What Is Rotator Cuff Pain?

The rotator cuff consists of four muscles that surround your shoulder blade. Each muscle has a tendon attaching it to your upper arm. These tendons allow you to lift and rotate your arm. When a tendon is injured, inflamed, or worn down, it can cause rotator cuff pain.

This article discusses the symptoms of rotator cuff pain and the three main causes—a tear, tendinitis, or tendinosis. It also explains how different types of rotator cuff injuries are diagnosed and treated.

rotator cuff pain causes

Verywell / Alexandra Gordon

Rotator Cuff Pain Symptoms

The symptoms of rotator cuff pain depend on the specific cause, but some overlap. Common symptoms may include:

  • Sharp or aching pain and swelling located over the front or outside (lateral) part of the shoulder and upper arm (usually due to tendinitis or a rotator cuff tear). In some cases, the pain can also be felt farther down the arm.
  • Difficulty performing activities such as combing your hair or reaching behind your back.
  • Loss of strength in the arm (especially with a tear). For instance, you may notice you have a hard time putting dishes away in upper cabinets or reaching into the refrigerator to lift a carton of milk.
  • Pain when sleeping on the affected shoulder. Throbbing pain at night is also common with rotator cuff tendinitis or a tear. Sometimes, shoulder pain may be severe enough to awaken you from sleep.

In some cases, people with rotator cuff tears do not have any pain. Also, more severe tears can sometimes cause less pain than partial tears. Rotator cuff tendinosis does not always cause pain either, especially early on.

When to See a Healthcare Provider

Not all shoulder pain is caused by a rotator cuff injury. You should call your healthcare provider if you have:

  • Severe shoulder pain that comes on suddenly
  • Swelling, bruising, redness, or warmth around the shoulder joint
  • Shoulder pain that is persistent or worsening
  • Shoulder pain along with trouble breathing, dizziness, or abdominal pain
  • Difficulty lifting your arm above your head or carrying objects
  • Any trauma or injury to the shoulder, especially if it looks deformed

Causes

The three main causes of rotator cuff pain include:

Rotator Cuff Tendinitis

Rotator cuff tendinitis is most common in young athletes and middle-aged adults. It occurs when a normal, healthy rotator cuff tendon becomes injured or inflamed.

Sports and activities that require a lot of throwing or overhead arm motion often cause tendinitis. Tennis, swimming, baseball, volleyball, and weightlifting are some examples.

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

Rotator Cuff Tear

A rotator cuff tear occurs when the tendon is torn from the arm bone. These tears are found mainly in middle-aged and older adults.

A tear may be caused by trauma (for example, a fall directly on the shoulder or a direct blow to the shoulder). Chronic overuse of the rotator cuff muscles can also contribute.

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

Rotator Cuff Tendinosis

Rotator cuff tendinosis is a condition in which the tendons start to weaken and thin out due to aging. This is because, as we get older, there is a decrease in 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 tendons are then more likely to tear or become inflamed.

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

Recap

Rotator cuff pain can be caused by playing sports that involve throwing or overhead reaching, such as baseball and swimming. Other causes include aging and weakening of the tendons and injuries to the shoulder.

Symptoms can include weakness in the arm and throbbing pain while sleeping. In some cases, however, people with rotator cuff injuries have no symptoms.

Diagnosis

If you think you may have a rotator cuff problem, there is a series of tests you and your healthcare provider can do to evaluate the rotator cuff tendons. These tests include:

At-Home Function Tests

You can perform some tests at home before your appointment if you'd like. Your healthcare provider will most likely repeat these tests during your visit, however, so it's not necessary.

A few of these tests include:

Empty Can Test

The empty can test is used to check your supraspinatus, a muscle located on the upper part of your shoulder. This is a simple test to perform. The motion is the same as if you were dumping out a can of soda. For this one, you will need someone's help.

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

If pain or weakness prevents you from keeping your arm in the "empty can" position, you may have a supraspinatus rotator cuff injury.

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. It is responsible for rotating your shoulder inward. To perform the lift-off test:

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

If you are unable to lift your hand away from your low back, you may have a subscapularis rotator cuff injury.

Resistance Testing

One way of determining if a rotator cuff tear is the cause of your shoulder pain is to perform manual strength testing of your rotator cuff muscles. To do this:

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

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

Pain-Relief Test

This test is commonly used by orthopedic surgeons and sports medicine specialists. It can help distinguish between pain caused by a rotator cuff tear and pain caused by tendinitis.

Your doctor injects lidocaine, an anesthetic that numbs the area, into your shoulder joint. If you have rotator cuff tendinitis, the lidocaine will relieve the pain and your muscle strength will remain normal. If you have a rotator cuff tear, the pain will be relieved, but the muscle will remain weak.

Distinguishing between these two conditions is important because they require different treatments.

Imaging

If your provider thinks you might have a rotator cuff tear, they will likely want you to have a magnetic resonance imaging (MRI) test. 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.

Other tests that may be used are an arthrogram (a type of detailed X-ray) and an ultrasound (which uses sound waves to see inside the body).

If a large tear is found, your primary care healthcare provider will refer you to an orthopedic surgeon. Sometimes large tears need surgery to repair them.

Recap

Doctors use a variety of tests to diagnose rotator cuff problems. Imaging tests, such as an MRI, are especially important for figuring out the specific cause of your pain.

Differential Diagnoses

Not all rotator cuff pain actually means you have an injury to that area. Doctors often want to rule out other possible causes for a person's symptoms in order to help them make the right diagnosis. This is called a differential diagnosis.

Some other musculoskeletal conditions (those that affect the muscles and bones) that may have similar symptoms to a rotator cuff injury include:

These conditions can be distinguished from one another through imaging tests. An X-ray can show signs of osteoarthritis. 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. These include a heart attack or heart disease, gallbladder disease, or nerve compression in the neck.

A heart attack is a medical emergency. If you have other symptoms such as chest pain or discomfort, shortness of breath, fatigue, or lightheadedness, or if you think you may be having a heart attack, call 9-1-1 without delay.

To rule out a heart attack, doctors in the emergency room may order a blood test to check your cardiac enzymes. They will also do an electrocardiogram (ECG or EKG). This measures your heart's electrical activity.

Gallbladder disease can usually be ruled out with a normal abdominal exam and an ultrasound. An MRI of the neck can help sort out whether a compressed nerve root is causing shoulder pain.

Treatment

The treatment of your rotator cuff problem depends on whether or not you have tendinitis, tendinosis, or a tear.

Rotator Cuff Tendinitis and Tendinosis

You can usually treat rotator cuff tendinitis and tendinosis by yourself. You can relieve the pain by:

  • Avoiding activities that aggravate the pain, like overhead reaching or reaching behind the back
  • Keeping your arm down, in front of and close to your body
  • Applying a cold pack to your shoulder for 15 to 20 minutes every four to six hours to reduce inflammation
  • Taking an over-the-counter nonsteroidal anti-inflammatory drug (NSAID) like Advil (ibuprofen)
  • Applying heat and performing light shoulder massage before exercising at home or going to physical therapy sessions
  • Seeing a physical therapist for stretching and range of motion exercises

Avoid using an arm sling. Slings can increase the risk of a frozen shoulder. This is a condition in which pain and stiffness make the shoulder hard to move. It can take months to years to heal.

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 healthcare provider. You may need an MRI to look for a rotator cuff tear.

Rotator Cuff Tear

Small rotator cuff tears are treated the same way as rotator cuff tendinitis. Often, physical therapy and a proper exercise program can improve the function of the shoulder joint to prevent pain that comes from a torn tendon.

However, sometimes surgery is necessary. Young athletes with rotator cuff injuries often need surgery.

Rotator cuff repair surgery can be done as an open procedure or a minimally invasive arthroscopic one. Your surgeon will recommend the approach that is best for you. This will depend on the exact location of your rotator cuff damage and how severe it is.

If you have surgery for a rotator cuff tear, you will need physical therapy for several months afterwards. This ensures that you heal properly and regain your shoulder function.

Prevention

There are a few things you can do to prevent developing a rotator cuff problem in the first place. 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)
  • Doing 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

Summary

Rotator cuff pain is very common, especially in athletes and as people age. The main causes are tendinitis, tendinosis, and tears in the tendons around the rotator cuff. Some people with these conditions have no symptoms at all.

Fortunately, the majority of people get better using simple measures like avoiding certain activities and going to physical therapy sessions. However, some people with tears in the rotator cuff may need surgery.

A Word From Verywell

Rotator cuff pain can limit the activities you do in daily life. If you are an athlete, they can sideline you. If you are experiencing pain or weakness in your shoulder, call your health provider. Performing some simple tests can help them give you a proper diagnosis and set you on the path to recovery.

Frequently Asked Questions

  • What sports can lead to rotator cuff injuries?

    The activities most likely to cause with rotator cuff tendinitis and other wear-and-tear injuries are baseball, tennis, rowing, weightlifting, basketball, golf, and swimming. Sports that pose a high risk of rotator cuff injuries due to falls or collisions are football, lacrosse, and ice hockey.

  • Can sleep position contribute to rotator cuff pain?

    It's commonly thought that sleeping on one side may promote or worsen rotator cuff pain on that side. That said, research has found it doesn't: In one study, side sleeping was not associated with shoulder pain, nor was sleeping on the back or on the stomach with the arms bent in a "T" shape.

  • When does rotator cuff pain tend to be worse?

    At first, you're likely to feel pain primarily when you lift your arms overhead—to dry your hair, for example. Over time, pain may be more frequent. It's especially common at night and may even wake you up.

  • What can happen if a torn rotator cuff isn't treated?

    Most rotator cuff tears are unlikely to improve without being repaired. Pain medication and physical therapy may relieve pain and some loss of mobility, but only surgery can restore range of motion.

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11 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
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