Shoulder pain is a common complaint, particularly among active individuals and older adults. Previously, terms such as “bursitis” and “shoulder impingement” were commonly used; however, they can be misleading as they tend to not reflect the true nature of the condition. The most common cause of shoulder pain is a condition currently referred to as “Rotator Cuff-Related Shoulder Pain” (RCRSP). Whether caused by overuse, injury, or age-related changes, RCRSP can significantly impact daily activities like reaching, lifting, or even sleeping comfortably. In this blog post, we’ll explore what RCRSP is, what causes it, and how physiotherapy plays a crucial role in recovery, pain management, and restoring shoulder function.
What is the Rotator Cuff?
The shoulder joint (AKA the glenohumeral joint) is a ball-and-socket joint that allows for a wide range of movement; in fact, it is the most mobile joint in our bodies. Due to this mobility, we rely heavily on stabilisers around the shoulder to help support the joint throughout this movement, which comes from two types of structures: passive and active stabilisers. Passive stabilisers of the shoulder joint consist of structures such as ligaments, the joint capsule, and labrum. Active stabilisation comes from muscles such as the rotator cuff. The rotator cuff consists of four distinct muscles that sit around the joint: supraspinatus, infraspinatus, teres minor, and subscapularis. Each individual muscle performs slightly different actions, but altogether they are the main active stabilisers of the shoulder.
Rotator Cuff Related Shoulder Pain
RCRSP commonly arises from two main conditions: tears and tendinopathies. Rotator cuff tendon tears may result from sudden trauma or develop gradually over time due to degenerative changes. These tears exist along a continuum, from partial-thickness tears to full-thickness tears and, in severe cases, complete ruptures. Interestingly, not all tears are painful or even symptomatic. Imaging studies show that around 25% of adults over the age of 65 have a rotator cuff tear, with this figure rising to over 50% by age 80. In fact, up to 90% of people without shoulder pain will show some form of abnormality (such as a tear, tendinopathy, bursitis, or arthritis) on imaging, highlighting the importance of matching scan findings to clinical symptoms.
Rotator cuff tendinopathy refers to pain and microscopic changes in the tendon structure, often triggered by excessive or unusual load. It’s commonly seen after a sudden increase in activity, such as unfamiliar lifting or overhead movement, which causes the tendon to react protectively. Contrary to the instinct to rest completely, too little activity can worsen the condition. Management involves a gradual loading program, progressively strengthening the tendon and surrounding muscles once pain is under control to build resilience and reduce the risk of recurrence.
Shoulder bursitis, inflammation of the small fluid-filled sacs (bursae) that cushion and reduce friction in the joint, is also frequently associated with rotator cuff pain. However, it’s rarely the primary cause. Bursitis often develops alongside tendon issues and usually resolves when the underlying rotator cuff problem is addressed.
People with RCRSP often describe a dull, deep ache in the shoulder or upper arm with occasional sharp catching pain, particularly when lifting, reaching overhead or behind, or lying on the affected side. Common symptoms include weakness, reduced range of motion, and difficulty with daily tasks such as dressing or carrying bags. While the pain may be intermittent at first, it often becomes more persistent without proper intervention.
What Physiotherapy Can Do
The good news is that physiotherapists, with their in-depth anatomical knowledge and exercise prescription skills, are well-placed to help with RCRSP. Physiotherapy plays a crucial role in managing this condition by addressing both the symptoms and underlying causes. During an assessment, they can rule in or out other potential causes of an individual’s shoulder pain, such as arthritis or referred neck pain. Through a tailored program that may include targeted exercises, manual therapy, and load management strategies, physiotherapy can help reduce pain, improve shoulder strength and mobility, and restore normal function. Education is also a key component, which entails helping individuals understand their condition, avoid aggravating activities, and build long-term resilience to prevent recurrence. In most cases, physiotherapy is highly effective and can eliminate the need for more invasive treatments like injections or surgery.
Q&A Section
1. Do I need to get a scan for my shoulder pain?
Your physiotherapist can help determine whether further scans or imaging is indicated; however, scans for RCRSP are usually not indicated and will often not change the advised treatment plan. A scan may be suggested if there is severe pain or loss of function, or if the pain persists longer than 3 months.
2. Can physiotherapy replace surgery for RCRSP?
Physiotherapy, particularly through progressive strength training, can yield outcomes comparable to or better than surgery for degenerative tears and most acute tears. Surgery is rarely necessary for rotator cuff tendinopathy, as non-invasive treatments are generally sufficient for managing tendinopathies, which are typically a load management issue. Early pain management significantly reduces the need for surgical intervention.
3. How does exercise benefit RCRSP?
Exercise plays a crucial role in encouraging healing and improving the tolerance of tendons and joints to loads, thereby reducing pain and the likelihood of recurrence. Physiotherapists provide guidance on safe and effective exercises tailored to individual recovery needs.