Overview

Tendons often become inflamed due to overuse, for example:

• repeatedly reaching overhead
• repeatedly throwing

Falling on the arm can also cause tendonitis.Bicipital tendonitis is often associated with rotator cuff conditions. Rotatorcuff tendonitis may result from age-related changes due to wear and tear.

Risk Factors

Risk factors that increase your chances of experiencing shoulder tendonitis include:

• age: 30 and over
• frequent use of the arm in an overhead position or throwing motion, as in:
  • tennis or other racquet sports
  • swimming
  • baseball
• jobs such as overhead assembly work, butchering, or using an overhead pressing machine

Diagnosis

Symptoms usually develop gradually over time and pain slowly increases with use. Symptoms may include:

• pain, usually a dull ache in the shoulder and upper arm
• pain at night, especially when sleeping on the injured side
• pain when trying to reach for a back zipper or pocket
• pain with overhead use of the arm
• shoulder weakness, usually due to pain with effort
• shoulder stiffness with some loss of motion

The doctor will ask about your symptoms and medical history, and perform a physical exam. Special attention will be given to your shoulders, checking tender areas, range of motion, and muscle strength.

Tests may include:

• x-rays
  This is a test that uses radiation to take a picture of structures inside the body, specifically the bones and joints.
• magnetic resonance imaging (MRI) scan
  A test that uses magnetic waves to make pictures of the inside of the body, in this case the tendons of the shoulder.
• CT arthrography
  A type of x-ray that uses a computer to make pictures of the joint after a dye has been injected.
• local anaesthetic injection
  Anaesthesia is injected into the bursa overlying the rotator cuff tendons. If pain is relieved, this may help to confirm the diagnosis of tendonitis.
• arthroscopy
  A long, thin instrument with a light on the end is inserted through a small incision in the shoulder to look at the structures inside. This procedure is done under anaesthesia. This is more likely to be done when a rotator cuff rupture is suspected.

Treatment Options

Therapy will depend on the extent of the injury, the cause, and other factors. Treatment may include:

• rest
  Avoid activities that produce pain in the shoulder.
• ice
  • To help control pain and swelling.
  • Use for 20 minutes at a time.
  • Use during the first 24 to 48 hours, or after exercise.
  • Protect your skin by placing a towel between the cold and your skin.
• heat
  • This may help relieve pain and is often used before exercises to help with motion.
  • Do not use with acute pain or following acute injury.
  • Check with a doctor or therapist before using heat the first time.
  • Use for 15 to 20 minutes at a time.
  • Protect your skin by placing a towel between the heat source and your skin.
• medication, such as:
  • nonsteroidal anti-inflammatory drugs (NSAIDs) to manage pain; for example aspirin or ibuprofen (Motrin, Advil)
  • steroid injection into the bursa overlying the rotator cuff to decrease the inflammation; do not exercise the shoulder for 7 to 10 days after an injection
• rehabilitation, such as:
  • Physical therapy to strengthen muscles that control the shoulder.
  • Exercises to maintain normal range of motion.
  • Exercises for specific muscles that are used in sports or job activities.
  • Gradual return to sports and work.
  • Learning how to modify activities to prevent re-injury.
• surgery
  • Depending on the injury, different procedures can be used, including:
  • arthroscopic surgery
  • open technique

Prevention

Guidelines to help protect the shoulder from injury include:

• Do regular exercise to strengthen the supporting muscles.
• Use proper athletic training methods.
• Do not increase exercise duration or intensity more than 10% per week.
• Avoid overusing your arm in an overhead position.
• Modify job requirements to avoid overhead activity.
• Do not ignore or try to work through shoulder pain.

Types of impingement include:

• Bursitis
  Frequent extension of the arm at high speed under high load, such as pitching a baseball or playing racquet sports, can cause bursitis. Medical research shows that the older you get, the more likely you are to develop bursitis.
• Tendinitis
  Tendinitis develops over time and is likely to occur when a person whose muscles are not in good condition starts an overly aggressive training program. In younger athletes, the causes of tendonitis are similar to those of bursitis.

How can I prevent a shoulder impingement?

One of the best ways to prevent these overuse injuries from recurring is to listen to your body and take a break, or seek medical care for your shoulder inflammation instead of trying to "work through the pain."

Furthermore, the rehabilitation exercises should be continued to ensure protective strength, range of motion, and stability of the injured area. Other preventive techniques include:

• Don't play tennis or golf in an attempt to "loosen up" tightness. When a shoulder injury is ignored, it can become the source of chronic problems.
• If your shoulder is sore after you use it actively, especially at the limits of your reach, give it some rest. If pain persists or worsens, consult your doctor.
• Do exercises to strengthen arm, back, and chest muscles.
• Learn the proper technique for exercise and sporting activities. This will decrease stress on all your muscles, ligaments, and tendons, including those around your shoulder.

Improving Sports Performance

The key to improving sports performance after recovering from a shoulder impingement is a proper rehabilitation program, and adhering to some of those same principles after the injury is gone. Refer to the rehabilitation exercises.

Remember the following:

• Do exercises to strengthen arm, back, and chest muscles.
• Learn the proper technique for exercise and sporting activities. This will decrease stress on all your muscles, ligaments, and tendons, including those around your shoulder.

Also, the single most important aspect of improving performance is stretching before and after you step onto the field, court, ice, or golf course.

Benefits derived from stretching include:

• increased physical efficiency and performance
• decreased risk of injury
• increased blood supply and nutrients to joint structures
• increased coordination
• improved muscular balance and postural awareness
• reduced stress
• enhanced enjoyment

Shoulder impingement rehabilitation

As an athlete, your number one concern is getting back to full strength as soon as possible so that you can return to training and competition. That is why appropriate rehabilitation is extremely important. Rehabilitation for a shoulder impingement often includes the following:

• rest during the acute phase
• ice injury multiple times per day
• compression of the injured shoulder with an elastic compression bandage (ACE bandage) to limit swelling and pain
• use anti-inflammatory medications such as ibuprofen to reduce inflammation and speed up recovery

Rehabilitation for shoulder impingement can include a sling to immobilize your arm and shoulder. You also may be required to temporarily wear a shoulder brace when you return to your sport. These devices help hold the shoulder in place while the impingement heals. Your doctor also may prescribe rehabilitation exercises once the sling is removed.

The major objectives of rehabilitation from a shoulder impingement are to increase flexibility, achieve pain-free range of motion, and strengthen the muscles of the shoulders, upper back, front chest, and upper arms. In severe cases, you should avoid activity that causes shoulder pain altogether. In these cases, you can still maintain cardiovascular fitness by cycling, unless otherwise prescribed by your doctor.

Surgery is rarely needed to repair a shoulder impingement. However, it may be needed to repair very serious bursitis.

Keep in mind that rehabilitation for bursitis may be much more involved. In these cases, your doctor may prescribe special physical therapy and recovery time will vary.

Rehabilitation exercises

Rehabilitation exercises often prescribed by your doctor may include stretching and strengthening exercises such as the following:

• Overhead stretch
  Lie on your back with your arms at your sides. Lift one arm straight up and over your head. Grab your elbow with your other arm and exert gentle pressure to stretch the arm as far as you can.
• Cross-body reach
  Stand and lift one arm straight out to the side. Keeping the arm at the same height, bring it to the front and across your body. As it passes the front of your body, grab the elbow with your other arm and exert gentle pressure to stretch the shoulder.
• Towel stretch
  Drape a towel over the opposite shoulder, and grab it with your hand behind your back. Gently pull the towel upward with your other hand. You should feel the stretch in your shoulder and upper arm.
• Shrugs
  Stand with hands at sides with no weight in either hand. Raise shoulders to the point of pain and hold for five seconds. Relax for five seconds. Perform this sequence 10 times, 3 times daily. As pain permits, hold dumbbells of equal weight in each hand while performing this exercise. Add weight by using hand-held dumbbells as pain permits.
• Bicep curls
  Stand with arms fully extended at sides while grasping 2- to 5-pound weights in each hand, held palm forward. Flex the arms at the elbow to approximately 100 degrees, or to the point of pain, whichever comes first. Hold this position for 5 to 10 seconds. Return to the start position. Rest for 5 seconds. Repeat this exercise 10 times. You can increase the weight as pain allows and strength develops.
• Triceps curls
  Stand with elbows directed upward over the shoulders and with arms relaxed. Extend arms at the elbow so that the hands proceed upward to the point of pain. Hold this position for five seconds. Return to the starting position and relax for five seconds. Perform this sequence 10 times, 3 times daily. As pain permits, add weight by using hand-held dumbbells.
• Chest raises
  Lie on belly with hands extended along sides of the body. Raise the upper chest from the floor to the point of pain and hold this position for 5 seconds. Return to the start position and relax for 10 seconds. Repeat this sequence 10 times, 3 times daily.
• Saws
  Reach out and place the unaffected side hand on a corner of a table. Bend at the waist. Flex the injured side arm at the elbow and pull the injured side arm backward and upward as if sawing wood. Slowly bring the shoulder blades as close together as pain will permit. Slowly bring the injured side arm down to its beginning position. Repeat this sequence 10 times, at least 3 times daily.
• Pendulum swings
  Stand with the hand of the unaffected arm resting on the corner of a table and supporting some of the body weight. Slightly bend the knee on the unaffected side and extend the other leg sideways. Allow the injured arm to hang loosely over the unaffected side foot. By shifting the body weight, cause the relaxed injured arm to swing in circles to the fullest extent possible as limited by pain. Perform 25 swings in a clockwise direction. Allow the injured arm to cease swinging. Perform 25 swings of the injured arm in a counterclockwise direction. Repeat this sequence at least 3 times daily.
• Shoulder rotation
  Stand in a doorway with affected side arm bent at the elbow and the palm of the hand against the doorframe. Turn the body away from the injured side hand until a stretching sensation is experience in the injured shoulder. Hold this position for 10 seconds. Return to the starting position. Relax for 10 seconds. Repeat this sequence 10 times at least 3 times a day.
• Shoulder Flexion
  Stand erect close to a wall. With the palm of the injured side arm turned so as to face you, slowly slide the forearm and then the upper arm up the wall by moving closer to the wall. Slide the arm upward to the point of initial significant pain. Hold this position for 10 seconds. Return to the starting position and relax for 10 seconds. Repeat this sequence 10 times, at least 3 times daily.
• Flexed elbow pull
  Bend and raise the injured side elbow to shoulder height. Grasp the injured side elbow with the uninjured side hand. Gently pull the injured side elbow toward the opposite shoulder until limited by first significant pain. Hold this position for 10 seconds. Relax for 10 seconds. Repeat this sequence 10 times at least 3 times daily.

Alternative exercises

During the period when normal training should be avoided, alternative exercises may be used. These activities should not require any actions that create or intensify pain at the site of injury. They include:

• water running
• stationary bicycle (add resistance gradually from one session to the next, as pain allows)

Rehabilitation after surgery

Although less common, surgery may be needed to repair a shoulder impingement. In these cases, you will need to wear a sling or figure-of-eight strap while you heal. When your doctor decides you are ready, you may start range-of-motion and strengthening exercises. You may be referred to a physical therapist to assist you with these exercises, and under no circumstance should you return to sports activity until your shoulder is fully healed.

A physical therapy program usually begins with range-of-motion and resistive exercises, then incorporates power, aerobic and muscular endurance, flexibility, and coordination drills.

How long will the effects of the injury last?

To some extent, the time to fully recover from a shoulder impingement is influenced by your dedication to your rehabilitation program. Typically, athletes require anywhere from 2 to12 weeks of healing time, depending on the severity, before returning to their sport.

When can I return to my sport or activity?

Return to full participation should be avoided until your shoulder impingement has healed and you can perform all skills and other requirements of your sport without pain.

Remember: the goal of rehabilitation is to return you to your sport or activity as soon as is safely possible. If you return too soon you may worsen your injury, which could lead to permanent damage. Everyone recovers from injury at a different rate. Return to your activity is determined by how soon your shoulder impingement recovers, not by how many days or weeks it has been since your injury occurred.