Rotator cuff tendonitis refers to inflammation of the tendons in the rotator cuff. This inflammation can cause pain, difficulty with range of motion of the shoulder, stiffness, weakness, and eventually damage to the tendons. Calcific deposits can form inside the tendon and will appear in radiographic imaging. This process is known as “calcific tendonitis.”
The rotator cuff is a musculotendinous structure composed of four muscles: supraspinatus, infraspinatus, teres minor and subscapularis. The four muscles unite to form a cuff of tissue (tendon) that inserts on the humeral head and acts to initiate and control motion of the shoulder. The supraspinatus, infraspinatus, and teres minor insert onto the greater tuberosity of the humerus while the subscapularis inserts on the lesser tuberosity, just medial to the long head of biceps tendon that runs in the bicipital groove. Like all tendons in the body, the rotator cuff is susceptible to inflammation and tendonitis.
Rotator cuff tendonitis typically occurs as the result of repetitive overhead motion and movements in combination with altered biomechanics of the glenohumeral joint. Sports that include repetitive overhead motion, including swimming, tennis, volleyball, and baseball, will predispose the patient to tendonitis of the rotator cuff. Chronic degeneration and calcification of the tendons can occur near the insertion of the rotator cuff and lead to a specific form of tendonitis known as “calcific tendonitis”. The condition can also be associated with subacromial impingement of the shoulder due to abnormal morphology of the acromion leading to impingement of the cuff during overhead movements. Calcification of the cuff is divided into three phases:
Pre-Calcific: Abnormal changes in the fibrocartilage are occurring, however the patient is usually pain-free.
Calcific: The calcific stage is broken down into three phases: formative, resting and resorptive phase. Patients usually begin feeling the most pain during the resorptive phase of the calcific stage.
Postcalcific: Crystals are formed in the tissue.
Patient History And Physical Exam
The patient may present with pain and crepitus of the shoulder that is exacerbated with overhead movements. One should take note of the physical activity/sports and occupation of the patient, which may direct the physician to the cause of the pathology. Repetitive sports such as tennis, baseball, volleyball, and swimming and occupations associated with repetitive overhead work (ex. paintor or laborer) can cause tendonitis of the rotator cuff. The patient should be assessed for muscular atrophy of the cuff muscles, not isolated to supraspinatus. Range of motion (ROM) testing should be used to identify decreased active ROM and scapular dyskinesis which can predispose the patient to tendinopathy of the cuff. Provocative testing should be used to test the patient for subacromial impingement signs (ex. Hawkins’ test). Rotator cuff testing is vital to isolate the primary muscles/tendons affected and to rule out a full thickness cuff tear.
Imaging And Diagnostic Studies
Radiographs should be taken in the following views: anteroposterior (AP), supraspinatus outlet view, and axillary views. These radiographs should be examined for calcification of the cuff tissue near its insertion onto the humeral head. Radiographs taken in the internal rotation view should be examined for calcification in teres minor. Radiographs taken in the external rotation view should be examined for calcification in the subscapularis. Typically, calcification can be found ranging anywhere from 1 to 1.5 cm from the insertion point of the supraspinatus tendon. A CT scan can help visualize the shoulder in a three-dimensional view. A magnetic resonance image (MRI) may be ordered for patients with refractory pain and may help identify a rotator cuff tear and other internal derangement of the shoulder.
Subacromial impingement syndrome
Superior Labral Tear (SLAP tear)
Acromioclavicular (AC) osteoarthritis
Nonoperative management includes the use of:
NSAIDs (Nonsteroidal Anti-Inflammatories
Platelet-rich Plasma (PRP) or bone marrow aspirate concentrate (BMAC)
Extracorporeal Shock-Wave Therapy
Approximately 60-70% of patients can find relief within 6 months of conservative treatment. However, failure can occur when large calcification deposits are the root cause of rotator cuff tendonitis, or when the deposits form under or are medial to the acromion within the muscle tissue.
Surgery is rarely necessary for the treatment of rotator cuff tendonitis.
Indications for surgery include:
Rotator cuff tendonitis is a common problem that can affect any active patient. If you’re suffering from shoulder pain that is affecting your ability to take part in your regular exercise and activities, contact Dr. Dold’s office for an appointment today!