Rotator Cuff Pain
The rotator cuff is a group of four muscles (supraspinatus, infraspinatus, teres minor, and subscapularis) and their tendons that attach the upper arm bone (humerus) to the shoulder blade (scapula). These muscles and tendons help to hold the humeral head against the shoulder socket (glenoid) and allow for a wide range of arm movements such as lifting, rotating, and reaching.
The tendons of the rotator cuff muscles are surrounded by a bursa, which is a fluid-filled sac that helps to reduce friction and provide cushioning. The rotator cuff tendons also pass through a narrow space called the subacromial space, and the most commonly injured rotator cuff tendon is supraspinatus.
Rotator cuff pain, sometimes known as subacromial pain, or shoulder impingement pain, is caused by inflammation and swelling of one or more of the rotator cuff tendons (known as tendinitis, or tendinopathy), but it can also occur of there is tearing of the tendons. Sometimes the subacromial bursa (a small fluid-filled sac which sits on top of the tendons) can be involved in rotator cuff pain.
The purpose of the subacromial bursa is to reduce friction and provide cushioning for the rotator cuff tendons as they pass through the subacromial space, and when the rotator cuff tendons become irritated, the bursa will also often become inflamed, known as a bursitis.
Shoulder bursitis is painful, and you’ll typically feel it on the outside of the upper arm – it may feel like it’s in your deltoid muscle. It can be very sensitive, and painful when lifting the arm out to the side, or when lying on your side at night.
What are the symptoms of rotator cuff pain, and what causes it?
Rotator cuff pain (aka subacromial pain, or shoulder impingement) is common.
You might experience pain on lifting your arm above your head or twisting it behind your back. Often it can hurt to put on your coat or your bra, and it can wake you at night-time. You might even feel that the arm is weak.
Rotator cuff tendinopathy is sometimes linked with conditions such as diabetes, or rheumatoid arthritis, but it’s most common in people who perform overhead activity, such as weightlifting, tennis, swimming, and CrossFit. Lots of unaccustomed loading of the tendons can cause rotator cuff tendinopathy, particularly if you’re returning to sport after time off (e.g., after pregnancy, or recovering from Covid).
Occasionally some people experience what’s known as calcific tendinopathy. This is when there is a rapid onset of severe pain, cause by calcium deposits being laid down in the supra or infraspinatus tendons. We don’t know why this happens to some people, but not others, but sometimes it’s linked to an autoimmune or metabolic condition, such as under-active thyroid.
Rotator cuff tears are another very common cause of pain, and as we age (and particularly once we’re over 50), these tears become increasingly common. Interestingly, small tears can cause a lot of pain for some people, whilst larger tears may only give mild symptoms for others.
A tear can be partial, or full, and some tears occur after a traumatic event (e.g. falling onto your outstretched hand), whilst others occur without trauma, and are probably degenerative in nature.
How is rotator cuff pain diagnosed?
Rotator cuff pain (aka shoulder impingement) can be diagnosed by your physiotherapist by taking a history of your symptoms, and then carefully examining you.
If you have typical rotator cuff pain symptoms, or difficulty lifting your arm, or laying on your side at night, you might have a rotator cuff problem.
When we assess patients with rotator cuff symptoms, we look for the range of movement of your shoulder, whether you have pain lifting your arms up and out to the side, whether there is any weakness or positive clinical signs (e.g., ‘painful arc’, and ’empty can’ tests).
It may occasionally be necessary to carry out some imaging to confirm the diagnosis (such as an ultrasound or MRI scan).
Physiotherapy for rotator cuff pain
Thankfully, most people with a rotator cuff pain will recover well with physiotherapy.
Hands-on physio can help soothe and release tight muscles, and stiffness in the upper back (thoracic spine) or neck, which might be contributing to the pain.
The mainstay of physio for a rotator cuff tendinopathy/tendinitis, is rehabilitation in the form of physio exercises. These strengthen the cuff muscles and correct any poor movement patterns of the scapula (shoulder blade) and stiffness or control around the thoracic spine. This process takes 2-3 months, and sometimes, if pain is inhibiting the rehab, we might recommend that you have an ultrasound-guided steroid injection of the bursa to settle the pain.
Most rotator cuff tears don’t require surgery, and nine out of ten times, physio alone is all that’s needed.
Tips for helping yourself if you have rotator cuff pain:
Rather than stop moving your shoulder completely, modify things so that you’re moving it as much as the pain will let you, and stop the activities that are really flaring it up.
Sleeping on your back with the affected shoulder supported by a pillow along the arm can help.
An ice pack applied to the shoulder before going to bed may also help.
Most importantly, don’t suffer on with shoulder pain – come and see us – book an appointment.