Rotator Cuff Pain: Best Exercises

 

What are the best exercises for rotator cuff pain?

By now you know that my answer to these types of questions is pretty much always “it depends”.  As professionals, we need to be more analytical in the way we select the exercises we provide our clients with as part of their self-care routine.

 

The biggest gap I see between the clinic and the gym is a lack of actual rehab programming and individualization.

 

People are typically given generic rotator cuff exercises for 3 sets of 10 and very little structure elsewhere.

It’s not that this is ALL wrong…I try to practice Buddhism and see the good in everything 😊! It’s just that I think it can be more optimal.  In rehab, we prescribe rotator cuff exercises to re-activate the cuff, as it becomes inhibited due to injury and/or pain.  Re-establishing that neuromuscular connection is an important part of the rehab process!  The problem is more about how we are choosing the exercises, the parameters we prescribe and the strategy within which we integrate them.

 

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PROVIDING STRUCTURE

One of the most important components of an effective rehab strategy is structure.  Here’s the typical rotator cuff rehab scenario:

  1. I have rotator cuff pain
  2. I get treatment (manual therapy and modalities)
  3. I am prescribed generic rotator cuff exercises with blue theraband and told not to do anything that creates pain, or even worse, stop training.

There are a number of things right with this, but also a number of things wrong.  Manual therapy is an important part of the rehab process, because pain will change the way an individual moves.  If someone is in pain, their willingness to move and their potential for movement will both be perturbed.  As for rotator cuff exercises, as mentioned above, they are important to address muscle inhibition.

There are however also a number of problems with this approach.

 

For one, rotator cuff exercises do not induce sufficient levels of activation to stimulate muscle growth and strength

 

I discuss this at length in my article The Overused and Misused Rotator Cuff Exercises.

Telling people not to do anything that creates pain starts a cascade of problems which usually results in people winding up not doing much at all.  For one, tendons that are tendinopathic become neurally sensitized such that even minor mechanical stress will induce pain that is not necessarily indicative of further tissue damage.

This also means that people will experience pain with many movements, which is why telling them not to do anything that creates pain winds up with them not doing anything at all.  For tendons, not doing anything is actually detrimental.  And further, not doing anything means you are also underloading surrounding healthy tissues, which only further increases the gap between rehab and performance.

On the other hand, asking an avid trainee or athlete to stop training is a hard pill to swallow, so they may end up doing exactly the opposite.  They won’t stop and will keep the cycle of pain and injury rolling.

We need to do a better job at accompanying clients through the process so that we can ensure strength in the continuum of care.  In last week’s article Rotator Cuff Pain Assessment: Which Muscle is it? , I discuss how to determine which muscle may be more irritable and some of the exercise modifications you can make to keep people moving.

 

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3 SETS OF 10?

Did you know rehab exercises don’t always have to be done using 3 sets of 10?  In fact, when working on rotator cuff exercises to address muscle inhibition, mind-muscle connection is more important than whatever number of sets and reps you prescribe.  Quality before quantity.

Isometrics

Initially, isometrics can be very useful for several reasons.  For one, they can provide an analgesic effect.  While the optimal dose that is needed to provide analgesic effects is not well-documented, both low-intensity, long-duration and high-intensity, short-during isometrics have been shown to have an analgesic effect.  If an individual is highly irritable, you might go for a lower intensity, higher duration contraction, pushing out into external rotation into a wall or squat rack for 15, 30 or 45 seconds for example.

Second, isometrics provide higher activation levels when compared to eccentric and concentric contractions.  An added advantage is that form, scapular stability and rep-to-rep variability are taken out of the equation when you use isometrics.  All the individual has to focus on is the contraction.

Eccentrics

Eccentric contractions are also very helpful in the initial stages.  Rotator cuff exercises can go very wrong if no attention is paid to scapular positioning.  On a side note, your interventions for rotator cuff pain should include scapular stabilization exercises.  Head to my article Functional Positions of the Shoulder You Need to Own for more on that.  Performing eccentric-only rotator cuff exercises makes it easier to maintain that scapular stability initially.

As well, the muscle spindle, which normally causes a reflexive contraction of the muscle during lengthening is inhibited to allow for an eccentric contraction to occur.  This increases cortical drive to the muscle, exactly what we want for better activation.

 

CHOOSING THE RIGHT EXERCISE

As discussed in my article last week, the rotator cuff tends to be viewed as having an external rotation function.  Yet, the subscapularis, which is the largest and strongest muscle of the cuff, is an internal rotator, and the supraspinatus’ function is rather to assist in abduction.

 

That’s a 50% chance you’re off the mark if you’re using an external rotation exercise

 

Here are a few suggestions of more specific exercises:

Supraspinatus

When choosing a rotator cuff exercise to reactivate the supraspinatus, having the arm down by the side is not ideal, nor is holding the arm at 90 degrees of abduction.  Prone external rotations are a better option, and side lying screwdrivers also work well.  You can see how the prone external rotations are done in the article I mentioned previously to see how to do the prone external rotations, and make sure to watch the main video of this article as I go through the side lying screwdriver and variations.

Subscapularis

Rotator cuff activation exercises for the subscapularis obviously have to provide an internal rotation resistance.  If someone was very irritable, you could have them just do an isometric belly press: simply place the hand on the belly and push into internal rotation.  Because the subscapularis is important for providing anterior stability of the shoulder, I also like to use a position that can target that, such as a band press with internal rotation resistance.  Again, watch the main video of this article to see what this looks like.

Infraspinatus and Teres Minor

The infraspinatus and teres minor, also referred to as the posterior cuff, are the main external rotators of the glenohumeral joint.  One of the more important things to know is that they do not have the equivalent posterior pull when compared to the antagonist anterior pull of the pec major.  If the pec major is facilitated (or tight), it may make it that much more difficult to activate the infraspinatus and teres minor via external rotation exercises.  Make sure you address that first in your Mobilization sequence.

Prone and side lying external rotation exercises are a good choice here.  The side lying wiper exercise is a fairly novel exercise I have started using and find to work quite well.  For one, it allows for more range of motion so people get a better feel and connection.  As well, studies have shown it to be more effective in isolating the infraspinatus when compared to other exercises.  Read about it here.

 

THE GOAL IS TO BE OPTIMAL

So, have you figured out what the best exercises for rotator cuff pain are?  There is rarely a single “best” exercise that will work well for everyone.  For one, there needs to be a strategy that dictates which exercises we use and why we are using them, and for that you need a proper assessment.  As well, we need to consider the client perspective.  Exercises work well not only when they are executed properly, but when they allow people to become aware of movement and improve their mind-muscle connection.  Especially for rotator cuff activation exercises!

Granted, no intervention is perfect.  Our goal is rather to provide the best structure based on all of the information that we can gather.  This requires us to move away from our standard protocol using generic exercises and rep schemes such as External Rotation 3 x 10.  We need to approach rehab as we would training to induce specific adaptations and then translate those adaptations into increases in performance.

 

References

Ha, S. M., Kwon, O. Y., Cynn, H. S., Lee, W. H., Kim, S. J., & Park, K. N. (2013). Selective activation of the infraspinatus muscle. Journal of athletic training, 48(3), 346–352. https://doi.org/10.4085/1062-6050-48.2.18

 


 


Mai-Linh Dovan M.SC., CAT(C)
Certified Athletic Therapist
Founder of Rehab-U

 

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