What is Shoulder Tendonitis?
(aliases: tendinitis, tendinopathy)
Shoulder tendonitis (or tendinitis) is an inflammation injury to the tendons of your shoulder's rotator cuff. Because inflammation is not always present in injuries to the shoulder tendons, this group of injuries are medically known as a rotator cuff tendinopathy or tendinopathies.
What Causes Shoulder Tendonitis?
The most common cause of shoulder tendonitis is repeated microtrauma to the rotator cuff tendons rather than a specific one-off trauma.
Rotator Cuff Impingement, where your rotator cuff tendon impacts against the acromion bone, should not occur during normal shoulder function. However, when repeated shoulder impingement occurs, your rotator cuff tendon becomes inflamed and swollen, a condition called shoulder tendonitis.
Shoulder bursitis commonly occurs in combination with rotator cuff tendonitis.
What are the Symptoms of Shoulder Tendonitis?
Shoulder tendonitis commonly has the following symptoms:
- Shoulder clicking and/or an arc of shoulder pain when your arm is about shoulder height.
- Pain when lying on the sore shoulder or lifting with a straight arm.
- Shoulder pain or clicking when move your hand behind your back or head.
- Shoulder and upper arm pain (potentially as far as your elbow).
- As your shoulder tendonitis deteriorates, your shoulder pain may even be present at rest.
How is Shoulder Tendonitis Diagnosed?
Your physiotherapist or sports doctor will suspect shoulder tendonitis based on your symptom history and some clinical tests.
An ultrasound scan is the preferred method of investigating a shoulder tendonitis and associated injuries such as shoulder bursitis.
X-rays do not identify shoulder tendonitis but can be useful to identify if bone spur encroachment (see picture) into the subacromial space is causing your tendonitis.
What the Prognosis for Shoulder Tendonitis?
Shoulder tendonitis is a progressive disorder that often co-exists with shoulder bursitis or bicipital tendonitis and can deteriorate into calcific tendonitis or rotator cuff tears, which may require surgery, with neglect or poor treatment.
The good news is that most shoulder tendonitis is reversible and very successfully treated.
Due to shoulder impingement being the primary cause of your shoulder tendonitis it is vital to thoroughly assess and correct your shoulder biomechanics to prevent future shoulder impingement episodes and subsequent rotator cuff tendonitis.
Shoulder Tendonitis Treatment
Researchers have concluded that there are essentially 7 stages that need to be covered to effectively rehabilitate shoulder tendonitis and prevent recurrence. These are:
Phase 1 - Early Injury Protection: Pain Relief & Anti-inflammatory Tips
As with most soft tissue injuries the initial treatment is Rest, Ice, and Support.
In the early phase you’ll most likely be unable to fully lift your arm or sleep comfortably. Our first aim is to provide you with some active rest from pain-provoking postures and movements. This means that you should stop doing the movement or activity that provoked the shoulder pain in the first place and avoid doing anything that causes pain in your shoulder.
Ice is a simple and effective modality to reduce your pain and swelling. Please apply for 20-30 minutes each 2 to 4 hours during the initial phase or when you notice that your injury is warm or hot.
Anti-inflammatory medication (if tolerated) and natural substances eg arnica may help reduce your pain and swelling. However, it is best to avoid anti-inflammatory drugs during the initial 48 to 72 hours when they may encourage additional bleeding. Most people can tolerate paracetamol as a pain reducing medication.
To support and protect your tendon injury, you may need to be wear a sling or have your shoulder taped to provide pain relief. In some cases it may mean that you need to sleep relatively upright or with pillow support. Your physiotherapist will guide you.
Your physiotherapist will guide you and utilise a range of pain relieving techniques including joint mobilisations, massage, acupuncture or dry needling to assist you during this pain-full phase.
Phase 2: Regain Full Range of Motion
If you protect your injured shoulder tendons appropriately the injured tissues will heal. Inflammed structures eg (tendonitis, bursitis) will settle when protected from additional damage.
Shoulder tendonitis may take several weeks to heal while we await Mother Nature to form and mature the new scar tissue, which takes at least six weeks. During this time period you should be aiming to optimally remould your scar tissue to prevent a poorly formed scar that may become lumpy or potentially re-tear in the future.
It is important to lengthen and orientate your healing scar tissue via joint mobilisations, massage, muscle stretches, and light active-assisted and active exercises. Researchers have concluded that physiotherapist-assisted joint mobilisations will improve your range of motion quicker and, in the long-term, improve your functional outcome.
In most cases, you will also have developed short or long-term protective tightness of your joint capsule (usually posterior) and some compensatory muscles. These structures need to be stretched to allow normal movement.
Signs that your have full soft tissue extensibility includes being able to move your shoulder through a full range of motion. In the early stage, this may need to be passively (by someone else) eg your physiotherapist. As you improve you will be able to do this under your own muscle power.
Your physiotherapist will guide you.
Phase 3: Restore Scapular Control
Your shoulder blade (scapula) is the base of your shoulder and arm movements. Your shoulder blade has a vital role as the main dynamically stable base plate that attaches your arm to your chest wall.
Normal shoulder blade-shoulder movement - known as scapulohumeral rhythm - is required for a pain-free and powerful shoulder function. Researchers have identified poor scapulo-humeral rhythm as a major cause of rotator cuff impingement. Any deficiencies will be an important component of your rehabilitation.
Your physiotherapist is an expert in the assessment and correction of your scapulohumeral rhythm. They will be able to help you to correct you normal shoulder motion and provide you with scapular stabilisation exercises if necessary.
Phase 4: Restore Normal Neck-Scapulo-Thoracic-Shoulder Function
You may find it difficult to comprehend, but your neck and upper back (thoracic spine) are very important in the rehabilitation of shoulder pain and injury.
Neck or spine dysfunction can not only refer pain directly to your shoulder, but it can effect a nerve’s electrical energy supplying your muscles cause weakness. Painful spinal structures from poor posture or injury doesn’t provide your shoulder or scapular muscles with a solid pain-free base to act upon.
In most cases, especially chronic shoulders, some treatment directed at your neck or upper back will be required to ease your pain, improve your shoulder movement and stop pain or injury returning.
Your physiotherapist will assess your neck and thoracic spine and provide you with the necessary treatment as required.
Phase 5: Restore Rotator Cuff Strength and Function
Your rotator cuff is the most critical group of shoulder control and stability muscles. Among other roles, your rotator cuff maintains “centralisation” of your shoulder joint. In other words, it keeps the shoulder ball centred over the small glenoid socket. This prevent impingement and dislocation injuries.
Your rotator cuff also provides the subtle glides and slides of your shoulder’s ball joint on the glenoid socket to allow full shoulder movement.
It may seem odd that you don’t attempt to restore the strength of your rotator cuff until a later stage in the rehabilitation. However, if a tendon structure is injured we need to provide nature with an opportunity to undertake primary healing before we load the structures with resistance exercises.
Having said that, researchers have discovered the importance of strengthening the rotator cuff muscles in a successful shoulder tendonitis rehabilitation program. Your rotator cuff exercises need to be progressed in both load and position to accommodate for your specifically injured rotator cuff tendon(s) and whether or not you have a secondary condition such as bursitis.
Your physiotherapist will prescribe the most appropriate rotator cuff strengthening exercises for you.
Phase 6: Restore High Speed, Power, Proprioception & Agility
If your shoulder tendonitis has been caused by sport it is usually during high speed activities, which place enormous forces on your body (contractile and non-contractile), or repetitive actions.
In order to prevent a recurrence as you return to sport, your physiotherapist will guide you with exercises to address these important components of rehabilitation to both prevent a recurrence and improve your sporting performance.
Depending on what your sport or lifestyle entails, a speed, agility, proprioception and power program will be customised to prepares you for light sport-specific training.
Phase 7: Return to Sport or Work
Depending on the demands of your chosen sport or your job, you will require specific sport-specific or work-specific exercises and a progressed training regime to enable a safe and injury-free return to your chosen sport or employment.
Sports that involve overhead arm positions such as racquet sports, throwing, bowling or swimming have high incidences of shoulder tendonitis. Your technique should ideally be assessed by your shoulder physiotherapist and/or sports coach.
The perfect outcome will have you performing at full speed, power, agility and function with the added knowledge that a through rehabilitation program has minimised your chance of future injury.