Rotator Cuff Tendinopathy

(Incorporates the former Rotator Cuff Disorders” note.) “The most common cause of shoulder pain — a continuum from subacromial impingement/bursitis → tendinopathy → partial/full-thickness tear → cuff arthropathy. Common in people doing overhead activity (swimmers, throwers) and those over 50. Rotator-cuff abnormalities are common and increase steeply with age, from around 5–10% in patients aged 20 and younger to 30–35% in people in their sixties and seventies, peaking at 60–65% in those aged 80 or older — most of which are asymptomatic. Smoking has a dose- and time-dependent association with rotator cuff tears.

Subacromial impingement / cuff tendinopathy

• History: insidious pain, worse with overhead activity; night pain and difficulty lying on the affected side.
• Examination: painful arc 60–120° on abduction; positive Neer and Hawkins impingement signs; positive empty-can test (supraspinatus), pain/weakness on resisted internal rotation (subscapularis) or external rotation (infraspinatus/teres minor). Active range of movement is typically limited but passive range is preserved — full passive-range loss instead suggests adhesive capsulitis, a different diagnosis and treatment path. Other supraspinatus tests include the Jobe test (pain or weakness resisting downward pressure at 90° forward flexion) and the drop-arm test; subscapularis integrity is further assessed with the lift-off and belly-press tests.
• Investigations: imaging not needed initially; X-ray + ultrasound assess impingement and tears if not settling.
• Management: analgesia (paracetamol/NSAIDs); physiotherapy (progressive loading) is the mainstay; subacromial corticosteroid injection (if no full-thickness tear) for short-term relief; consider surgery only after 4–6 months of failed conservative treatment. Physiotherapy (rotator cuff and periscapular strengthening, range-of-motion work) is first-line and can be used alone; NSAIDs alongside physiotherapy carry only a moderate evidence-based recommendation grade per AAOS guidance. Subacromial corticosteroid injection often gives rapid relief that helps patients participate in subsequent physiotherapy. In a cohort of almost 500 patients with atraumatic full-thickness tears (MOON Shoulder Group), nonoperative treatment gave 75% positive patient-reported outcomes at 2 years; the 25% who chose surgery typically did so 6–12 weeks after symptom onset.

Proximal biceps (long head) tendinitis/tendinopathy

Usually secondary to rotator cuff pathology — increasing long head of biceps (LHB) tendon inflammation tracks with worsening rotator cuff tendinopathy severity, since the biceps tendon sheath is a direct extension of the glenohumeral synovium. Suspect it with anterior shoulder pain localised to the bicipital groove on palpation. Provocative tests: Speed test (pain in the bicipital groove resisting forward elevation with the elbow slightly flexed and forearm supinated) and Yergason test; a popeye deformity (distal migration of the muscle belly) suggests LHB tendon rupture. As with cuff tendinopathy, full passive range of motion is preserved unless adhesive capsulitis coexists. Initial management is nonsurgical — rest, activity modification, and NSAIDs; surgery (biceps tenodesis or tenotomy) is reserved for an inflamed, frayed, or subluxing tendon found at arthroscopy, or for associated subscapularis tearing.

Biceps tendon rupture — typically an older adult, spontaneously or after a fall on outstretched hand; a tearing/snapping sensation with a “Popeye” deformity. Usually managed non-operatively; athletic patients with frequent cramping may opt for surgical intervention in the form of biceps tenodesis, particularly younger/active/power athletes.

Rotator cuff tears

Often asymptomatic and increasingly common with age (full-thickness tears in ~28% over 60, ~65% over 70). Degenerative in older patients; traumatic (often post-dislocation) in those under 40. Weakness in the active range (loss of power) distinguishes a tear from tendinopathy. Management is age- and tear-dependent — conservative for degenerative tears; early surgical repair for an acute full-thickness traumatic tear in a younger/active patient.

Red flags (refer urgently)

Suspected septic arthritis or fracture/dislocation; a first-time dislocation; posterior reduction with brachial-artery or nerve injury; significant/unexplained sensory or motor deficit; or vascular compromise.