Rotator cuff tendinopathy
- Stephen M Simons, MD, FACSM
Stephen M Simons, MD, FACSM
- South Bend Sports Medicine Fellowship
- David Kruse, MD
David Kruse, MD
- Primary Care Sports Medicine
- Orthopaedic Specialty Institute
- Section Editor
- Karl B Fields, MD
Karl B Fields, MD
- Editor-in-Chief — Primary Care Sports Medicine (Adolescents and Adults)
- Section Editor — Biomechanics, Rehabilitation, and Recovery; Sports-Related Injuries; Symptom Assessment and Physical Examination
- Professor of Family Medicine and Sports Medicine
- University of North Carolina at Chapel Hill
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
Shoulder pain is a common complaint in the primary care setting. Prevalence studies indicate that 16 to 34 percent of the general population suffers from shoulder pain [1,2]. Patients with rotator cuff pathology comprise a sizeable portion of this subpopulation. A thorough understanding of the anatomy and pathophysiology of the shoulder will help the clinician evaluate these patients.
The clinical pathophysiology, diagnosis, and management of rotator cuff tendinopathy will be reviewed here. The general evaluation of the patient with shoulder pain, the shoulder examination, other specific shoulder problems, and general treatments for tendinopathy are discussed separately. (See "Evaluation of the patient with shoulder complaints" and "Physical examination of the shoulder" and "Overview of the management of overuse (chronic) tendinopathy" and "Presentation and diagnosis of rotator cuff tears" and "Rehabilitation principles and practice for shoulder impingement and related problems".)
Knowledge of the pathogenesis of tendon overuse disorders remains incomplete. Histopathological, biochemical, and molecular studies reveal a degenerative process with little evidence of inflammation, although inflammation may play a role initially. The pathophysiology of chronic tendon disorders is discussed separately. (See "Overview of overuse (chronic) tendinopathy".)
The term "tendinitis" came into common parlance to describe chronic painful tendon injuries before the underlying pathology was better understood. The terms "tendinosis" or "tendinopathy" may better describe chronic tendon disorders. Despite support for the term "tendinopathy" among experts, the term "tendinitis" is deeply ingrained in clinical practice and the historical literature. In this review, we use the term "tendinopathy" to refer to symptomatic primary rotator cuff tendon disorders.
EPIDEMIOLOGY AND RISK FACTORS
The incidence of shoulder complaints is approximately 11.2 cases per 1000 patients per year . Shoulder pain occurs more often in the elderly [1,4]. In working populations, the incidence of shoulder-related symptoms may be as high as 14 to 18 percent . (See "Evaluation of the patient with shoulder complaints".)
- Urwin M, Symmons D, Allison T, et al. Estimating the burden of musculoskeletal disorders in the community: the comparative prevalence of symptoms at different anatomical sites, and the relation to social deprivation. Ann Rheum Dis 1998; 57:649.
- Silverstein BA, Viikari-Juntura E, Fan ZJ, et al. Natural course of nontraumatic rotator cuff tendinitis and shoulder symptoms in a working population. Scand J Work Environ Health 2006; 32:99.
- van der Windt DA, Koes BW, de Jong BA, Bouter LM. Shoulder disorders in general practice: incidence, patient characteristics, and management. Ann Rheum Dis 1995; 54:959.
- Chakravarty K, Webley M. Shoulder joint movement and its relationship to disability in the elderly. J Rheumatol 1993; 20:1359.
- Dela Rosa, TL, Wang, AW, Zheng, MH. Tendinosis of the rotator cuff: a review. J Musculoskel Res 2001; 5:143.
- Iannotti JP, Bernot MP, Kuhlman JR, et al. Postoperative assessment of shoulder function: a prospective study of full-thickness rotator cuff tears. J Shoulder Elbow Surg 1996; 5:449.
- Kaergaard A, Andersen JH. Musculoskeletal disorders of the neck and shoulders in female sewing machine operators: prevalence, incidence, and prognosis. Occup Environ Med 2000; 57:528.
- Chard MD, Hazleman R, Hazleman BL, et al. Shoulder disorders in the elderly: a community survey. Arthritis Rheum 1991; 34:766.
- Chard MD, Hazleman BL. Shoulder disorders in the elderly (a hospital study). Ann Rheum Dis 1987; 46:684.
- Mehta S, Gimbel JA, Soslowsky LJ. Etiologic and pathogenetic factors for rotator cuff tendinopathy. Clin Sports Med 2003; 22:791.
- Hijioka A, Suzuki K, Nakamura T, Hojo T. Degenerative change and rotator cuff tears. An anatomical study in 160 shoulders of 80 cadavers. Arch Orthop Trauma Surg 1993; 112:61.
- Sher JS, Uribe JW, Posada A, et al. Abnormal findings on magnetic resonance images of asymptomatic shoulders. J Bone Joint Surg Am 1995; 77:10.
- Hutton KS, Julin MJ. Shoulder injuries. In: Team Physician's Handbook, 3rd, Mellon MB, Walsh WM, Madsen C, et al. (Eds), Hanley & Belfus, Inc, Philadelphia 2002. p.397.
- Wendelboe AM, Hegmann KT, Gren LH, et al. Associations between body-mass index and surgery for rotator cuff tendinitis. J Bone Joint Surg Am 2004; 86-A:743.
- Lin TT, Lin CH, Chang CL, et al. The effect of diabetes, hyperlipidemia, and statins on the development of rotator cuff disease: a nationwide, 11-year, longitudinal, population-based follow-up study. Am J Sports Med 2015; 43:2126.
- Rees JD, Wilson AM, Wolman RL. Current concepts in the management of tendon disorders. Rheumatology (Oxford) 2006; 45:508.
- Riley G. The pathogenesis of tendinopathy. A molecular perspective. Rheumatology (Oxford) 2004; 43:131.
- Maffulli N, Khan KM, Puddu G. Overuse tendon conditions: time to change a confusing terminology. Arthroscopy 1998; 14:840.
- Khan KM, Cook JL, Bonar F, et al. Histopathology of common tendinopathies. Update and implications for clinical management. Sports Med 1999; 27:393.
- Harryman DT 2nd, Sidles JA, Clark JM, et al. Translation of the humeral head on the glenoid with passive glenohumeral motion. J Bone Joint Surg Am 1990; 72:1334.
- Vanderhooft, JE, Lippitt, SB, Harris, SL, et al. Glenohumeral stability from concavity-compression: a quantitative analysis. Orthop Trans 1992; 16:774.
- Uhthoff HK, Sano H. Pathology of failure of the rotator cuff tendon. Orthop Clin North Am 1997; 28:31.
- Naredo E, Aguado P, De Miguel E, et al. Painful shoulder: comparison of physical examination and ultrasonographic findings. Ann Rheum Dis 2002; 61:132.
- Broadhurst NA, Simmons N. Musculoskeletal ultrasound - used to best advantage. Aust Fam Physician 2007; 36:430.
- Lew HL, Chen CP, Wang TG, Chew KT. Introduction to musculoskeletal diagnostic ultrasound: examination of the upper limb. Am J Phys Med Rehabil 2007; 86:310.
- Teefey SA, Hasan SA, Middleton WD, et al. Ultrasonography of the rotator cuff. A comparison of ultrasonographic and arthroscopic findings in one hundred consecutive cases. J Bone Joint Surg Am 2000; 82:498.
- Teefey SA, Rubin DA, Middleton WD, et al. Detection and quantification of rotator cuff tears. Comparison of ultrasonographic, magnetic resonance imaging, and arthroscopic findings in seventy-one consecutive cases. J Bone Joint Surg Am 2004; 86-A:708.
- Ardic F, Kahraman Y, Kacar M, et al. Shoulder impingement syndrome: relationships between clinical, functional, and radiologic findings. Am J Phys Med Rehabil 2006; 85:53.
- Rutten MJ, Jager GJ, Kiemeney LA. Ultrasound detection of rotator cuff tears: observer agreement related to increasing experience. AJR Am J Roentgenol 2010; 195:W440.
- Ottenheijm RP, Jansen MJ, Staal JB, et al. Accuracy of diagnostic ultrasound in patients with suspected subacromial disorders: a systematic review and meta-analysis. Arch Phys Med Rehabil 2010; 91:1616.
- Roy JS, Braën C, Leblond J, et al. Diagnostic accuracy of ultrasonography, MRI and MR arthrography in the characterisation of rotator cuff disorders: a systematic review and meta-analysis. Br J Sports Med 2015; 49:1316.
- Papatheodorou A, Ellinas P, Takis F, et al. US of the shoulder: rotator cuff and non-rotator cuff disorders. Radiographics 2006; 26:e23.
- Kardouni JR, Seitz AL, Walsworth MK, Michener LA. Neovascularization prevalence in the supraspinatus of patients with rotator cuff tendinopathy. Clin J Sport Med 2013; 23:444.
- Page MJ, Green S, Mrocki MA, et al. Electrotherapy modalities for rotator cuff disease. Cochrane Database Syst Rev 2016; :CD012225.
- Green S, Buchbinder R, Hetrick S. Physiotherapy interventions for shoulder pain. Cochrane Database Syst Rev 2003; :CD004258.
- Page MJ, Green S, McBain B, et al. Manual therapy and exercise for rotator cuff disease. Cochrane Database Syst Rev 2016; :CD012224.
- Kibler WB. Rehabilitation of rotator cuff tendinopathy. Clin Sports Med 2003; 22:837.
- Holmgren T, Björnsson Hallgren H, Öberg B, et al. Effect of specific exercise strategy on need for surgery in patients with subacromial impingement syndrome: randomised controlled study. BMJ 2012; 344:e787.
- Jonsson P, Wahlström P, Ohberg L, Alfredson H. Eccentric training in chronic painful impingement syndrome of the shoulder: results of a pilot study. Knee Surg Sports Traumatol Arthrosc 2006; 14:76.
- Buchbinder R, Green S, Youd JM. Corticosteroid injections for shoulder pain. Cochrane Database Syst Rev 2003; :CD004016.
- Koester MC, Dunn WR, Kuhn JE, Spindler KP. The efficacy of subacromial corticosteroid injection in the treatment of rotator cuff disease: A systematic review. J Am Acad Orthop Surg 2007; 15:3.
- Arroll B, Goodyear-Smith F. Corticosteroid injections for painful shoulder: a meta-analysis. Br J Gen Pract 2005; 55:224.
- Alvarez CM, Litchfield R, Jackowski D, et al. A prospective, double-blind, randomized clinical trial comparing subacromial injection of betamethasone and xylocaine to xylocaine alone in chronic rotator cuff tendinosis. Am J Sports Med 2005; 33:255.
- Paoloni JA, Appleyard RC, Nelson J, Murrell GA. Topical glyceryl trinitrate application in the treatment of chronic supraspinatus tendinopathy: a randomized, double-blinded, placebo-controlled clinical trial. Am J Sports Med 2005; 33:806.
- Giombini A, Di Cesare A, Safran MR, et al. Short-term effectiveness of hyperthermia for supraspinatus tendinopathy in athletes: a short-term randomized controlled study. Am J Sports Med 2006; 34:1247.
- Gerdesmeyer L, Wagenpfeil S, Haake M, et al. Extracorporeal shock wave therapy for the treatment of chronic calcifying tendonitis of the rotator cuff: a randomized controlled trial. JAMA 2003; 290:2573.
- Huisstede BM, Gebremariam L, van der Sande R, et al. Evidence for effectiveness of Extracorporal Shock-Wave Therapy (ESWT) to treat calcific and non-calcific rotator cuff tendinosis--a systematic review. Man Ther 2011; 16:419.
- Bryan, WJ, Labossiere, D, Coleman, E, Bartz, R. Baseball Shoulder and Elbow Injury Rehabilitation of Varsity, High School, Intercollegiate, and Professional Baseball Players. Sports Med Arthro Rev 2001; 9:154.
- EPIDEMIOLOGY AND RISK FACTORS
- Risk factors
- CLINICAL ANATOMY
- BASIC BIOMECHANICS
- PATHOPHYSIOLOGY AND MECHANISM OF INJURY
- DIFFERENTIAL DIAGNOSIS
- CLINICAL PRESENTATION AND EXAMINATION
- Clinical presentation
- Physical examination
- RADIOGRAPHIC FINDINGS
- Plain radiographs
- Musculoskeletal ultrasound
- Additional ultrasound resources
- Magnetic resonance imaging
- INDICATIONS FOR ORTHOPEDIC REFERRAL
- General approach
- Acute treatment
- - Basic management
- - Adjunct therapies
- Physical therapy
- Subacute treatment
- - Glucocorticoids
- - Topical glyceryl trinitrate
- Experimental treatments
- APPROACH TO MANAGEMENT
- FOLLOW-UP CARE
- RETURN TO SPORT OR WORK
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS