Shoulder Rehab
Shoulder rehab: avoiding common errors that can lead to prolonged pain and dysfunction
The rotator cuff is a group of four muscles that function together to provide glenohumeral joint (shoulder joint) stability throughout movement. Rotator cuff tears, tendinitis and tendinopathy are extremely common musculoskeletal injuries for sports people and people who take part in regular overhead activities for work or recreation (Brukner & Khan, 2012). Injuries to the rotator cuff muscles can be caused by a sudden high-load exercise on the shoulder or frequent low-load exercise with poor underlying biomechanics. Risk factors for rotator cuff injuries include:
Increase in age
Genetics
Poor biomechanics: kyphotic (rounded) mid-spine, protracted scapular (forward rounded shoulder blades), internally rotated glenohumeral joints, and
Participating in regular overhead activities such as swimming, baseball or work related lifting.
Most rotator cuff injuries will be managed without surgery, with one main exception being a young high-level sports person with an acute full-thickness rotator cuff tear (Brukner & Khan, 2012). One of the biggest mistakes made in conservative treatment is the prescription of a rotator-cuff specific exercise program without correcting many of the underlying biomechanical faults that have lead to this injury. Think of it this way: you would never choose to build your house on unstable foundations. While it may start out looking good, over time the foundations would fail and you would lose all of the time and resources you put into building your house.
Like this analogy, there is little benefit in attempting to rehabilitate the rotator cuff, if you are doing so with a rounded mid-back, protracted shoulder blades and inward rotating shoulders. In this position, the rotator cuff muscles are in a sub-optimal position to stabilise the shoulder joint. Because of the complex nature of this multidirectional joint, exercising a shoulder with poor biomechanics is likely to have a domino effect leading to impingement, bursitis, instability and potentially more sever shoulder pathologies such as labral tears and frozen shoulder (adhesive capsulitis) (Brukner & Khan, 2012).
To ensure that you build stable foundations for your rotator cuff to function from, here are some essential phase 1 and 2 exercises that should be done prior to beginning exercises specifically focused on strengthen the rotator cuff.
Phase 1 Setting the foundations – Thoracic Spine (mid-back) and ribcage
The following two thoracic spine exercises are essential for people with poor posture, specifically people who are slumped forward through their mid-upper back and ribcage. These exercises will be especially important for people with shoulder pain bilaterally (on both the left and right side) (Brukner & Khan, 2012). Correcting the position of the spine and ribcage will allow the shoulder blade to glide correctly over the rib cage during overhead movements of the arms. It will also allow muscles controlling the shoulder blades to sit at an optimal length-tension relationship to avoid further pain and dysfunction.
Swan / Cobra
Purpose: improve thoracic extension
Parameters: 2x10reps daily
Begin by lying on your stomach with your hands beside your shoulders. Start to extend through your neck and then extend vertebrae-by-vertebrae down your spine towards your pelvis. Use your arms to assist in the intervertebral movement. Focus on shining your sternum (chest bone) out in front of you to increase upper-mid thoracic extension. Slowly lower yourself back to your start position by reversing the intervertebral movement now moving from your pelvis towards the base of your skull.
Book openings
Purpose: improve thoracic rotation
Parameters: 2x10 reps left and right side daily
Begin by lying on your side with your hips and knee stacked on top of each other and your arms at 90 degrees to your trunk. Reach your top hand forward sliding it along the ground in front of your bottom hand. Keeping your elbow straight, lift your top hand up towards the ceiling and then continue to move your arm towards the ground on the opposite side of your body. Follow your hand with your eyes ensuring that your mid-back and neck move along with your arm. As your spine rotates to allow this movement of your arm from one side of your body to the other, ensure your hips stay stacked on top of each other to achieve the full benefits of this mobility exercise. Reverse the movement of your arm to return to your start position and then repeat 10 times before coming onto the opposite side.
Phase 2: Setting the foundations - Scapula (shoulder blade) and glenohumeral joint
Once someone is able to come into the correct spinal alignment we can then start working to improve scapula control. Whilst everyone’s rehab is individualised, phase 2 exercises typically focus on improving strength of serratus anterior, lower fibres trapezius and middle fibres trapezius while working to dampen down over activity of upper fibres trapezius (Brukner & Khan, 2012). Overhead movement of the shoulder is made up of movements of both the glenohumeral joint and scapula. Correcting poor scapula control will provide a stable base for the rotator cuff to work off when providing stability to the glenohumeral joint through range.
Serratus Anterior punches
Purpose: Serratus anterior strength, scapula control
Parameters: 2-3 sets 8 reps, 60 second rest between sets. Resistance/weight to be determined by physiotherapist and individualised to each client’s program.
Begin by lying on your back and reach both arms up, perpendicular to your trunk. Without lifting your head, reach your arms up further noticing your scapular move towards the side of your ribcage away from your spine. Keeping you elbows straight, bring your arms back to their start position. Notice how this movement comes from the scapular moving back towards the spine. Progress this exercise by using a theraband or weights for resistance in this same position or by using a theraband in standing.
Scapula retraction with arms by side. Progress to Ts and Ys
Purpose: Middle and lower fibre trapezius strength, scapula control
Parameters: 2-3 sets 8 reps, 60 second rest between sets. Weight to be determined by physiotherapist and individualised to each client’s program.
Begin by lying on your stomach with arm by your side and palms on the ground. Retract your scapula moving them in toward your spine then lift your hands off the ground. Hold for 5 seconds. Return to your start position and repeat.
Progress this exercise by bringing your arms perpendicular (90 degrees) to your trunk for Ts. Place your palms on the ground. Lift your hands off the ground while squeezing your shoulder blades in towards your spine. Hold for 5 seconds. Return to your start position then repeat.
Progress this exercise further by sliding your arms along the ground up towards your head for the start position of Ys. Ys are the same as Ts except your arms start at approximately 120-130 degrees to your trunk, your hands are above your head and your thumbs face up.
Once we have good spinal alignment and adequate scapular control we need to ensure adequate glenohumeral joint mobility before we begin to strengthen muscles into this range. Typically this population will be limited into internal rotation and therefore the following stretch can be performed to increase internal rotation by stretching the posterior capsule (Brukner & Khan, 2012). The cross-body stretch has been found to be safer than the sleeper stretch and superior in stretching the posterior capsule.
Cross-Body Stretch
Purpose: Stretch posterior capsule, improve internal rotation of shoulder
Parameters: Begin with 3 sets of a 10 second gentle pain-free stretch (mild-moderate intensity), progress towards 2 sets of a 60 second gentle pain-free stretch (mild – moderate intensity).
Begin in standing with your shoulder blade retracted (pulled in towards your spine). Lift the arm up to 90 degrees and bent the elbow to 90 degrees. Use your other arm to gently bring the upper arm horizontally across your body. Make sure you do not let your shoulder blade move away from your spine as you hold this stretch.
Phase 3 and beyond: Rotator cuff exercises
From here, most people know how to progress their rotator cuff rehab programs correctly. Simple theraband or weighted exercises aimed at improving rotator cuff strength can be done with good body mechanics. Progress can be made by activating the rotator cuff through different ranges of shoulder elevation. Rehab is often focused on improving outward (external) rotation as it is usually much weaker than internal rotation. Exercise progressions move towards more function exercises and then sport/work specific exercises to ensure safe return to sport or work.
Rehab now days also focuses on preventative treatment for rotator cuff injuries. This can mean continuing rotator cuff rehab after pain has resolved to prevent future re-injury with continued overhead activity. Finally, please not that while we use rotator cuff injuries as the focus of this article, these phase 1 and 2 exercises can also be used with great benefit when rehabilitating many other shoulder injuries including impingement, bursitis and instability.
- Ayla
References:
Brukner, P., & Khan, K., (2012) Clinical Sports Medicine 4th Edition. Australia: McGraw-Hill Education Pty Ltd