Physical Therapy Guide to Rotator Cuff Tendinitis
Disorders of the rotator cuff and the tissues around it are the most common causes of shoulder pain in people over 40 years of age. Rotator cuff tendinopathy occurs when a shoulder tendon (a bundle of fibers connecting muscle to bone) is irritated and becomes sore. With continued irritation, the tendon can begin to break down, causing tendinosis—a more chronic condition. People who perform repetitive or overhead arm movements, such as weight lifters, athletes, and manual laborers, are most at risk for developing rotator cuff tendinopathy. Poor posture can also contribute to its development. A physical therapist can help you identify and correct risk factors for rotator cuff tendinopathy, and help you decrease your pain while improving your shoulder motion and strength.
What is Rotator Cuff Tendinitis?
The rotator cuff muscles are a group of 4 muscles that attach the humerus (upper arm bone) to the scapula (shoulder blade). The rotator cuff muscles help raise, rotate, and stabilize the upper arm. A tendon is a bundle of fibers that connects the muscles to the bone. Rotator cuff tendinitis occurs when the tendon connected to the rotator cuff muscles becomes inflamed and irritated. The condition can be caused by:
- Repetitive arm movements, such as those performed by a hairstylist or house painter
- Overhead shoulder motions, such as those performed by baseball pitchers or swimmers
- Weakness and muscle imbalances in the shoulder blades and shoulder muscles
- Tight muscles and tissues around the shoulder joint
- Bony abnormalities of the shoulder region that cause the tendons to become pinched
- Poor posture, such as rounded shoulders caused by leaning over a computer for long periods (shoulder impingement syndrome)
How Does It Feel?
Rotator cuff tendinopathy is characterized by shoulder pain that can occur gradually over time or start quite suddenly. The pain occurs in the shoulder region and sometimes radiates into the upper arm. It does not usually radiate past the elbow region, although it can. You may be symptom free at rest or experience a mild, dull ache; however, pain can be moderate to severe with certain shoulder movements and can be easily provoked. Reaching behind the body to perform a motion, as in fastening a seat belt, can be very painful. So can overhead activities, such as throwing, swimming, reaching into a cupboard, or combing your hair. The pain can worsen at night, especially when rolling over or attempting to sleep on the painful side. You may notice weakness when lifting and reaching for household items. Holding a heavy platter or taking a pan off the stove may become difficult. If the condition is left untreated, it is possible to begin to experience pain in other areas, such as the neck.
How Is It Diagnosed?
A physical therapist will perform an evaluation and ask you questions about the pain and other symptoms you are feeling. Your physical therapist may perform strength and motion tests on your shoulder, ask about your job duties and hobbies, evaluate your posture, and check for any muscle imbalances and weakness that can occur between the shoulder and the scapular muscles. Your physical therapist will gently touch your shoulder in specific areas to determine which tendon or tendons are inflamed, and may perform other special tests to detect rotator cuff tendinopathy. Generally, a physical examination is all that is needed to diagnose rotator cuff tendinopathy. If the symptoms do not resolve with physical therapy, imaging (eg, MRI) may be considered, to help determine any possible underlying condition that could be affecting the shoulder.
How Can a Physical Therapist Help?
It is important to get proper treatment for tendinitis as soon as it occurs. Over time, a degenerated tendon that is not treated can begin to tear, causing a more serious condition. Physical therapy can be very successful in treating rotator cuff tendinitis, tendinosis, and shoulder impingement syndrome. You will work with your physical therapist to devise a treatment plan that is specific to your condition and goals. Your individual treatment program may include:
Pain management. Your physical therapist will help you identify and avoid painful movements to allow the inflamed tendon to heal. Ice, massage, or moist heat may be applied for pain management. Therapeutic modalities, such as iontophoresis (medication delivered through an electrically-charged patch) and electrical stimulation (TENS) may be applied.
Patient education. Posture education is an important part of rehabilitation. For example, when your shoulders roll forward as you lean over a computer, the tendons in the front of the shoulder can become pinched. Your physical therapist may suggest adjustments to your workstation and work habits. Your physical therapist will also instruct you in ideal sitting, standing, and sleeping positions to help alleviate symptoms. Your therapist may suggest different ways to perform currently painful activities and show you movements to avoid while the shoulder is painful.
Manual therapy. Your physical therapist may use manual techniques, such as gentle joint movements, soft-tissue massage, and shoulder stretches, to get your shoulder moving again in harmony with your shoulder blade.
Range-of-motion exercises. You will learn exercises and stretches to help your shoulder and shoulder blade move properly, so you can return to reaching and lifting without pain.
Strengthening exercises. Your physical therapist will determine which strengthening exercises are right for you, depending on your specific condition. You may use weights, medicine balls, resistance bands, and other types of resistance training to challenge your weaker muscles. You will receive a home-exercise program, so you can continue rotator-cuff and shoulder-blade strengthening long after you have completed your formal physical therapy.
Functional training. As your symptoms improve, your physical therapist will help you return to your previous level of function, which may include household chores, job duties, and sports-related activities. Functional training can include working on lifting a glass into a cupboard or throwing a ball using proper shoulder mechanics. You and your physical therapist will decide what your goals are, and get you back to your prior level of functioning as soon as possible.
Can This Injury or Condition Be Prevented?
The likelihood of developing rotator cuff tendinopathy can be reduced by:
- Being aware of repetitive movements that may lead to pain—especially over your head, across your body, or behind your back—and modifying your activity if there are any symptoms of discomfort.
- Maintaining ideal shoulder and spinal posture during daily activities, including sitting at a computer. This can be accomplished by:
- Performing daily stretches to the shoulder and upper back to maintain normal movement. Tightness in the upper back, or a rounded shoulder posture will decrease the ability to move your torso, and that makes the shoulder have to work harder to perform everyday activities, such as reaching for objects.
- Keeping your upper body strong, including the upper back and shoulder-blade muscles, will help prevent tendinitis. Many people work the muscles in their chest, arms, and shoulders, but it is also important to work the muscles around the shoulder blade and upper back. These muscles provide a strong foundation for your shoulder function. Without a strong foundation, muscle imbalances occur and put the shoulder at risk for injury.
Real Life Experiences
Mary is a 51-year-old piano teacher with 14 students. She teaches 3 days a week; each session lasts 30 minutes. Mary also plays piano for her church, and for her own enjoyment. A few weeks ago, she began to feel pain in her left shoulder when reaching her arm overhead or behind her back. She began to experience pain even when at rest. Now the pain is so severe, it wakes her up at night; she can no longer sleep on her left side. She contacts her physical therapist.
Mary's physical therapist performs a full evaluation of her shoulder, and of her shoulder-blade and upper-back strength and mobility. Mary describes how long she sits at the piano each week. Her physical therapist gently feels all around her shoulder and finds that it is very tender over the rotator-cuff region. She has pain when he performs resistive-muscle testing to the rotator cuff. Her physical therapist also discovers that Mary has tightness in her upper back region that limits her ability to fully twist her body to the right and left. He performs special tests on her shoulder; the results indicate the rotator cuff is irritated. Based on these findings, he diagnoses rotator cuff tendinitis.
Mary and her physical therapist work together to establish short- and long-term goals for her treatment. He prescribes the application of ice packs to help decrease her pain, and teaches her some gentle movement and strengthening exercises. He also shows Mary how to improve her posture when sitting at the piano, and teaches her a home-exercise program of stretching, strengthening, and postural exercises, which he modifies throughout the course of her physical therapy as her condition improves.
Mary and her physical therapist work together in a 6-week program of 2 to 3 rehabilitation sessions per week. He performs gentle passive movements of her shoulder, shoulder blade, and upper back to increase her joint motion. Mary learns proper movement patterns for reaching her arm overhead. She finds that using a therapeutic chair helps improve her posture and strengthens her core during her piano lessons.
After a few weeks of diligent physical therapy sessions and working with her home-exercise program, Mary notices that she is able to sleep on her left side again without pain, and can easily reach to get a mug from her upper kitchen shelf.
Mary is soon able to return to all of her daily activities and to again enjoy her life as a piano teacher and pianist—free of pain!
This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case.
What Kind of Physical Therapist Do I Need?
All physical therapists are prepared through education and experience to treat rotator cuff tendinitis. However, you may want to consider:
- A physical therapist who is experienced in treating people with rotator cuff tendinitis. Some physical therapists have a practice with an orthopedic or musculoskeletal focus.
- A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in orthopedic or sports physical therapy. This physical therapist has advanced knowledge, experience, and skills that may apply to your condition.
You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you are looking for a physical therapist (or any other health care provider):
- Get recommendations from family and friends or from other health care providers.
- When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people who have rotator cuff tendinitis. During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.
The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for a visit with their health care provider.
The following articles provide some of the best scientific evidence related to physical therapy treatment of rotator cuff tendinitis. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.
Heron SR, Woby SR, and Thompson DP. Comparison of three types of exercise in the treatment of rotator cuff tendinopathy/shoulder impingement syndrome: a randomized controlled trial. Physiotherapy. 2017;103(2):167–173. Article Summary on PubMed.
Dejaco B, Habets B, van Loon C, van Grinsven S, van Cingel R. Eccentric versus conventional exercise therapy in patients with rotator cuff tendinopathy: a randomized, single blinded, clinical trial. Knee Surg Sports Traumatol Arthrosc. 2017;25(7):2051–2059. Article Summary on PubMed.
Childress MA, Beutler A. Management of chronic tendon injuries. Am Fam Physician. 2013;87(7):486-490. Free Article.
Scott A, Docking S, Vicenzino B, et al. Sports and exercise-related tendinopathies: a review of selected topical issues by participants of the second International Scientific Tendinopathy Symposium (ISTS) Vancouver 2012 [published correction in: Br J Sports Med. 2013;47(12):744]. Br J Sports Med. 2013;47(9):536-544. Free Article.
Littlewood C, Ashton J, Chance-Larsen K, et al. Exercise for rotator cuff tendinopathy: a systematic review. Physiotherapy. 2012;98(2):101-109. Free Article.
Yamamoto A, Takagishi K, Osawa T, et al. Prevalence and risk factors of a rotator cuff tear in the general population. J Shoulder Elbow Surg. 2010;19(1):116–120. Article Summary on PubMed.
Andres BM, Murrell GA. Treatment of tendinopathy: what works, what does not, and what is on the horizon. Clin Orthop Relat Res. 2008;466(7): 1539–1554. Free Article.
Senbursa G, Galtaci G, Atay A. Comparison of conservative treatment with and without manual physical therapy for patients with shoulder impingement syndrome: a prospective, randomized clinical trial. Knee Surg Sports Traumatol Arthrosc. 2007;15(7):915–921. Article Summary on PubMed.
*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.
Revised by Erica Sigman, PT, DPT, board-certified orthopaedic clinical specialist. Authored by Julie A. Mulcahy, PT, MPT. Reviewed by the editorial board.