Rotator Cuff Tendinopathy

Shoulder

Tendonits, Bursits, Impingement, Rotator Cuff Syndrome – these are all different names for the same thing used by different people. They all describe a painful shoulder and they all mean that the tendons are inflamed.

But let’s start at the beginning.

What is a tendon?

A tendon is the bit of tissue that joins a muscle to a bone and the easiest one to visualise is the Achilles Tendon that joins the calf muscle to the heel bone.

So is this the Rotator Cuff?

Yes. There are 3 tendons that make up the rotator cuff – one pulls the arm in and up the back; one pulls the arm outwards and one pulls the arm upwards. And it is the last one that almost always causes problems – the Supraspinatus Tendon.

Waited for a few weeks thinking it would get better but it hasn’t and now it’s waking me at night. So I need to get this sorted out.

That is often the way. You put up with it for a bit, maybe adapt around it as well, stop playing badminton or whatever causes the pain but it doesn’t go away and then gets worse. And once sleep is disturbed then that is frequently the trigger to get something done.

The usual course of action is to see your GP or therapist and see what they can do. In a lot of cases anti-inflammatories and some rehabilitation exercises can get rid of it. But if those don’t work then they should suggest you see a shoulder specialist.

And what are you going to do?

Make you better I hope!

Firstly I need to confirm the diagnosis and the key to that is you telling me the story of what’s been going on with your shoulder – how long it’s been giving you pain; any reason you can think of for it; what treatments have you tried and how bad is it.

The next step is the examination because there are other conditions that can present in the same way as tendonitis and I need to be sure what is actually going on. So I will get you to move your shoulders around in specific ways and do some tests to try and define which bit is causing the problems.

Why does everyone think this is my shoulder though? I get the pain in the arm not the shoulder.

You are right. The pain appears to be in the upper arm but it is coming from the shoulder and is ‘referred’ down the arm. It can go as far as the wrist but hardly ever into the fingers – that sort of pain is often from the neck. So upper arm pain IS from the shoulder.

My therapist says I need an MRI because I may have got a torn tendon. Are you going to do one?

You know it’s actually pretty difficult to tear a tendon – it’s tough old stuff tendon. If you’ve torn it you will know about it because there will have been a significant event – usually a heavy fall with the arm yanked in one direction or another. And it will have been painful straight away and its very likely you won’t have been able to lift or use the arm for several days or longer. That is a ‘torn’ tendon and that generally needs an operation because tendon does not reattach itself.

What the GP or therapist is really talking about is an erosion of the tendon. This is a chronic problem whereby the tendon rubs through slowly over a long period of time often without you knowing anything about it. It’s a bit like rubbing through the elbow of a jumper – it all seems ok until suddenly a proper hole appears.

And a proper tear and erosive hole are very, very, very different things. So everyone should be a bit wary of the terminology they use because it can frighten you, as a patient with a bit of shoulder pain for no obvious reason, to be told you have a TEAR and might need an OPERATION!

The other thing is that is absolutely normal for the tendon to rub through as you get older – that’s just what happens. In fact about 10% of 60 year olds have got holes (or full thickness degenerate tears to use the proper description) in their Supraspinatus and over 50% of 80 year olds have holes.

So we need to be very careful with what scans we do and match them up with what you are complaining about. If we did an MRI of 100 people aged 60 who had NO shoulder pain at all we would find holes in 10 of them! Just having a tear or hole in the tendon does not mean that is what is causing your problems and in most cases small holes are not an issue at all.

Fair enough. But are you going to do an MRI?

There are several different types of investigation that I use. I often start with good old fashioned x-rays.

Had one done and it was normal.

Two things there. Usually they don’t do the correct x-rays and they don’t really know about the subtle signs on an x-ray that give lots and lots of information. So I will repeat those done my way and, taken in conjunction with the history and examination, that may be all that’s needed to make a diagnosis and decide what to do to make your better.

A very useful investigation for the rotator cuff is a thing called an Ultra-sound Scan (USS). This is a dynamic scan during which the radiologist can move your arm around and see which bits of tendon are rubbing and where they are rubbing. It’s a very specialised skill though but an experienced shoulder radiologist using a good machine can get lots of information about the state of your tendon So we will know if it is inflamed, if there is a partial tear (i.e. the tendon has been rubbed some of the way through) or a complete tear and what size it is and where it is.

There is another benefit of the USS because the radiologist can also inject the area around the tendon with steroid as a way of treating the inflammation and getting rid of your pain.

I have heard a lot of bad things about steroids so I’m not keen on that. Won’t it just mask the symptoms?

Good point and there is a lot of bad press about steroid injections because they are often used badly! Steroid is a very strong anti-inflammatory medication but, oddly enough, it is actually a very natural substance rather than something created in Dr Frankenstein’s lab. It is what the body itself produces when it is injured but in a purified form. So really quite a holistic treatment.

The problem comes when someone tries to make your shoulder better with lots and lots of injections. In my hands you get one or, very occasionally, two. The steroid is either going to eliminate the inflammation and allow you to get back to a normal pain-free existence and doing your job, all your sports and activities without any recurrence – or it won’t. And if it doesn’t then you need an operation and we’ll come to that later.

I am very needle phobic so there is no way I am having an injection.

Don’t worry. That isn’t uncommon and what we can do is admit you to the hospital for half a day and do the injection with you knocked-out (sedated).

Not convinced about an injection though. My GP did one and it made no difference at all so why do another one?

By no difference at all what do you mean? I expect it was more painful for a few days but then was it any better even for a week or so? Because if it was, then we actually count that as a success. If the injection even gives a few days of a pain-free shoulder then I know I can achieve the same result for you on a permanent basis but it would mean surgery.

The other thing here is that, with respect, GPs don’t inject many shoulders and often use a rather out-dated approach and a very small volume of steroid and local anaesthetic. If their injection genuinely made no difference at all then I tend to discount that one and will suggest that I do an injection my way.

And in perhaps 60% of cases the injection plus physiotherapy (very important) will cure things.

You’ve convinced me but tell me a bit more about the injection. Will it hurt?

Yes it will. It is a needle after all but usually its nothing like as bad as you will be expecting – or as painful as your friends told you the injection they had into their elbow or heel was!

I inject a mixture of 80mg of Depomedrone (that’s the steroid part) and 8mls of Chirocaine (that’s the local anaesthetic part) through the back of the shoulder.

Do I get the local first and why are you injecting the back of my shoulder when all the pain goes down the front?

Putting the needle in through the back is the most accurate way of getting into the subacromial space – the gap between the tendon and the bone – and this runs from the back all the way to the front. So an injection placed by this route actually allows the steroid to bathe the whole of the tendon.

Sorry, no, you don’t get the local first so you will feel the needle. The local is used to spread the steroid all over the tendon and to numb the shoulder for the first few hours. That’s why you may feel all the pain has gone very quickly but the true test comes over the next few days.

When can I use the shoulder? Do I still take my anti-inflammatories?

In some people the shoulder can be a lot more painful for a couple of days. So if you have a long drive or something important in the two days after a proposed injection then it may be worth deferring the injection for a time when you have a few normal days afterwards – just in case.

Yes – do take your normal pain-killers or anti-inflammatories for the next few days. If the injection is going to work you will know and you will feel that there is no pain and then you stop all the tablets.

I suggest you rest the shoulder for about 4 – 5 days and then if you can get a couple of physiotherapy sessions in early that would be very beneficial. Remember your posture may have contributed to the tendonitis so that needs to be addressed and bad habits will have crept in to compensate for the shoulder pain.

A good physiotherapist will be more than happy to see you with a pain-free shoulder because they can get to work on preventing a recurrence by correcting any postural faults and strengthening the shoulder properly.

It is worthwhile using this initial pain-free window to really work hard on the fundamentals around the shoulder. I know it is tempting to get back in the gym but remember that may well have been where the problem was created! The therapist will show you special exercises to strengthen the Rotator Cuff and the Scapular Stabilisers – these are very important muscle groups that form the foundations of a strong, stable shoulder – and you must focus on those.

After a few weeks of therapy and specialist exercises it is time to test out your shoulder because it is no good if it is pain free sitting on your bottom doing nothing – it has to be capable of coping with what you want to do with it. So, go and play golf or tennis; get back in the gym (but be sensible) or finish painting the fence. But listen to what the therapist has told you and put that into practice: sit up straight at your desk with your elbows glued to your sides; don’t overstretch with that paint brush; use the hedge cutter at face height not right up overhead and forget trying to serve like Murray!

Well, it was great for about 4 weeks and I really thought you had cracked it but it’s all coming back again. Can I have another injection? Someone said you shouldn’t have more than 3?

I’d love to know who this someone is spreading all this dodgy information! No is the simple answer. If one didn’t cure you (i.e. get you back to normal function without short-term recurrence) then another won’t either and it is time to consider surgery.

Occasionally I will do a second injection shortly after the first but that is usually if we have to buy time because you can’t have your surgery until later in the year or if the scans really only showed minimal problems and your symptoms haven’t fully recurred.

But that would then be it and now we need to discuss an operation.

My shoulder hurts when I do some movements – it catches me and now its painful at night. Is that ‘tendonitis’?

It certainly sounds like it. For whatever reason, the tendon gets inflamed and becomes red and swollen – the same changes you see with a sting or a bash – and because it runs in quite a tight space when it moves, it can catch because it has become a bit bigger and that’s what gives you the pain. So simple things like putting on a jacket, reaching into your back pocket, doing up a bra or reaching forwards and upwards can cause pain.

But why? I didn’t do anything different.

Sometimes the reason is obvious – a fall; taking up a new sport; doing more weights in the gym; painting walls and ceilings; doing a lot of gardening or that sort of thing.

I see it a lot with people having their golf swing, tennis serve or swimming action changed by an over-enthusiastic coach who forgets that we aren’t all capable of doing what McIlroy, Federer or Adlington can do. Our shoulders aren’t built that way!

Or you start over-using the arm without having strengthened up the foundations of the shoulder – the scapular stabilisers.

Often though there doesn’t seem to be an obvious cause but rather more subtle and long-term actions have been storing up trouble and eventually the pain raises its ugly head and you don’t understand why. I am talking about postural problems here – sitting hunched over a desk for hours at a time; having a phone stuck under one ear for ages; carrying the baby on the same hip for months or doing a job that involves repeated overhead activity.

Sometimes it’s bad and sometimes it’s not and I thought it would get better but it hasn’t.

That is very typical of a shoulder problem. There can be big chunks of the day when it causes you no problems at all and then you do something and the pain is there again. Or worse – it all seems ok during the day but when you sit down and relax in the evening it starts to hurt.

So people with shoulder pain tend to put off doing anything about it for quite a long time. It’s not the same as having a problem with your foot, knee or hip where every step you take is painful and just getting about becomes an issue. They tend to visit their physiotherapist or doctor much earlier. With a shoulder problem people may put their bad hand in their pocket and forget about it for a while.