Clinical Notes : Orthopedics and Trauma

76. Rotator cuff pain

If the presenting shoulder pain is not referred from the neck then consider :

  1. Frozen shoulder

  2. Acromioclavicular joint pain

    • AC disruption

    • AC osteoarthritis

  3. Rotator cuff pain

  4. Shoulder instability

    • SLAP tear

    • Dislocation

  5. Glenohumeral arthritis

Urgent referral if shoulder pain in the presence of :

  • History of trauma with acute pain & weakness

    • AC joint tear or displacement

    • Rotator cuff tear

  • History of trauma or epileptic fit leading to loss of rotation

    • SLAP tear

  • History of instability or subluxation

    • Dislocation

  • Mass/swelling/erythema

    • Infective process

Shoulder Impingement


Impingement syndrome is pain and inflammation that occurs when the rotator cuff tendons rub against the acromion.

Etiology :

The rotator cuff surrounds the shoulder joint and is formed by the tendons of four muscles:

  • supraspinatus

  • infraspinatus

  • teres minor

  • subscapularis


The rotator cuff

  • helps raise and rotate the arm

  • keeps the humerus tightly in the socket of the scapula, the glenoid

The subacromial bursa

  • reduces friction between the acromion and the rotator cuff tendons

Impingement is caused by

  • prolonged work using arm above shoulder

  • repeated throwing activities

  • bone spurs on the acromion

Diagnosis :

Diagnosis is based on history and examination, with imaging to exclude other pathology.

Pain :

  • generalised aching pain in the shoulder and upper arm

  • weakness and pain when raising arm (combing hair or putting on shirt)

  • worse at night


  • x-ray to detect bone spurs or other acromion abnormality

  • MRI to detect tendon, muscle and bursa abnormality


​​Video : Differentiating shoulder impingement from AC joint dysfunction   (5:25)


​​Video : Diagnosing shoulder impingement   (2:22)

Management :

The main aim of treatment is to relieve the pain and maintain and restore the range of motion

  • Non-surgical (first 4 weeks)

    • NSAIDs

    • heat and cold application

    • stretching and strengthening exercises

  • Non-surgical (4th-6th week)

    • physio

    • subacromial bursa steroid injection

  • Surgical (after 6 weeks)

    • subacromial decompression

    • arthroscopic arthroplasty


​​Video : Shoulder impingement  home excercise program (4:47)


Rotator cuff tear


Etiology :

Rotator cuff tendons have areas of very low blood supply, which are particularly vulnerable to tear with

  • degeneration of aging

  • repetitive shoulder motions ( eg cleaning windows, washing and waxing cars, painting, tennis and other throwing sports)

  • excessive force (eg catching a heavy falling object or lifting an extremely heavy object with the arm extended)

  • blunt trauma (eg falling on the shoulder)

  • bone spurs (shoulder impingement)

  • smoking (increased incidence and delayed healing)

Diagnosis :


  • May not be painful (up to to 40%)

  • Pain depending on severity of tear (from dull ache to sharp pain)

  • Catching sensation on movement           

  • Crepitus at specific range of motion

  • Difficulty sleeping on affected shoulder


  • x-ray to detect bone spurs or other acromion abnormality

  • MRI to detect tendon, muscle and bursa abnormality

Management :

Refer suspected rotator cuff tear to secondary care


(Left) An overhead view of the four tendons that form the rotator cuff and stabilize the joint. (Right) A full-thickness tear (blue arrow) in the supraspinatus tendon, the most common location for rotator cuff tears.

Illustrations show the front view of (left) a normal rotator cuff, and (right) a full-thickness tear in the supraspinatus tendon.

​​Video : Diagnosing rotator cuff tear (2:32)


Calcific Tendonitis


Etiology :

Calcium deposits usually form on the supraspinatus tendon in the rotator cuff.

  • Often multifocal

  • More common in 40-60 yo

  • More common in women than men

  • The exact trigger for each phase is unknown

Calcific tendonitis, or reactive calcification, progresses through three stages:

  • Pre-calcific stage

    • the tendon changes in ways that make calcium deposits more likely to form

  • calcific stage

    • calcium crystals are deposited in the tendons

    • then they begin to disappear as the body simply reabsorbs the calcium deposits

    • it is during this stage that pain is most likely to occur

  • Post-calcific stage

    • healing and remodelling of the tendon with new tissue

Diagnosis :


  • Pre-calcific stage

    • may be painless, or only mild to moderate pain

  • Calcific stage

    • pain begins to decrease

    • may become intermittent

  • post calcific stage

    • flare-ups of severe pain

    • pain eventually resolves


  • ultrasound

  • x-ray to detect bone spurs or other acromion abnormality

  • MRI to detect tendon, muscle and bursa abnormality


Management :


  • Pre-calcific stage

    • NSAIDs

    • heat and ice

    • home excercises (as in shoulder impingement)

    • physio

  • Calcific stage

    • extra-corporeal shock wave therapy (ESWT)

    • ultrasound guided pulsing to promote break up of deposits and resorbtion

  • post calcific stage

    • during acute flare-ups of acute pain  with calcific deposits resorbtion in the calcific phase, needling with ultasoud guidance and local anesthetic and steroid injection is most effective.


For the 10% of patients who are resistant to non-surgical treatment

  • arthroscopic resection of deposits

  • may include subacromial decompression (acromioplasty) to create more space for the affected tendon


Comparison of manual therapy techniques with therapeutic exercise in the treatment of shoulder impingement: a randomized controlled pilot clinical trial.

Kachingwe AF, Phillips B, Sletten E, Plunkett SW. Journal of Manual and Manipulative Therapy. 2008;16(4):238-247



Shoulder impingement: Biomechanical considerations in rehabilitation.

Ludewig PM, Braman JP. Manual Therapy. 2011; 16:33-39



Coracoid impingement syndrome: a literature review

Okoro T, Reddy VRM, Pimpelnarkar A.. Curr Rev Musculoskeletal Med. 2009;2:51-55. DOI 10.1007/s12178-009-9044-9



Posterosuperior and anterosuperior impingement of the shoulder in overhead athletes-evolving concepts

Kirchhoff C, Imhoff AB.. International Orthopaedics. 2010; 34(7):1049-58


Prevalence and risk factors of a rotator cuff tear in the general population

Yamamoto A, Takagishi K, Osawa T, Yanagawa T, Nakajima D, Shitara H, Kobayashi T.. J Should Elbow Surg. 2010;19:116–120.



Symptomatic progression of asymptomatic rotator cuff tears: a prospective study of clinical and sonographic variables.

Mall NA, Kim HM, Keener JD, Steger-May K, Teefey SA, Middleton WD, Stobbs G, Yamaguchi K. J Bone Joint Surg Am. 2010;92:2623–2633


Cigarette smoking increases the risk for rotator cuff tears.

Baumgarten KM, Gerlach D, Galatz LM, Teefey SA, Middleton WD, Ditsios K, Yamaguchi K. Clin Orthop Relat Res. 2010;468:1534–1541.


Calcific tendinitis of the shoulder.

Speed CA, Hazleman BL.

N Engl J Med. 1999;340:1582–1584.



Calcifying tendinitis of the shoulder: advances in imaging and management.

Gosens T, Hofstee DJ.

Curr Rheum Rep. 2009;11:129–134.



Extracorporeal shock wave therapy for calcifying tendinitis of the shoulder.

Hsu CJ, Wang DY, Tseng KF, et al.

J Shoulder Elbow Surg. 2008;17:55–59.


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