(Shoulder Tendonitis / Tendinitis)
What is Shoulder Tendinopathy?
Because inflammation is not always present in tendon injuries, especially chronic tendon injuries, the term shoulder tendinopathy describes the full spectrum of shoulder tendon injuries. If your shoulder’s rotator cuff tendons are precisely injured, it is a rotator cuff tendinopathy.
Rotator cuff tendinopathies can also be described based upon the specific tendon that is injured. These can include supraspinatus tendinopathy, subscapularis tendinopathy or infraspinatus tendinopathy. While not an actual rotator cuff tendon, the long head of biceps is commonly injured. It is known as bicipital tendinopathy.
Calcific tendinopathy is where calcium (bone) has formed within the tendon.
What is Shoulder Tendonitis?
Shoulder tendonitis (or tendinitis) is an inflammation injury to the tendons of your shoulder’s rotator cuff. Inflammation usually is present in the acute phase of tendon injury and is a standard component of the natural tendon healing process. Until a few years ago, shoulder tendonitis was the common term used to describe shoulder tendinopathy. But, in reality, tendonitis is only present in a small percentage of shoulder tendinopathy patients.
What Causes Shoulder Tendinopathy?
The most common cause of shoulder tendinopathy is repeated microtrauma. That is, repeated trauma to the rotator cuff tendons, rather than a specific one-off incident.
Shoulder Impingement is 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 via friction and compression.
Shoulder bursitis commonly occurs in combination with rotator cuff tendinopathy or rotator cuff impingement.
What are the Symptoms of Shoulder Tendinopathy?
Shoulder tendinopathy commonly has the following symptoms:
- Shoulder clicking 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 you move your hand behind your back or head.
- Shoulder and upper arm pain – potentially down as far as your elbow.
- As your shoulder tendonitis deteriorates, your shoulder pain may even be present at rest.
How is Shoulder Tendinopathy Diagnosed?
Your physiotherapist or doctor will clinically suspect shoulder tendinopathy. They will base your diagnosis upon your symptom history and some clinical tests. An ultrasound scan is a preferred method of investigating shoulder tendinopathy. Ultrasound can also confirm or exclude associated injuries such as shoulder bursitis or other tendinopathies.
X-rays do not identify shoulder tendinopathy but can be useful to determine long-term bone changes. For example, bone spur growth into the subacromial space will predispose you to rotator cuff tendinopathy.
What the Prognosis for Shoulder Tendinopathy?
Shoulder tendinopathy can be a progressive disorder. It often co-exists with shoulder bursitis or bicipital tendonitis and can deteriorate into calcific tendonitis or rotator cuff tears. They can require surgery with neglect or inadequate treatment. The good news is that most shoulder tendinopathy is reversible and very successfully treated.
Shoulder impingement is a primary cause of your shoulder tendinopathy. It is vital to thoroughly assess how your shoulder is moving and correct your shoulder biomechanics to prevent future shoulder impingement episodes and subsequent rotator cuff tendinopathies.
A shoulder physiotherapist is high-qualified in shoulder assessment and biomechanical correction. For more advice, please consult your shoulder physiotherapist or a doctor with interest in shoulder rehabilitation.
Shoulder Tendinopathy Treatment
Every shoulder tendinopathy patient’s treatment will vary. Rehabilitation depending upon the assessment and joint problems, researchers have concluded that there are mostly seven stages that need to be covered to rehabilitate shoulder tendinopathy and prevent a recurrence effectively. 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 lift your arm or sleep comfortably fully. Our first aim is to provide you with some active rest from pain-provoking postures and movements. Active rest means that you should stop doing the action or activity that provoked the shoulder pain in the first place and avoid doing anything that causes shoulder pain.
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, e.g. arnica may help reduce your pain and swelling. However, it is best to avoid anti-inflammatory drugs during the first 48 to 72 hours when they may encourage additional bleeding. Most people can tolerate paracetamol as pain-reducing medication.
To support and protect your tendon injury, you may need to 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.
Shoulder Tendinopathy Exercises
Shoulder tendinopathy exercises will typically commence in phase II, as the acute pain settles.
Phase 2: Regain Full Range of Motion
If you protect your injured shoulder tendons appropriately, the injured tissues will heal. Inflammed structures, e.g. (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 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. Physiotherapist-assisted joint mobilisations may 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 stretching to allow normal movement.
Signs that you have full soft tissue extensibility includes being able to move your shoulder through a full range of motion: hand behind head, hand behind back, stop sign position and across your chest to touch your opposite shoulder blade. In the early stage, this may need to be passively (by someone else), e.g. your physiotherapist. As you improve, you will be able to do this under your 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 scapulohumeral rhythm as a major cause of rotator cuff impingement. Any deficiencies will be an essential 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 your normal shoulder motion and provide you with scapular stabilisation exercises if necessary.
Phase 4: Restore Normal Neck-Scapulo-Thoracic-Shoulder Function
Your neck and upper back (thoracic spine) are significant in the rehabilitation of shoulder pain and injury. Neck or spine dysfunction can not only refer pain directly to your shoulder, but it can affect a nerve’s electrical energy supplying your muscles cause weakness. Painful spinal structures from poor posture or injury don’t provide your shoulder or scapular muscles with a solid pain-free base.
In most cases, especially chronic shoulders, some treatment directed at your neck or upper back will ease your pain, improve your shoulder movement and stop symptoms 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 centralising prevents impingement and dislocation injuries.
Your rotator cuff also provides the subtle glides and slides off 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 architectures with resistance exercises.
Researchers have discovered the importance of strengthening the rotator cuff muscles in a successful shoulder tendonitis rehabilitation program. Your rotator cuff exercises progressed in both load and position to accommodate for your precisely 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 was sport-related, it is usually during high-speed activities, which place enormous forces on your body (contractile and non-contractile), or repetitive actions.
To prevent a recurrence as you return to your sport, your physiotherapist will guide you through exercises to address these critical components of rehabilitation to both prevent a recurrence and improve your sporting performance.
Depending on what your sport or lifestyle entails, a customised speed, agility, proprioception and power program will prepare 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 shoulder physiotherapist or sports coach should ideally assess your technique.
Your physiotherapist will discuss your goals, time frames and training schedules with you to optimise you for a complete return to sport or work.
Work-related injuries will often require a discussion between your doctor, rehabilitation counsellor or employer.
The perfect outcome will have you performing at full speed, power, agility and function with the added knowledge that a thorough rehabilitation program has minimised your chance of future injury.
For specific advice, please seek the professional advice of your shoulder physiotherapist.
Common Shoulder Pain & Injury Conditions
- Rotator Cuff Syndrome
- Shoulder Tendinopathy
- Rotator Cuff Calcific Tendinopathy
- Rotator Cuff Tear
- Bicep Tendinopathy
- Shoulder Impingement
- Swimmer's Shoulder
- Subacromial Decompression
- Shoulder Arthroscopy
- Rotator Cuff Repair
- SLAP Repair
- Biceps Tenodesis
- Biceps Tenotomy
- Total Shoulder Replacement
Researchers have discovered that managing your shoulder injury with physiotherapy is usually successful. Typically, you have two options: non-operative or a surgical approach. Your condition will dictate which option is best for you at this time. Non-operative care is conservative rehabilitation.
If shoulder surgery is required, then your physiotherapist may undertake:
Pre-operative rehabilitation - to either trial a non-operative/conservative treatment approach or to condition and prepare your shoulder and body for a surgical procedure.
Post-operative physiotherapy - to safely and methodically regain your normal range of movement, strength, speed and function.
PhysioWorks physiotherapists have a special interest and an excellent working relationship with leading shoulder surgeons. Our physiotherapy team provide you with both conservative and post-operative shoulder rehabilitation options. We aim for you attaining the best possible outcome for your shoulder injury.
For specific information regarding your shoulder, please consult your trusted shoulder physiotherapist.