Welcome to Part 2 of our blog article on treatment strategies for shoulder pain. In Part 1 we discussed why rotator cuff injuries are so complex to treat, and the evidence-base around using Photobiomodulation (laser therapy) to manage shoulder pain. In this article, we'll take a closer look at rotator cuff tendinopathy, including Rotator Cuff Calcification, and the studies that support the use of shockwave therapy in the treatment of calcific tendonitis. Finally, we’ll review some research backed strategies for shoulder impingement and tendon pathology.

Rotator Cuff

The rotator cuff is a group of muscles and tendons around the shoulder joint that keep the upper arm bone in the shoulder socket.1 Various levels of injury can occur to the rotator cuff, including tendonitis, chronic tendinopathy, partial tears, and full-thickness tears. Tendonitis commonly occurs due to trauma or overuse and can progress to a chronic state of tendinopathy. Once in this chronic stage, the rotator cuff may become weak and can lead to further tearing.2

Rotator cuff tears are extremely common, affecting at least 10% of those over the age of 60 in the United States, which equates to over six million cases per year.4 It has been shown that 23% of asymptomatic shoulders have tears with the percentages increasing each decade after 50 years of age.3

Cuff pathology is considered a progressive disorder. Twenty percent of asymptomatic tears are progressive, and do not get smaller with time.4

Industry estimates suggest rotator cuff surgeries are performed in the US on 75,000–250,000 patients per year and the failure rate for surgical repair of rotator cuff tears is between 25 and 90%.4 Fortunately, patients with failed repairs report satisfaction levels and outcome scores that are nearly indistinguishable from those whose repairs are intact.4

A number of retrospective case series and one randomized controlled trial have suggested that nonoperative treatment of full thickness rotator cuff tears may be successful in some patients.4

Rotator cuff injury symptoms and causes:

  • A dull deep shoulder ache
  • Pain that disturbs sleep
  • Discomfort with overhead movement and with moving the arm behind the back
  • Arm weakness

Common cause of rotator cuff injuries include:

  • Repetitive overhead movements making rotator cuff injuries common across a diverse patient population.1
  • Trauma such as falls, rapid humeral deceleration with throwers, or high resistive forces applied through the shoulder.1
  • Individuals over the age of 60 are more prone to rotator cuff injury.1
  • Subacromial bone spurs can contribute to impingement, leading to an increased likelihood of rotator cuff pathology.5
  • Weakness or imbalance of muscles surrounding the shoulder joint.1

Rotator Cuff Calcification

Rotator cuff calcification, also known as calcific tendonitis, occurs when calcium deposits build up in the tendons of the rotator cuff. These deposits can cause inflammation and severe pain, especially when they grow or become irritated.

Symptoms:

  • Sudden shoulder pain and stiffness
  • Intense pain with shoulder movement
  • Pain that disrupts sleep
  • Reduced range of motion in the shoulder

The exact cause isn’t fully understood, but it is more common in people between the ages of 40 – 60, and slightly more prevalent in women. Diagnosis typically involves imaging tests like X-rays or ultrasound scans to identify the calcium deposits.

Treatment options include:

  • Pain relief medications like paracetamol or ibuprofen
  • Physiotherapy to strengthen and maintain shoulder flexibility
  • Corticosteroid injections to reduce inflammation
  • Ultrasound-guided barbotage, a procedure to remove calcium deposits
  • Shockwave therapy, a non-invasive procedure to remove calcium deposits
  • Surgery in severe cases to remove the deposits and create more space in the shoulder joint

Research to support the use of shockwave therapy in the treatment of calcific tendonitis:

STRATEGIES FOR SHOULDER IMPINGEMENT AND TENDON PATHOLOGY

Plans of care for patients dealing with shoulder pain can vary from weeks to months depending on the specific pathology and stage of the condition (pain acuity).

Additional factors that can impact outcomes and length of care can include the patient’s age and general health, mental status, and level of desired functional return.6

Thoughtful consideration should be given to these factors when making a prognostic plan of care for any shoulder patient.

Pain reduction and restoring range of motion (ROM) are usually the top priorities for most shoulder conditions requiring clinical care. Getting pain under control is paramount to improving ROM and function and is also a critical component of gaining patient trust and improving patient compliance.

How important is it? In today’s climate of high deductibles/ co-pays, approximately 20% of tendinopathy patients self-discharge within the first three visits, while 70% of patients fail to complete their full plan of care. A white paper from Marquette University states that a lack of immediate results is one of the leading causes of high attrition rates. Data suggest that high symptom severity and low functional ability increase the rate of self-discharge.7

Educating patients that conservative care can help most shoulder problems is as important as proving it. Clinicians’ choices to address problems with pain, ROM, and functional deficits are based on various factors, including the specifics of the patient profile and diagnosis, as well as the technology they have at their disposal.

When addressing shoulder impingement and tendinitis, clinicians should be mindful of 5 basic components:8

#1 Identify and remove any external factors

  • Ensure there are no external, anatomical causes for the impingement. This could include surgical considerations regarding bone spurs and soft tissue abnormalities.
  • Address functional components that may create impingement due to poor posture, i.e., poor scapular position and/ or glenohumeral positioning.

#2 Estimate phase of the tendinitis/ tendinosis

An accurate description of early tendon pain is important. Acute injuries can be framed in one of three phases.

Early phase involves pain only after activity without significant loss of range. Pain usually resolves when activity stops. If mechanics and or tendon loading activities are not corrected, tendon irritation can progress.

Moderate pathology presents with extreme exertion and lasts 1-2 hours after activity. As it progresses, pain may be present with moderate activity and last four-six hours after exercise.

Severe pathology will present with pain during any activity that rapidly increases with continued activity. Pain can last 8-24 hours after exercise. Eventually all daily activities become painful.

Chronic tendon pain lasting > six months falls into the tendinosis category.

This is a state where a tendon physically starts to change. These changes may include hypoechoic areas as well as general thickening of the tendon evident on ultrasound.9

  • This pathology requires a careful loading program that focuses on high load, long duration resistive activities.
  • The Physical Therapy Program at The University of Delaware has done extensive research on tendinosis. Click here to see an example of this type of rehabilitation program for Achilles tendinopathy.10

#3 Determine appropriate focus of treatment

This will be based on how the patient is presenting. Acute pain will require rest, education, and treatments to address inflammation. More chronic conditions will require progressive loading programs.

#4 Institute appropriate tensile loading program based on the stage of tendon pathology.

#5 Control pain and inflammation

Any number of modalities could be used to help in this area. A recent meta-analysis of 177 trials that reviewed twenty treatment options for addressing subacromial dysfunction concluded that six modalities/ treatments had a high probability of being most effective, in the short term, for pain and function. These included:11

  • Acupuncture
  • Manual therapy
  • Exercise
  • Exercise plus manual therapy
  • PBMT (laser therapy)
  • Microcurrent (MENS) (TENS) 11

High power laser and radial shockwave technologies both have the ability to change pain quickly and restore ROM, albeit via different mechanisms.12,13 These devices should help restore ROM and reduce pain more effectively than exercise alone. A meta-analysis by Steuri et al. concluded that shoulder exercises should be part of the treatment program but that adding laser or shockwave therapy can provide an additional benefit to patients.14

Yilmaz et al. recommends a multimodal approach to control pain that can include treatments like TENS and superficial hot and cold applications.15

If you’re interested in finding out about the treatment of shoulder pain, including a multimodal playbook for shoulder tendinopathy/impingement, you can download our free eBook HERE

References:

1 Rotator cuff injury. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/rotator-cuff-injury/symptoms-causes/syc-20350225. Published May 11, 2023. 

2 Varacallo M, Bitar YE, Mair SD. Rotator Cuff Tendonitis. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK532270/. Published August 4, 2023.  

3 Tempelhof S, Rupp S, Seil R. Age-related prevalence of rotator cuff tears in asymptomatic shoulders. J Shoulder Elbow Surg. 1999;8(4):296-299. 

4 Kuhn JE, Dunn WR, Sanders R, et al. Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: a multicenter prospective cohort study. J Shoulder Elbow Surg. 2013;22(10):1371-1379. 

5 Oh JH, Kim JY, Lee HK, Choi JA. Classification and clinical significance of acromial spur in rotator cuff tear: heel-type spur and rotator cuff tear. Clin Orthop Relat Res. 2010;468(6):1542-1550. 

6 Hanlon SL, Pohlig RT, Silbernagel KG. Differences in Recovery of Tendon Health Explained by Midportion Achilles Tendinopathy Subgroups: A 6-Month Follow-up. J Orthop Sports Phys Ther. 2023;53(4):1-18. 

7 March 26, 2010. https://epublications.marquette.edu/researchexchange/2010/Papers/6/ 

8 Zachazewski JE, Magee D, Quillen W. Athletic injuries and rehabilitation. Philadelphia, PA: Saunders; 1996. 

9 Ohberg L, Lorentzon R, Alfredson H. Eccentric training in patients with chronic Achilles tendinosis: normalised tendon structure and decreased thickness at follow up. Br J Sports Med. 2004;38(1):8-11. 

10 Silbernagel KG, Hanlon S, Sprague A. Current Clinical Concepts: Conservative Management of Achilles Tendinopathy. J Athl Train. 2020 May;55(5):438-447. 

11 Babatunde OO, Ensor J, Littlewood C, et al. Comparative effectiveness of treatment options for subacromial shoulder conditions: a systematic review and network meta-analysis. Ther Adv Musculoskelet Dis. 2021 Sep 9;13:1759720X211037530 

12 Elsodany, A. M., Alayat, M. S. M., Ali, M. M. E., & Khaprani, H. M. (2018). Long-Term Effect of Pulsed Nd:YAG Laser in the Treatment of Patients with Rotator Cuff Tendinopathy: A Randomized Controlled Trial. Photomedicine and laser surgery, 36(9), 506–513. 

13 Dedes V, Stergioulas A, Kipreos G, Dede AM, Mitseas A, Panoutsopoulos GI. Effectiveness and Safety of Shockwave Therapy in Tendinopathies. Mater Sociomed. 2018;30(2):131-146. 

14 Steuri R, Sattelmayer M, Elsig S, et al. Effectiveness of conservative interventions including exercise, manual therapy and medical management in adults with shoulder impingement: a systematic review and meta-analysis of RCTs. Br J Sports Med. 2017;51(18):1340-1347. doi:10.1136/bjsports-2016-096515 

15 Yılmaz M, Eroglu S, Dundar U, Toktas H. The effectiveness of high-intensity laser therapy on pain, range of motion, functional capacity, quality of life, and muscle strength in subacromial impingement syndrome: a 3-month follow-up, double-blinded, randomized, placebo-controlled trial. Lasers Med Sci. 2022;37(1):241-250.