Rotator cuff exercises suck! … Or do they? I imagine I just wanted to get your attention. Actually, I don’t really think rotator cuff exercises suck, I just think they are overused and often misused as a means to all ends for everything shoulder pain related. Which, come to think about it, means they have the potential to suck. But it’s not the exercises that suck, it’s the application.
I had an internship student working with me this semester. She has known me for a long time and heard (or seen) many of my rants about dumbbell external rotation exercises. So, she was surprised when she saw me working with clients and actually using various external rotation exercises.
My answer was that it’s not that these exercises are wrong, nor are they useless. However, they can be if they are not executed properly, if they are not prescribed appropriately and/or if they are not placed within a strategy to optimize their effectiveness.
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The biggest gap I see between the clinic and the gym is a lack of actual rehab programming. People get treatment and (maybe) limit some of their activities in the gym. Best case scenario, they’re being given a generic rehab exercise or two to throw into their daily routine, such as an external rotation exercise…or maybe three. In the end, they feel better after treatment, but they don’t get better, or at least not in as timely a manner as they should. To know more about my thought on this, head to my blog to read my article There is More to Rehab than Manual Therapy.
EXTERNAL ROTATION EXERCISES
Is it wrong to give someone with a rotator cuff issue an external rotation exercise? It’s generally not, but it can be. I know that’s not an answer, but I will paint a clearer picture as we move forward through this article.
From a rehab perspective, an external rotation exercise is usually given to re-activate a muscle, which is important for many reasons. Joint injuries may cause arthrogenic muscle inhibition. This is a clinical impairment caused by an ongoing reflex inhibition of the musculature surrounding a joint following damage to structures of that joint.
Furthermore, immobilization, limitation, restriction and/or apprehension of certain movements or ranges of motions can lead to decreased muscle activation.
In training, we prescribe peripheral activation exercises to improve mind-muscle connection: to improve the capacity to recruit and contract a muscle. We can view our external rotation exercises in a similar manner. The objective is to stimulate neuromuscular activation.
WHERE THINGS GO WRONG
- Proper Execution
There is probably nothing more prevalent in our industry than simple exercises done wrong. Rotator cuff exercises are one of these. There is a place for simple, basic exercises, and they can be quite effective if they are done with proper execution, and perhaps even more importantly, with the proper intention.
Execution can go wrong for many different reasons. For one, I see activation exercises go wrong when people start to view them as strengthening exercises. The more you load an exercise, the more opportunity you create for compensation. And this is probably even more true for exercises that require meticulous execution. I make a point of telling my clients that an activation exercise should almost feel more cognitive than physical.
Another thing I’m sure you have also seen is people letting the shoulder roll forward with every rep. Is a muscle shortening or eccentrically lengthening if you move both insertion points? Being able to perform an external rotation exercise properly requires being able to control the scapula. As such, it is always a good idea to include scapular movement awareness and control exercises into the mix.
Watch the main video to hear about proper execution of rotator cuff exercises.
- Appropriate prescription
If you have heard my rants on external rotation exercises, you have heard me say that you can actually irritate someone’s rotator cuff even more using these. Part of that may come down to proper execution, which we will get to in a minute, but first let’s talk about prescription.
You can perform external rotation exercises in many ways. At zero degrees of abduction, at 90 degrees of abduction, side lying, with your elbow resting on your damn knee (my favorite, as you can see).
How do you choose? A better question: how should you choose? Often, we rely on research, and we choose exercises that have been shown to have the greatest EMG activation. For example, people often use an external rotation exercise at 0 degrees of abduction (with the arm down by the side), which has been shown to have high EMG activity, plus the position allows the scapula to “sit” and relaxes the scapular musculature. Sounds like it’s a go-to exercise right? You guessed it, not exactly.
Recent studies have shown that compression may play a role in tendinopathy. Cook and Purdam put out a very interesting article about this in 2011: Is compressive load a factor in the development of tendinopathy? Specifically, the combination of compressive and tensile loads on the tendon can be particularly damaging. At zero degrees of abduction, when your arm is by your side, the rotator cuff tendons, particularly the supraspinatus tendon, are essentially “bent over” the head of the humerus. Exercising the cuff in this position subjects the tendon to a high compressive load and can be quite irritable.
Contrary to what we might think, it’s sometimes safer to start external rotation at 90 degrees of abduction or sometimes higher. We just need to be smart about the positions we use.
Another muscle we need to keep in mind is the subscapularis. Unlike the other 3 muscles of the cuff, the subscapularis is an internal rotator, so it is often missed in the traditional external rotation exercise prescription. However, it plays an important role in preventing superior migration and anterior displacement of the humeral head.
- Optimal Strategy
While rotator cuff exercises work well to stimulate neuromuscular activation, they do not induce sufficient levels of activation to stimulate muscle growth and strength. And without strength, there is no resilience. This is why we need to ensure that we always have strength in the continuum of care and why I always use the expression “Rehab is training”.
Just throwing rotator cuff exercises into the mix, and doing nothing else aside from avoiding certain movements, or continuing to perform movements with less load is not an efficient strategy. Healthy tissues will end up being underloaded, compensation may occur, movement apprehension will set in…and the list goes on.
Rotator cuff exercises needs to be built into a structure that revolves around load management. Rehabilitative exercises are specifically concerned with restoring normal function following injury, but strength exercises should also be included.
Load management is nothing more than exercise modification. It means you select exercise variations, methods and loading schemes to:
- Limit exercises that are pain-triggering to prevent ongoing irritation of sensitive or sensitized structures
- Identify exercises that have the potential to load uninjured tissue without over-exposing injured tissue
- Progressively load the injured tissue without exceeding its tolerance
ROTATOR CUFF STRATEGY
Rotator cuff exercises CAN suck! Instead, I urge you to consider a rotator cuff strategy that can include these exercises. With injury to the cuff, the prime movers like the upper traps, deltoid, pecs and lats often become upregulated. It might be a good idea to downregulate these in the Mobilization sequence. The objective is to create space and avoid having these muscles “take over” when we work on the scapular musculature.
Since people often enjoy doing soft tissue release with a ball and find it alleviates their tension, you could use this strategy in the Mobilization sequence. Here’s an example for the upper traps using a lacrosse ball:
As mentioned earlier, being able to perform an external rotation exercise properly requires being able to control the scapula. Scap awareness and control exercises should precede rotator cuff exercises in the Activation sequence. The objective is to gain awareness and increase neuromuscular activation.
Here is an exercise I like to use to promote scapular awareness and control:
And here are 2 examples of alternative exercises for the rotator cuff:
You can add difficulty to this exercise by performing it with a kettlebell held in a bottoms-up position.
Despite the fact that this is performed at more than 90 degrees of abduction, it is typically well-tolerated by most people. As an added benefit, you can use it to bring awareness to scapular movement (posterior tilt) with external rotation.
Integration is essentially about maintaining awareness and positioning under load, and of course, load management as explained in the previous section. It’s basically everything you change within your programming to respect the rehab process.
And let’s not forget! There is much more to the rotator cuff that band and dumbbell isolation exercises. The muscles of the cuff work synchronously with specific activation patterns which cannot be replicated by voluntary contraction of the muscles alone using these isolation exercises. This dynamic and reactive stabilization is the true function of the cuff, that is, to provide functional stability. If you are interested in learning more about how to restore functional stability, I discuss it at length in this article.
Remember, it’s more about the strategy than the exercises!
References:
Andersen, L., Magnusson, S., Nielsen, M., Haleem, J., Poulsen, K., & Aagaard, P. (2006). Neuromuscular Activation in Conventional Therapeutic Exercises and Heavy Resistance Exercises: Implications for Rehabilitation. Physical Therapy, 86(5), 683-697
Cook, J., & Purdam, C. (2011). Is compressive load a factor in the development of tendinopathy?. British Journal of Sports Medicine, 46(3), 163-168
Edwards, P., Ebert, J., Joss, B., Bhabra, G., Ackland, T., & Wang, A. (2016). Exercise Rehabilitation in the Non-operative Management of Rotator Cuff Tears: A Review of the Literature. The International Journal of Sports Physical Therapy, 11(2), 279-301
Farina, D., & Negro, F. (2012). Accessing the Neural Drive to Muscle and Translation to Neurorehabilitation Technologies. IEEE Reviews in Biomedical Engineering, 5, 3-14.
Mai-Linh Dovan M.SC., CAT(C)
Certified Athletic Therapist
Founder of Rehab-U
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