Rotator Cuff Tendonitis - by SOS Shoulder Specialist Mr Richard Sinnerton

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What is tendonitis?

Tendonitis, bursitis, rotator cuff syndrome, impingement: these are terms that you may have heard used to describe the pain you are getting in your shoulder. Basically they all refer to problems affecting the 'soft-tissues' that hold the shoulder joint in place and allow it to move through the enormous range that it normally has. For the shoulder to move smoothly and without pain, each element of its complex mechanics has to be working properly and in synchronicity with the others. And when everything is working in concert the shoulder really is a fabulous joint, letting you manouvre your hand in a wide arc around the body to perform many functions.

What is a tendon and what do they do in the shoulder?

A tendon is the piece of tissue which attaches a muscle to a bone and a good example of this is the Achilles Tendon at the back of the lower leg which joins the calf muscle to the ankle bone. In the shoulder there are three main tendons which, together, are known as the Rotator Cuff. Their job is to keep the humeral head (the ball of the ball and socket joint) firmly centered on the glenoid (the socket) and, in conjunction with the much bigger outer muscles of the chest, back and soulder, help move the arm. Their muscle bellies sandwich the scapula (shoulder blade) with one on the front surface, one on the back and one on the top and their tendons pass outwards sideways to attach to the ball at the top of the humerus (upper arm bone). When the one on the front (subscapularis) contracts it pulls the arm inwards eg moving your hand up behind your back; when the one on the back (infraspinatus) contracts it pulls the arm outwards eg playing a tennis forehand; and when the one on the top (supraspinatus) contracts it pulls the arm up in the air eg painting the ceiling.


Why does the tendon get inflammed?

The tendon that is usually involved in tendonitis (-itis means inflammed) is the supraspinatus. When you lift your arm up to the side or the front, the tendon has to pass under the bone on the top of the shoulder (the acromion). Now, normally, there is just enough space for the tendon to go thorugh that space without catching or rubbing. But if the space gets too narrow (due to bone spurs or a cuved shape to that bone) or the tendon gets too thick (due to overuse or accident) then it will rub and cause pain.

What are the symptoms?

The classic symptoms of rotator cuff tendonitis are catching pain in certain positions, usually upwards and in front, pain with activities such as putting on a jacket, reaching behind the car-seat or reaching for the seatbelt and, often, pain at night. Frequently it becomes difficult to get your hand up behind your back ie to do up a bra. As the condition worsens it can become painful just to turn the steering wheel, hold a book or newspaper and use the hand in front of you as well as over shoulder height.


How did I get it?

So how can you irritate and inflame the rotator cuff? I like to descibe the main causes as over-use or ab-use! The abuse group covers falls and other accidents onto the shoulder or wrenching the shoulder as well as poor posture in the workplace especially using a keyboard and mouse. Overuse can come from a myriad of activities but the ones I commonly see are painting ceilings, cleaning windows, using hedge cutters and returning to overhead sports like tennis after a long lay-off. And the cause I see more and more often is bad posture - which involves abuse and overuse.

Patients often put up with the pain for months before they seek help in the reasonable expectation that it will all settle down. Sadly, in many cases it doesn't get better, begins to get worse and starts to affect sleep. And it is sleep disruption which is often the trigger that makes the sufferer decide to seek help.


How do you diagnose it?

The first thing to do with a painful shoulder is make the diagnosis because the treatments for tendonitis, frozen shoulder and arthritis are very different, incompatible and the wrong treatment won't help the right condition.

The diagnosis is made from a combination of your story (the 'history'), an examination of the shoulder and imaging (xrays and scans). If the shoulder doesn't move fully - especially upwards and outwards, and not just because of the pain - then you may have a frozen shoulder or, if you are older (65 plus) you may have arthritis. In tendonitis the shoulder usually moves everywhere except up the back but it is painful and catching.

Then there are also some special tests that your GP, physio or surgeon will carry out to help make the diagnosis.


Should I have an MRI?

And finally you will need some form of imaging. It is my opinion that a diagnosis should not be made without either an x-ray or an MRI or Ultra-sound scan. This is my position in every case but particularly in the older age group where so many people have been told they have a frozen shoulder when they actually have arthritis!


What are the treatments available?

Treatments start with the simple things such as avoiding the activities that cause the pain, taking regular anti-inflammatory tablets and having physiotherapy. If the underlaying structure of your shoulder is normal ie no spurs of bone digging into the tendon, no lumps of chalk within the tendon and a flat acromion, then these measures will settle the majority of 'rotator cuff syndrome' cases.


I am a bit anxious about having a steroid injection?

The next step up, if things either don't settle or settle then recur, is a steroid injection. Cortisone is basically a very strong anti-inflammatory which is injected into the subacromial space and bathes the whole of the tendon and bursa reducing the redness and swelling, shrinking the tendon back down to its normal size so that it can pass under the acromion without catching.

Many people get worried about having a steroid injection but most of those worries are entirely unfounded. Under my care you will only ever get one injection (except in unusual circumstances) so there are no long-term or build-up problems and you won't turn into a Russian weightlifter! In fact, as cortisone is a version of the steroids which occur naturally in the body as a response to injury, it is actually a very holistic and human derived treatment. Yes it can hurt but it's not too bad and many patients say afterwards 'is that it?'.

This is important - the steroid injection is used as a cure not just to mask your symptoms. When your pain settles we encourage you to have physiotherapy to rehabilitate and retune the shoulder so that you can get back to full activities and minimise the chance of the pain recurring.


How do you know if I need an operation?

If on the xrays there are structural abnormalities such as spurs or a hooked or curved acromion, then it may be that you will end up needing surgery to completely relieve your pain. However, even, if you have those changes I will still, probably, do the injection because it is simple and easy to do and may be all you will need. Should your symptoms then come back after 4 to 6 weeks I will discuss the options of an arthroscopic (keyhole) operation to rid you of your pain.

The basis of the surgery is to remove some bone and scar tissue from the space where the tendon runs so that it can pass through without catching and causing pain.

This is called an Arthroscopic Subacromial Decompression or ASD. It is a very good operation with a near 100% success rate and a very low rate of complications but it is not an instant fix and it takes between 3 and 6 months to make a full recovery back to entirely normal.


What sort of anaesthetic do I have?

The operation is done under a combination of an inter-scalene block (ISB) and a general anaesthetic (GA). The ISB is an injection of local anaesthetic given through the base of the neck towards the nerves that give power and feeling to the shoulder and arm. This means that when you wake up you should be pain free with a numb arm. I'm told that it is quite a strange sensation but the anaesthetist will talk you through it so that you are aware what to expect. You then have a full GA for the duration of the procedure so you won't know anything about what's going on.

What do you actually do in the operation?

I operate on you in what we call the beach-chair position. The procedure is carried out using long, thin instruments passed into the various parts of the shoulder through 1 cm long incisions. The shoulder is filled with water which flows down the camera and is sucked out through the various instruments used to clear soft tissues and bone taking the debris with it. The operation takes about 30 minutes to complete but remember, especially for those people waiting to see you afterwards, you will be away from the ward for maybe 2 hours to allow for the time to do the anaesthetic and to recover afterwards.


Will there be any stitches?

There will be one stitch in each of the 2/3 holes I use, covered with a plaster and your arm will be in a sling. Oh, and rather bizarrely, there will be a nappy stuck over your shoulder! That is there to absorb any fluid which may leak out in the first hour or so afterwards and we will take it off before you go home!


Can I go home the same day?

This procedure is now usually done as a day-case but can be an overnight stay depending on how late in the day you have you operation and your domestic circumstances (you have to someone at home with you if you want to go home.)

The physiotherapists will see you before you go home and demonstrate the starting exercises you need to do.

The sling is just for 48 hours. The stitches come out after 10 days either by your GP or back at the hospital. You need to start formal physiotherapy about 10 days after the operation and good rehabilitation is vital to achieve the best result. The surgery is only 50% of the final outcome with the rest coming from you and your physitherapist. I see you in the out-patients 2 weeks afterwards and again 3 months after the operation.

You should be able to use your arm relatively normally below shoulder height straight away and do normal day-to-day things like dressing, showering etc.


When can I drive?

If it is your right shoulder you should be able to drive within a few days and, if you have an automatic, the same goes for the left. If you have to change gear it may be 10 days before you can drive comfortably.


When can I return to work?

This entirely depends on what you do. If you have a desk job, are self-employed and you can get there, then you can go back virtually straight away. At the other extreme, if you are doing a heavy physical job such as brick-laying, then it may be 3 months before you can get back to work at full pace.


When can I return to sports?

It can be very frustrating being off games but a slow, structured return is essential. Many of my patients are golfers and, if that is you, then you can practice putting straight away. At 6 weeks you are permitted to go to the range but only to hit a dozen balls with a 9 iron. You will feel perfectly able to do more and you will be fine doing it at the time but when you wake up the next morning you will know that you have made a serious mistake! Then build up gently over the next 2 weeks working up through the bag and you shoud be playing 9 holes at 8 weeks and 18 at 10 weeks.

The same theory holds for tennis. Start off just spending 10 minutes hitting gentle forehands and backhands and build up from there through volleys before finally starting to hit serves after 8 to 10 weeks. Start with a spin serve before trying a flat, power serve.

Many people ask about going to the gym to do cardiovascular work and that can be a dangerous thing to do because, no matter how you try to relax, your shoulders will soon be pulled up under your ears! The best machine to use is a recumbent bike where you can really hang your arms by your side in a fully relaxed mode. After 4 to 6 weeks it is safe to run, bike and cross-train but avoid the rowing machine till 8 weeks.

And when you return to weights, get some proper advice from your physiotherapist or a personal trainer as there are many things you can do in the gym which you might think are doing good for your shoulders but are making them worse!


What are the complications?

I warn you about two potential problems. There is a theoretical risk of infection but I have never seen this in a keyhole operation of the shoulder in 8 years and many hundreds of operations. There is about a 1:100 risk of developing a post-operative frozen shoulder which is where the shoulder stiffens up in the weeks after surgery. Although this is a very annoying complication it can be fairly easily dealt with. (see frozen shoulder)

What are the results of an ASD?

The statistics for recovering from this operation are these: by three months 8 out of 10 people are 80% better. I think we actually have 9 out of 10 at 90%. That means virtually pain free and doing most of your activities and sports but with some discomfort and a few limitations. It probably takes another 3 months to reach 100% and 100% is the result I expect. I will ask you to fill in a score sheet before your operation and again at 3 months after it to audit my performance and outcomes.