Rotator cuff tendinitis: the most common shoulder pain (and how it's treated without surgery)

It hurts putting on a jacket, fastening a bra, reaching for something on the back seat of the car… and above all, it hurts at night. Shoulder pain from rotator cuff tendinopathy is, by some distance, the shoulder problem I see most in clinic. It is also one of the most rewarding to treat well: the vast majority improve without surgery.

What the rotator cuff is

The rotator cuff is a group of four tendons that wrap around the head of the humerus like a «cuff» and are in charge of moving and, above all, of centring the shoulder in every movement. They work in a narrow space, between bones, and that is why they are so prone to being overloaded: with the years, with jobs that involve working with the arms overhead, with throwing or racquet sports, or simply with a sudden increase in activity.

When the tendon is overloaded we talk about tendinopathy (the term «tendinitis» falls short: rather than being inflamed, the tendon is degenerated from excess load). Sometimes it comes with a bursitis — inflammation of the bursa that cushions the tendon — and in more advanced cases partial or complete tears can appear.

How do I know if my shoulder pain is from the cuff

• It hurts when you lift your arm, especially between shoulder height and your ear (the famous «painful arc»).
• It hurts at night, especially when sleeping on that side.
• Reaching behind your back is difficult (fastening things, scratching).
• You may notice a loss of strength when lifting weight with the arm straight.

Careful: not all shoulder pain comes from the cuff. Frozen shoulder, osteoarthritis of the acromioclavicular joint or a neck problem that radiates down can mimic the symptoms. That is why the diagnosis matters so much.

Ultrasound: seeing the tendon live

With musculoskeletal ultrasound I can see, in the consultation itself, the state of each tendon, whether there is bursitis, calcification or a tear — and how big it is. I can also examine the shoulder in movement, reproducing the gesture that hurts you, something neither an X-ray nor a static MRI scan allows. With that map, treatment stops being generic.

The treatment, in order

1. Therapeutic exercise: the treatment with the most evidence

Tendons recover by loading them progressively, not with complete rest. A well-prescribed programme to strengthen the cuff and the muscles that move the shoulder blade is the treatment with the most scientific backing, and in most cases it avoids the operating theatre. You can read more about how I approach shoulder pain here:

💪 Read more about shoulder pain

2. Controlling the pain so you can do the work

If the pain won't even let you start the exercises (or won't let you sleep), it makes sense to treat it in a targeted way: an ultrasound-guided injection into the bursa can break the pain-immobility cycle and open the window to work the shoulder. Always as a means, never as the only treatment.

3. Specific techniques depending on the finding

This is where the ultrasound diagnosis makes the difference. If there is a calcification in the tendon, ultrasound-guided barbotage allows it to be removed without surgery. In stubborn tendinopathies or selected partial tears, PRP can help the tissue recover.

When should we think about the surgeon?

Less often than people think. The clear indications are acute traumatic tears in young, active people, and cases that don't improve after several months of complete, well-done conservative treatment. For everything else — which is the vast majority — the route of guided exercise, supported by ultrasound-guided techniques when they are needed, gives excellent results without the risks of surgery.