Watch this video of Edel Fanning, Lead Shoulder Physiotherapist at SSC Sports Medicine discussing ‘Rotator Cuff Related Shoulder Pain: What Should I do?.
This video was recorded as a part of SSC Online Public Information Meeting focusing on the shoulder.
My name is Edel and I am a shoulder physiotherapist at SSC. I am going to talk about rotator cuff-related pain and what should I do. So what is the rotator cuff? A rotator cuff Is a group of four muscles that attach to the shoulder blade and the rotator cuff along with the bursa which is a small fluid-filled sac that works together to move and control the shoulder and allows you to do activities like reaching up playing golf and carrying out a tennis swing.
What is rotator cuff-related pain? Rotator cuff related pain presents with pain loss of function and weakness with movements of the shoulder and so it presents very differently to some other types of shoulder pathology such as a frozen shoulder which very much presents with a stiff shoulder or shoulder instability and so it is very much to do with pain loss function and weakness. Its an umbrella term, you may have heard of terms like subacromial impingement, tendinopathy, bursitis, and rotator cuff tears, and factor co-related cuff pain is now a widely used umbrella term for all of these pathologies mainly because the management of these pathologies are very similar and we’ll talk through that a little bit. So what are the causes of rotator cuff-related pain? rotator cuff related pain is often the onset of rotator cuff related pain is often due to a sudden change in tissue loads so for example if you went ahead and played tennis in the spring or summertime and hadn’t played tennis all winter, that is a sudden increase in load on the tissues of the shoulder which may predispose you to shoulder pain and it may be as simple as you have been out in the garden and hadn’t been out in the garden for a while and you knew it and shrimp the hedges again its sudden change in tissue load and often doesn’t have to be a massive change and again it depends on the quality of your tissues and your body type some people are more predisposed to tendon type pain than others and we’ll go into that in a little bit more detail. Other things that predispose you to a rotator cuff related pain or any type of pain are lifestyle factors so things as poor quality of sleep now we know that inadequate sleep over a long period caused an increase in chemicals in the body that predispose you to increases in pain and decreases your ability to repair and recover and the same with smoking it releases chemicals into the bloodstream that travels to muscles and tendons. It can have quite a large impact on recovery. The same with nutritional choices, poor nutritional choices cause an increase in visceral fat, visceral fat surrounds your visceral structures, and similar to smoking this fat releases chemicals into the bloodstream. Lack of physical pain, stress, and anxiety all have an impact on our recovery. Other things like genetics, age, and hormonal status all have an impact on your likelihood to pick up rotator cuff pain or any type of tendon pain. It’s an accumulation of these that exposes us to tendon pain.
When it comes to diagnosis, MRI scans or ultrasound to assess the integrity of rotator cuff muscles and now we’re fortunate unfortunate live in an age where we have access to imaging, and imaging can be very useful particularly if there has been a serious trauma, scans can pick up significant structural damage. In some other pathologies, we need to take a couple of things into account. The evidence is showing there is a really poor lack of correlation between changes in structures and pain, so the pain doesn’t correlate with the size of the tear, shapes of bones in the shoulder, calcium deposits, and bursa changes. Sometimes and a lot of times people have these types of changes and don’t get pain. Interestingly the biggest predictor of what you call rotator cuff pathology or morphology normal change is age so after the age of 20-25 we all get changes in our rotator cuff, so we all have small little intra-tenderness tears of our bursal types changes just like this the findings that I showed you a moment ago so what does that mean for you, in the absence of significant trauma often findings images are most likely not the reason for your symptoms and it is very important if you do have imaging for rotator cuff related pain that you do sit down with a healthcare provider who is familiar with these types of problems and will be able to explain them you.
There are lots of management options. The number one option like any type of tendon pain is to wait and see because often tendon pain does settle down by itself, often the pain will settle with a bit of relative rest and graded return back into playing tennis. If you haven’t played in a while every senile going back, you might do 20 minutes doubles to start with and gradually build it up. However, if it doesn’t settle with rest then it’s often time to seek further advice so other types of management options you may have heard of things like injections like cortisone injections. The evidence shows that for rotator cuff-related pain, injections help approximately 1 in 5 people, the transient relief from anything from 4-8 weeks, and often the relief is a small reduction in pain. So certainly a steroid injection is not the magic bullet sometimes it is useful in some cases, but it is important for this certain problem it only helps around 1 in 5 people. Next up we have a graded exercise program, there is positive and empowering news about exercise, and an exercise program for the shoulder. If shoulder symptoms aren’t caused by serious trauma, so you’ve had no major falls no major serious trauma research shows an exercise program together with addressing lifestyle factors will achieve the same outcomes as surgery plus exercise at 1,2, and 5 years follow up. Exercise tends to have the most positive impact on this type of rotator cuff pain.
When talking about a graded exercise programs that means it is a gradual progression, it’s over about 12-16 weeks, some up to 6 months it takes for rotator cuff pain to have a good response so you gradually build exercise up over those 3 months and often with a health care provider that can help guide you. For most of the rotator cuff pain that I see, I’ll often give them a program and send them away for two or three weeks because there almost not good enough to go to the next level and so most of it is managed by yourself and us guiding and coaching you n the exercises that we think our beneficial. The important thing here it takes a minimum of 12 weeks for rotator cuff-related pain to settle and some are longer. A couple of other things to consider is we have to consider load management, so how much are you asking of the shoulder? If we look at the left side the green tendon capacity so says, for example, your rotator cuff tendons may be working 60-70% of what they should be because it is painful and when we then ask on the red side that’s the low demand. So when we ask too much of that so we increase that load demand, it will tip that weighing scale. If you go back to playing tennis the tendon just can’t cope so when we go to try and manage this we might modify your load and we might drop it back by 30% of the tennis you are playing and then start increasing your tendon capacity, so gradually working on getting your tendons more robust to tolerate the load. You can do that yourself too, if you develop rotator cuff pain just drop back the load a little bit.
When it comes to pain and exercise, this is a frequently asked question, is it okay to get some pain while exercising and does are good at telling you if they can tolerate the amount you’re asking from, so we often use this traffic light system you see here in the right-hand side so pain during exercise so say if you get a 3 or 4 out of 10, it is very reasonable to get a little bit of pain during exercise as long as it settles relatively quick afterward, say you do a bit of swimming or tennis or golf it’s a little bit sore but it settles within half an hour afterward, that’s a good sign that tendons are tolerating that load. When you wake up the next morning or the day after and you’ve got quite a spike or increase in pain that’s a strong sign that the tendons probably are under the muscles aren’t tolerating the amount you’re asking from them so it is quite important then to drop back the load a little bit and that is important that traffic light system through your graded exercise program and also through your activities that you’re doing in every day and also look at the trend of symptoms over time, that is important as rotator cuff related pain is very up and down depending on what you ask of muscles, so every 2 or 3 weeks we would expect a little bit of improvement, a little bit of a jump if you are following an exercise program.
The road to recovery, you want the road to be nice and smooth. Any type of tendon pain is prone to this type of zig-zag pattern that’s just because we have to use your shoulders in everyday function, so when we overdo it a little bit we have a little are-up it’s not, particularly a setback, its just yit’sasked a little bit too much of that tendon. It is really important to listen to your shoulder and listen to those responses. On the timeframe, bear in mind that 12-week minimum period and they take time to settle and recover, there isn’t any quick fix but the good news is most respond well to supervised exercise. The other important thing to remember here it’s not just about the shoulder, 50-55% of shoulder powers come from energy transferred from the lower limbs and pelvis. So if your healthcare provider is creating an exercise program for your rotator cuff they will include lower limb exercises as well as upper limbs. Expect a wobble along the way.
The other big caveat here is lifestyle changes so we spoke about those early on so we know lifestyle factors have a huge impact on recovery. So when we look at putting together an exercise program it is important to look at behavioral changes around lifestyle changes as we talked about smoking, nutritional, etc all affect our recovery. Try to increase physical activity by 150 minutes per week and if you are a smoker, trying to reduce the amount of smoking or indeed stop, their chances are not easy nobody is judging, it takes time and often you need support and help and that’s where you go/healthcare provider can come in and help and try to give your support to make better lifestyle changes. Stress and anxiety too can have an impact there create chronic low-grade inflammation in our body which predisposes us as I said to lots of co-morbidity, so when we are tackling rotator cuff pain we do have to look at the full picture. We also have the option of surgery when symptoms do not resolve after exercise-based programs for 3-6 months and lifestyle changes you may wish to consider surgery. Remember that research has not proven that surgery and post-surgical rehabilitation outperform surgery with rotator cuff pain. Like exercise, surgery has no guarantee. Lifestyle factors impact success rate. There is no quick fix.
I have a couple of take home points, some lifestyle factors may cause or prolong symptoms, imaging doesn’t make noses, injection reduces pain in 1 out of 5 people, no difference when exercise is compared to surgery in the absence of significant trauma, and shared decision making is really important to input into you best management option. Thank you so much for taking your time out of your evening to listen, it is a real privilege to have the opportunity to speak to you and try to empower you and share some information about rotator cuff pain.
What exercise would you recommend for rotator cuff tendinitis & pain in the left pec muscle, is this related to tendinitis?
Often when we get shoulder pain you can get iit n lit lots of different areas, the pec muscle is quite a common area to get it, particularly when the rotator cuff isn’t doing its job, often the pec, muscle which normally helps moves the shoulder forward as we lift it has to take over the job of the rotator cuff because the rotator cuff isn’t doing its job and thats why we can often end up with pain in some of the pec muscles, They’ve been the symptom as the other muscles aren’t doing their job so when it comes to putting a rehab program together, we will look at trying to get the rotator cuff to function correctly. The rotator cuff is functional through everything, so exercises in lots of different directions and all its different roles are generally what we do so we try to fire up those small muscles, those deep rotator cuff muscles. Once they are up and running often we’ll then put in quite functional exercises things you might be familiar with things like floor press, or an overhead press with a dumbbell to build up the torque and strength of the muscles and again it depends what you are trying to get and depends on on what level of activity you want to get back to whether it is tennis or rock climbing or just doing the gardening. It’s not just exercising the shoulder, we know that increased physical activity helps recovery and so certainly if you’re not normally physically active will often give you and say for example a walking program to start getting you more physically active which can have a positive effect on recovery. It is important to be consistent with exercise for 12-16 weeks, it’s not just one exercise.
Can I attend physio specialising in shoulders without having attended a surgeon or having had surgery?
Yes that’s no problem, At sports medicine in the sports surgery clinic, if you just contact Sports Medicine Admin, we have a team that works in shoulders so if you say you have a shoulder problem they will generally put you in with someone who deals with shoulders.
Do you need to have physio after having cortisone and a further injection to the muscle of your shoulder?
We kind of know cortisone injections are transient relief, they are never really probably getting to the root of the cause and often they’ll settle the shoulder down, you may get some transient relief, they don’t work for everybody but certainly, if you had one use that as a good time to optimize the function of the shoulder so you want to try and build up the tendon capacity in the shoulder again getting nice and robust to tolerate load.
As I have mentioned in the talk, be aware that it’s not just the local shoulder that could affect the recovery, it’s making sure lifestyle changes are appropriate to try and get the outcome that you want, as well as addressing local shoulder exercises.
I have a mild rotator cuff pain for 3 years, I have had physio and injections in my early 30s, would you recommend keyhole surgery?
There is a lot of history in that question as we don’t know the full story of what you have undergone over those three years. The general advice would be to exercise first, the evidence has very much shown exercise versus manual therapy or acupuncture in terms of recovery and it’s not that you can have those stuff but certainly having a structured rehab program over a 12 to 16 weeks period, if you feel like you have tried that then I think its always reasonable to have a conversation with a surgeon but just be aware there is no guarantee with surgery like there is no guarantee exercise. The same things affect recovery with surgery things like if you are a smoker and your lifestyle will affect your outcome. Make sure you know the risks before making an informed decision.
X-rays are really useful, we generally use them for bone pathology so if we are concerned you had a fracture and perhaps we think something sinister was going on and we wanted to check the bone quality and make sure nothing was going on from a bone point of view then we would order an x-ray. If we’re more concerned about the rotator cuff tendons, or if there was a trauma and we would get an MRI to have a look at the muscles and tendons rather than an x-ray.
Frozen shoulder is a bit of what we think more of a systemic pathology so often frozen shoulder and through frozen shoulder presents with stiffness and pain, its not necessarily have to be an injury or a trauma, it generally isnt. We think it’s a systemic process that sets off this process of a frozen shoulder. You generally get it between the ages of 40 and 65. It is more common in women than men and it is more common in the non-dominant arm, but we they don’t know a definite answer to why some people get frozen shoulder and other people don’t. It is very common for 1-5% of the population will get a frozen shoulder. I think is one of the most painful conditions of the shoulder. We know when it comes to people with systemic issues like diabetes, cardiovascular problems, or thyroid issues are more prone to getting a frozen shoulder but anyone can get it.
Again like any other comorbidity out there, there is also a relationship with lifestyle factors, since the lock down activity levels have decreased and stress levels have increased and I have seen the most frozen shoulders in the last 6 months compared to previous years which I think is related to less physical activity over lock down and more stress with working and working from home. Treatment wise, as we know from earlier on there is inflammation in the shoulder and you would generally benefit from a steroid injection, which is very different from your rotator cuff tendinopathy the evidence is quite strong, and most frozen shoulders that present to me I would send them for an injection to calm down the pain and they do quite well with an injection. When it comes to rehab as it is quite inflamed you get this thickening and what we call the collagen thickens in the capsule, aggressive physio earlier on is not recommended.
The best type of exercise is gentle activity keep moving and often I give a supervised program and coach people through the process. Truly frozen shoulders last anything between 12 months and up to 3 years even longer. They are very painful but the good news is they do usually do well with an injection and supervised rehab to coach you through the stiffness stages. There is a small number that will have to consider surgery.