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Understanding Rotator Cuff Related Pain: Signs, Symptoms, Treatment, and Management
- Luke Schembri
- Mar 30
- 5 min read
Understanding rotator cuff-related pain is vital with regards to getting it better. It is one of the most common causes of shoulder pain, particularly among those over the age of 40. The rotator cuff consists of four muscles—supraspinatus, infraspinatus, teres minor, and subscapularis—that work together to stabilise and move the shoulder joint. This blog will provide an evidence-based overview of RCRP, including its signs and symptoms, treatment options, and management strategies, with a focus on the role of physiotherapy in facilitating recovery.
Signs and Symptoms of Rotator Cuff Related Pain
RCRP typically presents with a range of signs and symptoms and the condition is a spectrum of severity. Symptoms can be as minimal as some mild soreness after a 2 hour tennis match or as severe as struggling to lift a light bag of shopping. Common symptoms include:
Shoulder Pain: This is often the primary symptom and is usually localised to the anterolateral aspect of the shoulder, referring in to the upper arm. Patients often report feeling like their pain is in the bicep/tricep area rather than in the shoulder itself.
Weakness: Patients often report weakness, particularly when lifting the arm away from the body or performing overhead movements.
Reduced Range Of Movement: Limited range of movement is normally pain limiting. It
may also feel stiff and tight as a result of muscle tension and imbalances.
Aggravating Activities: Typical activities that people struggle with who have RCRP include putting their arm behind their back (doing up a bra movement), overhead activities, lifting/carrying made worse by attempting this away from the body, sleeping on the affected side and weight bearing through the arm.
Night Pain: Many patients with RCRP experience pain at night, particularly when lying on the affected shoulder, which can disrupt sleep. This is something that needs to be addressed quickly as sleep is an important part of recovery.
These symptoms can significantly impact daily activities and quality of life, making effective management crucial.
Physiological Basis of Rotator Cuff Related Pain
RCRP encompasses a spectrum of conditions, including tendinopathy, partial tears, and subacromial pain (SAP). Tendinopathy refers to a degenerative condition of the rotator cuff tendons, characterised by disorganized collagen fibres, increased ground substance, and neovascularization. Over time, these changes can lead to tendon thickening and, in some cases, partial tears.
SAP is a broader term that includes conditions such as bursitis and rotator cuff tendinopathy. It is believed that mechanical compression of the rotator cuff tendons and subacromial bursa beneath the acromion can contribute to pain, particularly during overhead activities. However, Jeremy Lewis, a leading expert in the field, has emphasised that RCRP is more likely the result of a combination of factors, including overuse, tendon degeneration, and changes in the shoulder’s biomechanics, rather than just mechanical compression alone (Lewis, 2016). Non physical ‘load’ like stress, poor sleep, low mood and depression are also factors that can affect SAP.
Prognosis and Time Frames for Recovery
The prognosis for patients with RCRP varies depending on the severity and duration of symptoms, the specific diagnosis, and adherence to the rehabilitation program. Generally, patients with acute or subacute tendinopathy may experience significant improvements in pain and function within 6-12 weeks of starting a physiotherapy program. However, chronic tendinopathy or cases involving partial tears may require a longer rehabilitation period, often 3-6 months or more (Lewis, 2016).
It is important for patients to have realistic expectations about their recovery. Full resolution of symptoms can take time, particularly for chronic conditions, and some degree of pain or discomfort may persist even after completing the rehabilitation program. However, with consistent adherence to a tailored physiotherapy plan, most patients can expect to regain functional use of their shoulder and return to their desired activities.
Treatment and Management of Rotator Cuff Related Pain
1. Physiotherapy: The Cornerstone of Treatment
Physiotherapy is the first line of treatment for RCRP and is supported by a strong body of evidence. The primary goals of physiotherapy are to reduce pain, improve function, and enhance the strength and endurance of the rotator cuff and scapular muscles. Key components of a physiotherapy program for RCRP include:
Exercise Therapy: Exercise is the cornerstone of physiotherapy for RCRP. Research by Jeremy Lewis (2016) and Jo Gibson (2017) has highlighted the effectiveness of progressive, load-based exercises in treating rotator cuff tendinopathy. The starting point for these exercises will depend on symptoms irritability and need to be tailored to the individual, avoiding a one-size fits all approach.
Manual Therapy: Techniques such as joint mobilisation and soft tissue treatment can help to reduce pain and improve the range of motion. However, as Lewis (2016) notes, as with most musculoskeletal conditions, manual therapy should be used as an adjunct to exercise, not as a standalone treatment.
Education: Educating patients about their condition, the importance of adherence to the exercise program, and the expected time frames for recovery is crucial. Patients should be informed that while pain relief can occur within a few weeks, full recovery may take several months, particularly in cases of chronic tendinopathy (Lewis, 2016).
2. Injection Therapy: An Adjunct for Irritable Symptoms
In cases where pain is severe and not adequately controlled with physiotherapy and appropriate oral analgesia alone, corticosteroid injections may be considered. Corticosteroid injections can provide temporary pain relief by reducing inflammation, allowing patients to engage more effectively in their rehabilitation program. However, evidence suggests that while injections may provide short-term relief, they do not address the underlying cause of the problem and should not be relied upon as a long-term solution (Gibson & Larkin, 2020).
I often describe the treatment of RCRP to my patients as two phases: calm the pain down, build the shoulder back up. An injection can be an adjunct for the first phase, however, unless the second phase is completed with strength and load capacity built back up there is always a risk of symptoms returning.
For patients who do not respond to conservative treatment, or for those with irritable symptoms that limit participation in physiotherapy, injections may be a useful adjunct. However, it is important to note that repeated injections can potentially weaken the tendons and should be used cautiously (Gibson, 2017).
3. Surgical Intervention: A Last Resort
Surgery is typically considered only when conservative treatment, including physiotherapy and injection therapy, has failed to provide adequate relief over a period of 6-12 months. Surgical options may include arthroscopic subacromial decompression or rotator cuff repair, depending on the extent of the tendon damage. However, studies indicate that surgery does not necessarily lead to better outcomes than a well-structured physiotherapy program in the long term (Kuhn et al., 2013). As such, surgery should be reserved for cases with significant structural damage or persistent symptoms despite comprehensive conservative management.
Conclusion
Rotator cuff-related pain is a common and often debilitating condition that requires a comprehensive and evidence-based approach to management. Physiotherapy plays a central role in the treatment of RCRP, with exercise therapy being the cornerstone of rehabilitation. While corticosteroid injections may provide temporary relief, they should be used cautiously and as an adjunct to physiotherapy. Surgical intervention is typically reserved for cases where conservative treatment has failed and is always last resort.
By adhering to a well-structured physiotherapy program and maintaining realistic expectations about recovery time frames, patients can achieve significant improvements in pain, function, and quality of life. For those experiencing shoulder pain, early intervention with physiotherapy is key to preventing chronic symptoms and promoting long-term recovery.
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