Rotator cuff tendon problems are the most common cause of shoulder pain. Problems with the rotator cuff tendons include tendonitis, calcification, and tears. Generally, treatment is exercise-based. Sometimes, however, we use a subdeltoid bursa injection to help with exercise. When should we use a bursa injection?
What is the rotator cuff?
The rotator cuff is a group of four tendons surrounding the shoulder’s ball and socket joint. They provide strength to lift the arm in all directions. However, they also provide stability to the shoulder to firmly hold the ball of the shoulder (head of the humerus) in the socket (glenoid).
Injuries to the rotator cuff
Injury to the rotator cuff can occur from a fall or repetitive overload. In addition, several problems can develop in the rotator cuff tendons.
Inflammation of the tendons from overload leads to bursitis or tendonitis. In some cases, calcium builds up in rotator cuff tendons, called calcific tendonitis.
Sometimes, this inflammation and continued repetitive movements lead to tearing. Also, a fall on the shoulder or an injury during contact sports (such as basketball or rugby) can tear the tendon. Generally, we describe tears as partial or full-thickness.
What are the symptoms of rotator cuff injury?
Pain is the most common problem associated with a rotator cuff injury. Generally, pain is located in the shoulder, but sometimes radiates to the upper arm and elbow. It is usually brought on by movements upwards above the head and inwards behind the back. Simple activities such as taking off a shirt cause pain. Also, night pain is sometimes a feature.
Although movements cause pain, rotator cuff tendon injuries often don’t cause gross restrictions in movement. However, movement restrictions are more common in conditions such as a frozen shoulder.
Weakness often occurs when the tendons are fully torn. However, it is sometimes difficult to know whether the weakness is true weakness from a complete tear or apparent weakness brought on by pain in the shoulder.
Many people with shoulder pain think it is related to their rotator cuff tendons. However, many different causes of shoulder pain have other treatments. Examples include frozen shoulder, AC joint arthritis, and long head of biceps tendonitis.
In some cases, we use imaging such as X-ray, ultrasound, or MRI to confirm a diagnosis. However, we need to be cautious about relying solely on imaging. Many people with no shoulder pain have changes on imaging, such as tendonitis or full tears.
Treatment options including a subdeltoid bursa injection
We treat most rotator cuff injuries without surgery.
Generally, physiotherapy is prescribed to improve shoulder strength and general shoulder mobility. Exercises should progress from isometric to therabands to light-weighted gym exercises. Importantly, you should see an expert in shoulder rehab to have the best chance of getting a good outcome. Some examples of simple shoulder exercises that can help with rotator cuff pain are outlined below:
Subdeltoid bursal injection
In addition, we often use rotator cuff injections in more complicated cases. Typically, we would use subdeltoid bursa cortisone injections for people with severe pain, night pain, or where the pain stops the progression of exercises. Cortisone is a potent anti-inflammatory that reduces pain and swelling of the rotator cuff tendons.
However, rotator cuff injections are not for everyone. For example, a recent study found cortisone injections were less effective for full-thickness rotator cuff tears. Conversely, they are more effective if done for calcific rotator cuff tendonitis.
Also, having a cortisone shot for rotator cuff tendinitis might increase the risk of the pain returning. A recent study comparing cortisone injection to physiotherapy found that cortisone improved pain compared to physiotherapy at eight weeks. However, the recurrence rate was much higher in the cortisone group (36% vs 7%).
We suggest using ultrasound to improve accuracy and make subdeltoid bursa injections more effective. Below is a video of Dr Masci performing a cortisone injection for shoulder bursitis with an ultrasound.
Other options for a subdeltoid bursa injection?
We suggest other injections if you’ve already had an unsuccessful cortisone injeciton or have a full-thickness rotator cuff tear.
Hyaluronic acid is a naturally occurring substance in bones and joints. While there is evidence for using hyaluronic acid in arthritis, we rarely use these injections for tendonitis, including rotator cuff tendons.
Platelet-rich plasma, or PRP, comes from whole blood. We spin the blood to separate the plasma from the red and white cells. We then inject the plasma into a tendon or bursa. A recent review assessed the impact of PRP injections compared to other injections for rotator cuff pain. At six months, PRP was better than cortisone or other injections. Another review found that PRP improved pain at 6 and 12 months compared to placebo or other injections. So, overall, PRP could be used instead of cortisone for rotator cuff pain.
And if a bursa injection and rehab don’t work?
We consider surgery for rotator cuff injuries if conservative treatment fails.
Many surgeons offer a shoulder decompression procedure for rotator cuff tendonitis to open up the space between the tendons and the bone above. However, recent evidence suggests that this decompression surgery has the same outcomes as physiotherapy, with perhaps increased risks. Also, a study comparing shoulder decompression with placebo surgery found no significant benefit. Nevertheless, surgeons still offer this option for cases that fail therapy and one or two injections.
The appropriateness of surgery for tendon tears depends on the type of tear, the patient’s activity levels, and previous treatment. Recent evidence collecting all high-level evidence for rotator cuff tendon repairs found no difference in physiotherapy. Nevertheless, surgery is more likely for the younger active patient with a full-thickness tear. Also, tears due to a fall or trauma are more likely to need early surgery.
Other frequently asked questions about rotator cuff pain:
Will a cortisone shot help a rotator cuff tear?
Generally, a cortisone shot is less effective for a complete rotator cuff tendon tear. Alternatively, a cortisone shot is more effective for tendonitis or a partial tear. An ultrasound or MRI can detect whether the rotator cuff is fully torn.
How soon can you exercise after a cortisone injeciton in the shoulder?
We recommend you rest your shoulder for seven days. After a week, you can re-engage with lighter shoulder exercises, but you should avoid heavier weight training for about two weeks.
When should you start physical therapy after a cortisone injection in the bursa?
Generally, we suggest you see a physical therapist about ten days after an injection.
Can PRP injections heal a torn rotator cuff?
We are unsure. Although some doctors think PRP can heal a partial tendon tear, we don’t believe it improves complete tears. However, a recent study showed that injections of PRP were better than cortisone for a partial rotator cuff tear at three months.
Do full-thickness rotator cuff tears require surgery?
Overall, it depends on the person. Generally, we recommend surgery for more significant tears, trauma-induced tears, and tears occurring in more active, younger patients.
What exercises are best for rotator cuff injuries?
We are still not sure, but a recent study showed promising results. This study outlined exercises that may help with rotator cuff pain. These exercises included shoulder presses, lateral shoulder raises, bent-over barbell rows, barbell chest fly, lying pullover, and side lift with rotation (see appendix of paper).
What is the difference between subacromial bursitis and rotator cuff tendonitis?
They often mean the same thing. For example, if you overload your rotator cuff tendons through sports or weight training, you develop bursitis first, followed by tendonitis. The treatment of subacromial bursitis is the same as that of rotator cuff tendonitis.
What lifestyle factors affect pain associated with rotator cuff tendonitis?
There are consistent associations between metabolic factors such as diabetes, obesity, and smoking and rotator cuff tendonitis. Treating these conditions (such as losing weight or general exercise) may help your shoulder tendonitis pain.
Final word from Sportdoctorlondon about a bursa injection
Rotator cuff tendon pain is common. If the pain is severe, we generally suggest physiotherapy followed by one cortisone injection. However, cortisone injections don’t work well with complete tendon tears. Also, the recurrence rate after a cortisone injection is higher than that after physiotherapy. Although PRP seems promising for long-term pain relief, we are unsure whether it is worth the cost. Speak to your doctor about the best treatment for your specific case.
Very useful. I was considering surgery but have decided to try cortisone and more excercises.
thanks
Informative and concise.
Excellent advice. Had a steroid injection today for a rotator cuff tear. I hope this works. 2nd one, after this and if it’s not better I will see the surgeon. I’ve not been given any follow up appointment and no exercises given
Very concise and clear – great graphics. I have calcium deposits, but after pain for 12 weeks it seems to be going away by itself.
I am given 2 x 2 weeks of Arcoxia 120 mg to take for my shoulder sub acromial inflammation. Is that too long? I read online that Arcoxia 120mg is only meant to be taken for a maximum of 8 days.
Is two weeks enough to see if Arcoxia has any impact on pain? I don’t feel much improvement.
I’m next option is to try cortisone injection. Does it matter if the doctor doing it is quite old?
2 weeks is a reasonable timeframe. Arcoxia 120mg is a high dose – I ususally prescribe 90mg daily for acute pain.
should a 76 year old woman with a small rotator cuff t at have surgery?
I’d try to avoid surgery.
I think it’s a good idea to use a bursa injection if the rotator cuff tendon is injured.
Recently I started experiencing severe right shoulder pain. Usually I feel it when I lay on my back watching tv with my hands up under my head. When I go to lower my right arm shoulder pain stops me from lowering it further. I stop then start lowering it all the way down & the pain stops me again. I’m seeing my pain management Doctor tomorrow for an injection. I have epidurals in my neck & lower back for disc pain that radiates down my right arm or my right leg. I’m nervous about this injection tomorrow.