What is the recommended treatment approach for patients with rotator cuff pain and impingement, accompanied by humerus and elbow pain?

Treatment Approach for Rotator Cuff Pain with Associated Humerus and Elbow Pain

When rotator cuff pain is accompanied by humerus and elbow pain on palpation and movement, you must first rule out concurrent elbow tendinopathy (lateral or medial epicondylosis) and then treat both conditions simultaneously with a multimodal conservative approach prioritizing NSAIDs, exercise therapy, and selective corticosteroid injections.

Initial Diagnostic Considerations

The presence of humerus and elbow pain alongside rotator cuff symptoms suggests either:

• Concurrent elbow tendinopathy (lateral epicondylosis affects the dominant arm 75% of the time and is 7-10 times more common than medial epicondylosis) 1
• Referred pain patterns from the shoulder pathology
• Kinetic chain dysfunction where shoulder impingement leads to compensatory elbow overuse

Key examination findings to differentiate:

• Elbow pain with resisted wrist extension indicates lateral epicondylosis 1
• Pain at the lateral or medial epicondyle on direct palpation confirms elbow tendinopathy 1
• Positive Hawkins' test (92% sensitive) or Neer's test (88% sensitive) confirms rotator cuff impingement 1

First-Line Treatment Protocol

Pharmacologic Management

Start with paracetamol (acetaminophen) combined with NSAIDs or COX-2 inhibitors as your foundation 2:

• This combination provides more effective pain control than either agent alone 2
• NSAIDs are particularly effective for both rotator cuff tendinopathy and elbow epicondylosis 1, 2
• Reserve opioids strictly for rescue analgesia when other methods fail 2

Exercise Therapy

Implement structured exercise programs immediately 2:

• Home exercise programs show significant improvements in pain at rest, pain at night, and functional scores after 3 months 2
• For elbow tendinopathy specifically, technique modification to minimize repetitive stresses is essential 1
• Exercise therapy has level II evidence for decreasing pain and improving function 2

Second-Line Interventions

Corticosteroid Injections

Use targeted corticosteroid injections strategically for each anatomic site:

For the shoulder:

• A single injection of corticosteroid with local anesthetic provides short-term improvement in both pain and function (moderate evidence) 1, 2
• Limit to single injections—do not repeat multiple times 2

For the elbow:

• Corticosteroid injections are more effective than NSAIDs in the acute phase of lateral epicondylosis 1
• However, they do not change long-term pain outcomes 1
• Use judiciously as a bridge to allow exercise therapy to take effect

Regional Analgesia for Severe Cases

If pain is severe and unresponsive to the above:

• Interscalene brachial plexus blockade is the first-choice regional technique for shoulder pain 2
• Suprascapular nerve block with or without axillary nerve block serves as an alternative 2

Treatment Pitfalls to Avoid

Critical mistakes that worsen outcomes:

• Overusing corticosteroid injections: Multiple injections do not improve long-term outcomes and may cause tissue damage 1, 2
• Using opioids as first-line treatment: This contradicts guideline recommendations and increases harm without improving outcomes 2
• Ignoring the elbow component: Treating only the shoulder while elbow tendinopathy persists leads to treatment failure 1
• Premature surgical referral: 60% of patients improve with conservative treatment within 2 years 3

When to Consider Surgical Referral

Refer to orthopedic surgery only if:

• Pain persists despite a well-managed conservative treatment trial of at least 6 months 1
• There is evidence of full-thickness rotator cuff tear with functional impairment 1
• Conservative management has genuinely failed (not just been inadequately implemented) 3

Modalities with Insufficient Evidence

Do not rely on these as primary treatments:

• Extracorporeal shock wave therapy shows mixed benefit for elbow pain 1
• Iontophoresis and phonophoresis lack well-designed RCT support 1
• Ice, heat, TENS, and PEMF lack sufficient evidence for rotator cuff conditions 2
• Orthotics for elbow tendinopathy have no definitive evidence, though they are safe to try 1

Practical Algorithm Summary

1. Confirm both diagnoses with targeted physical examination (impingement tests for shoulder, epicondyle palpation and resisted wrist movements for elbow) 1
2. Start NSAIDs + paracetamol immediately 2
3. Initiate exercise therapy for both shoulder and elbow with technique modification 1, 2
4. Consider single corticosteroid injection at 2-4 weeks if inadequate response 1, 2
5. Reassess at 3 months—most patients show significant improvement by this point 2
6. Refer to orthopedics only after 6 months of failed conservative management 1, 3