Causes of Rotator Cuff Pain and Treatment Options

Everything you need to know about rotator cuff tendinitis and tears

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Shoulder Pain Examination
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Rotator cuff pain is most commonly caused by an inflamed tendon (tendinitis) or torn tendon. The quality of the pain may range from a dull, aching sensation to sharp pain that moves down the upper arm when reaching overhead or sleeping on the affected side. Interestingly, the intensity of the pain does necessarily correlate with the degree of the injury. Less commonly, rotator cuff pain may from result from a condition called rotator cuff tendinosis—when the tendons become frayed or worn down as a result of increasing age and overuse.

The rotator cuff consists of four muscles (supraspinatus, infraspinatus, teres minor, and subscapularis) that surround your shoulder blade and attach to your upper arm (humerus) via their own tendon. These four tendons converge to form a "cuff" or covering over the head of the humerus, allowing you to lift and rotate your arm. Issues with any one of these can cause rotator cuff pain.

With both a rotator cuff tendinitis and tear, a person often experiences pain over the shoulder that worsens with activities, such as reaching overhead or throwing.

Causes

Rotator cuff issues may be anticipated possibilities for those who regularly engage in physical activity involving repetitive arm motion, like baseball pitchers, but may come as a surprise to many others for which such issues are also common.

Rotator Cuff Tendinitis

Rotator cuff tendinitis is most common in young athletes and middle-age people. It occurs when a normal, healthy rotator cuff tendon is injured or inflamed, often as a result of a repetitive overhead activity (for example, painting, tennis, swimming, baseball, volleyball, or weightlifting).

Certain chronic diseases are also associated with rotator cuff tendinitis. For example, diabetes and obesity may be a risk factor.

Rotate Cuff Tear

A rotator cuff tear (when the tendon is torn from the arm bone) is a disease found primarily in middle- to older-age individuals. A tear may be caused by trauma to the shoulder (for example, a fall directly on the shoulder or direct blow to the shoulder), as well as chronic overuse of the rotator cuff muscles.

Obesity and smoking may also increase a person's chance of tearing their rotator cuff.

Rotator Cuff Tendinosis

Rotator cuff tendinosis—a condition whereby the rotator cuff tendon degenerates—occurs as a result of increasing age. This is because, as we get older, there is a decreased blood supply to the rotator cuff tendons. As a result, when the tendons become stressed or injured, they do not recover or heal as well. These weakened or frayed tendons are then more vulnerable to inflammation and tearing.

Poor posture, smoking, repetitive overhead activity, and genes may also play a role in the development of rotator cuff tendinosis.

Symptoms

Sharp or aching pain and swelling from a rotator cuff tendinitis or tear are usually located over the front or lateral part of the shoulder and upper arm. People often complain of difficulty performing activities such as combing their hair, clasping a bra behind their back, reaching behind their back, or sleeping on the affected shoulder. Throbbing pain at night is also common in individuals with a rotator cuff tendinitis or tear. For some people, the shoulder pain may awaken them from sleep.

In addition, it's not uncommon for the pain of a rotator cuff tendinitis or tear to be felt further down the arm from the shoulder. This has to do with the location of the nerves that pass by the deeper parts of the shoulder. 

More specifically, with rotator cuff tears, deficits in strength are very common. For instance, many people noticed they have a hard time putting dishes away in upper cabinets or reaching into the refrigerator to lift a carton of milk.

Keep in mind, some people with rotator cuff tears do not experience any pain—and the severity of the tear (partial versus complete) does not correlate with the pain experience. In other words, a person with a partial tear may report severe pain while a person with a complete tear may report no pain at all.

Like a rotator cuff tear, rotator cuff tendinosis does not always cause pain, especially early on in the disease course. If pain is present, it's often described as a dull, aching pain that worsens at night and with certain shoulder movements, like reaching out or behind the back.

When to See a Doctor

Any severe shoulder pain and/or pain that comes on suddenly warrants medical attention, as does any significant swelling or bruising around the shoulder joint or signs of infection like redness and warmth.

Seek medical attention, as well, if your shoulder pain is associated with other unusual symptoms like trouble breathing, dizziness, or abdominal pain.

Other signs that warrant a doctor's visit include:

  • An inability to lift your arm above your head or carry objects
  • Any trauma or injury to the shoulder, especially if there is deformity to the joint
  • Shoulder pain that is persistent or worsening

Diagnosis

After reviewing your medical history, if your primary care doctor suspects a rotator cuff problem, he will perform a series of tests to evaluate the rotator cuff tendons. He will then order an imaging test of your shoulder if a rotator cuff tear is suspected.

At-Home Function Tests

Several tests are used to evaluate the rotator cuff, some of which can be performed at home prior to your appointment. If you are not comfortable, though, that's OK. Your doctor will repeat these tests during your visit.

A few of these at-home tests include:

Empty Can Test

The empty can test is used to assess the status of the supraspinatus, located on the upper part of your shoulder. This is a simple test to perform, and the motion involved mimics that of dumping out a soda can.

  • Sit or stand comfortably with a friend present.
  • Lift your painful arm out the side so it is parallel to the floor.
  • Bring your arm forward about 30 to 45 degrees.
  • Turn your hand over so your thumb is pointing toward the floor (as if you were trying to empty a can of soda).
  • Have your friend gently push your arm down.

If pain or weakness prevents you from maintaining your arm in the "empty can" position, you may have a supraspinatus rotator cuff injury. If so, check in with your doctor to confirm the diagnosis.

Lift-Off Test

The lift-off test is a shoulder test to determine if you have a tear in the subscapularis. This muscle is located on the underside of your shoulder blade and is responsible for rotating your shoulder inward. To perform the lift-off test:

  • Stand up and place the back of your hand on the small of your back.
  • Face the palm of your hand away from your back.
  • Attempt to lift your hand away from your body.

If you are unable to lift your hand away from your low back, it is suspected that a subscapularis rotator cuff injury may be present.

Resistance Testing

One way of determining if a rotator cuff tear is possibly causing your shoulder pain is to perform manual strength testing of your rotator cuff muscles. To do this, follow a simple procedure:

  • Sit comfortably in a chair.
  • Bend your elbow 90 degrees and keep your elbow tucked into your side.
  • Have someone push your hand in toward your belly.

If you are unable to hold this position and feel pain, you may have a rotator cuff tear.

Pain-Relief Test

The lidocaine injection test is sometimes used by some doctors (mostly orthopedic surgeons or sports medicine physicians) to help distinguish between a rotator cuff tendinitis and tear. Distinguishing between these two conditions is important because it affects the overall treatment plan.

During this test, lidocaine is injected into the shoulder joint. If a person has a rotator cuff tendonitis, the lidocaine will relieve the pain and muscle strength will remain normal. If a person has a rotator cuff tear, the pain will be relieved, but the muscle will remain weak.

Imaging

If a rotator cuff tear is suspected, an imaging test will be ordered. The test most commonly used to diagnose a rotator cuff tear is magnetic resonance imaging (MRI), but an arthrogram and an ultrasound may also be used. The MRI is helpful because it can show both complete rotator cuff tears and partial rotator cuff tears. The MRI can also show evidence of rotator cuff tendinosis, shoulder bursitis, and other common shoulder problems.

If a large tear is found, your primary care doctor will refer you to an orthopedic surgeon, as you may require surgical repair.

Differential Diagnoses

It's important to understand that pain in the rotator cuff region may not actually be related to a compromised rotator cuff. Some other conditions that may mimic a rotator cuff injury include:

The good news is that these other conditions can be distinguished from one another through imaging tests—for example, an X-ray can show signs of osteoarthritis, while an MRI can be used to diagnose a labral tear.

Besides musculoskeletal issues, several other health conditions can also cause shoulder pain within the rotator cuff region, such as a heart attack, gallbladder disease, or nerve compression in the neck.

When it comes to ruling out a heart attack, which is a medical emergency, in addition to a concise medical history and physical exam, your doctor may order cardiac enzymes (a blood test) and an ECG. Gallbladder disease can generally be ruled out with a normal abdominal exam and ultrasound. An MRI of the neck can help sort out whether a compressed nerve root is a culprit behind someone' s shoulder pain.

In the end, the vast differential for shoulder pain is why it's important to not self-diagnose, but rather to see a healthcare professional for a comprehensive evaluation.

Treatment

The treatment of your rotator cuff problem depends on whether or not you have a tendinitis, tendinosis, or tear, and if there is a tear, how severe it is.

Rotator Cuff Tendinitis and Tendinosis

The treatment of rotator cuff tendinitis and tendinosis is generally straightforward, encompassing six key strategies:

  • Avoiding activities that aggravate the pain, like overhead reaching or reaching behind the back
  • Keep your arm down, in front of and close to your body (avoid an arm sling, as you risk the development of a frozen shoulder)
  • Ice to reduce initial inflammation in tendonitis (apply a cold pack to shoulder for 15 to 20 minutes every four to six hours)
  • Take an anti-inflammatory medication like a nonsteroidal anti-inflammatory (NSAID)
  • Apply heat and perform light shoulder massage prior to home exercise or physical therapy sessions
  • See a physical therapist for stretching and range of motion exercises

After about two to three months of the above strategies, most people report an improvement in their pain. However, if pain persists, be sure to talk to your doctor. You may need an MRI to look for a rotator cuff tear.

Rotator Cuff Tear

The good news is, not every rotator cuff tear needs surgery. In fact, small rotator cuff tears are treated similarly to a rotator cuff tendonitis. However, when surgery is the best treatment, it's often better to proceed sooner rather than later, as the rotator cuff muscle can weaken (atrophy) and retract (pull back) over time. This can make repair less successful or even impossible. Therefore, it's good to discuss your treatment options with your orthopedic surgeon as soon as possible.

For people who choose nonsurgical treatment options, there are a number of ways to find relief of the shoulder pain caused by the rotator cuff tear. Often with physical therapy and a proper exercise program, people can improve the function of their shoulder joint to prevent pain that comes from a torn tendon of the rotator cuff.

Prevention

There are a few things you can do to prevent the development of a rotator cuff problem. These self-care strategies include:

  • Warming up before exercising
  • Learning how to lift weights properly (for example, using your legs and maintaining a straight back)
  • Engaging in stretching and strengthening shoulder exercises, such as those recommended by the American Academy of Orthopedic Surgeons
  • Practicing good posture
  • Avoiding smoking
  • Maintaining a healthy body weight

A Word From Verywell

A rotator cuff problem is a common condition, especially as people age. In fact, rotator cuff tears eventually become an expected finding, even in people who have little to no shoulder pain.

The good news is that often with simple measures like avoiding certain activities and physical therapy, the majority of people get better.

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View Article Sources
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