Rotator Cuff Tendinopathy: Overview and Evidence Summary

Condition Overview

Rotator cuff tendinopathy is one of the most common causes of shoulder pain, affecting individuals across a wide spectrum—from sedentary office workers to elite athletes. The term encompasses a range of pathological changes affecting the rotator cuff tendons, most commonly the supraspinatus, though the infraspinatus and subscapularis are frequently involved as well. It represents not a single condition but a continuum—from mild irritation and biochemical sensitization to structural degeneration, collagen disorganization, neovascularization, and eventual partial- or full-thickness tearing.

Historically labeled as “tendinitis,” the modern understanding paints a more nuanced picture. Rather than a simple inflammatory response, rotator cuff tendinopathy often reflects a combination of mechanical overload, age-related cellular changes, impaired tendon healing, and altered movement patterns within the shoulder complex. The rotator cuff functions as a dynamic stabilizer, maintaining the humeral head in the center of the glenoid during movement. When this delicate balance is disrupted—due to posture, weakness, overuse, or compensatory strategies—tendon overload occurs, particularly during elevation and overhead activity.

Patients commonly report a dull ache localized around the anterolateral shoulder, sometimes radiating into the deltoid region. Pain is often activity-dependent, especially during lifting, reaching, or repetitive overhead motions. Night discomfort is common and often disrupts sleep, particularly when lying on the affected side. Some individuals experience sharp pain during sudden or eccentric loading, such as lowering an object or catching themselves during a stumble. Over time, symptoms may progress from intermittent irritation to persistent pain and weakness.

Rotator cuff tendinopathy is strongly associated with age, as tendons naturally lose elasticity, vascularity, and resilience over decades. However, young athletes can also develop tendinopathy through sport-specific overload, particularly in throwing, swimming, tennis, or weightlifting. The condition often coexists with scapular dyskinesis, thoracic spine stiffness, glenohumeral capsular restrictions, and altered neuromuscular timing—each contributing to altered tendon loading.

The overarching therapeutic principle is simple yet profound: tendons respond to load, but only when that load is applied thoughtfully, progressively, and with respect for tissue irritability. Successful treatment requires a careful balance between rest and targeted stress, between mobility and stability, and between symptom control and functional restoration.

Summary of Current Evidence for Rotator Cuff Tendinopathy

Evidence-Based Management Discussion

Tendon Biology and the Continuum Model

Understanding rotator cuff tendinopathy requires an appreciation of how tendons respond to stress. Tendons are living tissues designed to transmit force, buffer mechanical load, and store elastic energy. When exposed to appropriate loading, tendons adapt positively: collagen fibers realign, cross-linking improves, and tensile capacity increases. However, when load exceeds capacity—either through sudden overload, repetitive strain, or accumulated microtrauma—tendons may begin to fail.

Modern tendinopathy theory describes a continuum:

1. Reactive tendinopathy: a short-term, non-inflammatory cellular response to overload, causing tendon swelling and increased pain sensitivity.

2. Tendon dysrepair: disrupted collagen organization, increased vascularity, and early signs of structural compromise.

3. Degenerative tendinopathy: widespread matrix breakdown, disorganized collagen, and areas of acellularity.

Importantly, these stages are not strictly linear and may overlap. Moreover, imaging does not always reflect symptoms; many asymptomatic adults have degenerative cuff changes, highlighting the need for individualized clinical assessment rather than reliance on scans alone.

Clinical Presentation and Functional Challenges

Rotator cuff tendinopathy interferes with everyday movements that seem deceptively simple. Reaching into a cupboard, placing a bag into the back seat of a car, or lifting a kettle can provoke sharp discomfort. Sudden eccentric loads—such as lowering a heavy pan or slowing an object’s descent—frequently cause pain because tendons struggle most when lengthening under strain. Individuals often develop subtle compensations, such as shoulder shrugging or trunk leaning, to avoid painful arcs, which can further disrupt biomechanics.

Night pain is particularly challenging. Tendons do not enjoy compression, and lying directly on the shoulder can increase sensitivity, reduce blood flow, and irritate the surrounding bursa. Over time, patients may become apprehensive about using the shoulder, leading to further deconditioning and increased disability.

Exercise Therapy

Exercise is the primary treatment for rotator cuff tendinopathy, and the approach must be personalized to the tendon’s irritability.

Early Phase: Reducing Irritation and Restoring Quality of Movement

Early rehabilitation avoids painful end-range loading and focuses on:

• Restoring scapular positioning

• Improving thoracic extension

• Encouraging gentle, controlled activation of the rotator cuff

• Avoiding provocative arcs such as mid-range elevation if excessively painful

Mobility work aims to reduce capsular restrictions, especially in the posterior shoulder, which often becomes tight and shifts the humeral head forward—placing additional strain on the supraspinatus.

Middle Phase: Progressive Strengthening and Tendon Loading

This phase emphasizes the slow, progressive loading that tendons need to recover strength and resilience. Approaches may include:

• Eccentric loading: gradually lengthening the tendon under tension

• Heavy slow resistance (HSR): controlled, deliberate movements emphasizing load tolerance

• Endurance training: to improve the cuff’s ability to stabilize the shoulder during prolonged or repetitive tasks

The goal is not only to strengthen the rotator cuff but also to re-teach the shoulder how to move efficiently and symmetrically.

Late Phase: Functional Restoration and Return to Meaningful Activity

Once symptoms settle and strength improves, therapy shifts to:

• End-range strengthening

• Power and velocity drills (for athletes)

• Integration of lower-body and trunk mechanics

• Sport- or occupation-specific tasks

By the end of this phase, individuals should feel more confident, resilient, and capable of handling unpredictable loads.

Manual Therapy

Manual therapy does not repair tendon fibers, but it can meaningfully support recovery by reducing pain, improving mobility, and reducing protective muscle tension. Soft tissue work targeting the posterior cuff, upper trapezius, deltoid, and pectoral muscles can create a more favorable environment for movement. Glenohumeral joint mobilizations—particularly inferior and posterior glides—are often beneficial for restoring shoulder mechanics.

The key is integration: manual therapy serves as a gateway to effective exercise, not a replacement for it.

Pain Management and Injections

While NSAIDs may provide temporary symptom relief, they do not address the underlying tendon pathology and must be used cautiously. Corticosteroid injections may offer short-term reduction in inflammation and pain, particularly in cases with significant bursitis. However, repeated steroid exposure can impair tendon healing and increase the risk of tearing. Biologic therapies such as platelet-rich plasma (PRP) have shown mixed results; some studies report improved outcomes in chronic tendinopathy, while others show little difference from placebo.

Surgical Considerations

Surgery is not the primary treatment for tendinopathy. It may be considered when:

• Symptoms persist beyond several months of structured rehabilitation

• There is significant functional impairment

• Imaging reveals a high-grade partial tear or a progressing full-thickness tear

Even then, the goal is not always repair; sometimes debridement or subacromial decompression is performed. However, evidence increasingly supports rehabilitation as the first and often best choice.

Clinical Considerations for Therapists

Therapists play a vital role in:

• Guiding patients through load management

• Teaching proper movement patterns

• Building confidence in using the arm again

• Addressing fear avoidance behaviors

• Encouraging consistency with rehabilitation

Success depends not on any single exercise but on a well-paced program that respects the biology of tendon adaptation.

References

Lewis, J., et al. “Rotator Cuff Tendinopathy: Clinical Presentation and Treatment Strategies.” British Journal of Sports Medicine, 2015.

Littlewood, C., et al. “Exercise for Rotator Cuff Tendinopathy: A Review of Current Evidence.” Journal of Shoulder and Elbow Surgery, 2012 and updates.

Cook, J., et al. “The Tendinopathy Continuum: A New Understanding of Tendon Pathology.” British Journal of Sports Medicine, 2009 and subsequent commentary.

Mall, N., et al. “Rotator Cuff Degeneration: Natural History and Pathogenesis.” Journal of Bone & Joint Surgery, 2014.

Seitz, A., et al. “Scapular Dyskinesis and Shoulder Tendinopathy: Mechanisms and Rehabilitation.” Sports Health, 2011.

Disclaimer

The information in this article is intended for educational purposes and is designed for qualified massage therapists, manual therapists, and rehabilitation professionals. It is not a substitute for medical advice, diagnosis, or treatment. Practitioners must work within their legal scope of practice and regional regulations. Hands-on techniques should only be performed by appropriately trained and licensed individuals. Niel Asher Education is not responsible for any injury, loss, or damage resulting from the use of this content.