One of the most common complaints of people we see come through the door is shoulder pain. Up to 50% of us will experience shoulder pain each year and it can be stressful and frustrating. I mean, we use our shoulders more than most joints in our bodies, so it can definitely affect our lifestyle. We often hear things like:
“I can’t pick up my child”
“I can’t do …”
“I haven’t been able to exercise”
Did you know that 80% of shoulder pain is rotator cuff related?! If you’ve ever had shoulder pain, you’ve most definitely heard of the rotator cuff! Rotator cuff related shoulder pain is an overarching term that includes subacromial (impingement) syndrome and bursitis, rotator cuff tears (partial and full thickness) and rotator cuff tendinopathy. This blog will focus on each of these common injuries and what they are, as well as signs and symptoms of each injury to help you better understand the rotator cuff and your pain.
What is the rotator cuff?
The rotator cuff is a group of 4 muscles that run from the shoulder blade to the upper arm. Their purpose is to:
- provide dynamic stability
- aid in rotation of the shoulder joint
Due to the shoulder joint being such a mobile joint allowing movement in several directions (as compared to the hip or knee joints which are very stable), it relies heavily on the rotator cuff for much of its stability, especially in activities in which we lift our arms overhead and away from our bodies. The interesting thing about the rotator cuff is that these muscles are not prime movers and so at different positions are almost always active and working to control and stabilise movement. So, you can imagine how important this becomes in EVERY activity involving our arms such as carrying shopping bags, reaching for things overhead, picking things up, exercises at the gym and the list goes on!
Traditionally, shoulder impingement was thought to be an issue where the rotator cuff tendons or bursa get “pinched” in the small space called the subacromial space. However, over the last few years, research suggests that this may not always be the case and does not always occur because of this mechanism specifically. The updated term for non-traumatic shoulder pain originating from this area is “Subacromial Pain Syndrome” or “Rotator Cuff Related Shoulder Pain”. This describes any irritation of structures in the subacromial space including rotator cuff tears, tendinopathy, bursa irritations and any other injuries relating to the rotator cuff. So, the term “impingement” is not always accurate and a comprehensive assessment to determine the root cause of your injury is vital.
Shoulder bursitis describes inflammation of a small fluid filled sac in the shoulder called the bursa. Everyone has bursae in their shoulders (and other parts of the body). Their job is to reduce friction between different structures such as tendons, bones, ligaments and muscles. A common misconception is that bursitis is a primary injury and is the cause of shoulder pain. Often, bursitis is a secondary symptom or result of dysfunction or injury to other structures, such as the rotator cuff. It is important to note that a bursa naturally enlarges with stress to this area, so mostly, a thickening of a bursa you may read on your scans is actually quite normal and protective of other structures in the shoulder. “Bursal thickening” or “subacromial bursitis” are one of the most common findings on a scan, but often is not a cause for concern!
- Painful arc – pain during the middle part of the movement when raising arm
- Pain on side or front of shoulder
- Pain can be either dull or sharp
- Pain when lifting overhead
- Decreased range of motion of your shoulder joint
- Pain when sleeping on the affected side
- Painful to touch
- Repetitive arm movements
- Rotator cuff dysfunction
- Sustained positions
Rotator cuff tear
A rotator cuff tear can occur from a traumatic injury such as falling onto an outstretched arm, lifting something really heavy or something that occurs over time due to ageing or repeated trauma and overuse. There are 2 main types: partial tear and full thickness tear. Interestingly, if you are over 60, around 50% of you with tears don’t have any symptoms in your shoulder. As we get older this percentage increases and tears become more prevalent than not…without any symptoms! It is also important to know that even with an asymptomatic tear, our bodies are still able to fully function. Active athletes such as baseballers have also been found to have asymptomatic rotator cuff tears. Crazy right?! A rotator cuff tear is not a cause for panic and unlike other muscles, may not have to fully “heal” for us to achieve full function. However that’s not to say we don’t need to treat it and have a good rehabilitation program.
So, when does a rotator cuff tear become an issue?
- Traumatic injury
- Loss of function
- Pain or weakness
- Inability to sleep
- Pain with movement, often eased with rest
- Inability to lift arm
- Reduced range of motion
- Pain when lying on affected shoulder
- Dull ache (around the deltoid area and upper arm) – pain can refer as low as the elbow
- Heavy manual work/Working above shoulder height
- Repetitive arm movements
- Age related changes
- Traumatic injury
Rotator cuff tendinopathy
Also known as “rotator cuff tendonitis”, a tendinopathy is where the tendons of the rotator cuff become irritated and/or inflamed causing pain and weakness, most often due to overuse.
Symptoms often occur gradually and are mainly experienced with movement. Initially, it may feel very mild and most people push through this, however over time symptoms usually worsen causing pain and weakness with increased frequency and intensity.
Below are some symptoms you might experience with a rotator cuff tendinopathy:
- Shoulder clicking and pain when raising arm above shoulder height
- Swelling in the front of the shoulder
- Pain reaching behind your back
- Pain when lying on the affected shoulder
- Shoulder and upper arm pain (can sometimes refer to other areas such as the elbow)
- Loss of movement and strength
- “Too much too soon”
- Heavy occupational work
- Repetitive arm movements
- Working above shoulder height
- Lack of rest
- Awkward sustained postures
- Muscle weakness
- Older age
- Sports with repetitive arm motions (boxing, baseball, swimming etc.)
Do I need a scan?
Imaging for rotator cuff injuries may not always be required. Your physio may refer you to get an X-ray to rule out any other injuries such as a fracture or osteoarthritis. Ultrasound imaging or MRI may also be considered if your GP or physio would like to rule in or out any injuries, or wants to determine the size of a traumatic tear. However, as mentioned earlier, there is such a high number of asymptomatic tears and bursitis that may come up on imaging that a scan may not always be helpful. Shoulder pain poorly correlates with imaging findings! There is also little to no correlation between shoulder bursitis diagnosed on a scan and pain! So, in line with the most up to date research, a clinical diagnosis can be made by your physio and a scan is not needed. The key message here, is that despite having a tear present, we CAN fully function and do it PAIN FREE. To learn how, stay tuned for our follow up blogs which will include treatment for rotator cuff injuries – injections, surgery, exercises and more!
At Revive Physiotherapy and Pilates we firmly believe in treating the person in front of us, not the scan they bring in!