What is rotator cuff pain?
The rotator cuff is made up of four muscles in the shoulder. These are; supraspinatus, infraspinatus, subscapularis and teres minor. These muscles attach to the ‘ball’ of the shoulder joint, known as the humeral head, via their tendons. These tendons help to lift and rotate your arm allowing pain free, smooth movement and they achieve this by keeping the ‘ball’ in the centre of the shoulder joint. The most commonly injured rotator cuff tendon is the supraspinatus.
Rotator cuff pain can be a very painful and debilitating condition. It can prevent patients from carrying out simple daily activities such as reaching up, lifting their arm and dressing/undressing. It is also commonly aggravated by overhead activities such as playing tennis and gym weight exercises.
The bursa (see image below), specifically the sub-acromial bursa is located above the rotator cuff. If the bursa is inflamed, which often occurs with rotator cuff issues, it is known as a bursitis. The bursal tissue is very sensitive and can often become painful when inflamed.
What causes rotator cuff pain?
Rotator cuff pain is further classified according to the type of rotator cuff injury. This information is gained by carrying out a diagnostic ultrasound.
At Complete every patient has a diagnostic ultrasound scan (at no extra charge) performed prior to an injection, to ensure the correct diagnosis.
- Rotator cuff tendinitis/tendinopathy: This is when the rotator cuff tendons become swollen and painful due to overuse and/or age. It is normally associated with a concurrent sub-acromial impingement and associated bursitis. The bursa is a thin sac that sits on top of the rotator cuff tendons (see image above).
- Rotator cuff tear: This is when the tendon has a tear. This can occur over a period of time or with a sudden incident such as a fall. These tears can be a full or partial tear of the tendon.
- Calcific tendinopathy (also known as calcific tendinitis): This is when there are bony deposits (known as calcification) in the rotator cuff tendon. It can cause acute, severe pain and a significant reduction in movement. The exact cause is unknown but can be related to some metabolic diseases such as abnormal thyroid and diabetic conditions.
How do you diagnose rotator cuff pain?
The diagnosis of rotator cuff pain is a “clinical diagnosis” which means that your physiotherapist can diagnose it during your initial assessment. However, to establish if you have a tendinopathy, a bursitis, a tear or calcification within the tendon a diagnostic ultrasound has to be carried out. It is not possible to ascertain this information without an ultrasound scan.
What injection is effective for rotator cuff pain?
The most effective injection for your shoulder pain depends on your specific diagnosis.
1. Injection options for rotator cuff tendinopathy/tendinitis
The most common ultrasound guided injection we carry out for rotator cuff tendinopathy is a steroid injection. Steroid (also known as corticosteroid) injections for rotator cuff pain are extremely effective, when the pain is not improving and particularly if the pain is waking the patient up at night. Steroid is a strong anti-inflammatory that can provide fast, effective pain relief.
Injections are particularly useful if patients are struggling to engage with a programme of physiotherapy due to high levels of pain. The injection provides a “window of opportunity” for you to carry out physiotherapy with significantly less pain.
It is important to note that the steroid does not go into the rotator cuff tendon itself, which is potentially detrimental to the tendon. The injection targets the inflammation of the overlying bursa (known as a sub-acromial bursitis). It is very common when you have rotator cuff pain that the subacromial bursa is also inflamed. The bursa is a very pain sensitive structure and therefore injecting into this structure, normally provides excellent pain relief.
At Complete all our injections are carried out using ultrasound guidance, to ensure we target the bursa and not the tendon. The bursa is approximately 2-4mm, so without ultrasound guidance it is not possible to target the bursa alone. Research has shown performing a ultrasound guided injection improves outcomes in shoulder pain when compared to unguided injections (Aly et al, 2015, Eustace et al, 1997,Finnoff et al, 2015).
2. Injection options for rotator cuff tears
The optimal management for rotator cuff tears depends on several factors, these include:
- Your Age
- The Size and location of tear (determined on the ultrasound scan)
- Your required demands on your shoulder i.e. what activities you want to get back to
There are two main injection options for rotator cuff tears:
The first option is a steroid injection into the subacromial bursa (similar to tendinopathy option). This provides a painfree window for you to engage in a course of physiotherapy. Exercise based treatment following a rotator cuff tear is essential to restore full strength and movement in the shoulder. However, it is not uncommon that patients struggle to perform physiotherapy exercises due to high pain levels and so the combination of treatment (injection and physiotherapy rehabilitation) works very well.
This combination is very successful in a significant percentage of our patients and often avoids the requirement for surgery.
The second option for a rotator cuff tear is Plasma Rich Platelet (PRP) injections. PRP injections are a novel injection technique which aims to encourage new healing of the tendon (Schneider et al, 2018). These injections are most effective in younger patients who have had a specific injury/incident that resulted in the tearing of the rotator cuff such as a fall or lifting weights in the gym.
It is most effective when carried out as soon as possible after the injury. It must be combined with a comprehensive physiotherapy programme. Three PRP injections are carried out over a six-week period, with one injection every two weeks.
3. What are the options for calcific tendinopathy/tendinitis?
If the rotator cuff pain is due to calcium/bony deposits in a rotator cuff tendon then there are three potential options:
1. Shockwave Therapy (this is not an injection): Shockwave is an effective treatment modality for calcific tendinopathy (Cacchio et al, 2016). Delivers acoustic energy into to the calcific areas to encourage breakdown and reabsorption. You will require a minimum of three sessions, once per week for three weeks.
2. Steroid Injection: An ultrasound guided steroid injection into the subacromial bursa can be very effective at reducing the pain associated with the calcific tendinopathy/tendinitis.
3. Barbotage/Lavage: This procedure is carried out using ultrasound guidance and extracts the calcium/bony deposits from the tendon using a needle. Traditionally removing the calcium did require a surgical procedure. This treatment is very effective and often avoids the need for surgery.
How many steroid injections can you have for rotator cuff pain?
A majority of our patients only require one injection. The role of the injection is to provide a window of opportunity to allow you to engage in a physiotherapy program to restore full range of movement and strength in the shoulder.
We always try and limit the number of injections we carry out on our patients, however on occasion, having more than one injection is sometimes required to achieve adequate pain relief.
If you would like to discuss your injury before booking in for an injection, then please call 02074823875 or email firstname.lastname@example.org and one of our expert clinicians will call you back.
Other shoulder conditions:
Aly, A. R., Rajasekaran, S., & Ashworth, N. (2015). Ultrasound-guided shoulder girdle injections are more accurate and more effective than landmark-guided injections: a systematic review and meta-analysis. Br J Sports Med, 49(16), 1042-1049.
Cacchio, A., Paoloni, M., Barile, A., Don, R., de Paulis, F., Calvisi, V., Ranavolo, A., Frascarelli, M., Santilli, V. and Spacca, G., (2006). Effectiveness of radial shock-wave therapy for calcific tendinitis of the shoulder: single-blind, randomized clinical study. Physical therapy, 86(5), pp.672-682.
Eustace, J. A., Brophy, D. P., Gibney, R. P., Bresnihan, B., & FitzGerald, O. (1997). Comparison of the accuracy of steroid placement with clinical outcome in patients with shoulder symptoms. Annals of the Rheumatic Diseases, 56(1), 59-63.
Finnoff, J. T., Hall, M. M., Adams, E., Berkoff, D., Concoff, A. L., Dexter, W., & Smith, J. (2015). American Medical Society for Sports Medicine position statement: interventional musculoskeletal ultrasound in sports medicine. Clinical Journal of Sport Medicine, 25(1), 6-22.