Rotator Cuff Tendonopathy

Definitions
Tendinopathy a generic term without biochemical or histological
implications and is used to describe pathology in, and pain arising from, a
tendon
Tendon injuries that can be found on any tendon of the body, however
more prevalent in three areas:

musculotendinous junction (where the tendon joins

the muscle)

mid-tendon (non-insertional tendinopathy)

tendon insertion (eg into bone)

When a tendon is inflamed due to the bodys healing response to

repetitive overloading of these junctions (usually acute), it is called
tendonitis.

Rotator cuff tendinopathy (UpToDate)

Usually known as/presented with shoulder pain

Common in primary care setting
Brought on by increased compression and tension at the site of the
shoulder tendons
Usually a gradual onset condition
Tendons can be damaged by repetitive movements or overload of the
shoulder

Source: http://www.performancepodiatry.com.au/rotator-cufftendinopathy.html

Epidemiology
General population
In a Dutch study1 on musculoskeletal pain, it was found that the shoulder
was the second most common site of musculoskeletal pain behind the
lower back, with 30.3% of people having experienced some form of
shoulder pain in the last 12 months, 20.9% experiencing pain at the time
of the survey and 15.1% experiencing chronic shoulder pain. Furthermore,
only a third of shoulder pain sufferers visited a GP, physiotherapist or
specialist whist 30% reported limitation in daily activities due to their
shoulder pain. In terms of gender, more women (26%) reported having
shoulder pain compared to men (16%).
In regards to age, a Finnish study2
found shoulder pain in adults is
shown to generally increase with
age with a peak in the 45-64-yearold age group most likely due to the
degeneration of joints over time.
However, there is a notable spike in
the number of cases of shoulder
pain in adolescents especially 16-18
year olds where around 40%
reported to have shoulder pain. This
is hypothesized to be largely due to
an increased level of computer usage which promote repetitive
movements and static posture.
Occupational factors
Numerous studies have shown the impact of working conditions and
occupational requirements on the prevalence of shoulder pain. Factors
that contribute to shoulder injuries include manual handling, prolonged
static work, awkward postures, repetition, working with hands above
shoulder level and working with vibrating tools.
One study3 found 60% of slaughterhouse workers suffered from shoulder
pain as they performed repetitive and manually intensive work that
required their arms to be raised above their shoulders.
Athletes
The prevalence of shoulder pain in athletes is generally above the general
population, especially in overhead sports (sports that require repetitive
overhead use of the shoulder) which include swimming. In swimming, the
shoulder joint is particularly vulnerable and is the most injured area. One
study4 reports 65% of swimmers experienced some form of shoulder pain
and 23% of high level swimmers experienced shoulder pain that required
a reduction or complete cessation of training5.

In terms of injuries, another study6 found 23% of swimmers suffered some

form of acute or chronic shoulder injury that required treatment from an
Allied health professional. Of this 23%, the two most common injuries
were subacromial syndrome and rotator cuff tendinitis, each of which
accounted for a quarter of all injuries.
Whilst swimming involves repetitive overhead motions, players in other
overhead sports such as the ones listed on the table on the next page
experience high rotational forces in the shoulder during rapid acceleration
and deceleration. This kind of movement places soft tissue structures in
the shoulder at risk and accounts for the higher shoulder injury incidence
rates in these sports compared to swimming

Causes/Risk Factors of Rotator

Cuff Tendinopathy
The risk of developing rotator cuff tendinopathy can be increased by the
following actions and or behaviours:
-

Sports which involve activity which utilise the rotator cuff group
extensively (especially overhead movements) such as
o Weightlifting, swimming, tennis, throwing (baseball, cricket etc.),
golf, volleyball and gymnastics.
Instability or hypermobility of the glenohumeral joint which is not related
to muscle weakness
High BMI, diabetes, hyperlipidaemia
Anatomical variations which may predispose the person to rotator cuff
impingement (temporary entrapment/compression)
Scapular instability (dyskinesis)
Old age
Work, especially in labourers, which involve overhead movement of the
arms and rotator cuff muscle group.

The condition is caused by general wear and tear, progressive

degeneration or substantial injury (for example, in trauma) to the

shoulder. In all these scenarios the tendons failure to regenerate properly

results in inflammation, loss of function, disorganisation and thickening of
the tendon.

Shoulder Anatomy
Bones:
The shoulder region is made up of the clavicle and the scapula which
together form the pectoral girdle/shoulder girdle.
Proximal end of humerus fits into
glenoid fossa of scapula.
-

Large triangular bone which is

composed of 3 angles (superior,
inferior and lateral), 3 borders
(superior, lateral and medial)
and 3 processes (acromion,
spine and coracoid - pointy bits)
as shown on diagram.
The fossas are concave, shallow
cavities within which certain
muscles sit.

The acromial end forms the acromioclavicular

joint with the acromion of the scapula.
The sternal end forms the sternoclavicular joint
with the manubrium; the superior most part of
the sternum.
The inferior aspect of the clavicle is usually
rougher due to attachments of the muscles
compared to the smooth superior surface.

The proximal head of the humerus sits in the the

glenoid fossa of the scapula.
While the anatomical neck marks the distal end
of the head of the humerus the surgical neck
marks the point at which fractures are most
likely to occur.

The glenohumeral joint occurs between the

proximal head of the humerus and the glenoid
fossa. (The long head of the biceps brachii attaches in the
intertubercular groove whereas the short head attaches at
the coracoid process of the scapula.)

Muscles + Nerves they are innervated by, Ligaments and

Tendons:
-

The diagram shows the different

ligaments in the shoulder region.
The trapezoid ligament attaches at the
trapezoid line of the clavicle.

Basic muscles of the shoulder region include:

Trapezius: The triangular

muscle that is attached at the
spine as well as the superior
edge of the crest of the spine
of the scapula, acromion and
posterior border of the lateral
one third of the clavicle. Main
movement: elevation and
rotation of scapula during
abduction of humerus.
Deltoid: a teardrop shaped
muscle at the lateral side of the
humerus - attached at the
inferior edge of the spine of the
scapula, lateral margin of
acromion, anterior border of
the lateral one third of the clavicle and the deltoid tuberosity of humerus.
Main movement: Abduction after 15 degrees.
Innervated by axillary nerve.

Rotator Cuff Muscles:

A group of muscles that hold
the humerus to the trunk
and enable the shoulder to
rotate, abduct, extend etc.
They are made up of:
Supraspinatus: Involved
in abduction,
External/Internal rotation
- Origin: supraspinous fossa
of the scapula
- Insertion: superior aspect
of greater tubercle
Infraspinatus: Involved in
external rotation,
abduction and rotation.
- Origin: Infraspinous fossa
of the scapula
- Insertion: Medial aspect of greater tubercle
Subscapularis: sits in the subscapular fossa (on the anterior aspect of the
scapula.)
Teres Minor: Involved in External rotation, abduction and extension.
- Origin: Upper third of lateral border of scapula

Insertion: Inferior aspect of greater tubercle

All rotator cuff muscles are innervated by the subscapular nerve which
branches off the superior trunk made up of roots C5 and C6 in the brachial
plexus except the Teres Minor which is innervated by the axillary nerve.
Subacromial bursa (fluid filled sac to prevent friction between a joint and
skin) lies above rotator cuff.
Other muscles include: biceps brachii and triceps brachii both of which are
located on the anterior and posterior aspects of the humerus respectively.
Latissimus dorsi can be seen attached to spinal processes and the
humerus (near the intertubercular groove.)
Pectoralis major and minor are located on the anterior surface of the body.
Serratus Anterior on the lateral aspect, over the ribs, giving it a serrated
appearance.
Patho-Physiology:
Swimmers shoulder is generally a reference to a tear or inflammation of
the tendons or bursa in the shoulder region due to overuse.
The image on the left shows
the tendon joining the
supraspinatus muscle
tearing leading to
inflammation. The image on
the right shows how the
bursa may rub against this
tendon and cause the
same.
Problems can also arise
with inflammation of other
tendons such as the
biceps or pectoralis major
ones (may not be relevant
to our gal tho.)

SOME ANATOMY HERE IF U WANT TO INCLUDE SUPER BRIEFLY LIKE ONE

SLIDE EACH:
Arteries:
The diagram on the left is just to
show the relative position of all
structures. As can be seen the

axillary inlet is the pathway for arteries, nerves and veins to access the
the arm, forearm and hand.

Subclavian artery branches off

aorta and is referred to as the
axillary artery once it enters the
axillary inlet. Divided into 3 sections
at which the artery divides:
1. Superior Thoracic division
branches off
2. Thoracoacromial and lateral
thoracic branch off
3. Subscapular, posterior and
anterior circumflex humeral
arteries branch off here.

Nerves: Super quick diagram + explanation of brachial plexus (if

you think this is relevant)
Enter through axillary inlet of
shoulder region even though nerve
roots themselves originate in the
cervical and thoracic regions of
spine (eg neck area). Diagram is
pretty self explanatory - just part of
shoulder anatomy.

Rotator Cuff Injury Clinical

Signs and Symptoms
Patients with a rotator cuff injury can be symptomatic or asymptomatic
For those who do experience symptoms, there is a spectrum i.e. not all symptoms may be
experienced and, if they are, they may not to be the same degree.
Signs objective, something that can be observed by anyone

Limited mobility of shoulder

Difficultly or inability to raise affected arm above shoulder height
Difficulty or inability to externally/laterally rotate affected arm and shoulder

Symptoms subjective, something that is felt by the patient as a result of the injury
At time of injury

Intense pain
Snapping sensation
Immediate weakness in upper arm

After injury

Pain in affected shoulder and (potentially) in the upper arm

o At rest
o At night especially if lying on affected shoulder
When lifting or lowering arm
Weakened shoulder causes difficultly in performing everyday tasks
(i.e. brushing hair, reaching higher shelves, getting dressed)
Feeling of instability in affected anterior shoulder
Crepitus (grating and/or crackling sounds and/or sensation) when moving shoulder in
certain positions
Numbness in affected hand and arm

References
1

P. Vikat, M. Rimpela, J. J. Salminen, A. Rimpela, A. Savolainen, S. M.

Virtanen, Neck or shoulder pain and low back pain in Finnish adolescents.
Scand J Public Health. 2000164173.
2

A. Vikat, M. Rimpela, J. J. Salminen, A. Rimpela, A. Savolainen, S. M.

Virtanen, Neck or shoulder pain and low back pain in Finnish
adolescentsScand J Public Health, 2000164173
3

P. Frost, J. H. Andersen, Shoulder impingement syndrome in relation to

shoulder intensive work. Occupational and Environmental Medicine.
199956494498
4

K. Bak, P. Faun, Clinical findings in competitive swimmers with shoulder

pain. Am J Sports Med. 1997 Mar-Apr. 25225460
5

S. Rupp, K. Berninger, T. Hopf, Shoulder problems in high level swimmersimpingement, anterior instability, muscular imbalance?Int J Sports Med.
1995 Nov. 16855762
6

K. Laudner, R. Sipes, The Incidence of Shoulder Injury among Collegiate

Overhead Athletes. Journal of Intercollegiate Sport. 2009.
http://journals.humankinetics.com/AcuCustom/Sitename/Documents/Docu
mentItem/17656.pdf
Mario Pribicevic (2012). The Epidemiology of Shoulder Pain: A Narrative
Review of the Literature, Pain in Perspective, Dr. Subhamay Ghosh (Ed.),
InTech, DOI: 10.5772/52931. Available from:
http://www.intechopen.com/books/pain-in-perspective/the-epidemiologyof-shoulder-pain-a-narrative-review-of-the-literature
http://www.uptodate.com.ezproxy.lib.monash.edu.au/contents/rotator-cufftendinopathy#H3
http://www.mayoclinic.org/diseases-conditions/rotator-cuffinjury/symptoms-causes/dxc-20126923
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4004132/

American Society for Surgery of the Hand. (2016). Rotator Cuff Injuries. Retrieved July 31,
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