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Rotator cuff tendinopathy

Updated: May 25, 2020

anatomical illustration of the shoulder displaying the rotator cuff muscles

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.

Risk Factors

  • Previous shoulder injury (such as dislocation, tendon tear)

  • Shoulder instability

  • Neck pain

  • 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.

illustration of a man standing and lifting his arm to 120 degrees

  • 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?

Activity Modification

  • 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.


Progressive loading programmes increase the tendon’s ability to transfer load effectively and reduce pain. These exercises can be mildly painful but the symptoms must settle within 24hrs or it may be too much strain. They also require consistency and commitment over a three month period to show the best results.

You should seek guidance from a suitably trained physio or exercise / rehab specialist to guide you on exercises, resistance levels, and progression.

Bike Fit

  • A position on the bike that places excessive strain or load through the arms is commonly seen alongside shoulder problems. Excessive reach and drop will often be two of the culprits.

  • Handlebar width is another one to pay attention to - if the bars are too wide this will force much greater pressure out on the shoulder to support your position.

  • If your position is unstable on the saddle (for example, from a saddle position that is too high) this can then create extra (un-necessary) work for the arms and shoulders to maintain your stability on the bike.

Shockwave Therapy

There is now a good body of evidence to support the use of shockwave therapy for many tendon related problems. A course of treatment will normally be 3-4 sessions spaced one week apart.

For best outcome this should be combined with a structured tendon loading programme.

It has been shown to be particularly effective in ‘calcific’ rotator cuff tendinopathy.


  • If a diagnosis of rotator cuff tendinopathy has been established then it is less likely that a steroid injection is a suitable option due to the concern over possibly increasing risk of future tendon rupture.

  • Other injections such as Platelet Rich Plasma (PRP) or hyaluronic acid (eg Ostenil) have not been shown definitively to add clinical benefit to outcomes.

  • In the case of underlying shoulder joint pain as the main cause of the symptoms then steroid or ostenil may be indicated.


There is no definitive role for surgery in the case of rotator cuff tendinopathy but in the case of rotator cuff tears where rehab has failed to improve symptoms then rotator cuff repair combined with structured post-op rehab has very good outcomes.

What else could it be?

  • Biceps tendon irritation

  • Acromioclavicular (AC) joint synovitis / sprain / arthritis

  • Glenohumeral joint (main shoulder joint) arthritis

  • Frozen Shoulder (adhesive capsulitis)

  • Subacromial bursitis

  • Labral tear

  • Referred pain from the neck

If you are having issues with your shoulder and want to get in touch about booking a consultation or a bike fit then please email us:

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