Rotator cuff problems

Also called Shoulder impingement, Rotator cuff tear, Subacromial pain

The commonest cause of shoulder pain. Exercise beats surgery for most people, and most people are offered neither promptly.

What it is

The rotator cuff is four muscles and their tendons, holding the shoulder joint stable and moving it. Problems with it account for the majority of shoulder pain.

The terminology has shifted. Impingement is now more often called subacromial pain syndrome, because the old model of a bone pinching a tendon turned out not to explain the pain well.

The evidence has shifted too, and substantially. Trials comparing subacromial decompression surgery with placebo surgery found no meaningful difference, and structured exercise produces similar outcomes to surgery for most people with degenerative cuff problems.

That makes physiotherapy the first-line treatment rather than the thing you do while waiting for an operation.

Signs you might notice

Pain on the outer upper arm rather than the point of the shoulder.

Pain on reaching overhead, behind the back, or out to the side.

Pain at night when lying on that side, which is often the worst part.

Weakness, particularly lifting the arm out to the side.

Unlike frozen shoulder, passive movement by somebody else is usually much better than active movement.

Sudden weakness after a fall or a lift may be an acute tear and warrants earlier assessment.

How it can affect day-to-day life

Night pain is what drives people to the GP, and months of disturbed sleep affect everything else.

The natural instinct is to stop using the arm, which causes stiffness and weakness and makes recovery slower.

Waiting lists mean people often spend a year in pain expecting surgery that the evidence suggests will not help more than the exercise they could have started immediately.

Supporting someone well

Start exercise early and keep going. A structured, progressive programme over three months is the treatment, and short bursts do not work.

Do not rest the arm completely. Move within a tolerable pain range.

Sleep with a pillow supporting the arm, or wedged behind the back to prevent rolling onto it.

Ask about a steroid injection to allow rehabilitation to start if pain is preventing exercise, rather than as a treatment on its own.

Ask what the evidence says before agreeing to decompression surgery.

Acute weakness after trauma should be assessed sooner, since large acute tears in younger people are the group most likely to benefit from repair.

Where to get help

A physiotherapist, often by self-referral, is the right first contact.

Arthritis UK and the Chartered Society of Physiotherapy publish exercise programmes.

Sudden inability to lift the arm after an injury needs prompt assessment.