The shoulder is the most mobile joint in the human body — and one of the most vulnerable. In athletes who throw, swim, or strike overhead (baseball, tennis, swimming, volleyball), shoulder tendinopathy is among the most common injuries encountered. Dr Sébastien Labrecque-Sauvé, sports medicine physician at Clinique Sport Santé (Saint-Sauveur and Laval), presents this comprehensive guide to understanding, diagnosing, and treating this condition.
Rotator Cuff Anatomy
The rotator cuff is a group of four muscles and their tendons that surround the glenohumeral joint, providing both stability and mobility:
- Supraspinatus: primary arm abductor; the most commonly affected tendon in tendinopathy
- Infraspinatus: external rotator; essential for throwing athletes
- Teres Minor: accessory external rotator
- Subscapularis: internal rotator; protects the front of the shoulder
The subacromial bursa is a fluid-filled sac that lubricates tendon gliding beneath the acromion. Its inflammation (bursitis) frequently accompanies tendinopathy.
The subacromial space measures approximately 9 to 10 mm at rest. Any reduction promotes subacromial impingement.
Causes and Risk Factors
Overuse
Sports involving repetitive overhead movements (swimming, tennis, baseball, volleyball, Olympic CrossFit lifting) subject tendons to repeated stress exceeding their recovery capacity.
Subacromial Impingement
A Type II (curved) or Type III (hooked) acromion, acromioclavicular osteophytes, or scapular stabilizer weakness leads to mechanical pinching of the supraspinatus tendon during abduction between 60° and 120° (the painful arc).
Age-Related Degeneration
After age 40, tendon vascularization decreases in the critical zone. Micro-tears accumulate without adequate repair — explaining why rotator cuff tears are more prevalent after age 50.
Other Factors
- Muscular imbalance (dominant internal rotators, weak external rotators)
- Underlying glenohumeral instability
- Poor athletic technique (swim stroke, tennis serve)
- Returning too quickly after inactivity
Types of Rotator Cuff Pathology
- Non-torn tendinopathy: collagen degeneration without macroscopic rupture; conservative treatment effective in >80% of cases
- Partial tear: involves part of the tendon; prognosis varies with depth
- Full-thickness tear: complete tendon rupture; may be asymptomatic in older patients or require surgery in active athletes
- Subacromial bursitis: bursal inflammation; often associated but sometimes isolated
- Calcific tendinopathy: calcium deposits within the tendon; acute intense pain possible during resorption
Symptoms
- Painful arc: pain during abduction between 60° and 120°, typical of subacromial impingement
- Anterolateral shoulder pain, sometimes radiating into the arm
- Muscle weakness: difficulty lifting the arm or holding a heavy object in external rotation
- Nocturnal pain: pain when lying on the affected side — a sign of active inflammation
- Crepitus during certain movements
- Progressive limitation of range of motion if untreated
Diagnosis
Clinical Examination
Dr Labrecque-Sauvé uses several validated orthopedic tests:
- Jobe Test (Empty Can): resisted abduction at 90° in internal rotation — tests supraspinatus (sensitivity 69%, specificity 66%)
- Neer Test: pain during passive arm flexion in internal rotation (sensitivity 72%, specificity 60%)
- Hawkins-Kennedy Test: 90° flexion with forced internal rotation (sensitivity 79%, specificity 59%)
- Gerber Lift-Off Test: evaluates subscapularis
- Resisted External Rotation Test: evaluates infraspinatus and teres minor
Imaging
Musculoskeletal ultrasound is the first-line tool: dynamic, accessible, radiation-free. It visualizes tendon thickness, tears, bursal effusion, calcific deposits, and guides injections.
MRI is the gold standard for characterizing tears and planning surgery.
Plain radiographs detect calcifications, AC arthritis, and acromial morphology.
Conservative Treatment
Relative Rest and Activity Modification
Reduce or adapt painful activities (complete rest is not recommended) to maintain vascularization and avoid deconditioning.
Physiotherapy
- Strengthening external rotators and scapular stabilizers
- Eccentric and isometric exercises for tendon rehabilitation
- Joint mobilization to restore internal rotation deficit
- Postural correction and scapular kinematics retraining
Minimum program duration: 6 to 12 weeks. Outcomes comparable to surgery for partial tears and non-torn tendinopathy.
Advanced Treatments
Subacromial Cortisone Injection
Cortisone injection guided by ultrasound into the subacromial bursa rapidly reduces inflammation, enabling physiotherapy participation. Maximum 2 to 3 injections per year.
PRP Injection
PRP injection concentrates platelet growth factors to stimulate tendon regeneration. Promising for chronic resistant tendinopathies and partial tears.
Shockwave Therapy
Extracorporeal shockwave therapy is particularly effective for calcific tendinopathy and chronic insertional tendinopathies. Level 1A evidence for calcific shoulder tendinopathy.
Surgery
Surgery is reserved for:
- Full-thickness tear in an active patient (<65 years, high functional profile)
- Deep partial tear (>50% of thickness) failing 6 months of conservative treatment
- Calcific tendinopathy refractory to shockwave therapy
- Severe structural subacromial impingement (Type III acromion)
Main procedures: arthroscopic acromioplasty, arthroscopic rotator cuff repair (suture anchors), mini-open repair for extensive tears. Recovery: 4–6 weeks immobilization + 4–6 months physiotherapy.
Prevention and Return to Sport
- Muscular balance: strengthen external rotators (ER/IR ratio >65%)
- Athletic technique: optimized swim stroke, serve without hyperextension, correct throwing mechanics
- Load progression: <10% increase per week
- Sport-specific warm-up before throwing or swimming
- Adequate recovery: rest periods and sufficient sleep
Return-to-sport criteria: no pain at rest or exertion, external rotation strength ≥85% of contralateral side, full range of motion, clearance by Dr Labrecque-Sauvé.
FAQ — Shoulder Tendinopathy
How long does recovery from shoulder tendinopathy take?
Recovery varies with severity. Mild to moderate tendinopathy typically responds within 6 to 12 weeks of well-followed conservative treatment. Partial tears require 3 to 6 months. Surgery followed by rehabilitation requires 6 to 12 months before full return to sport.
Can I continue sports with shoulder tendinopathy?
In most cases, yes — with modifications. Complete rest is not recommended: it slows tendon healing. Reducing volume and intensity of painful activities combined with a strengthening program is preferable. Dr Labrecque-Sauvé can establish a sport maintenance plan tailored to your situation.
What is the difference between tendinitis and tendinopathy of the shoulder?
Tendinitis refers to acute tendon inflammation (early phase). Tendinopathy is the modern, more precise term encompassing all tendon conditions, including chronic degeneration where inflammation plays a minor role. Most persistent shoulder pain in athletes represents degenerative tendinopathy rather than true tendinitis.
Is cortisone injection effective for shoulder tendinopathy?
Subacromial cortisone injection is effective short-term (relief in 2–4 weeks) for reducing bursal inflammation and enabling physiotherapy. It does not treat underlying tendon degeneration. Maximum 2 to 3 injections per year at the same site.
When should surgery be considered for a rotator cuff injury?
Surgery is primarily indicated for full-thickness tears in active patients, significant partial tears (>50% of thickness) resistant to 4–6 months of conservative treatment, and severe structural subacromial impingement. A consultation with Dr Labrecque-Sauvé will determine if surgery is warranted.
Suffering from shoulder pain? Dr Labrecque-Sauvé offers specialized sports medicine consultations in Saint-Sauveur and Laval, with on-site musculoskeletal ultrasound. Book an appointment online or visit our page on tendinopathy in general.