What is 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 tendinitis 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 chronic, long-term condition. People who perform repetitive or overhead arm movements, such as weightlifters, overhead athletes, and manual laborers are most at risk for developing rotator cuff tendinitis. Poor posture can also contribute to its development. A physical therapist can help you identify and correct risk factors for rotator cuff tendinitis, and help you decrease your pain while improving your shoulder motion and strength.

What are common causes of 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 connect the muscles to the bone. Rotator cuff tendinitis occurs when the tendon connected to the rotator cuff muscles becomes inflamed and irritated. It can be caused by:

• Poor posture, such as rounded shoulders caused by leaning over a computer for long periods of time.
• Repetitive arm movements, such as those performed by a hair stylist or painter.
• Overhead shoulder motions, such as those performed by baseball pitchers or swimmers.
• Tight muscles and tissues around the shoulder joint.
• Weakness and muscle imbalances in the shoulder blade and shoulder muscles.
• Bony abnormalities of the shoulder region that cause the tendons to become pinched (shoulder impingement syndrome).

Where does it hurt?

In most cases of a rotator cuff tendinitis, patients report top and back shoulder pain with certain active motions. This is normally due to altered biomechanics overloading a rotator cuff muscle. Shoulder impingement can also cause similar symptoms too. Understanding the root cause of your pain is fundamental to treating your pain in the long run and will decrease your dependence on painkillers or treatment that only addresses the symptoms.

What are common symptoms of rotator cuff tendinitis?

Rotator cuff tendinitis 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. You may be symptom free at rest or experience a mild, dull ache; however, pain can be moderate to severe with certain shoulder movements. 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.

Can rotator cuff tendinitis be treated?

Yes, rotator cuff tendinitis pain can be treated and with great results. Even better, many times it can be treated conservatively without needing injections, pain medications, or surgeries if you catch it early enough. The key to treatment is to solve the root cause of your pain so you can get the best results and a long-term outcome.

Some root causes of shoulder rotator cuff tendinitis pain can be:

• Forward head posture
• Rounded shoulders with impingement
• Weak mid back and shoulder blade muscles
• Overload to the shoulder joint with active motions
• Tight neck and mid back
• Poor biomechanics causing impingement
• Decreased mid-back rotation
• Tight rotator cuff muscles

If you have failed multiple treatment approaches already, your clinician missed the real root cause of your pain and was just chasing the symptoms. The pain or symptom is the effect, not the cause. What do I mean by this? Say your fire alarm goes off in your house. Its purpose is to protect you and make you aware that something is wrong, i.e., that there is a fire in your house. The “alarm” is like your pain (your body’s way of telling you something is wrong) and the “fire” is the root cause. When the fire alarm goes off, you don’t run upstairs and just turn it off, right? You run through the house with the fire extinguisher, trying to find the room where the fire is at. You try to find out what caused the alarm to go off so you can put it out. Once the fire is out, then the fire alarm can go off. Solve the “root” cause of your pain, and then the pain (“the effect”) eventually goes away.

Additionally, there is a common root cause which many clinicians misdiagnose. They treat the shoulder pain with a cookie cutter approach, hoping it will work and treat it as a simple muscle problem. They tend to rely on stretching, ultrasound, massage and focus treatment directly on the shoulder joint. However, often the root cause is missed and the symptoms return. So many healthcare clinicians treat pain like this and thus show poor treatment outcomes which results in the pain coming back. Why? They missed the root cause of your shoulder pain. This is also the case when patients turn to injections, nerve blocks and other surgeries which are still not effective because the actual problem still is not solved, their treatment was just chasing the pain.

The first step in treatment is to identify the root cause of your pain. A specific and individualized treatment approach for your type of pain can lead to a successful outcome for you and resolve your symptoms for the long term. This is why you can’t rely on a standard cookie cutter approach; you need a customized and individualized treatment approach specifically for your type of shoulder rotator cuff tendinitis pain.

“Dr. Ron Miller is the best! Several months ago I developed shoulder pain that was limiting my physical activity, computer work, and even sleep. One week after the first treatment I was playing tennis with much more strength in my serve and groundstrokes. After just three sessions we’re done!“

Lily P.
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What happens if it goes untreated?

Minor case – If it is a minor case of pain from rotator cuff tendonitis, research shows that many acute cases of pain may spontaneously go away in 4-8 weeks. You may have had the rotator cuff tendonitis before you had your shoulder pain, so it may be a false positive finding and not the cause of you shoulder pain? But who wants to wait 8 weeks to get pain free? Let’s try to solve the root cause of your pain in 2-3 weeks and address all of the risk factors present (so it never returns!) and get you back to your favorite activities faster! We still recommend that you get it checked out by a one of our board-certified physical therapists to ensure that it is just a minor case, to solve all risk factors, and to get the optimal outcome in the fewest visits needed. Most minor cases resolve on their own in time, or get better with some stretching and strengthening. But, the sooner you take action, the sooner you are pain free. (And research supports this!)

Severe case – If it’s more of a severe and chronic case of pain from rotator cuff tendonitis, your pain will probably start to worsen and increase because the root cause of the pain is not being treated. Something is overloading the rotator cuff tendon. Many people turn to pain medication at this time but this only blocks the pain for short term. You may not feel the pain when taking pain medications, but the underlying problem is still there. Many people say after the pain medication is stopped, then usually the pain returns and sometimes it returns even worse. This is when the shoulder pain gets worse, every lifts hurts, you are unable to lift your arm above your head, and sleeping at night may increase shoulder pain. If you keep overloading your shoulder without solving the root cause, then the rotator cuff tendinitis may turn into a rotator cuff tear. Even though it’s more chronic now, we can still help. Once the root cause and all risk factors are addressed, then we can start decreasing your pain, regardless of how chronic and severe the pain is. This is the crucial first step. It just may take more time to recover from a chronic case. Usually with chronic and severe cases, the longer you have your pain and injury, the longer it takes to resolve.

What outcome can you expect from treatment?

As we’ve discussed, the first step is to solve the root cause of your rotator cuff tendinitis pain. This is the most essential step to plan a treatment specialized for you and your unique type of pain. Your root cause will guide your treatment and dictate what is the best way to treat your pain. This, along with identifying risk factors that may be predisposing you to have your pain and injury, will allow you to start getting pain free again. The next step is to start decreasing pain, modifying activities, and start addressing all of the impairments causing your pain which we discovered during your evaluation. With each session, pain should start to decrease and you should start to regain range of motion with less pain and symptoms. Any radicular and referred pain should resolve fast as well. At this point, we begin light and basic strengthening only if it does not increase pain. Treatment will consist of a lot of manual therapy and light exercises.

The next step is to achieve full range of motion, (which should correlate to being pain-free) and now we can start progressive strengthening. Strengthening the muscles is crucial and research shows that this gives you the best long-term outcome! As you start to get stronger and maintain your mobility, your pain will continue to decrease if it is not already gone. Your increased strength will allow you to perform more activities and prevent flare-ups. This usually does take up to 4 weeks. As you clear our goals, then we can start easing you back into sport, golf, running, and whatever your favorite activities are. This is when we start winding down treatments and getting you back into functional strengthening, sport specific training, return to run programs, golfing, and whatever your goals are. In the end, we reassess everything, making sure we achieved all of our goals, your goals, that all risk factors are gone, and finalize your long-term home exercise program. There are many factors which can influence your outcome, but 85-90% of our patients respond well to our treatment approach and achieve a successful outcome when completing their plan of care.

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 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 special tests may need to be performed to determine this.

Do you need an X-ray and MRI imaging for rotator cuff tendinitis pain?

For most common orthopedic cases, imaging is not needed and the diagnosis can be made with a simple physical therapy evaluation. No need to waste thousands of dollars on unwarranted diagnostic imaging. We also have clinical tests which we can perform to help rule in and rule out pathologies that correlate to MRI findings (which is WAY cheaper than an MRI!). An expensive MRI may just tell us what we already know. Also, often times the positive findings found on x-rays, MRIs, and EMGs may not actually be the root cause of your pain. What does that mean? Many positive findings on an MRI are also found in asymptomatic (pain-free) individuals, so diagnostic imaging may not be able to tell us what is actually causing your pain. For example: many people have a herniated disc in their low back but do not have any low back pain. So if herniated discs can cause no pain, just because someone with low back pain has a herniated disc does not mean that is what’s causing their pain. The key is to find out if your clinical evaluation findings during your evaluation at Pursuit match the MRI findings. If so, then we can decide what is the best way to treat it.

How can a Physical Therapist treat it?

It is important to get proper treatment for tendinitis as soon as it occurs. 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, ice massage, or moist heat maybe used for pain management. Therapeutic modalities, such as iontophoresis (medication delivered through an electrically charged patch) and ultrasound may be applied.

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 scapula.

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 to continue rotator cuff and scapular strengthening, long after you have completed your formal physical therapy.

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.

Functional training. As your symptoms improve, your physical therapist will help you return to your previous level of function that 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.

“After at least three years of doctor-hopping […] looking for someone to alleviate my constant dizziness and neck pain, I finally found Dr. Miller. I have more energy and less pain, and have halved my dependence on painkillers. He shouldn’t be the last stop on your road to recovery, he should be the first.”

Lisa B.
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How long does it take for recovery?

Recovery time for rotator cuff tendinitis pain depends on multiple factors:

• The severity and chronicity of your pain
• Whether your pain is an easy or complex case
• If the root cause of your pain was solved or if it was missed (this is the key to getting a great recovery!)
• How long you have been in pain for and when you need to be pain-free by
• Other therapies and treatments you have tried
• Which medical professional(s) you saw prior to seeing us
• How active you are in trying to resolve your pain
• Which treatment approach is chosen and if it is proven to work for your pain

There are many factors that influence your recovery time and every patient’s recovery time is different. If you do nothing and don’t pursue treatment, it could gradually get better on its own, you could continue to have the same pain persist, or it could continue to get worse. As stated earlier, most acute cases may or may not resolve in 4-8 weeks. If you get expert treatment that solves the root cause of your pain, some cases resolve in 1-3 weeks! Then you can get back to sports, exercise, and your favorite activities without flare-ups and recurrences. Some of our patients are pain-free in 1-3 visits and back to 100% in 2 weeks!

If it is a complex case with chronic pain, your recovery may take longer, but you can still get a good outcome. Some chronic cases can resolve as fast as 2 months but can take as long as 4-6 months. It varies with every patient because every case of rotator cuff tendinitis pain is different. Every patient’s recovery varies depending on the factors listed above. After a thorough evaluation here at Pursuit Physical Therapy, you will know your exact timeline of recovery, your prognosis, and when you should reach your goals.

How much does it cost?

The average cost of care for a case of spine pain in the US is $1800-$6600. This high price is due to many factors: the over-inflated cost of healthcare, the over expensive cost of unwarranted imaging (x-rays, CT scans, and MRIs) that is not needed, over-utilization of care (which increases the number of visits needed to be treated, requiring multiple visits to different doctors and physical therapists for the same diagnosis), and getting billed for unnecessary and unproven treatments that you don’t even need. All of these factors increase cost and this is why healthcare is so expensive. We strive to end that unnecessary, expensive cycle. In fact, we are currently publishing our first-year data with the University of Central Florida that shows the cost-effectiveness of our treatment approach.

This year, the average cost of our care was shown to be $814-$1141. Some of our patients get even as low as $315 for the full treatment! So if you have a deductible of $3,000-$10,000 and you have to pay out of pocket for your treatment, we can save you lots of money.

Remember, every case of pain is different and not all rotator cuff tendinitis pain is the same. It is hard to predict exactly how much your treatment is going to cost you. But after a thorough evaluation, we can tell you exactly what is causing your pain, how long it is going to take, what the best way to treat it will be, and exactly how much it is going to cost. We have no hidden fees, no co-pays, and no miscellaneous bills that you will be surprised by 3 months after you receive treatment. Your pain, your diagnosis, your goals, and what is best for you dictate your treatment and how much it will cost, and while it varies for every patient, treatment at Pursuit is still much more affordable than standard healthcare.

How long are sessions?

Our evaluations are always one-on-one with one of our board-certified specialists and 60-90 minutes long. We like to perform thorough evaluations so we can solve the root cause of your pain, identify all risk factors, and make sure that we do it right. After the evaluation, you will know your diagnosis, the root cause of why you have your pain and symptoms, your prognosis, an expected timeline of when you should see results, what the best way to treat your pain is, how much it will cost, and your expected recovery outcome. We want you to fully understand everything about your pain and injury. What is best for you and will get you the best outcome is what will dictate your care and treatment. There will be plenty of time for you to ask questions so we can make sure you fully understand why you have your pain and what the best way to treat it will be. After the evaluation is completed, all treatment sessions are 60 minutes going forward and still one-on-one with your physical therapist. You and your physical therapist will design a customized treatment plan that works for you and that will achieve your goals.

How can it be prevented?

Rotator cuff tendinitis can be prevented by:

• Maintaining proper shoulder and spinal posture during daily activities, including sitting at a computer.
• 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.

What are next steps?

Getting started is simple. The first step, and the key to getting you pain free again, is to solve the root cause or your case of pain. Remember, not all pain is the same. Your pain is different than someone else’s pain, even though it may be in the same area. If you’re ready to get pain free, give us a call at (407) 494-8835 or fill out the form below. The next step is to schedule your evaluation so we can solve the root cause for you. We’re happy to answer any questions you may have and we would love the opportunity to help you.