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57

Review article                                                       DOI: https://doi.org/10.35469/ak.2023.392
received: 2023-06-06                UDC: 796.88:615.8

PHYSICAL THERAPY OF ROTATOR CUFF INJURIES OF 
OLYMPIC WEIGHTLIFTERS – A SYSTEMATIC LITERATURE 

REVIEW

Janez KONJAR1, Živa ARKO2

1Basketball Club Ratiopharm Ulm, Deutschland
2Alma Mater Europaea – ECM, Department of Physiotherapy, Maribor, Slovenia

Corresponding author:
Janez KONJAR 

Kolenčeva pot 15, 1241 Kamnik
Telephone: +386 51 668 797
E-mail: konjar15@gmail.com

ABSTRACT 

From an injury-rate standpoint, Olympic weightlifting is a relatively safe sport. 
Despite that, a large number of repetitions, the ballistic nature of the lifts and the high 
forces sustained by the shoulder joint during their execution can lead to shoulder inju-
ries, specifically rotator cuff injuries. The purpose of this paper was to investigate the 
scientifically proven physiotherapy methods and what their indications are when deal-
ing with rotator cuff injuries of Olympic weightlifters.

A qualitative literature review method was used, and the following online databases 
were included: PubMed, Scopus, Wiley, and PEDro in ResearchGate. The keywords in 
the literature search were: rotator cuff, shoulder, injury, physiotherapy, sport, weight-
lifting and Olympic weightlifting. The final analysis included fully published and ac-
cessible research papers in English from 2012 onwards, focusing on the physiotherapy 
of rotator cuff injuries.

In total, 16 research papers were included in the final review. Management of rota-
tor cuff injuries is a complex process, especially in sports with overhead movements. 
We found that the success and effectiveness of the physiotherapy process can be im-
proved through a proper combination of kinesiotherapy, physical agent modalities, 
manual methods and other forms of therapy. 

The choice of the specific methods and their duration depends on the pathology of 
the individual injury. Further research focusing on Olympic weightlifting is needed to 



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ANNALES KINESIOLOGIAE • 14 • 2023 • 1

create precise and conclusive guidelines for rehabilitation, especially for sport specific 
phases occurring later in the rehabilitation process.

Keywords: Olympic weightlifting, rotator cuff, rehabilitation, injuries, physiotherapy.

FIZIOTERAPIJA PO POŠKODBAH ROTATORNE MANŠETE PRI 
OLIMPIJSKIH DVIGALCIH UTEŽI – SISTEMATIČNI PREGLED 

LITERATURE

POVZETEK

Olimpijsko dviganje uteži je z vidika pogostnosti poškodb relativno varen šport. 
Kljub temu veliko število ponovitev, balistična narava športa in visoka sila na ramenski 
sklep lahko povzročijo poškodbe ramena, še posebej rotatorne manšete. Namen tega 
dela je s pregledom literature raziskati, katere fizioterapevtske metode so dokazano 
učinkovite in kakšne so njihove indikacije za obravnavo posameznih tipov poškodb 
rotatorne manšete pri olimpijskih dvigalcih uteži.

V kvalitativni pregled literature so bile vključene te podatkovne baze: PubMed, 
Scopus, Wiley, PEDro in ResearchGate. Ključne besede pri iskanju literature so bile: 
»Rotator cuff«, »Shoulder«, »Injury«, »Physiotherapy«, »Sport«, »Weigltlifting« in 
»Olympic Weightlifting«. V končno raziskavo smo vključili v celoti objavljene in do-
stopne raziskave v angleškem jeziku, ki so bile objavljene od leta 2012 in neposredno 
raziskujejo fizioterapevtsko rehabilitacijo poškodb rotatorne manšete.

V končno analizo je bilo vključenih 16 raziskav. Obravnava poškodb rotatorne man-
šete je kompleksen proces, še posebej kadar gre za športe z aktivnostmi nad glavo. 
Ugotovili smo, da je izboljšanje uspešnosti rehabilitacije omenjenih poškodb mogoče 
doseči s pravilno kombinacijo kinezioterapije, fizičnih dejavnikov, manualnih in drugih 
metod obravnave. 

Izbira posameznih metod in njihovo trajanje sta odvisna od patologije posamezne 
poškodbe. Jasno je, da so za izoblikovanje natančnih smernic celotne rehabilitacije, 
predvsem v poznejših športno specifičnih fazah, potrebne raziskave usmerjene samo v 
dvigalce uteži. 

Ključne besede: olimpijsko dviganje uteži, rotatorna manšeta, rehabilitacija, po-
škodbe, fizioterapija.



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INTRODUCTION

Olympic weightlifting is often misinterpreted as a very dangerous sport. 
While it is true that athletes in this sport are constantly lifting relatively heavy 
weights, this alone cannot be the reason to label a sport as dangerous. This is 
clear if we consider that the execution, volume and intensity of the sessions 
and movements in this sport can be often tracked and managed better than for 
example in team sports. Aasa, Svartholm, Andersson and Berglund (2017) con-
cluded that the injury rate in weightlifting is between 2.4 to 3.3 injuries/1000 
hours of training. We can compare this to American football where the injury 
rate is much higher at 9.3 injuries/1000 hours of training or even 35.9 inju-
ries/1000 hours of competition (Hootman, Dick & Agel, 2007). Even when 
comparing these numbers to the injury rate of 3.57 injuries/1000 hours of expo-
sure to non-contact sports like track and field (Jacobsson et al., 2013), Olympic 
weightlifting is a relatively safe sport.

Researchers found that the most injured anatomical regions within weight-
lifting were the lower back, shoulder and knee joints (Calhoon & Fry, 1999; 
Raske & Norlin, 2002). In terms of the severity and nature of those injuries, 
we found conflicting results. Calhoon and Fry (1999) found that most of the 
injuries to the mentioned regions required less than one day of missed training, 
suggesting that most of the injuries and associated pain were minor. On the 
other hand, Raske and Norlin (2002) reported the injuries to be more severe, 
requiring more than one month to recover. For comparison, the majority of 
track and field injuries were severe, requiring more than three weeks of missed 
training (Jacobsson et al., 2013). The most common diagnosis was tendinitis, 
muscle spasms, muscle tears and ligament tears (Calhoon & Fry, 1999).

Since Olympic weightlifting includes ballistic movements with weight 
overhead, athletes can be expected to be at a higher risk for subacromial impin-
gement (Page, 2011; Escalante, 2016). This is in line with claims that repetitive 
lifting overhead presents a certain risk for soft tissue shoulder injuries (Van der 
Wall et al., 1999; Raske & Norlin, 2002; Bedi, 2011). Escalante (2016) and 
Gross, Brenner, Esformes and Sonzogni (1993) claim that the primary reason 
for risk with those movements is increased stress on the inferior glenohume-
ral ligament while the upper extremity is abducted and externally rotated. The 
required catch and stabilization of the weight overhead in the end shoulder 
range of motion and the involvement of shoulder musculature practically thro-
ughout the whole Olympic lifts are also important risk factors to consider (Ser-
rano, 2020). 



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ANNALES KINESIOLOGIAE • 14 • 2023 • 1

During the lift-off, the first pull and transition phases of snatch and clean 
shoulder muscles are contracting primarily isometrically. During the explosive 
second pull and turnover phases, they are contracting concentrically, as they 
do during the drive phase of the jerk. Lastly, the greatest shoulder musculature 
isometric force requirements are present during the catch phase of the snatch 
and jerk. The required dynamic glenohumeral stability and humeral head cen-
tralization during those phases depend primarily on the rotator cuff muscles and 
the long head of the musculus biceps brachii (Serrano, 2020). Any limitations 
or deficiencies in shoulder range of motion and passive or active stability may 
compromise the technical execution of the lifts and contribute to or lead to 
injuries (Henoch, 2017).

When assessing a patient with shoulder pain, the first goal should be to 
determine the underlying cause of the pain. This is usually performed through 
a combination of an interview, palpation, diagnostic imaging, pain-provoking 
and range of motion tests. Treatment plans and physiotherapeutic methods sho-
uld be based on that information (Ristori et al., 2018; Serrano, 2020). One of 
the primary goals of diagnostics is determining whether the pain is specific 
or non-specific and if surgical treatment is needed. Additional assessments of 
shoulder stability, thoracic mobility and scapula movement all provide physi-
otherapists with additional crucial information that should be used to guide 
interventions (Moser 2014; Panagiotopoulos & Crowther, 2019)

When dealing with the majority of specific rotator cuff injuries, researchers 
suggest starting with conservative treatment and opting for surgery only when 
conservative treatment fails (Ryösä et al., 2017; Nazari, MacDermid, Bryant 
& Athwal, 2019; Millett, Wilcox, O’Holleran & Warner, 2006). Ristori et al. 
(2018) suggested that both diagnostic imaging and pain-provoking tests should 
be interpreted only in association with functional activity and pain. The main 
reasons for this are the often large discrepancies found between diagnostic re-
sults, actual functional limitations and pain. 

In the past authors proposed similar models of rotator cuff rehabilitation. 
The main difference between the 3-phase post-operative (Sgroi & Cilenti, 2018) 
model proposed for the general population and the 4-phase (Millett et al., 2006) 
or 5-phase (Serrano, 2020) models for athletes, is that the latter two usually 
last longer as they define sport specific phases. Cools et al. (2021) emphasized 
the importance of a comprehensive return to sports protocol for athletes, which 
should be able to detect and correct possible asymmetries in shoulder range of 
motion, stability and strength.

Today we have a good amount of clinical research on effective physiothera-
peutic modalities for rotator cuff treatment. There is however virtually no cli-



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Janez KONJAR, Živa ARKO: PHYSICAL THERAPY OF ROTATOR CUFF INJURIES OF OLYMPIC WEIGHTLIFTERS .., 57–78

nical research specifically done on Olympic weightlifters. The 5-phase model 
proposed by Serrano (2020) is a rare work that focuses on collecting existing 
research and knowledge on rotator cuff injuries and forming rehabilitation gui-
delines specifically for Olympic weightlifters. 

The goal of our work was to focus primarily on the role of the physiothera-
pist in the process of the aforementioned rehabilitation. We wanted to highlight 
clinically proven effective physiotherapeutic interventions and how they could 
be used specifically for the rehabilitation of Olympic weightlifters with rotator 
cuff injuries. 

METHODS

We systematically reviewed the literature using a systematic qualitative lit-
erature review method. Data was extracted from the online databases PubMed, 
Scopus, Wiley, PEDro, and ReserchGate during the period between 25 May 
2022 and 3 June 2022. In conjunction with the operator AND and/or OR, the 
following keywords were used: rotator cuff, shoulder, injury, physiotherapy, 
sport, weightlifting and Olympic weightlifting. 

Articles were first evaluated based on title, followed by the abstract, then 
a quick full-text overview and lastly based on the inclusion and exclusion cri-
teria. The inclusion criteria were: i) fully accessible clinical studies, ii) fully 
written in the English language, iii) published after 2012, and iv) investigating 
physiotherapeutic interventions during the rehabilitation of rotator cuffs. The 
exclusion criteria were: i) meta-analysis, systematic literature reviews and case 
studies, ii) studies investigating the efficiency of pharmaceutical interventions, 
iii) choosing between operative and conservative treatment, iv) entirely home-
based unsupervised kinesiotherapy, v) research in which all subjects were older 
than 50 years or the average age was higher than 55 years were also excluded. 

Microsoft Office Excel 2016 (Microsoft Corporation, New York, USA) was 
used to collect and present the summary of the results with tables. The search 
process and the final selection of articles were performed using the PRISMA 
2020 guidelines (Page et al., 2021). 

Additionally, we used additional filters when searching the databases as 
shown in Table 1.



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ANNALES KINESIOLOGIAE • 14 • 2023 • 1

Table 1: Additional search filters applied in the online databases

Database Search filters

PubMed Articles published between 2012 and 2022, randomized control 
studies and clinical trials

Scopus English articles published between 2012 and 2022 

Wiley Articles published between 2012 and 2022

PEDro PEDro grade at least 5/10 and articles published after 2012

ReserchGate Not able to choose additional search filters within the database

RESULTS

The initial search in databases returned 1302 hits. After applying additional 
search parameters from Table 1, the search results included 248 hits. Next, after 
reviewing the titles and abstracts we narrowed our search to 49 studies. Lastly, 
we eliminated duplicates and read the full articles. After reviewing the content, 
we eliminated an additional 33 articles and thus analyzed 16 relevant studies. 
The systematic review process is presented in Figure 1. 

A total of 724 individuals with rotator cuff injuries were included in the 
analyzed studies. Out of the 16 studies, 14 provided information on partici-
pants’ gender, with women representing a slightly larger share (54%). The du-
ration of the studies varied from one week up to a year. Most of the studies, 
their eligibility requirements and the period between checkups were in line with 
the following differentiation based on the length of the symptoms (Koç et al., 
2020):

 – Acute pain: symptoms lasting less than 6 weeks
 – Sub-acute pain: symptoms lasting between 6–12 weeks
 – Chronic pain: symptoms lasting more than 12 weeks

Chronic injuries were the most researched within our sample. Seven studies 
investigated exclusively chronic rotator cuff injuries, while six other studies 
also included them among others. Sub-acute injuries were exclusively investi-
gated within one study while they were included among others in eight other 
studies. There was no research focusing exclusively on acute injuries, but they 
were part of six mixed studies. Only one of the studies specifically defined that 
all of the patients underwent surgical intervention. 



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Figure 1: Systematic review process



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Janez KONJAR, Živa ARKO: PHYSICAL THERAPY OF ROTATOR CUFF INJURIES OF OLYMPIC WEIGHTLIFTERS .., 57–78

ANNALES KINESIOLOGIAE • 14 • 2023 • 1

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Janez KONJAR, Živa ARKO: PHYSICAL THERAPY OF ROTATOR CUFF INJURIES OF OLYMPIC WEIGHTLIFTERS .., 57–78
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sl

ig
ht

ly
 sm

al
le

r s
ca

pu
la

r l
at

er
al

 ro
ta

tio
n.

 
St

at
is

tic
al

ly
 si

gn
ifi

ca
nt

 h
ig

he
r a

ct
iv

at
io

n 
of

 th
e 

m
id

dl
e 

m
us

cu
lu

s t
ra

pe
zi

us
, p

ai
n 

re
du

ct
io

n,
 a

nd
 im

pr
ov

in
g 

th
e 

fu
nc

tio
n 

7-
10

 d
ay

s a
fte

r t
he

 m
an

ip
ul

at
io

n.
 

Zh
an

g 
et

 a
l. 

20
20

In
flu

en
ce

 o
f S

ca
pu

la
 

Tr
ai

ni
ng

 E
xe

rc
is

es
 o

n 
Sh

ou
ld

er
 Jo

in
t F

un
ct

io
n 

A
fte

r S
ur

ge
ry

 fo
r R

ot
at

or
 

C
uff

 In
ju

ry

46
 p

eo
pl

e 
(2

0 
fe

m
al

es
 a

nd
 2

6 
m

al
es

) a
fte

r t
he

 a
rth

ro
sc

op
ic

 
su

rg
er

y 
of

 p
ar

tia
l o

r f
ul

l 
th

ic
kn

es
s t

ea
r o

f t
he

 ro
ta

to
r 

cu
ff.

R
an

do
m

iz
ed

 
cl

in
ic

al
 tr

ia
l

A
 c

om
bi

na
tio

n 
of

 tr
ad

iti
on

al
 

ph
ys

io
th

er
ap

y 
an

d 
sp

ec
ifi

c 
sc

ap
ul

ar
 

ex
er

ci
se

s i
s e

ffe
ct

iv
e 

in
 re

du
ci

ng
 th

e 
dy

sf
un

ct
io

ns
 a

fte
r t

he
 su

rg
er

y.
 A

fte
r 6

 
w

ee
ks

 sp
ec

ifi
c 

sc
ap

ul
ar

 e
xe

rc
is

es
 h

av
e 

a 
st

at
is

tic
al

ly
 si

gn
ifi

ca
nt

 e
ffe

ct
 o

n 
re

du
ci

ng
 

sh
ou

ld
er

 p
ai

n,
 im

pr
ov

in
g 

R
O

M
 a

nd
 

fu
nc

tio
n.

 A
fte

r 1
2 

w
ee

ks
 th

e 
po

si
tiv

e 
eff

ec
t o

f t
ho

se
 e

xe
rc

is
es

 is
 a

ls
o 

se
en

 o
n 

m
us

cl
e 

st
re

ng
th

 te
st

in
g.

 
M

en
ek

, 
Ta

ra
kc

i, 
&

 
A

lg
un

 2
01

9

Th
e 

eff
ec

t o
f M

ul
lig

an
 

m
ob

ili
za

tio
n 

on
 p

ai
n 

an
d 

lif
e 

qu
al

ity
 o

f 
pa

tie
nt

s w
ith

 R
ot

at
or

 c
uff

 
sy

nd
ro

m
e

30
 p

eo
pl

e 
(1

2 
fe

m
al

es
 a

nd
 1

8 
m

al
es

) w
ith

 p
ar

tia
l r

ot
at

or
 c

uff
 

ru
pt

ur
e,

 a
cu

te
 sy

m
pt

om
s, 

an
d 

w
ith

ou
t s

ur
gi

ca
l t

re
at

m
en

t.

R
an

do
m

iz
ed

 
cl

in
ic

al
 tr

ia
l

6-
w

ee
k-

lo
ng

 tr
ea

tm
en

t p
ro

to
co

l w
ith

 
M

ul
lig

an
 m

ob
ili

za
tio

n 
re

su
lts

 in
 a

 
st

at
is

tic
al

ly
 si

gn
ifi

ca
nt

 p
ai

n 
re

du
ct

io
n,

 
im

pr
ov

in
g 

fu
nc

tio
n 

an
d 

R
O

M
.

Fr
as

sa
ni

to
 e

t a
l. 

20
18

Eff
ec

tiv
en

es
s o

f 
Ex

tra
co

rp
or

ea
l S

ho
ck

 
W

av
e 

Th
er

ap
y 

an
d 

ki
ne

si
o 

ta
pi

ng
 in

 c
al

ci
fic

 
te

nd
in

op
at

hy
 o

f t
he

 
sh

ou
ld

er

42
 p

eo
pl

e 
(2

6 
fe

m
al

es
 a

nd
 1

6 
m

al
es

) w
ith

 d
ia

gn
os

ed
 c

al
ci

fic
 

ro
ta

to
r c

uff
 te

nd
in

op
at

hy
, a

nd
 

fu
nc

tio
na

l i
ss

ue
s p

er
si

st
in

g 
at

 
le

as
t 2

 w
ee

ks
.

R
an

do
m

iz
ed

 
cl

in
ic

al
 tr

ia
l

Th
e 

ad
di

tio
n 

of
 k

in
es

io
ta

pi
ng

 to
 

ex
tra

co
rp

or
ea

l s
ho

ck
 w

av
e 

th
er

ap
y 

ad
ds

 
to

 p
ai

n 
an

d 
in

fla
m

m
at

io
n 

re
du

ct
io

n 
in

 th
e 

sh
or

t t
er

m
. T

hi
s a

dd
iti

on
 th

us
 p

ot
en

tia
lly

 
he

lp
s t

o 
re

du
ce

 th
e 

re
ha

bi
lit

at
io

n 
tim

e.



66

Janez KONJAR, Živa ARKO: PHYSICAL THERAPY OF ROTATOR CUFF INJURIES OF OLYMPIC WEIGHTLIFTERS .., 57–78

ANNALES KINESIOLOGIAE • 14 • 2023 • 1

A
ut

ho
r(

s)
 a

nd
 

ye
ar

 o
f p

ub
l.

A
rt

ic
le

 ti
tle

R
es

ea
rc

h 
sa

m
pl

e
A

rt
ic

le
 ty

pe
R

es
ul

ts

A
kb

ab
a 

et
 a

l. 
20

19
Th

e 
eff

ec
tiv

en
es

s o
f 

tri
gg

er
 p

oi
nt

 tr
ea

tm
en

t i
n 

ro
ta

to
r c

uff
 p

at
ho

lo
gy

41
 p

eo
pl

e 
w

ith
 d

ia
gn

os
ed

 
pa

rti
al

 ro
ta

to
r c

uff
 te

ar
, a

t l
ea

st
 

3 
ac

tiv
e 

sh
ou

ld
er

 tr
ig

ge
r-p

oi
nt

s, 
an

d 
sy

m
pt

om
s p

er
si

st
in

g 
at

 
le

as
t 3

 m
on

th
s.

R
an

do
m

iz
ed

 
cl

in
ic

al
 tr

ia
l

A
dd

iti
on

al
 tr

ig
ge

r-p
oi

nt
 tr

ea
tm

en
t d

oe
s 

no
t r

es
ul

t i
n 

st
at

is
tic

al
ly

 si
gn

ifi
ca

nt
 

im
pr

ov
em

en
t o

f r
eh

ab
ili

ta
tio

n 
ou

tc
om

es
. 

K
lü

te
r e

t a
l. 

20
18

El
ec

tro
m

ag
ne

tic
 

tra
ns

du
ct

io
n 

th
er

ap
y 

an
d 

sh
oc

kw
av

e 
th

er
ap

y 
in

 8
6 

pa
tie

nt
s w

ith
 ro

ta
to

r c
uff

 
te

nd
in

op
at

hy

86
 p

eo
pl

e 
(4

5 
fe

m
al

es
 a

nd
 4

1 
m

al
es

) w
ith

 d
ia

gn
os

ed
 ro

ta
to

r 
cu

ff 
te

nd
in

op
at

hy
, s

ym
pt

om
s 

la
st

in
g 

at
 le

as
t 3

 m
on

th
s, 

pa
in

 
gr

ad
ed

 a
t l

ea
st

 5
 o

n 
a 

VA
S 

sc
al

e,
 a

nd
 fa

ile
d 

pr
ev

io
us

 
co

ns
er

va
tiv

e 
tre

at
m

en
t. 

R
an

do
m

iz
ed

 
cl

in
ic

al
 tr

ia
l

A
 c

om
bi

na
tio

n 
of

 e
le

ct
ro

m
ag

ne
tic

 
tra

ns
du

ct
io

n 
th

er
ap

y 
an

d 
sh

oc
kw

av
e 

th
er

ap
y 

ha
s a

 st
at

is
tic

al
ly

 si
gn

ifi
ca

nt
 

su
pe

rio
r e

ffe
ct

 o
n 

pa
in

 re
du

ct
io

n 
an

d 
im

pr
ov

in
g 

fu
nc

tio
n 

th
an

 sh
oc

kw
av

e 
th

er
ap

y 
on

ly
. T

hi
s w

as
 th

e 
ca

se
 6

, 1
2,

 a
nd

 
24

 w
ee

ks
 a

fte
r t

he
 la

st
 th

er
ap

y.
Li

 e
t a

l. 
20

21
Eff

ec
tiv

en
es

s o
f 

Fo
cu

se
d 

Sh
oc

kw
av

e 
Th

er
ap

y 
ve

rs
us

 R
ad

ia
l 

Sh
oc

kw
av

e 
Th

er
ap

y 
fo

r 
N

on
ca

lc
ifi

c 
R

ot
at

or
 C

uff
 

Te
nd

in
op

at
hi

es

46
 p

eo
pl

e 
(2

5 
fe

m
al

es
 in

 1
9 

m
al

es
) w

ith
 M

R
I-

di
ag

no
se

d 
no

n-
ca

lc
ifi

c 
ro

ta
to

r c
uff

 
te

nd
in

op
at

hy
 w

ith
ou

t r
up

tu
re

. 
Su

bj
ec

ts
 h

ad
 sy

m
pt

om
s l

as
tin

g 
at

 le
as

t 3
 m

on
th

s, 
re

st
ric

te
d 

R
O

M
, p

ai
n 

w
ith

 o
ve

rh
ea

d 
m

ov
em

en
ts

 a
nd

 g
ra

de
d 

th
ei

r 
pa

in
 w

ith
 a

t l
ea

st
 5

 o
n 

a 
VA

S 
sc

al
e.

 

R
an

do
m

iz
ed

 
cl

in
ic

al
 tr

ia
l

N
o 

st
at

is
tic

al
ly

 si
gn

ifi
ca

nt
 d

iff
er

en
ce

 in
 

pa
in

 re
du

ct
io

n 
w

ith
in

 2
4 

w
ee

ks
 o

f t
he

 
in

te
rv

en
tio

n 
be

tw
ee

n 
fo

cu
se

d 
an

d 
ra

di
al

 
sh

oc
kw

av
e 

th
er

ap
y.

 F
oc

us
ed

 sh
oc

kw
av

e 
th

er
ap

y 
re

su
lts

 in
 su

pe
rio

r l
on

ge
r-t

er
m

 
pa

in
 re

du
ct

io
n.

K
oç

 e
t a

l. 
20

20
D

oe
s b

al
ne

ot
he

ra
py

 
pr

ov
id

e 
ad

di
tiv

e 
eff

ec
ts

 to
 p

hy
si

ca
l 

th
er

ap
y 

in
 p

at
ie

nt
s w

ith
 

su
ba

cu
te

 su
pr

as
pi

na
tu

s 
te

nd
in

op
at

hy
?

90
 p

eo
pl

e 
(5

3 
fe

m
al

es
 a

nd
 3

7 
m

al
es

) w
ith

 M
R

I d
ia

gn
os

ed
 

un
ila

te
ra

l s
ub

-a
cu

te
 u

ni
la

te
ra

l 
te

nd
in

op
at

hy
 o

f m
us

cu
lu

s 
Su

pr
as

pi
na

tu
s, 

at
 le

as
t o

ne
 

po
si

tiv
e 

pa
in

-p
ro

vo
ca

tiv
e 

te
st

 
an

d 
fu

ll 
R

O
M

.

R
an

do
m

iz
ed

 
cl

in
ic

al
 tr

ia
l

A
 st

at
is

tic
al

ly
 si

gn
ifi

ca
nt

 im
pr

ov
em

en
t o

f 
sh

ou
ld

er
 R

O
M

, f
un

ct
io

n,
 g

rip
 st

re
ng

th
, 

qu
al

ity
 o

f l
ife

 a
nd

 p
ai

n 
re

du
ct

io
n 

w
ith

 
th

e 
ad

di
tio

n 
of

 b
al

ne
ot

he
ra

py
 to

 th
e 

tra
di

tio
na

l p
hy

si
ot

he
ra

py
 p

ro
to

co
l. 



ANNALES KINESIOLOGIAE • 14 • 2023 • 1

67

Janez KONJAR, Živa ARKO: PHYSICAL THERAPY OF ROTATOR CUFF INJURIES OF OLYMPIC WEIGHTLIFTERS .., 57–78
A

ut
ho

r(
s)

 a
nd

 
ye

ar
 o

f p
ub

l.
A

rt
ic

le
 ti

tle
R

es
ea

rc
h 

sa
m

pl
e

A
rt

ic
le

 ty
pe

R
es

ul
ts

El
so

da
ny

 e
t a

l. 
20

18
Lo

ng
-T

er
m

 E
ffe

ct
 o

f 
Pu

ls
ed

 N
d:

YA
G

 L
as

er
 

in
 th

e 
Tr

ea
tm

en
t o

f 
Pa

tie
nt

s w
ith

 R
ot

at
or

 C
uff

 
Te

nd
in

op
at

hy

60
 p

eo
pl

e 
w

ith
 d

ia
gn

os
ed

 
ro

ta
to

r c
uff

 te
nd

in
op

at
hy

, p
ai

n 
pe

rs
is

tin
g 

fo
r o

ve
r 3

 m
on

th
s, 

an
d 

po
si

tiv
e 

pa
in

 p
ro

vo
ca

tiv
e 

te
st

s t
ha

t i
nd

ic
at

e 
ro

ta
to

r c
uff

 
pa

th
ol

og
y.

 S
ub

je
ct

s w
er

e 
al

so
 

de
al

in
g 

w
ith

 im
pa

ire
d 

sh
ou

ld
er

 
ab

du
ct

io
n,

 in
te

rn
al

 a
nd

 e
xt

er
na

l 
ro

ta
tio

n 
R

O
M

.

R
an

do
m

iz
ed

 
cl

in
ic

al
 tr

ia
l

R
eh

ab
ili

ta
tio

n 
pr

og
ra

m
 c

om
bi

ni
ng

 H
IL

T 
an

d 
ex

er
ci

se
 in

te
rv

en
tio

n 
pr

og
ra

m
 w

as
 

m
or

e 
eff

ec
tiv

e 
in

 re
st

or
in

g 
sh

ou
ld

er
 

fu
nc

tio
n,

 R
O

M
, a

nd
 re

du
ci

ng
 p

ai
n 

th
an

 
ex

er
ci

se
 in

te
rv

en
tio

n 
pr

og
ra

m
 a

lo
ne

. 

C
ar

lis
i e

t a
l. 

20
18

Fo
cu

se
d 

ex
tra

co
rp

or
ea

l 
sh

oc
k 

w
av

e 
th

er
ap

y 
co

m
bi

ne
d 

w
ith

 su
pe

rv
is

ed
 

ec
ce

nt
ric

 tr
ai

ni
ng

 fo
r 

su
pr

as
pi

na
tu

s c
al

ci
fic

 
te

nd
in

op
at

hy

22
 p

eo
pl

e 
(1

4 
fe

m
al

es
 a

nd
 

8 
m

al
es

) w
ith

 sh
ou

ld
er

 p
ai

n 
pe

rs
is

tin
g 

fo
r m

or
e 

th
an

 6
 

w
ee

ks
, c

lin
ic

al
 si

gn
s o

f s
ub

-
ac

ro
m

ia
l i

m
pi

ng
em

en
t, 

an
d 

fu
ll 

pa
ss

iv
e 

R
O

M
. A

ll 
of

 th
e 

su
bj

ec
ts

 a
ls

o 
ha

d 
a 

co
nfi

rm
ed

 
ca

lc
ifi

c 
te

nd
in

op
at

hy
 o

f t
he

 
su

pr
as

pi
na

tu
s t

en
do

n.
 

R
an

do
m

iz
ed

 
cl

in
ic

al
 tr

ia
l

Fo
cu

se
d 

ex
tra

co
rp

or
ea

l s
ho

ck
 w

av
e 

th
er

ap
y 

is
 a

n 
eff

ec
tiv

e 
m

et
ho

d 
fo

r 
re

du
ci

ng
 sh

ou
ld

er
 p

ai
n 

an
d 

im
pr

ov
in

g 
fu

nc
tio

n.
 A

dd
iti

on
al

 sh
ou

ld
er

 a
bd

uc
to

r 
ec

ce
nt

ric
 e

xe
rc

is
e 

pr
ot

oc
ol

 d
oe

s 
no

t p
ro

vi
de

 st
at

is
tic

al
ly

 si
gn

ifi
ca

nt
 

im
pr

ov
em

en
t i

n 
tre

at
m

en
t o

ut
co

m
es

 
co

m
pa

re
d 

to
 fo

cu
se

d 
ex

tra
co

rp
or

ea
l s

ho
ck

 
w

av
e 

th
er

ap
y 

al
on

e.
C

ho
u 

et
 a

l. 
20

18
C

om
pa

ra
tiv

e 
ou

tc
om

es
 o

f 
ex

tra
co

rp
or

ea
l s

ho
ck

w
av

e 
th

er
ap

y 
fo

r s
ho

ul
de

r 
te

nd
in

iti
s o

r p
ar

tia
l t

ea
rs

 
of

 th
e 

ro
ta

to
r c

uff
 in

 
at

hl
et

es
 a

nd
 n

on
-a

th
le

te
s

35
 p

eo
pl

e 
(1

9 
fe

m
al

es
 a

nd
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DISCUSSION

Evaluation and diagnostics

Reviewed studies analyzed symptoms differently both at the beginning and 
during check-ups. This indicates that there is a lack of consensus on how to 
screen patients with potential rotator cuff pathology (Ristori et al., 2018). De-
spite that, all of the researchers used a combination of different questionnaires 
about the pain and function of the shoulder joint. Eleven studies used the Visual 
Analogue Scale (VAS), while the Numeric Rating Scale (NRC) was the second 
most commonly used. Concerning functional assessment, the Disabilities of the 
Arm, Shoulder, and Hand (DASH) questionnaire was the most common, with 
a full version in seven pieces of research and a shortened version used within 
two more. The second most commonly used was the Constant-Murley Score 
(CMS). 

Nine out of sixteen included studies used different physiotherapeutic asses-
sments to test the active and passive range of motion (ROM), muscle strength 
and function. Among those, the passive range of motion assessment was the 
most commonly used in six studies. Half of the studies also used pain-provo-
king tests to confirm rotator cuff pathology, but only one study used those tests 
during control check-ups. Half of the research also included at least one dia-
gnostic imaging method, with magnetic resonance imaging (MRI) used within 
seven, ultrasound within six and X-ray within three studies. 

We believe that the basic assessment of injured Olympic weightlifters sho-
uld not be significantly different than that of the general population and should 
focus on diagnosing the underlying mechanisms of pain. This includes the in-
terview with the athlete, diagnostic imaging, pain-provoking testing, passive 
and/or active ROM assessment, and function and pain assessment. Based on 
that information the therapist should be able to determine if the pain is the result 
of the rotator cuff symptomatic and what would be the appropriate course of 
action. A physiotherapist has to consider how long and how severe is the pain, 
and especially how it affects the function and performance. It is crucial to look 
at an individual’s training load and plan to identify possible injury-contributing 
factors. Physiotherapists must thus collaborate closely with the coach and at-
hlete to modify both training load and activities to ensure alignment with the 
rehabilitation plan.



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 Physical Agent Modalities

Some authors have included similar physical agent modalities in the “tradi-
tional physiotherapy” for rotator cuff injuries (Zhang et al., 2020; Menek, Ta-
rakci & Algun 2019; Koç et al., 2020; Coşkun et al., 2018). Those models con-
sisted of ultrasound, cryotherapy or thermotherapy and transcutaneous electri-
cal nerve stimulation (TENS). Cryotherapy as a modality seems to be primarily 
suitable for acute and subacute injuries. Parle, Riddiford-Harland, Howitt & 
Lewis (2017) found that cryopak is an effective method for reducing pain sen-
sation and improving the function of the shoulder joint when dealing with non-
traumatic acute or subacute pain. Zhang et al. (2020) found that a combination 
of 5 to 20 minutes of cryotherapy within the first four weeks after the operation 
and 5 to 10 minutes of moving method ultrasound therapy with the dosage of 
1.5–2.5 W/cm2 between the 4th and 12th week is effective in reducing the pain 
and improving the function of the shoulder joint after the arthroscopic surgery. 
Similarly, Menek et al. (2019) observed significant improvements in function 
and reduction of pain after 6 weeks of using a combination of cryotherapy, 
6-minute ultrasound therapy at a frequency of 1.5 MHz and TENS at a frequen-
cy of 100 Hz after partial rotator cuff tears. Koç et al. (2020), using the same 
parameters for the ultrasound and 20-minute TENS at a frequency of 60–80 
Hz for three weeks also demonstrated pain reduction and improved function in 
patients suffering from subacute supraspinatus tendinopathy. A similar protocol 
with a 20-minute TENS and 10-minute ultrasound therapy at 1.5 MHz frequen-
cy was also successfully used for a week by Coşkun et al. (2018) with patients 
dealing with various rotator cuff injuries. Interventions in all of the mentioned 
studies were carried out at least five times per week. We should emphasize that 
the “traditional physiotherapy” model always included some form of kinesi-
otherapy. Most of the studies also indicate that even though the improvements 
with “traditional physiotherapy” are significant, it can be expected that combi-
ning those methods with other physiotherapeutic modalities leads to superior 
patient outcomes. 

Elsodany, Alayat, Ali & Khaprani (2018) found that for the treatment of ro-
tator cuff tendinopathy high-intensity laser therapy (HILT) combined with exer-
cises provides superior results in terms of pain reduction, increasing shoulder 
ROM and function compared to performing exercises alone. Chou et al. (2018) 
found that one to two sessions of extracorporeal shockwave therapy (ESWT) 
enabled all 13 included overhead athletes to return to a competitive level within 
3 months after the intervention. 3000 impulses of the shockwave at 0.32 mJ/mm2 

energy flux density were applied to the affected shoulder under ultrasonographic 



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guidance during the sessions. The inclusion criteria in this study were an at least 
three-month-long unsuccessful conservative treatment. The recurrence rate was 
quite high at 62% though, much higher than the 18% observed in the non-athlete 
group, which shows the importance of comprehensive sport-specific phases of 
rehabilitation. Carlisi et al. (2018) found that three focused ESWT sessions with 
1-week breaks in between were effective in terms of reducing shoulder pain and 
improving joint function in individuals dealing with sub-acute or chronic pain 
resulting from supraspinatus calcific tendinopathy. The amount of energy influx 
during a single therapy was lower, 0.15 mJ/mm2 applied with 1700 impulses. 
Four sessions with focused ESWT, 3000 impulses at 0.09 ± 0.018 mJ/mm2 ener-
gy flux density applied, and a 5-to-9-day break between them, have been proven 
more successful in the treatment of non-calcific supraspinatus tendinopathy than 
a protocol with radial ESWT (Li et al., 2021). Three ESWT sessions with 2000 
impulses at 0.32 mJ/mm2 energy flux density within two weeks also resulted in 
shoulder pain reduction and function improvements within a group of patients 
with non-calcific rotator cuff tendinopathy. 

Combining ESWT therapy with 8 sessions of electromagnetic transduction 
therapy within 4 weeks resulted in superior results. Each electromagnetic trans-
duction therapy treatment lasted 20 minutes at 80 mT, with an impulse fre-
quency of 3 Hz and a discharge voltage of 30 KV (Klüter et al., 2018). Chou et 
al. (2018) and Klüter et al. (2018) also monitored long-term ESWT results and 
both concluded that the improvements are greater in the long-term.

Manual methods

Adding 12 sessions of rotator cuff myofascial trigger-point release to stan-
dard conservative treatment does not significantly improve outcomes of the 
patients with symptomatic rotator cuff ruptures (Akbaba et al., 2019). The addi-
tion of Mulligan mobilization to all 30 sessions of “traditional physiotherapy” 
within six weeks results in superior outcomes. Menek et al. (2019) observed 
both pain reduction, an increase in shoulder ROM and an improvement of sho-
ulder function after the described addition of an approximately 20-minute-long 
protocol of Mulligan mobilization. Muth, Barbe, Lauer and McClure (2012) 
found that a single intervention of thoracic spine and cervicothoracic junction 
manipulation is effective for reducing pain and improving shoulder function in 
patients with chronic rotator cuff pathology. Manipulation resulted in improve-
ments both immediately after and 7–10 days after the intervention.



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Exercise interventions

Different combinations of passive, active, actively assisted and range of mo-
tion exercises were used. The addition of scapular mobilization, stabilization 
and surrounding musculature strengthening to the standard physiotherapeutic 
protocol results in superior outcomes 12 weeks after the surgical repair of parti-
al rotator cuff tears (Zhang et al., 2020). In this study, active exercises for surro-
unding joints and corresponding musculature were applied to all patients a day 
after the operation, while Codman pendulum exercises were introduced after a 
week. Four weeks after the surgery, actively-assisted exercises were introduced 
and after six weeks exercises in a closed kinetic chain. Similar exercise proto-
cols including pendulum exercises, actively-assisted exercises, strengthening 
and ROM exercises were used in other included studies emphasizing conserva-
tive treatment (Menek et al., 2019; Elsodany et al., 2018). Both of those studies 
concluded that another physiotherapy method, specifically Mulligan mobiliza-
tion or HILT, results in additional improvements in shoulder function and pain 
reduction for patients with rotator cuff tendinopathy. De Oliveira, de Fontenay, 
Bouyer Desmeule, and Roy (2020) concluded that individualized six-week ki-
nesiotherapy with an emphasis on sensorimotor control, strengthening and edu-
cation significantly improves ROM, and function and reduces pain associated 
with the symptomatic rotator cuff. This was evident not only in the short- and 
mid-term, but also in the long-term. 

Some studies also defined the number of sets and repetitions executed in the 
respected protocols. All used three sets of 10 repetitions (Carlisi et al., 2018; 
Menek et al., 2019; Boudreau, Gaudreault, Roy, Bédard & Balg, 2019), while 
Carlisi et al. (2018) additionally defined a progressive number of sets and repe-
titions at the initial two weeks. Carlisi et al. (2018) and Boudreau et al. (2019) 
stated that mild pain (<4 on the VAS scale) was allowed during the performance 
of the exercises. 

Parle et al. (2017) found that isometric exercises (10–20 second holds in 
three to five series, executed daily) are a viable and effective short-term option 
to reduce acute or subacute shoulder pain as a result of rotator cuff tendino-
pathy. Boudreau et al. (2019) found a 6-week-long intervention of strengthe-
ning exercises focusing on m. serratus anterior, m. trapezius and rotator cuff 
muscles result in reduced movement pain, while the pain at rest and shoulder 
function do not improve significantly. Additional strengthening of glenohume-
ral adductors in this study also did not contribute to better outcomes. Carlisi 
et al. (2018) also found no benefits with the addition of eccentric shoulder ab-



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ductor training for calcific supraspinatus tendinopathy during a 9-week-long 
treatment protocol combined with ESWT.

Other physiotherapeutic interventions and methods

The addition of balneotherapy to the “traditional physiotherapy” model 
is effective for patients with subacute supraspinatus tendinopathy. Koç et al. 
(2020) found it improves ROM, pain reduction, and shoulder function. Guan et 
al. (2020) found improvements in shoulder function and reduced inflammation 
with the addition of Electroacupuncture Therapy to “traditional physiotherapy” 
twice per week. The 6-week, 3-day-per-week intervention was carried out on 
a population with full-thickness rotator cuff tears, with failed six months of 
conservative treatment. 

Kinesiotaping is also a potentially applicable method for symptomatic rota-
tor cuff injury treatment. A 1-week-long addition of kinesiology tape results in 
improved function and pain reduction compared to “traditional physiotherapy” 
only (Coşkun et al., 2018). The authors of this study pointed to enhanced senso-
rimotor and proprioceptor effects as the likely mechanisms for those improve-
ments. Frassanito, Cavalieri, Maestri and Felicetti (2018) found that the ad-
dition of kinesiotaping reduces the required rotator cuff calcific tendinopathy 
treatment response time compared to when using only ESWT. The improve-
ments of kinesiology tape addition were seen both in short- and medium-term 
outcome results. During their 6-week long study, De Oliveira et al. (2020) 
found that adding kinesiotaping to the established rehabilitation program with 
an emphasis on sensorimotor training does not provide superior medium- or 
long-term outcomes for individuals with rotator cuff-related shoulder pain. The 
study identified the greater influence of exercise and the absence of a more de-
tailed diagnosis as possible reasons for those results.

Guidelines for rotator cuff injury treatment for Olympic 
Weightlifters

While we can conclude that “traditional physiotherapy” is suitable for ad-
dressing the majority of rotator cuff injuries, physiotherapists should use addi-
tional methods to improve outcomes. This is vital with Olympic weightlifters, 
whose primary goal is usually to return to training as soon as possible after 
sustaining an injury. 



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Kinesiotaping and thoracic spine mobilization are two easily applied me-
thods that may improve treatment outcomes of a wide range of rotator cuff 
pathologies. Mulligan mobilization can be added if the individual is dealing 
with a partial rotator cuff tear, while electroacupuncture may be more suitable 
for small to medium full-thickness tears. 

ESWT seems to be a very effective method for addressing sub-acute and 
especially chronic rotator cuff tendinopathies, and its effectiveness can be en-
hanced with the addition of electromagnetic transduction therapy. HILT and 
balneotherapy are other methods that can be utilized for chronic pathologies if 
ESWT is not available. 

We believe that comprehensive exercise intervention is an essential part of 
any shoulder rotator cuff injury rehabilitation, but is especially crucial for Olym-
pic weightlifters. A suitable exercise program should be based on the results of 
the initial diagnostic testing which should provide information about shoulder 
ROM, stability and both periscapular and rotator cuff muscle strength imbalan-
ces and deficits. Even minimal, 1–2 millimetres of uncontrolled shoulder joint 
translation can result in pain and shoulder symptomatic (Horsley & Ashworth, 
2016). Addressing found deficits should thus be the physiotherapist’s priori-
ty along with methods for reducing pain, inflammation and swelling (Weiss, 
Wang, Hendel, Buzzerio & Rodeo, 2018). 

Any possible exercise technique flaws that may be connected with the 
symptoms should also be identified and addressed in collaboration with coa-
ches, while the activities that cause the pain should be discontinued or at least 
modified (Escalante, 2016). Additionally, an examination of possible spikes in 
weightlifters’ training loads should also be performed as those correlate with 
injury incidence (Jones, Griffiths & Mellalieu, 2017). 

If the shoulder pain is severe and accompanied by any kind of functional im-
pairment or if the primary interventions failed to solve the issues within a short 
period, more detailed imaging diagnostics should be prioritized. It is crucial to 
assess if the pain is associated with structural rotator cuff damage, which would 
warrant a larger modification of the training plan. Determining if the continua-
tion of the specific overhead activities presents a risk for further complications 
or more severe injury is also warranted. Based on the diagnosis, utilizing the 
appropriate combination of the aforementioned physiotherapeutic methods is 
vital for the most effective rehabilitation.  

Lastly, if surgical treatment is chosen to treat the rotator cuff injury, physi-
otherapists can improve functional outcomes by adding scapular training exer-
cises to “traditional physiotherapy” protocols within the first 12 weeks after the 
injury (Zhang et al., 2020). Based on multiple sources, Serrano (2020) recom-



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mends introducing basic overhead activities approximately 16–20 weeks and 
more weightlifting-specific activities approximately 20–26 weeks after the sur-
gery. It should be emphasized that the exact timeline for these activities should 
be tailored to each individual’s progression and capabilities.

CONCLUSIONS

With appropriate diagnostic tests and an optimal combination of physio-
therapeutic methods, the rehabilitation effects of acute, sub-acute, and chronic 
rotator cuff injuries can be improved. While “traditional physiotherapy” in-
volving kinesiotherapy coupled with ultrasound, TENS and cryotherapy or 
thermotherapy is effective, the addition of ESWT or Mulligan mobilization re-
sults in superior outcomes for chronic and sub-acute rotator cuff pathologies. 
Furthermore, combining ESWT with electromagnetic transduction therapy and 
kinesiotaping seems to provide additional benefits. Early-stage shoulder injury 
rehabilitation of Olympic weightlifters may not be significantly different from 
that for the general population. Shoulder ROM, rotator cuff and periscapular 
musculature strengthening are all critical for later more sport-specific stages of 
rehabilitation, during which gradual exercise and training load progression are 
crucial for returning to full weightlifting training.

The main limitation of this work is that practical research on physical the-
rapy protocols specifically for Olympic weightlifters dealing with rotator cuff 
injuries is very limited. This must be considered especially when interpreting 
the results and deciding on optimal physiotherapeutic interventions in later, 
more sport-specific stages of the rehabilitation process. 

We believe that future research on rotator cuff injury rehabilitation in Olym-
pic weightlifting should focus on effective sport-specific late-rehabilitation 
stage protocols and long-term post-operative rehabilitation protocols. Lastly, 
defining a unified approach with comprehensive diagnostic testing, both for 
guiding the progressions through phases of rehabilitation and identifying sport-
-specific issues and pain within the shoulder joint is essential. This enables 
practitioners and coaches to better understand and identify the rotator cuff inju-
ry risk factors that may originate from the training process itself. 



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