Rotator Cuff Tendinopathy in Crossfit

Rotator cuff tendinopathy is a common shoulder injury in Crossfit athletes. Since rotator cuff tendinopathies are considered an overload condition, Crossfit athletes are susceptible to this injury because of the high loads placed on the shoulder especially with overhead presses, snatches, kipping pull ups, and clean & jerks.

What is a rotator cuff tendinopathy? 

Rotator cuff tendinopathy is an umbrella term used for all rotator cuff pain related to the tendon. This means the supraspinatus, infraspinatus, teres minor, and subscapularis tendons are all considered a rotator cuff tendinopathy. 

There are two types of rotator cuff tendinopathy: (1) reactive tendinopathy and (2) degenerative tendinopathy. 

In a reactive tendinopathy, a sudden increase in loading triggers the tendon to create more tendon cells leading to swelling inside the tendon. The influx of water into the tendon causes mild separation of the tendon fibers which can lead to pain. With sufficient relative rest, the fluid in the tendon is removed and the tendon returns to normal. 

When the load placed on the tendon continues without adequate rest, the tendinopathy can progress to a degenerative tendinopathy. In degenerative tendinopathy, the continued accumulation of fluid in the tendon causes disorganization of the tendon fibers. There can also be death of the tendon cells which can appear as a rotator cuff tear. The changes in a degenerative tendinopathy are generally not reversible.

How is a rotator cuff tendinopathy diagnosed? 

A thorough history and physical examination can diagnose a rotator cuff tendinopathy. A sudden increase in load or prolonged history of overload can help determine whether it is a reactive or degenerative tendinopathy. Stress testing of the rotator cuff muscles can then help to differentiate which muscles are involved.  

Imaging of the shoulder is not necessary to diagnose a rotator cuff tendinopathy but either an ultrasound or MRI can be used to assess the integrity of the rotator cuff muscles, if needed. 

What treatments help with rotator cuff tendinopathy? 

Both reactive and degenerative rotator cuff tendinopathy can be treated conservatively, with surgery rarely being indicated. However, the treatment approach for rotator cuff tendinopathy varies depends on whether it is a reactive or degenerative tendinopathy. 

Reactive Tendinopathy Treatment

The crucial treatment strategy for a reactive tendinopathy is load management. In other words, the stress on the tendon needs to be reduced to allow the fluid inside the tendon to go away. The tendon doesn't need to be completely off loaded during recovery but there needs to be a period of relative rest for the tendon to adapt. It might be best to temporarily avoid movements that place a heavy, quick load on the rotator cuff tendons in reactive tendinopathy. These movements can include: kipping pull ups, clean and jerks, snatches, and burpees.  

Isometric exercises, contracting the muscle without moving the joint, have been shown to reduce tendon pain for 30-45 minutes post contraction. The isometric contraction is generally held for 30-45 seconds and repeated for 3-5 repetitions. 

Soft tissue therapy, such as Graston or manual therapy, can also help reduce the pain in the shoulder. These soft tissue therapies stimulate the receptors in the skin which decreases the pain, similar to when you hit your elbow on something and you rub on it. Kinesiology tape, such as Rocktape, can also be beneficial in for reactive tendinopathy. The tape stimulates the receptors in the skin as described above, which is helpful in starting to rehab the rotator cuff muscles. Kinesiology tape also has a de-compressive effect, lifting up the skin to help reduce fluid in the shoulder. 

Degenerative Tendinopathy Treatment

For a degenerative rotator cuff tendinopathy, the main focus is on progressive loading on the tendon. The goal is to stimulate the tendon to create new healthy tendon which will increase its ability to tolerate load. 

Isometric exercises can still be used for pain control in the degenerative tendinopathy, but the emphasis will be on concentric and eccentric exercises. There is not a "optimal" loading program, but generally it is recommended to perform between 5-10 repetitions for 3-5 sets depending on the tendons tolerance. 

Soft tissue therapies can still be used for a degenerative rotator cuff tendinopathy, however, these therapies won't improve the rotator cuff tendons' tolerance to loading. These therapies should be seen as adjunct therapies to a progressive exercise program for the rotator cuff. 

Regardless of whether it is a reactive or degenerative rotator cuff tendinopathy, it is important that the rehabilitation movements and loads are similar to what is experienced in Crossfit. Banded rotator cuff strengthening is great, but it isn't the same amount of load as a kipping pull up or a snatch. If the difference between loading in rehab and loading in Crossfit is large, there is a higher potential risk of re-injury. Progressive loading of the rotator cuff in the rehab setting will help set Crossfit athletes up for a successful return.