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  • Writer's picturePaul Monaro

Shoulder - Rotator Cuff Tendinopathy update 2016

I recently attended a course run by UK shoulder clinician & researcher Dr Chris Littlewood. Below is a summary of some of the very interesting facts provided during the course. This information adds to a growing bank of research evidence that is changing the way we think about the diagnosis and management of this extremely common disorder.


Shoulder pain is the third most common musculoskeletal condition which leads a patient to seek care. It is estimated that around two-thirds of all shoulder pain is due to rotator cuff pathology.

The prognosis for a new episode of shoulder pain is not great. 70% will still have pain at 6 weeks, 50% at 6 months & 40% at one year (Ottenheijm et al 2011).

Rotator cuff related pain has been given several labels over the years. In the 1970’s, Neer coined the term subacromial impingement syndrome (Neer 1972). It has also been called rotator cuff tendinitis, subacromial bursitis, & subacromial pain syndrome. However none of these terms accurately describe the pathology. A ‘swollen’ bursa is frequently seen in asymptomatic as well as symptomatic shoulders. ‘Tendinitis’ is no longer described, as no inflammatory markers are found with tendon related pain. And the concept of impingement under the acromion is inaccurate. Any associated rotator cuff tears are under-sided, not on the subacromial surface as would be expected with impingement. And ‘pathological findings’ like a hooked acromion are common in asymptomatic shoulders (Worland et al 2003). In fact, the concept of impingement is potentially harmful. It implies to the patient that a bony spur is digging into their tendon, and that movement is causing damage. Disuse and dyskinesia are likely to follow.


Rotator cuff related pain, like tendon pathology in other parts of the body, is usually due to tendinopathy. Such a tendon is less able to sustain loads, and this ultimately leads to pain. The end result of this process may be partial or full thickness tears. However the presence of rotator cuff tearing does not necessarily correlate with the source of pain. Equal numbers of rotator cuff tears were found in both symptomatic and asymptomatic subjects (Frost et al 1999). By middle-age, up to 40% of asymptomatic individuals have rotator cuff tears (Worland et al 2003), and this proportion increases with age (Templehof et al 1999). Bony morphology and the presence of cuff tears on imaging are used to guide popular treatments, including subacromial decompression surgery. However expert consensus is that many of these findings may be normal consequences of ageing (Frost et al 1999; Worland et al 2003).

The next newsletter will discuss conservative management versus injection and surgical intervention.


References:

1. Frost, P et al (1999). Is supraspinatus pathology as defined by MRI associated with clinical sign of shoulder impingement? Journal of Shoulder & Elbow Surgery, 8. 6, 565-568.

2. Lewis, J et al (2015). Rotator cuff tendinopathy. JOSPT, Epub.

3. Neer, C (1972). Anterioor acromioplasty for the chronic impingement syndrome in the shoulder. JBJS, 54, 41-50.

4. Ottenheijm, R et al (2011). The Maastricht untrasould shoulder pain trial (MUST): ultrasound imaging as a diagnostic triage tool to improve management of patients with non-chronic shoulder pain in primary care. BMC Musculoskeletal Disorders, 12, 154.

5. Templehof, S. et al (1999). Age-related prevalence of rotator cuff tears in asymptomatic shoulders. Journal of Shoulder & Elbow Surgery, 8. 4, 296-9.

6. Worland, R et al (2003). Correlation of age, acromial morphology, and rotator cuff tear pathology diagnosed by ultrasound in asymptomatic patients. Journal of the Southern Orthopaedic Association, 12, 1, 23-26.



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