An evidence-based approach to treating shoulder pain due to rotator cuff problems

April 11, 2013 | By More

The following post is based on an article that I wrote which appeared in the Connacht Tribune Lifestyle section on 11/4/13

The most common shoulder problem that I see is called rotator cuff tendinopathy. The rotator cuff is a sling of muscles which arise from the shoulder blade and then narrow to become a series of tendons before attaching onto the head of humerus (the ball of the ball and socket joint) of the shoulder. These tendons are extremely important as they work to keep the ball centred in the socket as we lift up our arm.

For many years it was assumed that pain coming from these tendons was due to inflammation. However numerous research studies examining samples of tendon tissue have revealed that true inflammation is rarely present. In fact more often than not, structural changes to the tendon are the source of pain.

Spag 3

Thinking about spaghetti is a good way to visualise these structural changes in the tendon.

Tendons are composed of millions of tiny strings called collagen fibres. A healthy, strong tendon contains mainly type 1 collagen which is strong and packed closely together in parallel orientation – a bit like a bunch of uncooked spaghetti. Over time, due to various factors, this type 1 collagen can become replaced by weaker less organised collagen. This resembles a mass of cooked spaghetti and often has significant gaps or holes in it that fill up with fatty tissue. These changes make the tendon much weaker and more susceptible to small tears, splits or eventually larger tears or even complete ruptures.

The factors that contribute to tendon health are multi-faceted but in general are very similar to the risk factors for your cardiovascular system. Smoking, obesity, high fat foods, lack of exercise, high cholesterol and having Diabetes are all associated with poor tendon health and make you more susceptible to getting pain in the tendons. However one of the factors that most frequently causes a sudden flare-up of pain in the shoulder tendons is a sudden change in activity. Like many of us, tendons do not like change and they often react badly to a sudden change in activity levels – particularly with the arm above 90 degrees. Activities such as DIY, suddenly increasing the amount of swimming or gym activities or a weekend looking after grandchildren are common culprits. However often the patient cannot pinpoint a particular activity and it may be that over time the shoulder has been getting weaker and finally gives in and fails to cope with everyday activities such as washing your hair, holding the hairdryer or reaching upwards.

Broadly speaking there are three approaches to treating rotator cuff tendinopathy – physiotherapy exercises, corticosteroid injections and surgery. Surgery is generally only a last resort or suitable for younger people who have completely torn the tendons from an injury. I spend a lot of my time carefully assessing the problem and then explaining and discussing at length the pros and the cons and the risks and the benefits of the different approaches.

The most important aspect of an exercise programme for any tendon is to remember that tendons don’t like change. Therefore the exercises must specifically target the problematic area and ever so gradually build up the strength and function. I always tell my patients that we have to trick the tendon into thinking that nothing is changing even though we are gradually loading it more and more. The minimum time to make a lasting change is in the region of 12 weeks but exercise and activity levels need to be maintained to prevent recurrence. If other lifestyle factors are contributing to poor tendon health then to optimally manage the problem, it is important to address these factors as much as possible e.g. by seeking smoking cessation advice.

Injection with corticosteroid may seem like a quick fix and in fact it is often extremely useful in the management of these conditions. However this does not cure the problem. It simply reduces the pain and creates a window of opportunity where progress can be made with the targeted exercise programme. Tendon problems can be tricky to treat but ultimately, most people respond well to a considered and evidence-based treatment package as long as they are not looking for a miracle overnight cure!

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    Comments (4)

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    1. Kevin Conroy says:

      Love the bit about looking after grandchildren!

    2. joan moore says:

      Hi there, at last I get a full explanation of shoulder pain and rotator cuff, I guess my tendons are the dried bits of spaghetti. Had conservative treatment ie pt that didnt work, got cortisone shot from gp, that didnt work, was diligent doing exercises. Had impingement with bursitis and bone spurs and got all that sorted but still in pain until I got deep cortisone shot from consultant.
      That has relieved the pain for every day functions but as for pushing grandson in buggy forget it! I am now back at work but careful not to overstretch forwards or upwards. Arm still at 90 degrees and not budging despite doing the exercises. I also had capsulitis discovered during surgery. Will it ever resolve?????

      • Eoin Ó Conaire says:

        Thank you for your comments. I am glad that you found the spaghetti analogy helpful. I am sorry to hear about your ongoing problems with your shoulder. Obviously without examining you, I cannot give an accurate answer to your question on whether it will ever resolve and how best to facilitate that. However if your arm is still not able to move above 90 degrees then it sounds to me like the main problem now is capsulitis (Frozen Shoulder) rather than the rotator cuff. If this is the case then you will almost certainly get better. I will blog here about Frozen Shoulder in the near future.

    3. Lyndsey says:

      Just wanted to say thanks for the article, that’s an in-depth but still easy to understand summary of what causes rotator cuff and tendon issues. I agree Kevin, the bit about looking after grandchildren made me chuckle.