Rotator Cuff Related Shoulder Pain / Subacromial Shoulder Pain | Diagnosis & Treatment

Rotator cuff related shoulder pain (RCRSP) is a common condition that affects a large proportion of the population. It is characterized by pain and discomfort in the shoulder region, often accompanied by a limited active range of motion and inability to produce force. The etiology of RCRSP is multifactorial, with several potential contributing factors, including anatomical, mechanical, and biological factors.

There are numerous terminology options for this pathology such as subacromial shoulder pain, subacromial impingement syndrome, subacromial bursitis, and subacromial bursopathy. However, “Rotator cuff related shoulder pain” or a weak and painful shoulder are preferred and the term ‘impingement’ should be avoided (Littlewood et al., 2019).

Pathomechanism

Tendinopathy is a persistent pain and loss of function in tendons due to mechanical loading. It is most commonly seen in the rotator cuff, patellar, and Achilles tendons. The pathogenesis of rotator cuff tendinopathies is still mostly unknown and based on animal studies and surgically removed tendons. Tendinopathy is caused by collagen disruption, inflammation, or tendon cell response and the imbalance of synthesis and degradation may lead to disorganization. There is no direct relationship between structure, pain, and dysfunction, and tendinopathy can result in decreased muscle strength and control.

Tendinopathy may be driven by reduced stimulation of the tendon cell, secondary hyperalgesia, and intrinsic factors such as genetics, age, and loading history. Despite many scientific articles published on this subject, it is still challenging to construct a simple and robust model that accommodates all aspects of the condition (Scott et al. 2015).

The pain mechanisms in tendinopathy are not clear but are thought to involve local nociception mediated by changes within the tenocytes (Rio et al. 2014).  The etiology of chronic tendinopathy is complex and multifactorial. The current understanding is the imbalance between the load demands placed on the tendon and its capacity to remodel (Cook et al. 2009).

Clinical Presentation & Examination

More than 80% of shoulder pain is classified as rotator cuff-related shoulder pain (Ostör et al 2005). According to the 2022 clinical guidelines, rotator cuff tendinopathy encompasses subacromial pain syndrome, rotator cuff-related shoulder pain, subacromial impingement syndrome, subacromial bursopathy, long head biceps tendinopathy, and partial thickness rotator cuff tear (Lafrance et al 2022). In this article, RCRSP is seen as an overlapping diagnosis, and synonymous with rotator cuff tendinopathy.

To classify as one of these conditions pain should be broadly over the deltoid and upper arm region. The pain will be activity-related and worse with overhead or behind-the-back reaching. Pain in the neck, reproduction of shoulder pain with neck movements, and distal neurovascular symptoms reduce suspicion. Changes in occupation and participation – rather than nature alone – might raise the index of suspicion.

When doing your clinical examination, there should be no significant loss of passive range of movement, particularly in external rotation. Familiar pain should be reproduced with resisted abduction and/or lateral rotation. Assessment of sleep, nutrition, alcohol, physical activity, and smoking should be done with the promotion of change where relevant (Littlewood et al 2019).

Orthopedic tests

Most diagnostic tests for the shoulder are unreliable or not validated and combining provides little use for clinical practice (Hegedus et al 2012). However, in the clinical practice guideline by Lafrance and colleagues, there are several recommendations — although caution is required. These are seen in the bullet points below.

Use the following tests to confirm or rule out a diagnosis of tendinopathy or full-thickness rotator cuff tear.

Combinations to confirm a diagnosis:

·         Full-thickness supraspinatus tear: Jobe/Empty Can + Full Can + External Rotation Lag Sign

·         Full-thickness infraspinatus tear: External Rotation Lag Sign

·         Full-thickness subscapularis tear: Lift-off + Belly Press or Belly Press + Bear Hug

·         Rotator cuff tendinopathy/Partial tear: Painful Arc Test

Tests to rule out a diagnosis:

·         Full-thickness supraspinatus, infraspinatus, or subscapularis tear: none

·         Rotator cuff tendinopathy/partial tear: painful arc test or Hawkins-Kennedy test

To perform these tests, watch the following videos closely:

Jobe test/empty can test:

Full can test:

External rotation lag sign:

Lift off test:

Belly press test:

Bear hug test:

Painful arc test:

Hawkins-Kennedy test:

Other orthopedic tests for RCRSP are:

• Neer’s test
• Posterior impingement test
• Drop arm test
• Yocum’s test

Imaging

Medical imaging is usually not needed, except when you are suspicious of a more sinister pathology during the history taking. Outside of this exclusion use, imaging results will not change non-surgical management in RCRSP (Littlewood et al 2019).

Imaging can be useful when the patient experiences shoulder trauma, when there’s a suspicion of a full-thickness tear, or when non-surgical management isn’t going according to plan. Consider using ultrasound as opposed to MRI since it is cheaper, often quicker, and has similar diagnostic properties for tears. It is important to discuss the diagnostic values and interpretation of the imaging results with the patient (Lafrance et al 2022).

If your patient already got an MRI or ultrasound, know that  ‘abnormalities’ are normal, even in asymptomatic individuals. Be aware of this when interpreting imaging results. Teunis et al (2014) investigated this. The following image gives an overview of rotator cuff abnormalities per age group.

Treatment

The guidelines recommend the following treatment pathway for individuals suffering with RCRSP:

Education

How can you explain what’s going on to your patients? You could tell them that there’s an issue with the muscles and tendons of the shoulder. They lack strength, capacity, tolerance, and fitness; making them complain when you lift your arm.

Medication

With medications, most recommendations are based on indirect evidence (Lafrance et al 2022), and corticosteroid injections may reduce pain in the short term but increase the risk of retearing and revision after surgery (Puzzitiello et al 2019).

Surgery

If surgery is necessary, repairing the cuff is an option. However, it is important to consider prognostic factors associated with an increased disability after surgery, such as a large tear, lower preoperative strength, low patient expectations, diabetes, obesity, and a sedentary lifestyle (Lafrance et al 2022). A Cochrane review shows high-quality evidence against the use of decompression surgery in rotator cuff disease (Karjaleinen et al 2019).

Exercise & manual therapy

There is strong evidence to suggest that exercise therapy is the way to go for RCRSP. This can be combined with manual therapy (Pieters et al 2020, Franco et al 2019). A treatment program for at least 12 weeks is suggested (Lafrance et al 2022).

Currently, the optimal dose and further specifics are unknown so further elaborations are hard to make (Lafrance et al 2022, Puzzitiello et al 2019). However, a consensus statement by Littlewood et al (2019), suggests the following:

It is essential to follow a comprehensive exercise program for at least 12 weeks for the best prognosis. The preferred treatment for rotator cuff injuries is loading through progressive exercise, including the kinetic chain, and working to fatigue with an acceptable symptom response. Exercising on alternate days is sufficient, and heavy loading or plyometrics may require two to three sessions per week. Three exercises are usually enough and should address personal functional limitations. While exercises can provoke pain, they should be continued as long as symptoms settle sufficiently.

Shockwave (ESWT)

If an ultrasound or MRI confirms calcification of the rotator cuff tendons and the patient remains refractory to initial nonsurgical management, shockwave or an arthroscopic lavage can be considered (Lafrance et al 2022). However, a Cochrane systematic review contradicts the shockwave statement (Surace et al 2020) and the lavage is supported by low-quality evidence (Lafrance et al 2019).

References

Rio, E., Moseley, L., Purdam, C., Samiric, T., Kidgell, D., Pearce, A. J., Jaberzadeh, S., & Cook, J. (2014). The pain of tendinopathy: physiological or pathophysiological?. Sports medicine (Auckland, N.Z.), 44(1), 9–23.

Cook, J. L., & Purdam, C. R. (2009). Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British journal of sports medicine, 43(6), 409–416. 

Scott, A., Backman, L. J., & Speed, C. (2015). Tendinopathy: Update on Pathophysiology. The Journal of orthopaedic and sports physical therapy, 45(11), 833–841.

Hegedus, E. J., Goode, A. P., Cook, C. E., Michener, L., Myer, C. A., Myer, D. M., & Wright, A. A. (2012). Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. British journal of sports medicine, 46(14), 964–978.

Ostör, A. J., Richards, C. A., Prevost, A. T., Speed, C. A., & Hazleman, B. L. (2005). Diagnosis and relation to general health of shoulder disorders presenting to primary care. Rheumatology (Oxford, England), 44(6), 800–805.

Teunis, T., Lubberts, B., Reilly, B. T., & Ring, D. (2014). A systematic review and pooled analysis of the prevalence of rotator cuff disease with increasing age. Journal of shoulder and elbow surgery, 23(12), 1913–1921.

Puzzitiello, R. N., Patel, B. H., Nwachukwu, B. U., Allen, A. A., Forsythe, B., & Salzler, M. J. (2020). Adverse Impact of Corticosteroid Injection on Rotator Cuff Tendon Health and Repair: A Systematic Review. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association, 36(5), 1468–1475.

Lafrance, S., Charron, M., Roy, J. S., Dyer, J. O., Frémont, P., Dionne, C. E., Macdermid, J. C., Tousignant, M., Rochette, A., Doiron-Cadrin, P., Lowry, V., Bureau, N., Lamontagne, M., Sandman, E., Coutu, M. F., Lavigne, P., & Desmeules, F. (2022). Diagnosing, Managing, and Supporting Return to Work of Adults With Rotator Cuff Disorders: A Clinical Practice Guideline. The Journal of orthopaedic and sports physical therapy, 52(10), 647–664.

Karjalainen TV, Jain NB, Page CM, Lähdeoja TA, Johnston RV, Salamh P, Kavaja L, Ardern CL, Agarwal A, Vandvik PO, Buchbinder R. Subacromial decompression surgery for rotator cuff disease. Cochrane Database of Systematic Reviews 2019, Issue 1. Art. No.: CD005619.

Pieters, L., Lewis, J., Kuppens, K., Jochems, J., Bruijstens, T., Joossens, L., & Struyf, F. (2020). An Update of Systematic Reviews Examining the Effectiveness of Conservative Physical Therapy Interventions for Subacromial Shoulder Pain. The Journal of orthopaedic and sports physical therapy, 50(3), 131–141.

Franco, E. S. B., Puga, M. E. D. S., Imoto, A. M., Almeida, J., Mata, V. D., & Peccin, S. (2019). What do Cochrane Systematic Reviews say about conservative and surgical therapeutic interventions for treating rotator cuff disease? Synthesis of evidence. Sao Paulo medical journal = Revista paulista de medicina, 137(6), 543–549.

Littlewood, C., Bateman, M., Connor, C., Gibson, J., Horsley, I.G., Jaggi, A., Jones, V., Meakins, A., & Scott, M. (2019). Physiotherapists’ recommendations for examination and treatment of rotator cuff related shoulder pain: A consensus exercise. Physiotherapy Practice and Research.

Surace, S. J., Deitch, J., Johnston, R. V., & Buchbinder, R. (2020). Shock wave therapy for rotator cuff disease with or without calcification. The Cochrane database of systematic reviews, 3(3), CD008962.

Lafrance S, Doiron-Cadrin P, Saulnier M, Lamontagne M, Bureau NJ, Dyer JO, Roy JS, Desmeules F. Is ultrasound-guided lavage an effective intervention for rotator cuff calcific tendinopathy? A systematic review with a meta-analysis of randomised controlled trials. BMJ Open Sport Exerc Med. 2019 Mar 9;5(1):e000506. doi: 10.1136/bmjsem-2018-000506. PMID: 31191964