Shoulder Tendinopathy: Causes and How Physiotherapy Addresses It

The shoulder is the most mobile joint in the body. This mobility comes at a cost: the greater the range of movement, the greater the demand on the dynamic stabilisers — the muscles and tendons of the rotator cuff — which must work constantly to keep the humeral head centred in the glenoid.

When these structures are overloaded or subjected to repetitive friction, a degenerative process begins: tendinopathy. It is one of the most common causes of shoulder pain and, although it is often confused with "inflammation", the current evidence points to a degenerative mechanism for which therapeutic exercise is the fundamental treatment.

Anatomy of the subacromial space

The subacromial space is the narrow corridor between the head of the humerus and the undersurface of the acromion. Within it pass the tendons of the rotator cuff, the long head of the biceps and the subacromial bursa, which acts as a cushion to prevent friction.

When the subacromial space narrows — due to postural changes, muscle imbalances, overload or structural alterations — friction occurs between the tendons and the acromion, generating pain and accelerating tendon degeneration: this is what is known as subacromial impingement syndrome.

Rotator cuff tendons

Why does shoulder tendinopathy develop?

There are two main mechanisms. Mechanical overload: acute increase in activity (a DIY project, a move, resuming sport after months without training) or accumulation of repeated tasks above shoulder height. And muscle imbalance: weakness of the rotator cuff external rotators in relation to the internal rotators, or poor scapular stabilisation, are the most common biomechanical factors in the development of tendinopathy.

Posture also plays a role. A rounded back with protracted scapulae reduces the subacromial space and increases friction on the cuff tendons. This is especially relevant in people who spend many hours at a computer.

Physiotherapy approach in five steps

• 1
  Precise assessment

  Before treating, it is essential to identify which structure is involved and what factors are contributing. We assess active and passive range of motion, specific tests for each cuff tendon, scapular kinematics and cervical involvement. If there is suspicion of a complete tear or major structural involvement, we refer for imaging.

• 2
  Pain management and tissue preparation

  Manual therapy, analgesic electrotherapy and Indiba Activ radiofrequency to reduce pain and improve tissue condition before introducing exercise. The goal is to reach the loading phase as soon as possible, since the tendon only responds to mechanical stimulus.

• 3
  Rotator cuff strengthening

  The cornerstone of treatment. Progressive external rotation exercises with elastic bands, side-lying external rotation with dumbbell, and exercises to improve internal rotation strength. The goal is to restore the strength balance between the different muscle groups and re-centre the humeral head during movement.

• 4
  Scapular stabilisation

  The scapula is the platform from which the rotator cuff works. Weakness of the trapezius (especially its middle and lower portions), the serratus anterior or the rhomboids compromises shoulder movement mechanics. Wall push-ups, prone Y/T/W exercises, and scapular retractions are the basis of this phase.

• 5
  Functional progression and sport return

  Progressively incorporating overhead movements, sport-specific exercises and activities that involve the full range of motion of the shoulder. The return criteria are not based on the absence of pain, but on functional strength and stability.

When is surgery necessary?

The majority of shoulder tendinopathies — including subacromial impingement, partial cuff tears and bicipital tendinopathy — respond very well to conservative treatment. Several comparative studies show that physiotherapy achieves equivalent results to surgery at two years of follow-up in patients without complete structural tears.

Surgery is considered in complete rotator cuff tears with functional deficit, cases that do not respond to a correctly applied conservative programme after 3–6 months, or in specific structural situations (bone spurs, acromial shape) that compromise recovery.

Prevention