Rotator cuff tendon problems are the most common cause of shoulder pain. Problems with the tendons include tendonitis, calcification, and tears. Generally, treatment is exercise-based. Sometimes, we use a cortisone bursa injection to help with exercise. When should we use a bursa injection?

What is the rotator cuff?

rotator cuff injury

The rotator cuff is a group of four tendons that surround the ball and socket joint of the shoulder. 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 of the rotator cuff 

Injury to the rotator cuff can occur from a fall or due to repetitive overload. There are a number of problems that can develop in the rotator cuff tendons.

Inflammation of the tendons from overload leads to a condition called bursitis or tendonitis. In some cases, calcium builds up in rotator cuff tendons also called calcific tendonitis.

Sometimes, this inflammation and continued repetitive movements lead to tearing. Also, a fall on the shoulder or an injury during contact sport (such as basketball or rugby) can lead to tearing of 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 at the shoulder but sometimes radiates to the upper arm and even to the elbow. Usually, pain is brought on by movements upwards above the head and inwards behind the back.  Simple activities such as putting on a coat or 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 frozen shoulder.

Weakness often occurs when the tendons are fully torn. However, it is sometimes difficult to know whether the weakness is due to true weakness from a full tear or apparent weakness bought on by pain in the shoulder.

Many people with shoulder pain are often told by family or friends that their shoulder pain is related to rotator cuff tendons. However, there are many different causes of shoulder pain that have different 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 such as tendonitis or full tears on imaging.

Treatment options including a cortisone bursa injection

We treat most rotator cuff injuries without surgery.

Generally, physiotherapy is prescribed to improve shoulder strength and general shoulder mobility. Exercises should be progressed 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.

In addition, we often use injections in more difficult cases. Normally, we would use cortisone injections for people with severe pain, night pain, or where the pain is stopping the progression of exercises. Cortisone is a powerful anti-inflammatory that reduces pain and swelling of the rotator cuff tendons. However, cortisone injections are not for everyone. For example,  a recent study found that cortisone injections were less effective for full-thickness rotator cuff tears. Conversely, they are more effective if done for calcific tendonitis.

In general, we suggest using ultrasound to improve accuracy and make them more effective. Below is a video of Dr Masci performing a bursa injection with ultrasound.

Other options apart from a cortisone bursa injection?

In cases that have a significant rotator cuff tear or have had a cortisone injection, we suggest other possible injections.

Hyaluronic acid is a naturally occurring substance in bones and joints. While there is evidence for use of 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. Some doctors use PRP to inject partial or full-thickness tendon tears, although the evidence for an effect is still unclear.

And if a bursa injection and rehab don’t work?

We consider surgery for rotator cuff injuries if conservative treatment fails.

For rotator cuff tendonitis, many surgeons offered a shoulder decompression procedure 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 an increase in 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.

For tendon tears, the appropriateness of surgery 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 to 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.

Final word from Sportdoctorlondon

Rotator cuff tendon pain is common. Generally, we suggest physiotherapy followed by one cortisone injection if the pain is severe. However, cortisone injections don’t work well with full tendon tears. Speak to your doctor about the best treatment for your specific case.

Other common shoulder conditions:

Dr. Masci is a specialist sport doctor in London. 

He specialises in muscle, tendon and joint injuries.

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