Rotator Cuff Tendinopathy

History:

Gradual onset of lateral shoulder pain referring to the upper arm (C5 distribution). Worse with overhead activity, reaching behind the back, and lying on the affected side. Night pain is common.

Examination:

The painful arc (60-120 degrees of active abduction) is a hallmark feature, with pain above 120 degrees pointing to ACJ pathology. Diagnosis rests on a cluster of findings, not a single test.

Useful tests:

• •Jobe's (empty can) for supraspinatus

• •Neer's and Hawkins-Kennedy for subacromial pain

• •Resisted external rotation for infraspinatus

Passive ROM is preserved (distinguishes from frozen shoulder). True weakness on resisted testing suggests a tear, not isolated tendinopathy.

Red flags:

Acute traumatic weakness (massive tear), weight loss or night sweats (Pancoast), fever or acute swelling (septic), bilateral shoulder stiffness over age 50 (PMR).

RCRSP is a clinical diagnosis. Imaging is not essential to start treatment (BESS 2025).

• •Plain radiographs: First-line if imaging is needed - trauma, red flags, severe or atypical symptoms. May show acromial spurs or subacromial sclerosis (often incidental).

• •USS: Use when a tear needs excluding. Operator-dependent but accessible and cost-effective.

• •MRI: Not first-line. Reserve for diagnostic uncertainty, inconclusive USS, or surgical planning.

• •Bloods: Not routine. ESR or CRP if inflammatory cause suspected.

• •Outcome measures: Oxford Shoulder Score (OSS), SPADI.

First-line (community) per NICE CKS:

• •Education: explain the tendinopathic nature, expected recovery within 3 months, and the central role of active rehabilitation. Address fear-avoidance early.

• •Activity modification: reduce aggravating overhead load. Avoid complete rest.

• •Analgesia: paracetamol or short-course oral NSAIDs. Topical NSAIDs are an alternative.

• •Physiotherapy: supervised progressive loading is the mainstay and outperforms passive treatments.

Subacromial corticosteroid injection:

Consider when pain prevents engagement with rehab or significantly disrupts sleep. Provides short-term relief only. BESS 2025: no added benefit from repeat injections, and USS-guided is not superior to landmark injection. Warn diabetic patients of 24-48 hours of hyperglycaemia.

Referral:

Refer if symptoms persist beyond 3 months of conservative management. Urgent referral within 2 weeks (BESS) for acute traumatic loss of rotator cuff function.

Surgical options:

Routine arthroscopic subacromial decompression (ASD) is not recommended for isolated subacromial pain. The CSAW (2018) and FIMPACT trials showed no benefit over sham surgery; BESS 2025 recommends reconsidering routine use.

Stage 1 - Pain-dominant phase (0-6 weeks):

• •Isometric rotator cuff holds at 30-50% MVC, 5x 30-45 second holds, 1-2x daily. Useful for early pain modulation.

• •Scapular setting and postural correction in pain-free range.

• •Avoid provocative overhead or end-range positions.

Stage 2 - Loading phase (6-12 weeks):

• •Progressive isotonic strengthening: external rotation, internal rotation, abduction. Start at 3 sets of 12-15 reps, progress load over 8-12 weeks.

• •Add scapular stabilisation (low row, prone Y/T/W).

• •Gradually reintroduce overhead movement once pain is controlled.

• •Include thoracic mobility and posterior capsule stretching.

Stage 3 - Functional and return-to-sport phase (12+ weeks):

• •Sport- or occupation-specific drills.

• •Plyometric and eccentric loading for overhead athletes (medicine-ball throws, deceleration drills).

• •Progressive return-to-throw or return-to-overhead programme over 6-8 weeks.

Progression criteria between stages:

• •Pain less than 4/10 on loaded testing.

• •Symmetrical strength on resisted testing at the previous stage's load.

• •No night pain.

Address the kinetic chain throughout: thoracic spine extension, scapular dyskinesis, posterior capsule tightness, and core or lower-limb strength for athletes.

• •CSAW Trial (Beard et al., Lancet 2018) - Arthroscopic subacromial decompression provided no significant benefit over sham surgery for isolated subacromial pain at 12 months.

• •FIMPACT Trial (Paavola et al., BMJ 2018) - Independent multicentre trial confirming ASD is not superior to diagnostic arthroscopy alone for shoulder impingement syndrome.

• •BESS 2025 Care Pathway for Subacromial Shoulder Pain - Rebrands the condition RCRSP, prioritises supervised exercise, and discourages routine ASD or repeated injections.

• •NICE CKS: Shoulder Pain - Recommends education, activity modification, analgesia, and physiotherapy first-line. Refer after 3 months if conservative management fails.

• •Cochrane review on exercise for shoulder pain (Page et al.) - Supervised progressive loading produces clinically meaningful improvement; passive modalities offer little additional benefit.

• •Painful arc 60-120 degrees of abduction is the hallmark - pain above 120 degrees suggests ACJ pathology, not rotator cuff.

• •Preserved passive ROM is the key feature distinguishing RCRSP from frozen shoulder.

• •Know the CSAW trial (Lancet 2018): arthroscopic subacromial decompression is no better than sham surgery for isolated subacromial pain.

• •Acute traumatic loss of rotator cuff function needs urgent referral within 2 weeks (BESS 2025).

• •Don't confuse degenerative tendinopathy with calcific tendinopathy - the latter presents with acute severe pain and is visible on plain X-ray.