How Should I Manage My Rotator Cuff Pain?

Rotator cuff tendinitis is the most common shoulder injury for swimmers, says Gabriella Ode, a sports medicine and shoulder specialist at Prisma Health in Greenville, S.C. That’s largely because of swimming’s repetitive nature and demanding training programs, says Ode, who has treated professional and Division 1 athletes.

Many competitive swimmers have a lot of laxity, or multidirectional instability, in their shoulder joints, she says. 

“The shoulder joint can feel like it is moving more than it should or slipping out of place,” she says.

That can put a lot of stress on the shoulder’s soft tissue to keep it in place during swimming and gradually contributes to shoulder joint pain, altered kinematics of the shoulder blade, and sometimes secondary rotator cuff injury, Ode says. Evaluation by a sports medicine doctor or shoulder specialist should pinpoint the issue. 

Ice, over-the-counter anti-inflammatory medications, and physical therapy are the first line of treatment, especially for multidirectional instabilities, Ode says.

“Surgical treatment for pain from [multidirectional instabilities] is rare and only considered after at least a year of focused physical therapy without improvement,” she adds.

Ode typically places patients with a rotator cuff injury in a physical therapy program focusing on relieving pain, light shoulder stretching, and progressing to rotator cuff strengthening and scapula stabilization.

According to the American Physical Therapy Association, a typical rehabilitation program covers four phases: maximal protection when the shoulder is at the greatest risk of reinjury and the arm is in a sling; moderation protection during which mobility is restored; return to partial activity levels; and a full return. 

Swimmers should augment physical therapy with home-based daily exercises to prevent reinjury after recovery, says Ode, who cautions swimmers to not swim through pain. You can maintain your swimming conditioning during recovery by kicking with your arms by your side.

“Work up to lower-stress swim strokes followed by returning to your preferred stroke, as long as you don't have pain,” Ode says. “Start with shorter repetitions and distances before building back up to your normal routine. You don't want to get into a cycle of returning to high-intensity swimming too soon and have a reoccurrence of pain.”

Some studies conclude the butterfly is more likely to cause pain than other strokes due to its repetitive internal and external rotation, Ode says, and breaststroke likely puts the least stress on the shoulders, because it does not require arms to be raised overhead or out to the side as much as other strokes.

Given different training styles, there is no consensus on whether strength training and cross training helps or hurts efforts to prevent shoulder pain, Ode says. 

“Rotator cuff muscles are small but efficient muscles,” Ode says. “We use them all day when we reach for items overhead or behind us. This is different from the bigger muscles around the chest and back like the pecs and lats, the more powerful muscles we use less often.”

Heavy lifting can build bigger muscle strength and mass but bring fatigue to rotator cuff muscles, which can lead to shoulder pain, Ode says.

“Strengthening rotator cuff muscles is about making them work more efficiently, coordinating the muscle balances around the shoulder and not building up more muscle mass,” Ode says.

The best exercises for rotator cuffs utilize resistance bands or body weight, which stabilize the shoulder blades where the rotator cuff muscles attach, Ode says. 

The American Physical Therapy Association advises that swimmers focus on these five things to improve stroke and avoid injury: bilateral breathing, correct posture, kicking from the hips, practicing catch and pull, and body rotation.