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Rotator Cuff Tendonitis
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Contents
Other Names
- Subacromial Bursitis
- Subacromial Impingement Syndrome
- Rotator Cuff Tendinitis
- Rotator Cuff Tendinopathy
- Shoulder Impingement Syndrome
- Partial Rotator Cuff tear
Background
- This page describes tendinopathies of the Rotator Cuff (RC)
- Because it is clinically indistinguishable from subacromial bursitis and impingement syndrome, those entities are also discussed here
- Additionally, partial rotator cuff tears also land on this spectrum of disease but are generally discussed on the Rotator Cuff Tear page
Epidemiology
- Most common cause of shoulder pain, accounting for up to 50% of cases[1]
- Incidence ranges from 0.3% to 5.5%[2]
- Prevalence from 0.5% to 7.4%
- Up to 14% of the working population may have symptomatic RC tendinopathy[3]
Pathophysiology
Etiology
- Extrinsic[4]
- Anatomic variations of the Acromion causing irritation to the superior aspect of the rotator cuff
- Thickened Coracoacromial Ligament
- Postural abnormalities
- Intrinsic
- Alterations in tendon vascularity, physiology or mechanical properties have been proposed
- Age-related degeneration
- History of trauma
Pathoanatomy
- Rotator Cuff Muscles
- Other Relevant Structures
- Subacromial Bursa
- Long head of the Biceps Brachii
- Function
- Dynamic stability of glenohumeral joint in coronal, transverse plane
Associated Injuries
Risk Factors
- Sports
- Overhead athletes
- Throwing sports
- Anatomic
- Type III or II acromions
- Previous shoulder injury or trauma
- Increased age
- Occupational[5]
- Overhead or above shoulder work
- House painting
- Carpentry
Differential Diagnosis
- Fractures
- Proximal Humerus Fracture
- Humeral Shaft Fracture
- Clavicle Fracture
- Scapula Fracture
- First Rib Fracture (traumatic or atraumatic)
- Dislocations & Separations
- Arthropathies
- Muscle & Tendon Injuries
- Rotator Cuff
- Bursopathies
- Ligament Injuries
- Neuropathies
- Other
- Pediatrics
- Coracoid Avulsion Fracture
- Humeral Head Epiphysiolysis (Little League Shoulder)
Clinical Features
- History
- Patients will most commonly report atraumatic shoulder pain
- Location is typically lateral or anterior, but can be nonspecific
- Worse at night
- Worse with overhead activity
- Often a history of repetitive overhead activity, less commonly acute
- Other symptoms can include clicking, popping
- Physical: Physical Exam Shoulder
- Observe for any asymmetry in musculature of the scapula
- Tenderness to rotator cuff insertion along proximal humerus
- Special Tests
- Rent Test: Can demonstrate defect with passive extension
- Hawkins Test: Shoulder and elbow flexed to 90°, internally rotated
- Neers Test: Shoulder flexed to 90°, thumb pointed towards floor and flexed against resistance
- Yocums Test: Place hand of affected arm on opposite shoulder, elevate arm
- Supraspinatus
- Drop Arm Test: Arm is passively abducted and slowly allowed to return to a neutral position
- Painful Arc Test: Painful active abduction and adduction
- Jobes Test: Similar to empty can test
- Empty Can Test: Shoulder flexed to 90°, thumb pointed towards floor and flexed against resistance
- Full Can Test: Similar to empty can but with external rotation
- Infraspinatus/ Teres Minor
- External Rotation Lag Sign: Hold arm in internal rotation, observe for lag
- Hornblowers Sign: Inability to maintain arm in 90° elbow flexion and 90° shoulder abduction
- Subscapularis
- Lift Off Test: Arm placed behind back, lift off against resistance
- Belly Press Test: Internally rotate arm, press against abdomen
- Internal Rotation Lag Sign: Hold arm in external rotation, observe for lag
Evaluation
Radiographs
- Start with Standard Radiographs Shoulder
- Typically normal, useful to exclude other causes of shoulder pain
MRI
- Useful in cases of suspected tear or unclear diagnosis
Classification
Neer Classification
- Stage I: edema and hemorrhage within the rotator cuff[6]
- Stage II: progression to fibrosis and thickening of the subacromial bursa and chronic supraspinatus tendinitis
- Stage III: partial or full-thickness tears of the rotator cuff and biceps tendon lesions
Management
- 46% of people improve with conservative therapy at 6 months, 77% at 18 months[7]
Nonoperative
- First line therapy
- Activity modification
- NSAIDS
- Low-to-moderate evidence they provide short term pain relief, no change in function[8]
- Similar efficacy to corticosteroid injections
- Corticosteroid Injections
- Short term benefit compared to placebo[9]
- Physical Therapy
- Multimodal (non-specific) therapy beneficial in medium and long term without any short-term benefit[9]
- Exercise
- Littlewood et al systematic review found exercise superior to placebo or no treatment[9]
- Manual Therapy: short term benefit when combined with exercise
- Acupuncture showed short term benefits compared to placebo[9]
- Not beneficial
- Unknown value
Operative
- Indications
- Failure of conservative treatment for a minimum of 6 months
- Technique
- Acromioplasty (sometimes referred to as subacromial decompression)
- Low-to-moderate quality evidence acromioplasty is no more effective than exercises for the treatment of RC tendinopathy[10]
- Bursectomy
- Radiofrequency (RF)-based microtenotomy
- Acromioplasty (sometimes referred to as subacromial decompression)
Rehab and Return to Play
Rehabilitation
- Needs to be updated
Return to Play
- Non-surgical
- After a period of relative rest, graduated RTP with throwing program
- Surgical
- Longer recovery period at discretion of surgeon
- Typically 6-12 months
- After surgical repair, overall rate of return found to be 84.7%[11]
- Overall athletes: 65.9% returned to equivalent level of play
- Professional athletes: 49.9% returned to same level of play
Complications
- Chronic pain
- Inability to return to sport
- Diminished strength, range of motion
See Also
- Internal
- External
- Sports Medicine Review Shoulder Pain: https://www.sportsmedreview.com/by-joint/shoulder/
References
- ↑ Tekavec E, Joud A, Rittner R, Mikoczy Z, Nordander C, Petersson IF, et al. Population-based consultation patterns in patients with shoulder pain diagnoses. BMC Musculoskelet Disord 2012; 13: 238.
- ↑ Littlewood, Chris, Stephen May, and Stephen Walters. "Epidemiology of rotator cuff tendinopathy: a systematic review." Shoulder & Elbow 5.4 (2013): 256-265.
- ↑ Adebajo A, Hazleman B. Soft tissue shoulder lesions in the African. Br J Rheumatol 1992; 31:275–6.
- ↑ Seitz AL, McClure PW, Finucane S, Boardman ND III, Michener LA (2011) Mechanisms of rotator cuff tendinopathy: intrinsic, extrinsic, or both? Clin Biomech 26(1):1–12
- ↑ 7. Bodin J, Ha C, Le Manac’h A, et al. Risk factors for incidence of rotator cuff syndrome in a large working population. Scand J Environ Health 2012; 38:436–46.
- ↑ 35. Neer, C. S., II. Impingement lesions. Clin. Orthop. 173:70-77, 1983.
- ↑ Bartolozzi, A., D. Andreychik, and S. Ahmad. Determinants of outcome in the treatment of rotator cuff disease. Clin. Orthop. 308:90-97, 1994.
- ↑ Boudreault, Jennifer, et al. "The efficacy of oral non-steroidal anti-inflammatory drugs for rotator cuff tendinopathy: a systematic review and meta-analysis." Journal of rehabilitation medicine 46.4 (2014): 294-306.
- ↑ 9.0 9.1 9.2 9.3 Toliopoulos, Panagiota, et al. "Efficacy of surgery for rotator cuff tendinopathy: a systematic review." Clinical Rheumatology 33.10 (2014): 1373-1383.
- ↑ Toliopoulos, Panagiota, et al. "Efficacy of surgery for rotator cuff tendinopathy: a systematic review." Clinical Rheumatology 33.10 (2014): 1373-1383.
- ↑ Klouche S, Lefevre N, Herman S, Gerometta A, Bohu Y. Return to sport after rotator cuff tear repair: a systematic review and metaanalysis. Am J Sports Med. 2016;44(7):1877–87. This recent analysis details the overall return-to-play in both professional and competitive athletes.
Created by:
John Kiel on 11 June 2019 01:34:06
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Last edited:
1 October 2022 19:09:39
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