Rotator cuff tendinopathy is a shoulder pain. It is most commonly felt on the front and outside of the shoulder especially with overhead movements or loaded movements with the arm away from the body. It can occasionally refer pain into the upper arm but if it goes further below the elbow it is more likely linked to a neck problem.
Irritation of the rotator cuff tendons (tendinopathy) is the most common cause of shoulder impingement and pain within cyclists, excluding traumatic pain associated with fractures
What causes Rotator cuff tendinopathy?
Cycling posture places an imbalanced strain and demand on the shoulders which leads to a forward slide in shoulder blade position (scapular protraction). This in turn can impair flexibility at the back of the shoulder leading to stiffness and increased pressure on the rotator cuff tendons (these are the vital stability muscles of the shoulder joint).
Once the tendons become irritated there is impaired rotator cuff function and thus impaired stability within the shoulder which can then continue to aggravate the problem.
Triathletes are at greater risk of developing shoulder related problems such as rotator cuff tendinopathy due to the extra demands placed on the shoulder in overhead positions from swimming and also the role shoulder stability plays in using the aero extension bars on longer rides.
Previous shoulder injury (such as dislocation, tendon tear)
Poor bike fit with excessive pressure through arms
Triathletes are at higher risk due to swimming / use of TT bars.
What are the symptoms?
Classically there is a slow progressive onset to this problem which gradually becomes more painful or limiting over time if not addressed.
The most commonly described symptom of rotator cuff tendinopathy is what is known as a ‘painful arc’ of movement (pictured below). This occurs between 60-120° when elevating the arm in front or out to the side.
Pain may also be present during pressing type movements such as a push-up or pushing a door open with an outstretched arm.
You may find that your shoulder or arm feels weaker on lateral movements or more rapid shoulder movements such as throwing a ball.
There are a number of imaging modalities suitable for looking at shoulder and rotator cuff related injuries. If the problem is likely tendon-related then a dynamic ultrasound scan is the best exam to characterise and examine the tendon.
If the diagnosis is uncertain between the tendons and deeper structures of the shoulder then an MRI may well be indicated.
In the case of an extremely stiff and painfully restricted shoulder, this may raise the suspicion of a frozen shoulder and in this case an x-ray is a good first line investigation to rule out shoulder joint arthritis or other causes.
How can I manage Rotator cuff tendinopathy?
Cyclists most often complain of this pain when riding out of the saddle so you should immediately look to limit this.
If you are a triathlete, or also a swimmer, you should look to reduce or stop swimming in the short term.
Dressing is also cited as a time when the shoulder can be aggravated so if putting on jumpers / t-shirts / jackets try to put the affected arm in first so as to minimise reaching behind back or overhead.
The mainstay of physiotherapy input for rotator cuff input should centre around well structured loading programme (see below).
Manual therapy such as soft tissue release, massage, joint mobilisation around the shoulder, neck, and upper back can be helpful in the early stages.
Taping can provide good short term pain relief, provide some support and work as a reminder or postural cue for shoulder position.
Identifying if there are other strength or postural deficits leading to excess pressure around the rotator cuff can be extremely helpful as part of a combined approach. Particular areas of attention are the neck and upper back and all of the scapular stabilising muscles such as rhomboids, serratus anterior, trapezius etc.