Rotator Cuff Tendinopathy – Tendinitis – Tendinosis
In this article Danielle Steilen-Matias, PA-C, discusses diagnosis and treatment of Rotator Cuff Tendinopathy. Treatments include arthroscopic surgery, conservative care (medications, physical therapy and other non-surgical applications) and the emerging science of biological augmentation (Comprehensive Prolotherapy to include Platelet Rich Plasma Therapy and Stem Cell Therapy).
- If you have questions about Rotator Cuff Tendinopathy treatments, get help and information from our Caring Medical staff
Rotator Cuff Tendinopathy can be categorized as a cause and effect problem of shoulder instability.
- In other words, shoulder instability, a loose, wobbly shoulder is the cause of Rotator Cuff Tendinopathy
- What is causing the shoulder to wobble? Damage and weakness to the shoulder ligaments including the Glenohumeral Ligaments and rotator cuff tendons.
So here you are with rotator cuff degenerative problems caused by shoulder instability and you have shoulder instability in part caused by rotator cuff degenerative problems. You are stuck in a degenerative cycle that not only include the tendons but the whole joint, shoulder ligaments and cartilage.
When shoulder instability occurs, the body has three protective mechanisms:
- engage or spasm the muscles to hold the shoulder together,
- swell the joint,
- and grow more bone. This is why bone spurs and arthritis are the long-term result of joint instability which was treated only for the symptoms it produced: inflammation and muscle spasms.
Corticosteroid shots and anti-inflammatories address the shoulder swelling and inflammation, so the symptoms appear better and people keep taking them, but rotator cuff degenerative problems caused by shoulder instability continues.
Swelling protects the shoulders, when anti-inflammatories take the swelling away, the shoulder is again vulnerable.
Shoulder instability is excessive destruction motion of the shoulder. Without the “protection” of the joint swelling, which helps prevents excessive motion and destructive joint forces, further pressures continue to be exerted on the vital rotator cuff tendons.
Without resolution of the labral tear in relations to degenerated shoulder tendons, or shoulder ligament injury in relationship to degenerated shoulder tendons, or the tendinopathy itself causing the shoulder instability, the body will eventually overgrow bone to stabilize the joint. This is why long-term labral tears that are not treated lead to shoulder immobility and impingement. Later in this article we will make the case for treatment with comprehensive Prolotherapy.
Rotator Cuff Tendinopathy – Tendinitis – Tendinosis
What is the difference in Tendinopathy, Tendinitis, and Tendinosis, of the rotator cuff? In her article published in the International journal of therapeutic massage and bodywork, Evelyn Bass, LMT wrote that:
- Tendinitis is the inflammation of the tendon and results from micro-tears in an acute injury
- Tendinosis (literally diseased tendon) is a degeneration in response to chronic overuse; when overuse is continued without giving the tendon time to heal and rest, such as with repetitive strain injury, tendinosis results. Even tiny movements, such as clicking a mouse, can cause tendinosis, when done repeatedly. The confusion about the difference between tendinitis (inflammation of the tendon) and tendinosis (diseased tendon without inflammation) is widespread.
- Tendinopathy refers to generally to damaged and injured tendons.
Many injuries commonly presumed to be tendinitis are actually tendinosis.
The suggestion that tendinitis (inflammation) comes before tendinosis (chronic degenerative disease) is at odds with the fact that a healthy tendon is up to twice as strong as the muscle, making the body of the tendon unlikely to tear before the muscle unless the tendon has already been weakened by degenerative changes.(1)
- In other words, you do not need an inflamed joint to have a diseased tendon. However, that does not mean that inflammation will not lead to tendinosis.
Rotator cuff tendinosis degeneration in response to chronic overuse
The shoulder is made up of two joints, the glenohumeral joint and the acromioclavicular joint. The glenohumeral joint is a ball and socket joint formed by the top of the humerus and the socket of the scapula. The rotator cuff is a group of four muscles and tendons that surround the glenohumeral joint and hold the head of the humerus into the scapula. The Glenohumeral Ligaments however are the main stabilizers.
The rotator cuff functions to stabilize the shoulder and allow the arms to move through a full range of motion. The rotator cuff works together with the deltoid muscle to provide motion and strength to the shoulder for activities that require motion above the waist and shoulders.
Rotator cuff tendinosis (the disease and degeneration process) occurs when the small muscles of the rotator cuff, the supraspinatus, infraspinatus, teres minor, and subscapularis, become strained causing weakness of these structures and subsequent tendonitis (tendon inflammation). As we mentioned above, the muscles go first before the tendon in most cases. This is especially true in the the small and relatively weak rotator cuff muscles which are asked to perform key functions.
- The supraspinatus helps seat the humeral head (ball) into the glenoid cavity (socket) when the arm is raised from the side (abducted).
- The infraspinatus and teres minor rotate the forearm away from the body or in the hand-waving position (external rotation),
- and the subscapularis rotates the forearm towards the body (internal rotation).
Once the balance between motion and joint stability is altered through weakness in the static structures (ligaments) or the dynamic structures (rotator cuff muscles), pain and impaired function will invariably ensue. Baseball pitchers, quarterbacks, tennis players (serving), and swimmers are prone to rotator cuff tendonitis and rotator cuff impingement syndrome. This is because these athletes perform a lot of overhead movements. The rotator cuff is most vulnerable in this position.
Other causes of rotator cuff tendinosis include:
- occupational overuse (working with the arm overhead for many hours or days);
- an existing weakness of the rotator cuff muscles, ligaments or tendons;
- use of improper technique during a sport or occupational activity;
- poor posture;
- sleeping on the same arm each night; Sleeping on the shoulder causes a pinching of the rotator cuff muscles and can lead to rotator cuff weakness. There are cases where the cause of the rotator cuff tendon laxity was due to years of sleeping on the shoulder.
- cervical spine nerve pinching;
- an improper training schedule, such as too much too soon;
- a direct trauma, such as a fall directly onto the shoulder or onto an outstretched arm;
- poor muscle control or coordination; poor posture over the years; or a loose or unstable shoulder joint following a previous dislocation.
- If the rotator cuff continues to be injured or inflamed it will eventually tear, resulting in a more serious problem.
Focus on the supraspinatus tendon and progression to rotator cuff tears
A supraspinatus tendon problem is manifested by pain with abduction and external rotation of the shoulder, especially when reaching for things above shoulder level, or pain in the shoulder after sleeping due to compression of the supraspinatus tendon. The supraspinatus tendon often refers pain to the back of the shoulder.
Those who have supraspinatus tendon laxity causing pain will stop moving their arms into the painful position. Although they may not realize it, they are slowly but surely losing shoulder movement.
The progression from tendinitis to rotator cuff tear was documented in new research from doctors at the Seoul National University College of Medicine in South Korea who published their findings in the journal Knee surgery, sports traumatology, arthroscopy.
This study showed that the degeneration of supraspinatus tendon increases as the stage of rotator cuff disease progresses from tendinopathy to partial rotator cuff tear, and then to full rotator cuff tear. Significant tendon degeneration began from the stage of partial rotator cuff tear. The clinical relevance of the study is that strategies and goals of the treatment for rotator cuff disease should be specific to its stage, in order to prevent disease progression for tendinopathy and partial rotator cuff tear, as well to restore the structural integrity for full rotator cuff tear.(2) In other words, treat it early!
Rotator Cuff Tendinosis Treatment
The initial treatment for rotator cuff tendinosis is frequently to limit above shoulder level activity, application of ice to the shoulder, anti-inflammatory medications for pain, and physical therapy to maintain flexibility.
Although common in the treatment of rotator cuff tendonitis, the use of anti-inflammatories and steroids may actually hinder the healing of soft tissues such as tendons and ligaments, and do not address the root of the problem. Likewise, physical therapy does not help heal the affected ligaments and tendons. Although these treatments may help temporarily, they do not address the original cause of the problem, thus, it eventually returns. In addition, degenerative fraying and tearing of the tendon may occur with constant irritation of the tendon.
When symptoms persist, patients who experience rotator cuff tendonitis are commonly referred to a surgeon for arthroscopic surgery.
Arthroscopic rotator cuff surgery
Arthroscopic rotator cuff surgery can remove bone spurs and inflamed tissue around the shoulder. While small tears can be treated with arthroscopic surgery, larger tears would require open surgery through a larger incision to repair the torn tendon. Unfortunately, surgery may make the problem worse because they are concentrating solely on the tear or an MRI or X-ray finding that, again, the overall joint weakness is not addressed. Let alone, decisions to remove cartilage or other tissue will most commonly fast-track the onset of arthritis.
- Doctors from Finland writing in the Bone and Joint Journal, suggest that arthroscopic decompression not be recommended for patients with rotator cuff tendinopathy.
In their study patients were randomized into two treatment groups:
- arthroscopic acromioplasty (shaving down bone to relieve pressure), and a supervised exercise treatment
- and a similar supervised exercise treatment alone.
Self-reported pain on a visual analogue scale (VAS) questionnaires was the primary means of determining the study’s results.
The researchers also looked for problems of disability, working ability, pain at night.
- A total of 90 patients (64%) returned questionnaires at an average 12 years after research began.
- Both treatment groups reached statistically significant improvement compared with the baseline for pain, but there was no significant difference between groups.
The same was true in the secondary outcome measures. Due to group changes, the results were also analyzed per protocol: operated or not. No significant differences between the groups were found.
The researchers were forced to conclude that surgery was of no added benefit. The summarized the research findings as such:
- Even though the patients who underwent operative treatment had a stronger belief in recovery, which is likely to be surgical and the effect of placebo, the exercise group obtained similar results.
- In the future, an optimum exercise regime should be searched for, as the most clinically and cost-effective conservative treatment for rotator cuff tendinopathy.(3)
If there is no added benefit to the surgery, why take the risk of complications and failed procedure?
In the Journal of Hand Therapy doctors at the The University of Queensland suggest that patients receiving surgery for upper extremity disorders including Carpal tunnel syndrome, Lateral epicondylalgia and Rotator cuff tendinopathy from work place overuse injury needed to be better categorized after surgery failure. We have written extensively about rotator cuff surgery failure rates.
Here we have a situation of a large group of people with surgical failure, yet doctors are in disagreement to what level of failure these patients are in. It should seem that failure is failure. In this study the Australian doctors recognized this disagreement and found in their surveys the experts say:
- Forty-two experts defined a delayed return to work as either a worker not returning to pre-injury (or similar) work within the expected time frame (45%);
- not returning to any type of work (36%);
- or recovering slower than expected (12%).
Two-thirds of the experts believed that universal time points to delineate delayed Return To Work should be avoided. In other words, there is no accurate way to determine how long recovery from Rotator cuff tendinopathy will take or how successful a worker will be in returning to work in full or less than full capacity.(4)
Rotator Cuff tendinopathy treatments
Comprehensive Prolotherapy for rotator cuff tendonitis involves multiple injections of dextrose-based solution to the various ligament and tendon attachments around the shoulder, as well as inside the joint. Prolotherapy to all of the adjacent structures stimulates a natural inflammatory response in the weakened rotator cuff tissues. This mild, localized inflammatory reaction draws immune cells to the area to regenerate the injured tissues. The increase in blood flow and regenerative cells is the body’s natural healing response. The body also responds by depositing collagen at the site of injury, strengthening the rotator cuff tendons that once were weak.
- Prolotherapy injections strengthen the ligaments and the tendinous insertions of the rotator cuff and deltoid. This combined with the gradual re-strengthening of the rotator cuff muscles promises an excellent chance for a full recovery and full performance in many patients.
Treatment to heal the whole shoulder is Prolotherapy
The core concept of comprehensive Prolotherapy is to treat the whole shoulder. This concept of whole joint treatment was discussed by doctors in Denmark researching the best exercise therapy for subacromial impingement syndrome (SIS). SIS is often characterised by rotator cuff tendinopathy. The Danish team suggests that doctors focus on shoulder pain as components (parts of the whole), and to look at tendinopathy treatment programs that assist in healing the whole shoulder.(5)
PRP and Stem Cell Prolotherapy Injections
There is a lot of research to support the use of Comprehensive Prolotherapy injections for Rotator Cuff Tendinopathy.
The needle itself heals
- In the medical journal The Physician and sportsmedicine, researchers from Ohio State University suggest that gently inserting a needle into a tendon (tendon needling) improves patient-reported pain scores in patients with tendinopathy.The addition of autologous blood products (Platelet Rich Plasma Therapy or Stem Cell Therapy) improve these outcomes further.(6)
- In the medical journal Manual Therapy, the benefits of dry needling were also confirmed by research from U.S. Army-Baylor University doctors who found changes in shoulder range of motion and pain sensitivity after dry needling to the infraspinatus muscle (one of the rotator cuff muscles) in patients with subacromial pain syndrome (subacromial or shoulder impingement syndrome). These changes generally occurred 3-4 days after dry needling.”(7) So the injection of a needle creates healing.
- Results are even being achieved with sterile water injections. Researchers in Spain writing in the Muscles, ligaments and tendons journal found that injecting salt water, improved calcific tendinopathy in the shoulder.(8)
- In addition to Platelet rich Plasma and stem cell injections, University of British Columbia, University of Kansas, University of Missouri-Kansas City doctors found that Prolotherapy treatment in patients with painful rotator cuff tendinopathy resulted in superior long term pain improvement and patient satisfaction compared with blinded saline injection .(9)
If you have questions about Rotator Cuff Tendinopathy treatments, get help and information from our Caring Medical staff
1. Evelyn Bass, LMT Tendinopathy: Why the Difference Between Tendinitis and Tendinosis Matters Int J Ther Massage Bodywork. 2012; 5(1): 14–17. [Google Scholar]
2. Jo CH, Shin WH, Park JW, Shin JS, Kim JE. Degree of tendon degeneration and stage of rotator cuff disease. Knee Surgery, Sports Traumatology, Arthroscopy. 2017 Jul 1;25(7):2100-8. [Google Scholar]
3. Ketola S, Lehtinen JT, Arnala I. Arthroscopic decompression not recommended in the treatment of rotator cuff tendinopathy: a final review of a randomised controlled trial at a minimum follow-up of ten years. Bone Joint J. 2017 Jun;99-B(6):799-805. [Google Scholar]
4. Peters SE, Coppieters MW, Ross M, Johnston V. Experts’ perspective on a definition for delayed return-to-work after surgery for nontraumatic upper extremity disorders: Recommendations and implications. J Hand Ther. 2017 Mar 21. pii: S0894-1130(17)30045-5. doi: 10.1016/j.jht.2017.02.009. [Google Scholar]
5. Ingwersen KG, Christensen R, Sørensen L, Jørgensen H, Jensen S, Rasmussen S, Søgaard K, Juul-Kristensen B. Progressive high-load strength training compared with general low-load exercises in patients with rotator cuff tendinopathy: study protocol for a randomised controlled trial. Trials. 2015 Jan 27;16(1):27. [Google Scholar]
6. Frey D, Borchers J, McCamey K. Tendon needling for treatment of tendinopathy: a systematic review. Phys Sportsmed. 2015 Jan 22:1-7. [Google Scholar]
7. Koppenhaver S, Embry R, Ciccarello J, Waltrip J, Pike R, Walker M, Fernández-de-Las-Peñas C, Croy T, Flynn T. Effects of dry needling to the symptomatic versus control shoulder in patients with unilateral subacromial pain syndrome. Man Ther. 2016 Dec;26:62-69. [Google Scholar]
8. Del Castillo-González F, Ramos-Álvarez JJ, Rodríguez-Fabián G, González-Pérez J, Calderón-Montero J. Treatment of the calcific tendinopathy of the rotator cuff by ultrasound-guided percutaneous needle lavage. Two years prospective study. Muscles Ligaments Tendons J. 2015 Feb 5;4(4):407-12. [Google Scholar]
9. Bertrand H, Reeves KD, Bennett CJ, Bicknell S, Cheng AL. Dextrose Prolotherapy versus Control Injections in Painful Rotator Cuff Tendinopathy. Arch Phys Med Rehabil. 2015 Aug 21. pii: S0003-9993(15)01091-6. [Google Scholar]