Provider Practice Essentials registered nurse continuing education

Common Shoulder Pain Issues and an Emerging Tendinopathy Treatment

Shoulder pain is the third most common complaint seen in orthopedic offices (Garving et al., 2017). The exact culprit of shoulder pain can sometimes be challenging to diagnose, due to the complexity of the shoulder joint and surrounding tissue. Objectively, there are many shoulder orthopedic tests that can be utilized to narrow in on a diagnosis but they may not always lead to the specific issue. Subjectively, what the patient tells the provider is
always of utmost importance. Getting a full history of the issue is key. Often times, with shoulder pain there will not be a specific injury. When asking about onset of the pain, the patient may not be able to give an exact answer, “oh I don’t know, I first noticed it a couple of months ago, maybe.” This can stem from shoulder pain being a result of years of repetitive movements, shoulders rounded forward posture, an individual’s shoulder anatomy and so on. Imaging studies are needed in the majority of cases startin with plain film x-rays, most useful for differentials. If there is significant limitation of the joint or after conservative treatment for 6 weeks with little to no improvement, then further imaging and referral to a specialist is recommended (Garving et al., 2017).

It’s all about what is not functioning correctly in the shoulder complex. Let’s look at two common causes of shoulder pain:

Shoulder Impingement

Not a fun issue to have, as it is not a quick fix. Initial rest of avoiding aggravating factors such as overhead movements for the first couple of weeks is recommended. Conservative treatment with nonsteroid anti-inflammatories, physical therapy, therapeutic taping and shoulder specific exercises yields satisfactory results within two years in 60% of cases (Garving et al., 2017). If symptoms do not improve with conservative treatment after 3 months, surgery is often incorporated into the treatment plan.

What is shoulder impingement? It is a painful syndrome in which soft tissues become entrapped in an area of the shoulder joint. In general, this patient population is over the age of 40 and they typically complain of pain when laying on the affected side and with raising the arm out to the side and above the head. Objectively, there are a few different orthopedic tests that can be done, the “painful arch” test, Hawkins and Neers test are reliable to perform (Garving et al., 2017).

Shoulder Tendinopathy

What is this? Besides annoying, it is calcific deposits in the rotator cuff muscles and subacromial subdeltoid bursa when the calcification spreads around the tendons. This issue is primarily seen in women in their forties and fifties and is not correlated with physical activity or injury. Twenty percent of cases are asymptomatic. When symptoms are present there is often pain ranging from mild to severe. Conservative treatment of rest, physical therapy and non-steroid anti-inflammatories is also recommended for this common cause of shoulder pain (Chianca et al., 2018).

An Emerging Tendinopathy Treatment

While traditional conservative treatment is the first line of defense with common shoulder pain issues, there is a “newer” (I just discovered it about one year ago) treatment available that has promising results. The treatment is Extracorporeal Shockwave Therapy (ESWT). Dedes et al. (2018) performed a study on various tendinopathy patterns in the elbow, achilles, plantar fascia and rotator cuff, utilizing ESWT. The study showed that ESWT is an effective treatment option for increasing function and quality of life and reducing pain in the various tendinopathies. Extracorporeal shockwave therapy is not only convenient for the patient, as it is done on an outpatient basis and there are no restrictions following treatment, but it is safe and has no significant side effects.

How does it work? The device is applied to the area of injury. The “shockwaves” delivered are high energy sound waves that induce neovascularization, new blood vessel formation, at the junction of the tendon and bone. Through the process, various growth factors are released to achieve the overall goal of improving the blood supply to regenerate and repair the injured area (Dedes et al., 2018).

So, the next time you have a patient with shoulder pain that is caused by a shoulder tendinopathy pattern, consider prescribing ESWT along with traditional, conservative treatment.


Chianca, V., Albano, D., Messina, C., Midiri, F., Mauri, G., Aliprandi, A., Catapano, M., Pescatori, L. C., Monaco, C. G., Gitto, S., Pisani Mainini, A., Corazza, A., Rapisarda, S., Pozzi, G., Barile, A.,
Masciocchi, C., & Sconfienza, L. M. (2018). Rotator cuff calcific tendinopathy: From diagnosis to
treatment. Acta Biomedica, 89(1-S), 186–196.

Dedes, V., Stergioulas, A., Kipreos, G., Dede, A. M., Mitseas, A., & Panoutsopoulos, G. I. (2018).
Effectiveness and safety of shockwave therapy in tendinopathies. Materia socio-medica, 30(2),

Garving, C., Jakob, S., Bauer, I., Nadjar, R., & Brunner, U. H. (2017). Impingement syndrome of the shoulder. Deutsches Arzteblatt international, 114(45), 765–776.

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