Do not ignore rotator cuff tendonitis
By the faculty of Harvard Medical School for The Harvard Medical School Adviser

Q: I swim regularly for exercise, but lately my shoulder has been hurting so much I've had to give up my swimming. What could be wrong?

A: The shoulder has an enormous range of motion. It allows you swim the crawl, dig in the garden, place a book on a high shelf and reach back to put your arm into your sleeve. You rely on this mobility for so many activities that when the shoulder hurts, it can be disabling. For younger people, sports injuries and overuse are the main culprits. But older nonathletes can suffer from normal wear and tear. Over time, this wear and tear weakens shoulder tissues and leaves them vulnerable to injury. The risk is greatest for people with occupations or hobbies that require repetitive or overhead movements, such as cashiering, using a computer, painting or gardening.

A likely cause of your shoulder pain is a common injury known as rotatorcuff tendonitis -- inflammation of key tendons in the shoulder. The rotator cuff includes four tendons, each of which attaches a muscle to the scapula (shoulder blade) and the humerus, or upper arm bone (see illustration). The tendons work together to stabilize the joint, rotate the shoulder and lift the arm above the head. Rotator-cuff tendonitis usually starts with swelling or inflammation of one tendon and gradually involves the three other tendons as the condition progresses.

The earliest symptom is a dull ache around the outside tip of the shoulder that gets worse when you push, pull, reach overhead or lift your arm up to the side. Lying on the affected shoulder also hurts, and the pain may wake you at night, especially if you roll onto that shoulder. Even getting dressed can be a trial. Eventually, the pain may become more severe and extend over the entire shoulder.

If you do nothing about it, tendonitis can lead to the fraying or tearing of tendon tissue. Fortunately, rotator-cuff tendonitis (and even tendon tears) can usually be treated without surgery. Most clinicians diagnose rotator-cuff tendonitis by taking a history and performing a physical examination. Your clinician will also check for tenderness at a point near the top of the upper arm and look for pain as the arm is raised and moved in certain ways. Your muscle strength and the shoulder's range of motion will also be tested. Pain with normal muscle strength suggests rotator-cuff tendonitis. Pain with weakness may indicate a tear. If the problem seems unusual or severe, your clinician may request an MRI.

As we get older, tendon tissues thin out and tears become more likely. Up to one-third of older people with rotator-cuff tendonitis have a tear. Minor ones can be treated with rest, ice and physical therapy, but major ones may require an operation.

The minimum time for recovery from rotator cuff tendonitis or a small tear is two to four weeks. Stubborn cases can take several months. Early on, the aim is to reduce swelling and inflammation of the tendons and relieve pressure on the tissues in the subacromial space, near the top of the upper arm. Later, you can start exercises to strengthen your muscles and improve your range of motion.

During the first few days, apply an ice pack to your shoulder for 15 to 20 minutes every four to six hours. If you still have a lot of pain, take a nonsteroidal anti-inflammatory drug (NSAID), such as ibuprofen. Your clinician may also suggest a corticosteroid injection. But there's no clear evidence that this offers any advantage in the long term over physical therapy and NSAID use.

While you're in pain, avoid lifting or reaching out, up or overhead as much as possible. On the other hand, you don't want to stop moving your shoulder altogether, because that can lead to "frozen shoulder," a condition in which the tissues around the shoulder stiffen and reduce your range of motion.

It's a good idea to work with a physical therapist who can show you special exercises to help heal your shoulder. Once you've learned them, you can do them on your own. Before exercising, warm up your muscles and tendons in a warm shower or with a heating pad. You may experience some mild soreness after you exercise, but applying ice should help. If you develop sharp or severe pain, however, stop the exercises and check in with your clinician.

Shoulder pain is nothing to shrug off. But if you come down with rotatorcuff tendonitis, chances are that a little patience and persistence will soon have you back in the swim of things!

Copyright 2007 the President and Fellows of Harvard Developed by Harvard Health Publications (www.health.harvard.edu) . Distributed by UFS. Submit questions to harvard_ adviser@hms.harvar d.edu.