Shoulder Pain

Causes Of Rotator cuff Tendeopathy

The exact cause of rotator cuff tendinopathy remains unknown. So far, many causes have been explained, and, as a result, the disease appears to be multifactorial.

Mostly, extrinsic factors of the disease lead to compression of the tendons and narrowing of the subacromial space. These risk factors include:

• Postural abnormalities such as keeping the arms overhead for a long time
• Decrease in performance of shoulder muscles
• Muscle overuse in people who play sports or have an occupation that involves repetitive overhead movements
• Acromyan or subacromial anatomical variations

On the other hand, Intrinsic factors which lead to degeneration and wear and tear of the tendons are as follows:

• Changes in biology, morphology, vascularity, and mechanical properties
• Genetics and family history
• Old age
• Trauma
• Increase in load on the tendon (obesity)

Clinical Features

Rotator cuff tendinopathy signs and symptoms include:

• Dull, aching pain deep in the shoulder
• Pain triggered when raising and lowering the arm
• Shoulder joint stiffness
• Swelling and tenderness at the front of the shoulder and the side of the arm
• A clicking sound when raising the arm overhead

When the problem becomes severe, the following symptoms are present

• Pain at night that wakes the person up or requires them to change position
• Sharp pain when reaching behind the back or lifting something up
• Loss of joint strength and mobility

Diagnosis

Indeed, doctors make a diagnosis based on the following:

• Symptoms, their start, their occurrence, and their progression
• Medical history, recent falls, or any injuries
• Physical examination of the shoulder to check for tenderness, abnormalities, range of motion, etc.
• Strength of the shoulder joint by asking the patient to press against their hand
• X-ray to check for bone spur
• MRI or ultrasound to check for inflammation and signs of tearing or degeneration

Mostly, the imaging tests are usually performed to rule out other possible conditions.

Treatment

Recovery from the disease depends upon its severity. Usually, people see improvements within six to twelve weeks of rehabilitation. The minimum recovery time from a small tear is generally two to four weeks. But large tears may take months to recover. Ultimately, the aim is to reduce inflammation and compression of the tendon.

RC tendinopathy may cause long-term disability and chronicity if combined factors are involved. It badly affects the quality of life and may be associated with substantial morbidity.

1. Conservative Treatment

For minor to mild conditions, doctors recommend the following conservative treatments.

• Take non-steroidal anti-inflammatory drugs like ibuprofen, naproxen when symptoms flare-up
• Rest, and especially avoid activities that cause pain
• Apply ice to the shoulder for fifteen minutes, three or four times a day
• Apply heat once the pain goes away to lessen stiffness in the shoulder
• Avoid sleeping on the sore shoulder
• Sometimes, a person may also benefit from over-the-counter analgesic ointments, creams, or patches such as menthol, capsaicin, and methyl salicylate.
  • Physical therapy is one of the first treatments doctors recommend. You may also see a physical therapist. Doctors or physical therapists recommend the following exercises
• The weighted pendulumexercise to reduce pressure on the rotator cuff muscles
• The crossover shoulderexercise
• Muscle strengthening exercises
• Stretching shoulder throughout the day

1. Advanced Non invasive Regenerative Therapies

• Low level Laser Therapy (Cold laser therapy)
• Extracorporeal Shock Wave Therapy
• Non invasive Pulsed Radio Frequency Neuromodulation
• Pulsed Electromegnetic Field Therapy

Above  mention therapies not only induce but also assist the healing process needed for the cure of the shoulder pain.

Interventional pain management

1. Platelet-rich plasma (PRP) injection:

PRP injections in the shoulder has replaced steroid injection in most types of shoulder pain. It is effective in tendinopathies, tendon tears, frozen shoulders, or early osteoarthritis of the glenohumeral joint. PRP injection is also called regeneration therapy because it can regenerate degenerated tendons, ligaments or joints. However, this process of regeneration is slow and takes almost one to two month/s for its optimum action. Also, PRP injections are effective in early diseases. In advanced conditions, the PRP injections are repeated at 3-8 weeks intervals.

PRP injections are always done under the guidance of ultrasonography to identify the pathological area and to inject exactly at the site where it is needed. For PRP injection, the patient’s own blood is taken in a kit which is then centrifuged in a special centrifuge machine, and the separated PRP is taken in the syringe for injection.

PRP injections are not effective if the patient’s platelet count is very low; if the patient is taking strong anti-platelet medicine like clopidogrel or taking a steroid for some reason.

2. Prolotherapy

Ultrasound-guided hypertonic dextrose injection at the affected tendon’s enthesis site is a potentially effective adjuvant intervention to physical therapy for patients with rotator cuff tendinopathy ranging from tendinosis to partial-thickness and small full-thickness tears. It not only induce healing but also provides strengthening to the muscles tendons.

3. Steroid injection in shoulder pain: Injection of depo-steroid is beneficial and recommended in arthritis, bursitis, or joint effusion. This depot steroid has minimal systemic side-effects with the recommended doses. But repeated steroid injections are harmful and are not recommended.
4.  Surgery

Most of the time, medication, rest, ice, and physical therapy is all that are needed to treat RC tendinopathy. Surgery is rarely performed and is the last resort. Its appropriateness depends upon age, the severity of the injury, physical demands, and overall health. Surgeries include tendon repair, tendon transfer, or shoulder replacement. Surgery has its own risks of anesthesia and surgical procedures and costly also. That is why non-surgical treatments are always preferable.