Rotator Cuff Tendinopathy: Natural History and Treatment Options

Your arms can perform a wide range of activity without experiencing pain when tissues and muscles surrounding the rotator cuff that connects the arm bone to the shoulder blade are healthy. Supporting the rotator cuff are tendons which consist of water and collagen. The tendon functions in a characteristic stretching and compressing action at either end of the muscle. However, constant movement at the tendon can make it susceptible to injury that is manifested by shoulder pain.

Various factors such as ageing, underuse, overloading, profound changes within the structure of the shoulder joint and trauma can cause recurring injury and pain in a condition known as rotator cuff tendinopathy. Ignoring the problem can lead to further deterioration of the rotator cuff as tendinopathy can naturally progress to an advanced stage of irreparable injury. Treatment options will depend on the stage of tendinopathy so it’s important to identify its natural history prior to rehabilitation.


A Model of The Continuum of Rotator Cuff Tendinopathy:

Normal tendon stage: The normal rotator cuff tendon may exhibit some tears as a result of daily activity but it does not present pain. At this stage, it is still possible to perform normal functional activities without experiencing pain and strengthen the tendon by gradually increasing loads to the normal tendon.

Underloaded or normal tendon overload: Underusing the rotator cuff tendon can lead to degradation and swelling in the tendon while overloading or subjecting it to loads or activity in excess of the tendon’s normal capacity can also cause degeneration and swelling. Subjecting the underused tendon to a brief overload can restore normal function of the tendon. On the other hand, when normal tendon overload is temporary, the rotator cuff tendon may return to its previous state without shoulder pain.

Reactive tendinopathy: This is the first stage of rotator cuff tendon injury and it can develop when the tendon is subjected to a burst of unaccustomed activity. There may be increased swelling within the tendon, possibly involving an effusion of fluid found in the bursa (the pocket of fluid that lubricates shoulder joint movement). Constant or intermittent shoulder pain is also present.

Tendon disrepair: When substantial overload at the tendon continues and the injured tendon is not repaired, the rotator cuff can fail to control movement of the shoulder joint which can lead to irritation of the tendon fibres and small partial thickness tears. The tendon can experience substantial swelling and pain which can worsen at night.

Degenerated tendon: The final stage of rotator cuff tendinopathy is marked by a degenerated tendon and a substantial failure of the rotator cuff. Large partial thickness, full thickness and massive rotator cuff tears are present.



Treatment plan:

Load reduction and relative rest: Decrease tendon load with controlled activity levels and relative rest, not complete rest, because underuse can also lead to tendon degeneration.

Pain reduction: Pain arising from inflammation in the tendon may be managed by NSAIDs or ibuprofen. Other options include guided injections and cryotherapy.

Manual therapy and exercises: Appropriate exercises and manual therapy can help restore shoulder movement and function.

Diet: Dietary changes can also help in the management of rotator cuff tendinopathy as studies suggest a link between excess body fat and this disease.

Stop Smoking: Smoking has disastrous effect on healing tissues non more so than rotator cuff tendons.

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