Rotator Cuff Tendinopathy

What is rotator cuff tendinopathy?

  • Rotator cuff tendinopathy refers to pain and weakness, most commonly experienced with movements of shoulder rotation and lifting, as a consequence of excessive load on the rotator cuff tissues.

How common is rotator cuff tendinopathy?

  • Rotator cuff tendinopathy is a relatively common condition.
  • The prevalence of shoulder complaints in the UK is estimated to be 14% (1).
  • Rotator cuff problems account for up to 70% – 85% (2).

Should I worry?

  • No.
  • With the right rehabilitation approach rotator cuff tendinopathies generally recover well.
  • Rotator cuff tendinopathies are not linked to other serious pathology.

Who is most likely to suffer from rotator cuff tendinopathy?

  • Common age is normally 35 to 75 years old (4).
  • Repetitive, unaccustomed, sustained or increased use of the shoulder (particularly above head) during occupation or activity (8).
  • People who are obese.
  • Reduced muscle strength.
  • Smokers.
  • Reduced joint range of motion.
  • People who suffer from diabetes (9, 10).

What are the common symptoms?

  • Pain on the front and side of the upper arm.
  • Pain raising the arm from the side.
  • Pain with lifting/picking things up.
  • Often presented with a well-maintained movement in the shoulder.
  • Difficulty laying on the affected shoulder – can disturb sleep.

What can I do?

  • Modify your activity.
  • Progressive and appropriate loading of the tendon has been shown to be one of the most effective treatments.
  • Advice by a qualified physiotherapist will be helpful in most cases.
  • Take simple painkillers/anti-inflammatories if you can do so.
  • Improving lifestyle choices, such as sleep hygiene, healthy weight, quitting smoking, increasing muscle strength and physical activity.

How long will it take to recover?

  • Most cases see improvements within 3-6 months.
  • Persisting symptoms and recurrence can present, with estimates of 14% of patients still seeking advice after 3 years (3).

1. Introduction

This condition commonly presents with pain at the front, back or side of the shoulder and/or upper arm region. Tendinopathy of the rotator cuff tendon may also be termed ‘impingement syndrome’, ‘subacromial pain syndrome’ or ‘rotator cuff related pain’ as we often cannot distinguish one singular structure associated with the pain, and so these alternative terms refer to the region or nature in which pain is referred.

For a long time, we referred to tendinopathies as ‘tendinitis’. This was because we believed there was a lot of inflammation involved in the condition leading to treatments such as steroid injections and strong anti-inflammatory medication (such as diclofenac or naproxen). However, our understanding of tendon related pain has improved and we now know that tendon degeneration, as opposed to inflammation, is the primary factor in most tendinopathies.


2. Signs & Symptoms

3. Causes

The tendon function is to transmit muscle force to the bone and they are normally very tolerant to the load. Sudden increase of activity/load is the most common cause; however, it can also come on gradually with no clear cause. This is because many factors influence the condition.

Repetitive movements and prolonged arm elevation (such as working in construction and hairdressing) (8) are associated with a higher risk of shoulder disorders. Consequently, ergonomic adjustments should be considered.


4. Risk Factors

This is not an exhaustive list. These factors could increase the likelihood of someone developing rotator cuff tendinopathy (9, 10). It does not mean everyone with these risk factors will develop symptoms.


5. Prevalence

The prevalence of shoulder complaints in the UK is estimated to be 14% (1) and rotator cuff disorders account for up to 70% – 85% (2), with 1%–2% of adults consulting their GP annually regarding new onset shoulder pain (3).

Shoulder pain is the third most common musculoskeletal presentation in primary care after back and knee pain. Rotator cuff pain is very common in people aged between 35-75 years old (4).

6. Assessment & Diagnosis

The diagnosis is based on history and examination carried out by our experienced physiotherapists who see this condition on a regular basis due to its high prevalence in shoulder pain. Further investigation is not normally needed due to the high likelihood of finding elements not linked to your symptoms on scans unless there is a very acute onset as a result of a traumatic event or the condition is not responding accordingly to what is expected by the treatment.

7. Self-Management

Relative rest from the painful activities can be helpful initially to allow the pain to settle, alongside analgesics (paracetamol) and anti-inflammatories (NSAIDs such as ibuprofen – contraindicated if you have a history of gastrointestinal bleeding, ischaemic heart disease or renal problems). Physiotherapy and graded exercise progression are normally key (4, 5). Consider a short period of time off work (for example 1 week), if the job duties appear to be directly relevant to the shoulder symptoms.


8. Rehabilitation

The treatment aim is to achieve symptom free shoulder movement and function. Expect ups and downs and setbacks during the rehabilitation.

Below are three rehabilitation programmes created by our specialist physiotherapists targeted at addressing rotator cuff tendinopathies. In some instances, a one-to-one assessment is appropriate to individually tailor targeted rehabilitation. However, these programmes provide an excellent starting point as well as clearly highlighting exercise progression.

9. Rotator Cuff Tendinopathy Rehabilitation Plans

Early Plan

Exercises aim to stimulate the recovery of the rotator cuff tendons and to reduce the level of pain. This should not exceed any more than 4/10 on your perceived pain scale.

Early Plan - Rating

Intermediate Plan

If pain is manageable, or the early rehabilitation plan is going well, more active movements are included and repetitions and resistance need to be gradually increased. This should not exceed any more than 4/10 on your perceived pain scale.

Intermediate Plan - Rating

Advanced Plan

Generally, this will involve increasing the load, speed and stability to prepare your full return to previous levels and will normally involve pushing, pulling, carrying, lifting and throwing exercises, depending on your needs. This should not exceed any more than 4/10 on your perceived pain scale.

Advanced Plan - Rating

10. Return to Sport/Normal Life

For patients wanting to achieve a high level of function or return to sport, we would encourage a consultation with a physiotherapist as you will likely require further progression beyond the advanced rehabilitation stage.

As part of a comprehensive treatment approach, your musculoskeletal physiotherapist may also use a variety of other pain-relieving treatments to support symptom relief and recovery. Whilst recovering you might benefit from further assessment to ensure you are making progress and to establish the appropriate progression of treatment. Ongoing support and advice will allow you to self-manage and prevent future reoccurrence.

11. Other Treatment Options

The suggestions for non-surgical management include a minimal number of exercises prescribed to challenge the functional deficit of the patient over a minimum 12-week period. Imaging can aid to exclude serious pathology or if the patient does not respond to treatment as expected, but is not key for the management of the injury. Steroid injections would not be considered a first-line intervention unless pain is severe and preventing sleep and engagement with the exercises (6).


Book an Appointment

Please book an appointment with one of our physiotherapists if you think you are suffering from this condition and would like to find out more.

We have Pure Physiotherapy clinics across the country including Norwich, Dereham, Bolton, Manchester, Rochdale, Sheffield and Barnsley. Please view our clinics to find the closest physiotherapy clinic for you.


  1. Urwin M, Symmons D, Allison T, et al. (1998). Estimating the burden of musculoskeletal disorders in the community: the comparative prevalence of symptoms at different anatomical sites, and the relation to social deprivation. Ann Rheum Dis; 557, 649–55. 3.
  2. Mitchell C, Adebajo A, Hay E and Carr A. (2005). Shoulder pain: diagnosis and management in primary care. BMJ; 331, 1124–8.
  3. Artus M, Holt T A and Rees J. (2014) .The painful shoulder: an update on assessment, treatment, and referral. BJGP; 64 (626), e593-e595.
  4. Kulkarni R et al .(2015). BESS/BOA Patient Care Pathway Subacromial Shoulder pain. Shoulder & Elbow. 7(2) 135-143.
  5. Green S, Buchbinder R, Hetrick S; (2003). Physiotherapy interventions for shoulder pain.
  6. Mohamadi A, Chan J, Chen N et al. (2017). Corticosteroid injections give small and transient pain relief in rotator cuff tendinosis: A meta-analysis. Clinical Orthopaedics and Related Research.475, 232-243.
  7. Page, MJ, Green, S, McBain, B, et al. (2016). Manual therapy and exercise for rotator cuff disease. Cochrane Database Syst Rev. DOI: 10.1002/14651858.CD012224.
  8. Littlewood, C, Bateman, M, Connor, C, et al. (2019). Physiotherapists’ recommendations for examination and treatment of rotator cuff related shoulder pain: a consensus exercise. Physiother Pract Res. 40, 87–94.
  9. Svendsen et al. (2004). Work related shoulder disorders: quantitative exposure-response relations with reference to arm posture. Occup Environ Med. 61: 844-853.
  10. Dean & Sonderland. (2015). Lifestyle and MSK Conditions. Grieve MSK Physiotherapy.
  11. Franceschi et al. (2014). Obesity as a risk factor for tendinopathy. A SR. Int Journal of Endocrinology.
  12. Lewis J. (2016). Rotator cuff related shoulder pain: Assessment, management and uncertainties. Manual Therapy, Elsevier. 23, 57-68.
  13. Jafari et al. (2017). Pain & Respiration: A SR. Pain 158 (6), 995-1006.
  14. Fermin et al. (2016). The effect of contralateral exercise on patient pain and range of motion. Journal of Sport Rehabilitation.
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