Patient Information Guide
Rotator Cuff Tendinosis
237 Route 108, Suite 205
Somersworth, NH 03878
Ph: (603) 742-2007
Fx: (603) 749-4605
www.sosmed.org
Summary:
Rotator cuff tendinosis is a very common disorder
that causes shoulder pain and loss of function,
generally in people over age 40. While many cases are caused by overuse, there is often
no clear reason why this condition occurs. Tendinosis refers to intrinsic tendon
degeneration or failure of the tendon fibers at a microscopic level. The goal of treatment
of this condition is to provide an opportunity for the tendon to repair itself through an
adequate tissue healing response. This involves rest, activity and technique modification,
correction of underlying mechanical abnormalities of the shoulder such as muscle
weakness and fatigue and, finally, patience. Tendon healing is a slow process that takes
many weeks to several months.
Tendon Anatomy:
Tendons are composed of collagen which is the
building block of our connective tissues. In tendons,
this collagen is arranged into fibers and fibers are
arranged into bundles much like a rope. This highly
organized arrangement allows tendons to transmit
the force generated by a muscle to the adjacent
bone. Collagen is manufactured by cells within the
tendon called tenocytes. These cells are responsible
for maintaining tendon health and for tissue repair
and remodeling. Most tendons have relatively little
blood supply. Consequently, tendon healing can be very slow. When tendons heal, new
collagen must be formed through a repair process. This collagen must then mature from
early scar tissue into organized tendon tissue. Not until this reorganization process is
complete and the tissue reconditioned are tendons capable of withstanding the demands
of everyday activities.
Rotator Cuff Anatomy
The rotator cuff is composed of four tendons that
surround the humeral head (ball). In addition to
moving the shoulder joint, the rotator cuff
compresses the ball into the socket. This
compression helps stabilize the shoulder joint,
providing the shoulder the widest range of motion of
any joint in the body.
The most common tendon involved in tendinosis and
rotator cuff tears is the supraspinatus tendon. This
tendon is positioned between the humeral head and
the acromion bone which provides a roof above the
ball and socket joint.
Supraspinatus
Definition:
Tendinosis refers to internal tendon degeneration. This occurs because on an imbalance
between tendon breakdown and tendon repair. Thus, tendinosis can result either from an
increase in breakdown such as from overuse or injury, or from a decrease in the healing
response.
Tendonitis refers to tendon inflammation. While this term is commonly used to describe
activity related pains in various joints of the body, recent studies have shown that there
is very little inflammation present in the majority of cases of tendon-related pain.
Bursitis is another commonly used term to describe
shoulder pain. The bursa is a fluid filled sack located
between the acromion bone and supraspinatus tendon.
This bursa can becomes inflamed, swollen and scarred
in chronic rotator cuff conditions. As with tendonitis,
however, the bursa is frequently not found to be
significantly inflamed in most cases of rotator cuff
tendinosis. Thus, the common conception that shoulder
pain is a result of bursitis is probably only true a fraction
of the time and cases of shoulder pain diagnosed as
bursitis are likely more commonly rotator cuff
tendinosis.
Bursa
Causes/Risk Factors:
Rotator cuff tendinosis has many possible causes that may act alone or in combination to
result in tendon degeneration. The causes are listed as follows:
 Age: as we age, our tendons and ligaments lose strength and their internal
capacity for tissue repair and healing decreases. Thus, they are equally more
prone to injury and less likely to recover quickly.

Overuse: repetitive use of the arms, especially at or above shoulder level may
cause fatigue and damage to the rotator cuff tendons. If the rate of tissue
breakdown exceeds the rate of tissue healing, tendon degeneration may occur.
This may be know as Repetitive Strain Injury (RSI). Giving the damaged tissue
sufficient time to heal is essential to recovery. Continued pain during activity is an
indicator of internal tissue damage and should not be ignored. Efforts to “work
through” the pain will likely only result in further injury.

Poor Posture: forward slumping of the shoulders causes the shoulder blade to tilt
forward and down. This narrows the space available for the rotator cuff tendons
and may cause abrasion of the tendon’s surface. In addition, excess pressure from
the downward sloping acromion bone may “wring out” the tendon’s blood supply
resulting in tissue breakdown.

Weakness: many people who engage in repetitive motion activities, whether
through work, sport or recreation, develop fatigue in the rotator cuff muscles. If
the muscles are not allowed sufficient time to rest, recover and remodel, fatigue
can lead internal damage to the muscle and tendon. In addition, fatigue promotes
faulty mechanics in the ball and socket mechanism that accelerate this damage.

Stiffness: injury to the shoulder, whether from a
single incident or from repetitive overuse, often causes
the capsule surrounding the ball and socket joint to
contract and tighten. This is particularly true for the
posterior capsule of the shoulder. Posterior capsule
tightness causes the ball to slide upwards on the socket
during many activities such as reaching and lifting. This
abnormal movement of the ball on the socket results in
abrasion of the rotator cuff on the acromion bone and
coracoacromial ligament which form the roof above the
tendons.

Instability: some people are born with particularly elastic connective tissue and
may have shoulder joints that are very lax (wide range of motion). Such
“hyperlaxity” may predispose some people to develop subtle shoulder instability
whereby the ball does not stay properly centered in the shoulder socket during
shoulder movement. This condition may be associated with impingement of the
rotator cuff on the acromion bone and coracoacromial ligament.

Smoking: as with many other tissues in the body, the connective tissues of the
musculoskeletal system are adversely affected by smoking. Specifically, smoking
damages the circulation to tendons and bones. This not only places these tissues
at risk for injury but also slows or prevents their healing during a recovery period.
Symptoms and Signs
Symptoms: Progressively worsening pain both with use and at night are typical features
of rotator cuff tendinosis. Most patients cannot recall a single incident that caused the
onset of pain. Pain with reaching and lifting, especially at or above shoulder height, are
common complaints. Many patients may be unable to sleep on the affected side or may
be awoken at night when they roll onto the that side. Most patients are relatively
comfortable at rest with the arm at the side. Because the tendon is structurally intact
and not torn, strength is generally unaffected but limited by pain. Some patients have
pain that radiates into the neck, back or upper arm due to shoulder fatigue.
Signs: the physical exam of rotator cuff tendinosis typically reveals pain when the arm is
passively elevated in front of the body. This called an “arc of pain.” Maneuvers which
tighten the posterior shoulder capsule also typically worsen pain because they compress
the rotator cuff against the acromion bone. Strength testing generally indicates intact
rotator cuff function however testing of supraspinatus strength may result in increasing
pain by placing stress on the diseased tendon. This is called a “tendon sign.”
How is Rotator Cuff Tendinosis Diagnosed?
In straight forward cases, the patient’s history and physical exam may be all that is
necessary to make a diagnosis of cuff tendinosis. In some patients, extreme pain may
make it difficult to adequately assess the degree of tendon disease, raising suspicion of a
possible partial or full thickness rotator cuff tear.
Plain X-rays are generally obtained to screen for other possible causes of shoulder pain
including arthritis or calcific tendonitis. These films also show the shape of the acromion
bone, presence of abnormal bone spurs and the relationship of the ball to the socket.
If the clinical history and exam are suspicious of a possible
rotator cuff tear, an MRI with dye injected into the shoulder
joint is the most accurate diagnostic study to assess the
integrity of the tendon and look for tendinosis versus
rotator cuff tear. Swelling and fluid in the tendon substance
where it inserts into the humerus bone are consistent with
rotator cuff tendinosis.
What is the Natural History of Rotator Cuff Tendinosis?
Tendinosis tends to be a self-limited process that resolves with adequate treatment.
Tendon healing, however, is a slow process that may take many weeks and up to a few
months. During this time, the patient must avoid exposing the tendon to the same
conditions that caused tendonitis in the first place, especially overuse of the arm. In
some cases, tendinosis may progress to a rotator cuff tear. Progressive weakening of the
tendon fibers and internal tendon damage may result in partial or complete tendon
failure. This is unusual before the age of 40 but becomes increasing common with
advancing age.
How is Rotator Cuff Tendinosis Treated?
The goal of treatment for rotator cuff tendinosis is fourfold. The first goal is to promote
tendon healing by promoting rest and avoidance of aggravating activities. The second
goal is to correct any underlying mechanical abnormalities that may have promoted the
development of tendinosis. The third goal is to promote tendon strengthening and
remodeling once adequate healing has occurred. The fourth goal is to prevent recurrence
through a maintenance program of flexibility, strengthening and aerobic conditioning. If a
thorough course of non-operative treatment fails to result in resolution of pain and
restoration of shoulder function, surgical treatment may be necessary. Generally surgery
is not entertained or recommended until 3-6 months of non-operative treatment have
been completed.
Non-Operative Treatments

Activity Modification and Rest: Tissue healing can only begin when repeated injury
stops. Those activities that result in worsening pain must be avoided to prevent
continued tissue injury during the recovery phase. Activities that can be performed
in a range of motion that does not cause pain are encouraged to prevent muscle
atrophy and stiffness which can occur from disuse.

Ice: Cold therapy acts to decrease tissue swelling and reduce pain. It is especially
important after exercise sessions. Apply ice or a cold pack to for 15 to 20 minutes,
4 times a day for several days to keep swelling down. Wrap the ice or cold pack in
a towel. Do not apply the ice directly to your skin

Non-steroid Anti-inflammatory Medications (NSAIDS): these medications include
Ibuprofen, Motrin, Advil, Naprosyn, Alleve, Vioxx, Bextra, Celebrex, and many
others. They active both to reduce inflammation and to relieve pain. They may be
more effective in the early phases of rotator cuff tendinosis when inflammation is
more prevalent. Long term use of NSAIDS may be associated with risks such as
irritation of the stomach lining, ulcers and kidney problems. Patients should
become informed about the possible short and long-term side effects of each
medication prior to use.

Physical Therapy: the goals of physical therapy are to correct any mechanical
abnormalities that may be resulting in rotator cuff tendinosis. This includes the
following: 1) stretching exercises to restore proper flexibility to the shoulder
capsule; 2) exercises the strengthen the rotator cuff muscles once adequate
healing has occurred; 3) exercises to improve posture and strengthen the muscles
that control the position and coordination of the shoulder blade; 4) aerobic
conditioning exercises to improve fatigue tolerance; 5) transitioning back to work
or sport related activities that place significant demands on the shoulder.

Home Exercise Program: Because formal physical therapy may only be performed
2 or 3 times per week, it is essential that patients have a structured home exercise
program to perform on the in-between days. This is especially true for stretching
exercises as the shoulder is prone to re-stiffen if these exercises are not performed
daily if not several times a day.

NOTE: Many patients will have engaged in a previous program of physical therapy
but may have failed to improve. Often these programs will have focused on early
rotator cuff strengthening before abnormalities such as posterior capsular
tightness have been corrected. Our repeated observation is that may patients who
have failed previous physical therapy will benefit from further treatment once the
appropriate diagnosis has been established and the exercises focused on
correcting underlying mechanical deficiencies. This in combination with a properly
performed home exercise program will often provide substantial benefit with time
and persistence. Most importantly, patients must recognize that recovery is a slow
process. One should not give up if immediate and early gains are not seen.

Other Medications: Narcotic pain medications, muscle relaxants and sleeping pills
are generally not recommended for rotator cuff tendinosis as prolonged use may
diminish their effectiveness and may cause medication dependence or even
addiction.

Cortisone Injections: Cortisone is a powerful anti-inflammatory medication that
can be injected adjacent to the rotator cuff into the subacromial bursa. Although
rotator cuff tendinosis is not primarily an inflammatory condition, cortisone acts to
modify pain receptors in the tissue so that pain is diminished. This effect may last
anywhere from a week to several months and is variable between patients.
Repeated cortisone injections can cause weakening of the tendon tissue and may
cause more harm than good.
Who Should Consider Surgery
Surgery may be considered if a concerted effort at non-operative treatment has failed to
result in improvement in comfort and function after 3-6 months. Surgery is entirely
elective. The decision should be based on how the rotator cuff tendinosis affects a
person’s quality of life and one’s tolerance for waiting out the healing process.
The success of surgery can be maximized if patients are motivated and committed to the
recovery process. Thus, one should not consider this course unless a substantial
allotment of time and effort can be devoted to the goal of a comfortable and functional
shoulder.
What Does Surgery Entail?
Surgery must be directed at the underlying cause of rotator cuff tendinosis. Typically,
surgery involves a diagnostic shoulder arthroscopy. This involves putting a small camera
inside the shoulder that allows the surgeon to look directly at all of the tissues including
bones, ligaments, tendons, cartilage, and bursa. Assuming that the rotator cuff is not
partially or completely torn, the shoulder is manipulated to break up any adhesions and
scar tissue that may result in tightness of the posterior capsule. Sometimes a portion of
this capsule is resected so that capsular tightness does not recur during the healing
process. The biceps tendon is carefully inspected for evidence of fraying or tissue
damage and any inflamed capsule is removed.
The main part of the procedure involves releasing the
coracoacromial ligament from the acromion bone and
beveling the undersurface of the acromion so that it is
smooth. This process creates more room for the tendon and
prevents pressure on the tendon from wringing out its blood
supply during shoulder motion. This procedure is called an
acromioplasty or a subacromial decompression.
In some patients, if there is symptomatic arthritis in the joint
between the end of the collarbone and the acromion, this
must treated as well. This involves removing the end of the
collarbone to prevent bone on bone abrasion. This is not
necessary in every case. This procedure is called a distal
clavicle resection.
What Does Recovery Involve?
As long as no tendon repair process is performed, the recovery process is relatively
quick. Patients are encouraged to start immediate range of motion exercises to prevent
shoulder stiffness. In order to allow the diseased tendon a chance to heal, active use of
the shoulder for strenuous activities such as lifting, pushing and pulling anything heavier
than 5 pounds is discouraged for a few weeks.
Exercises to strengthen the rotator cuff and shoulder girdle muscles are started after the
tendon has healed and after full range of motion is recovered. The aim of these exercises
is to restore shoulder strength and endurance much of which may be lost during the
tendinosis process as patients favor the shoulder.
Outpatient physical therapy starts 5-7 days after surgery and generally includes 2-3
visits per week. Patients are instructed in a home exercise program and it is essential
that daily flexibility exercises are performed a few time per day. Routine use of ice packs
helps to alleviate pain in the immediate postoperative period.
Potential Risks and Complications of Surgery
The risks of surgery include, but are not limited to, infection, damage to nerves and
blood vessels, infection, shoulder stiffness, recurrent shoulder pain and complications
related to anesthesia. While these risks and complications are infrequent, they can occur
in anyone. Patients should consider these when electing to undergo surgery. Any one of
these problems can limit the outcome of the procedure.
What are the Results of Surgery
Surgery can be very successful in patients who have failed to respond to non-operative
measures, assuming that the correct diagnosis has been made. The results of surgery
depend on two important factors. First is that the surgeon has performed an adequate
assessment of the shoulder and an adequate decompression. Second is that the patient
adhere to the postoperative regimen. A perfect decompression can be unsuccessful if the
shoulder develops postoperative stiffness or if the tendon is not given sufficient time to
heal.
Future Treatments
Tendinosis affects millions of Americans and the cost to society from medical care and
lost productivity is measured in billions of dollars. For this reason, a host of centers are
investigating methods of augmenting the tendon healing response. The studies are
pursuing artificial tendon tissue, therapeutic injections to boost the rate of tendon healing
and other biological remedies. Although none of this research has yet reached fruition in
terms of treating patients with tendinosis, there is a high likelihood that within 5-10
years, we will have novel regenerative approaches to managing this chronic condition.