning the arm above the shoulder level, or lying on the side. Painful daily activities may also include putting on a shirt or brushing hair. The pain may prevent comfortable sleep or awaken a person from sleep, particularly if he or she sleeps on or rolls onto the shoulder.

Tear — Symptoms of rotator cuff tear nearly always include weakness in the specific muscle-tendon unit and may include pain in the shoulder, although some people have few or no symptoms. In addition, the severity of the tear does not necessarily correlate with the severity of a person's pain; in other words, a person with a partial tear may have severe pain while a person with a complete tear may have little or no pain.

ROTATOR CUFF INJURY TESTS — The diagnosis of rotator cuff tendinitis or tear is usually based upon a careful medical history, the person's symptoms, and a physical examination. Again, as inflammation is seldom involved in these injuries, particularly if more than 36 hours have passed since the inciting event, most experts prefer the terms "tendinopathy" or "tendinosis" to the term "tendinitis."

To differentiate rotator cuff tendinitis from tear, some health care providers may inject the shoulder joint with a local anesthetic. In people with tendinopathy, the anesthetic relieves pain, and muscle strength is usually normal. In people with a full thickness tear, the anesthetic relieves the pain, but muscle function does not improve.

In most cases, radiographs and other imaging tests are not needed to diagnose tendinopathy. However, if the person's symptoms do not improve after a course of conservative treatment, an imaging test (eg, radiograph, ultrasound, and/or magnetic resonance imaging [MRI]) may be recommended. Radiographs do not typically diagnose a rotator cuff tear but are useful for identifying alternative conditions such as calcific tendinopathy or joint wear from arthritis. Ultrasound or MRI can be used to confirm the rotator cuff diagnosis.

If the pain or weakness does not improve, or if a large tear is confirmed with an imaging test, most people are referred to a specialist (orthopedic surgeon) for further evaluation and management. (See 'Surgical repair of rotator cuff tears' below.)

ROTATOR CUFF INJURY TREATMENT — Treatment of rotator cuff injuries focuses on decreasing pain and swelling of the tendon, preserving or restoring normal range of motion, strengthening muscles important to shoulder function, and restoring normal shoulder mechanics. The first goal of treatment is to preserve the ability to move the shoulder. In many people, a decreased ability to move the shoulder means that they use the joint less frequently, which can further reduce range of motion and lead to a frozen shoulder. (See "Patient education: Frozen shoulder (Beyond the Basics)".)

There are two basic options for treatment: conservative, non-surgical treatments and surgery. Conservative treatment is discussed here while surgical treatment is discussed later. (See 'Surgical repair of rotator cuff tears' below.)

Conservative treatment usually includes:

Ice — Ice can be used to reduce the inflammation that often occurs in rotator cuff injuries. Ice can be applied over the upper and outer portion of the shoulder muscle for 15 to 20 minutes every four to six hours. The response to ice is variable since the rotator cuff tendons are located deep within the shoulder.

Rest — Rest means avoiding activities that aggravate symptoms, including overhead activities that elicit symptoms. Avoiding painful activities in general will alleviate strain on the injured area. These activities vary depending on the tendon that is irritated, but examples may include lifting, overhead reaching, and reaching behind (eg, reaching into the back seat or putting on a coat). It is safest to keep the arm down, in front of and close to the body. Use of an arm sling is not recommended because this may lead to a frozen shoulder.

Some general rules to decrease shoulder strain with activities include:

●Lift objects close to the body.

●Only lift light weights and limit lifting to below shoulder level.

●Do sidestroke or breaststroke when swimming.

●Throw balls underhand or sidearm.

●Avoid pushing exercises at the gym (eg, pushups, bench press, flies, shoulder press).

●Do not serve overhand in tennis.

●Maintain good posture with writing, assembly work, and other tasks by focusing on maintaining a tall spine, ribs down, and shoulders down and back.

Reduce inflammation — A nonsteroidal antiinflammatory drug (NSAID; eg, ibuprofen or naproxen) is often used to reduce pain and inflammation. The dose of medication needed to reduce inflammation is higher than that recommended for pain relief. You should check with your health care provider before using high-dose NSAIDs. (See "Patient education: Nonsteroidal antiinflammatory drugs (NSAIDs) (Beyond the Basics)".)

Heat and massage — Heat and massage help prepare the tissues for range of motion exercises and are recommended before performing these exercises. The best method to warm the tissues is to take a warm shower or bath for 10 to 15 minutes. Local heat (eg, with a moist heating pad or a hot pack warmed in a microwave) is an alternative, although local heat is generally not as effective because of the deep location of the rotator cuff tendons.

Light massage to the surrounding tissues is a very effective way to prepare the area for range of motion and strength exercises.

Stretching and range of motion exercises — Range of motion exercises are recommended early in the recovery period to help maintain joint mobility and flexibility of the muscles and tendons in the shoulder. Stretching exercises should generally be performed once per day every day.

Exercises should not cause more than a mild level of pain. If you experience pain, decrease the intensity of the stretch or the number of repetitions; anyone who feels sharp or tearing pain should stop exercising immediately and consult with their health care provider.

Pendulum stretch — The pendulum stretching exercise helps to stretch the space in which the tendons pass and helps to prevent the development of a frozen shoulder. This exercise can be started almost immediately after a shoulder injury or after receiving a steroid injection into the shoulder joint. The exercise is performed as follows (figure 2):

●Relax your shoulder muscles.

●While standing or sitting, keep your arm vertical and close to your body (bending over too far may pinch the rotator cuff tendons).

●Allow your arm to slowly swing forward to back, then side to side, then in small circles in each direction (no greater than 1 foot in any direction). Only minimal pain should be felt.

●Stretch the arm only (without added weight) for three to seven days. Increase the stretch by adding 1 to 2 pounds (0.5 to 1 kg) per week and gradually increase the diameter of the movements (not to exceed 18 to 24 inches/45 to 60 cm).

Pulley exercise

●Forward flexion (using a pulley with a 1.5- to 2-pound (0.5 to 1 kg) weight attached to one handle) – Sitting with back to the door, allow the pulley to lift the involved arm upward within a pain-free range of motion slowly and painlessly for two minutes using slow, steady movement (two to three seconds to raise and two to three seconds to lower the weight) (picture 1). Motion must be kept within a pain-free range. Discontinue the exercise if pain develops.

Wand exercises — The goal of this exercise is to fully extend the arm at shoulder height, 90 degrees from the body. You will need a long wooden rod (or broomstick).

●Hold the end of the rod with the hand on the injured side (left in this example) as the opposite hand (right in this example) holds the rod in the middle (picture 2).

●Use the right hand to guide the rod so that the left arm is extended away from the body until the left hand is at approximately shoulder height (or lower, if pain is felt). Keep the left arm straight at all times.

●Slowly lower the left arm until it is next to the body. Rest as needed and repeat 15 to 20 times (this is one set) each day.

To vary the stretch, use the rod to direct the hand in front of the body (no higher than shoulder height) and slightly behind the body. Do not proceed if this stretch causes pain.

Once you are able to fully extend the arm at shoulder height, you can try a modified version of this same exercise:

●Start by lying on your back, holding the rod against the abdomen with both elbows straight and hands shoulder-width apart.

●Keeping elbows straight, lift arms up to shoulder height while keeping shoulder blades squeezed down and back together.

●Return wand to rest on abdomen.

Perform 5 to 10 repetitions (this is one set), lifting the wand to 90 degrees (shoulder height), then, if there is no pain, move the wand slowly through a full range of motion (over the head). Pause for two to three seconds at the end of each repetition. When you can perform a set of 10 repetitions through a complete range of motion without pain, you can increase to two sets.

Posterior capsule stretching — Tightness in the ligaments/capsule of the shoulder can develop in people with rotator cuff injuries. This tightness can contribute to further movement abnormalities and pain in the shoulder. Tightness is caused by any of the following:

●Injury to the shoulder including rotator cuff strains, partial tears, or tears

●Poor posture (forward shoulder posture)

●History of repetitive throwing or racquet sports

●Guarded movement, as when protecting the shoulder

Although the posterior capsule is most effectively stretched passively by a skilled professional, one way you can stretch this area yourself is the cross-arm stretch:

●Reach your affected arm across your body at chest height. Use your other hand to pull your arm closer to your body (picture 3). Hold for 30 seconds. You can do this regularly throughout the day.

Rotator cuff strength and function exercises — Rotator cuff strength and coordination exercises help to restore functional use of the arm and prevent future injury. You can begin performing such exercises as long as they can be done without pain. Consult with your provider or physical therapist to determine when to begin strengthening exercises.

As pain improves, the level of difficulty of these exercises should be increased. Increased difficulty is necessary to improve shoulder strength and control to a degree that reduces the risk of reinjury. Mild soreness is expected with these exercises, although pain should not continue for more than 24 hours. Sharp or severe pain during or after exercising may indicate a flare of the underlying problem; stop these exercises for a few days if this occurs.

Preparing for strengthening exercises — Before performing strength exercises, we suggest that the emphasis of therapy be on restoring maximal mobility of the shoulder. Stretch the injured shoulder with the pendulum stretch or wand exercises, which are described above. (See 'Pendulum stretch' above.)

Rest after stretching for two or three minutes, then perform repetitions as outlined below. Flexible rubber tubing, a bungee cord, or a large rubber band can be used for each exercise (figure 3).

Do not perform ANY exercise below if you experience acute discomfort or pain in the shoulder. Strengthening exercises should not cause ANY sharp or severe pain while they are performed.

Scapular squeezes — Lie on your back with your knees bent and feet flat (picture 4). Your arms should be straight out, 6 to 12 inches (15 to 30 cm) away from the side of your body, with palms facing upward. Keeping your low back flat against the ground, squeeze your shoulder blades downward and towards each other, towards the spine. Make a conscious effort not to shrug your shoulders and keep the neck relaxed. You should feel the lower muscles between your shoulder blades contracting. Hold for five seconds. Rest as needed, then repeat 10 to 15 times. Do this exercise two to three times per day.

The difficulty can be increased by performing the squeezes while sitting. Hold a piece of tubing in each hand and pull the hands apart while squeezing the shoulder blades together, as described above.

Quadruped (all fours) elbow taps — Assume a position on all fours (weight on arms and legs), keeping a flat back with palms flat on the ground and elbows straight (movie 1). Remove the non-involved arm and place that hand on your opposite elbow without losing the position of the trunk and spine or arm and shoulder that are maintaining proper body position. Hold this position for five to eight seconds. Return the hand to the ground and pause three to five seconds. Repeat this exercise for five to eight repetitions on each side. You should feel the arm that holds the body up as well as your trunk. To make this exercise easier, you can rock a bit back toward your legs to remove some of the weight from your arms.

Outward rotation exercise — Hold your elbows at 90 degrees, close to your sides; holding a towel between your torso and the inside of your elbow will cue you to keep your elbow by your side. Hold one end of a long rubber band (eg, Theraband) in each hand and rotate the affected forearm outward two or three inches, holding for five seconds (picture 5). Repeat 10 to 15 times.

Perform the exercise through all available pain-free ranges of motion. Keep the shoulder blades squeezed down and back while performing this exercise.

Inward rotation exercise — Hold your elbow at 90 degrees, close to your side. Hook a rubber band (eg, Theraband) onto a door handle and grasp with only one hand. Rotate your forearm towards the body two or three inches and hold for five seconds (picture 6). The forearm swings like a door. Repeat 10 to 15 times.

Abduction exercise — Bend your elbow to 90 degrees. Place the rubber band near the elbows. While keeping your shoulder blades squeezed down and backwards, lift your arms up four or five inches away from the body, holding for five seconds (picture 7). Repeat 10 to 15 times. Avoid shrugging the shoulders while performing this movement.

Scapular strengthening — For these exercises, you should lie face down on an elevated surface, like a bed, exercise bench, or large exercise ball. Alternatively, a quadruped (all fours) position may be used, in which case and the trunk and shoulder positions are maintained with the non-moving arm while the other performs the Y, T, W, and L exercises. The head should be held in line with the body, hanging over the edge of the bed or bench. Let the arms rest below the body. Extend the arms next to the head to form a "Y"; make sure your thumbs are facing up (picture 8). Hold the position for a second or two, then let the arms return to the floor. Repeat 10 to 15 times. Movements should be steady, smooth, and pain free.

Using the same body position, squeeze your shoulder blades down and backwards towards the spine while moving the arms to form a "T." Raise the arms straight out to each side, parallel to the floor (picture 9). This can be done with the thumbs up or down. Hold for a second or two, then return the arms to the starting position; repeat 10 to 15 times.

Position the arms to form a "W." Hold the arms bent with elbows pointed towards the feet and hands pointed towards the head (picture 10). Squeeze the shoulder blades and raise the arms until they are parallel with the floor, hold for a second or two, then return arms to the starting position; repeat 10 to 15 times.

Position the arms to form an "L." Hold arms bent with upper arms parallel to the floor and hands pointed towards the floor (picture 11). Rotate the arms such that the forearms become parallel with the floor. Hold for a second or two, then return to the starting position; repeat 10 to 15 times.

To increase the difficulty of these exercises, increase the number of repetitions to 20 to 30 times. Using one-pound weights can further increase the difficulty.

Maintenance exercises — Once rehabilitation is complete, it is important to keep the shoulder muscles strong to maintain fitness and prevent a recurrence of pain. Non-athletes may continue to perform the exercises.

Athletes may perform exercises that are similar to those required in their sport. As examples, a tennis player may perform a service-type motion using a five-pound dumbbell, while a pitcher may perform a throwing motion using a three-pound dumbbell.

Anyone who performs frequent overhead activities needs to maintain strong shoulder blades and rotator cuff muscles to prevent overuse injuries of these areas. These muscles are essential in preventing aggravation to the tendons.

Return to activities — Most people with rotator cuff tendinitis see improvement in pain and function after 6 to 12 weeks of rehabilitation.

IF PAIN PERSISTS — If shoulder pain does not improve after several weeks of physical therapy exercises, most clinicians will recommend further evaluation. (See 'Rotator cuff injury tests' above.)

If tendinitis is confirmed with an imaging study, some clinicians will inject a steroid/local anesthetic mixture into the joint. Although clinical studies of steroid injections do not show that the injection is helpful in all cases, some people do benefit. The injection benefit is usually temporary, which may be helpful to facilitate therapy efforts. In these people, pain and inflammation may improve quickly, usually within a few days.

OTHER NONSURGICAL TREATMENTS — Manual therapy, shockwave therapy, and taping have shown modest benefit over placebo. Newer treatments such as topical nitroglycerin and platelet-rich plasma injections may play a role in nonsurgical management, but further research is needed before making definitive recommendations for these treatments.

If you have another cause for your pain (eg, rotator cuff tear, nerve impingement), you will usually be referred to an orthopedic surgeon for further evaluation and treatment.

SURGICAL REPAIR OF ROTATOR CUFF TEARS — The need to surgically repair a torn rotator cuff depends upon your age, activity level, and the severity of your tear (see 'Rotator cuff tear' above):

●Surgical repair is usually recommended for people with a complete rotator cuff tear, especially if the person is young and/or active. Surgery is usually recommended soon after the injury, if possible, to prevent the tendon and muscle from shrinking.

●Conservative treatment is usually recommended first if you do not have a complete rotator cuff tear or are older, less active, or if there is minimal pain. Conservative treatments (eg, stretching and strengthening exercises, injection of a steroid) are usually recommended first.

●Surgery may be recommended if you do not improve after stretching and strengthening exercises and you have persistent pain, limited strength, arthritis or spurs that cause pain and interfere with rehabilitation, or if a new injury occurs and you have a previous rotator cuff injury.

There are several ways to repair the rotator cuff, including open and arthroscopic techniques:

●Open repairs require a three- to four-inch incision in the skin over the shoulder.

●Arthroscopic surgery requires several (two or three) smaller incisions through which a telescope-like device with a camera and light (called an arthroscope) and other instruments are inserted.

The advantage of arthroscopic surgery is that there is usually less pain and a faster return to normal activities, including sports.

Most surgeries are performed in a hospital or surgical center, after you are given general anesthesia. The surgery takes one to two hours. Most people can go home several hours after the surgery is completed.

Return to activities — After surgical repair, most people require six months of rehabilitation before strength and shoulder function return to normal. Post-surgical rehabilitation is necessary, and use of the shoulder must be limited. Immediately after surgery, you will be allowed to use the affected arm with your elbow at your side for eating, using the keyboard, using the telephone, and driving. Above-the-shoulder activities are not usually allowed for three months after surgery.

Sporting activities can be gradually restarted, including golfing at four months, light weightlifting at four months, swimming at five months, and throwing and tennis playing at five to six months.

WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials:

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Rotator cuff injury (The Basics)
Patient education: Biceps tendinopathy (The Basics)
Patient education: Frozen shoulder (The Basics)
Patient education: Elbow tendinopathy (tennis and golf elbow) (The Basics)
Patient education: Shoulder impingement (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Biceps tendinitis or tendinopathy (Beyond the Basics)
Patient education: Elbow tendinopathy (tennis and golf elbow) (Beyond the Basics)
Patient education: Frozen shoulder (Beyond the Basics)
Patient education: Nonsteroidal antiinflammatory drugs (NSAIDs) (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Evaluation of the adult with shoulder complaints
Frozen shoulder (adhesive capsulitis)
Presentation and diagnosis of rotator cuff tears
Rotator cuff tendinopathy

The following organizations also provide reliable health information:

●National Library of Medicine

     (https://medlineplus.gov/healthtopics.html)

●American Academy of Orthopaedic Surgeons

     (http://orthoinfo.aaos.org/)

●National Institute of Arthritis and Musculoskeletal and Skin Disease

     (www.niams.nih.gov)

●American Physical Therapy Association

     (www.apta.org)

●Arthritis Foundation

     (www.arthritis.org)

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