My 5 Least Favourite Shoulder Rehab Exercises

https://thesportsphysio.wordpress.com/2014/02/20/my-5-least-favourite-shoulder-rehab-exercises/

Following on from my previous piece 'My 5 Favourite Shoulder Rehab Exercises' which I honestly thought would cause more controversy and gnashing of teeth than it did, I thought I would write another piece looking at my five least favourite shoulder rehab exercises. This again will be heavily based on my own personal opinion and experience with some supporting evidence, and as before I'm hoping it will create some debate and discussion, so please leave your comments below or on Twitter

I need to thank Matt Croger aka @PTPain for giving me the idea for this post in a conversation we had, so please go follow him as a thank you from me!

Now, before I go any further I need to put a disclaimer in here and say that really I don't think there are many 'bad' exercises, just bad choices and recommendations by therapists and bad execution and compliance by patients. Most of the time its not the exercise that should be blamed, rather the therapist giving them out or the patient doing them poorly, if at all, however, these exercises I've chosen are arguably either ineffectual, problematic or at worst dangerous!

So here we go, my 5 least favorite shoulder rehab exercises!

No 1: Scapular Setting

This exercise easily gets my No 1 as my least favourite, ineffectual, shoulder rehab exercise, even it's name winds me up, scapular setting, setting for what?

Scapular setting is regularly given to patients who are seen to have rounded or slouched shoulders, or when a 'winging scapular' is noted (see images below). 

Winged Scapular

The patient is instructed to sit or stand and asked to pull/squeeze their shoulder blades back together and down (see image below), it is commonly given out in an attempt to correct and improve the resting position and static posture of the shoulder girdle, it is also thought to strengthening the lower trapezius muscle and so given out on the premise of improving posture, reducing scapular winging and relieving pain! 

Scapular Setting Exercise

However, in my experience it does none of these, if anything it often makes matters worse and increases pains and problems by asking people to hold themselves in braced, stiff, awkward and strained positions sometimes for extended periods of time.

The notion that there is a preferred or correct way to hold your shoulders, or any other part of your body for that matter, is in my opinion. nonsense! Anatomical, environmental and activity variability make this so, we are all different, we all look different and we all move different, if we weren't the world would be a very boring place. There is no robust evidence that one posture is any better than another, yet we insist as therapists on advising and instructing our patients to adopt 'textbook' postures and positions, based on ideals that are false and misleading.

Variability of position is far more important in my opinion, an ability for an individual to change positions and postures is far more useful than being able to maintain just one, and above all else, all positions of posture should be comfortable and pulling your shoulders back and down just isn't for most!

The notion that scapular setting will reduce a winging scapular by strengthening the lower trapezius muscle is also flawed, we know that a winged scapular is an issue due to a weakend Serratus Anterior and scapular setting does not target the Serratus Anterior, it's more targeted towards the lower trapezius muscle

But the reasoning to use scapular setting to 'strengthen' the lower trapezius is also a flawed one, the low force of contraction produced in this position will not produce the required tension to effect a change in its strength, there are far better exercises for achieving this goal, such as the 'prone Y lift' as mentioned in my 5 favourite shoulder rehab exercises (source).

Finally is scapular winging really that much of an issue? There is no clear association with scapular winging and shoulder dysfunction (source), so should we even worry about it, although I do attempt to 'improve' it in most I see with it, and we know that there is no association with a shoulders static resting posture and its dynamic ability (source), so just beacuse a scapular is winged or sits anteriorly titled or downward rotated does not mean it will say this way when it begins to move.

No 2: The Barbell Upright Row

This next exercise almost got my No 1 spot as I loathe it with a passion, but as there are some variations of it that I do think can be useful for some so it was downgraded to No 2! But the standard weighted barbell upright row is just a horrible and potentially dangerous exercise that has no place in shoulder rehab, nor in strength training for that matter!

This exercise is performed by holding a barbell and lifting it up the front of your body until the bar is under your chin (see image below).

Upright Row

Not only does this make you look like a demented chicken, flapping your elbows up and down, but the end position of the shoulder joint is in combined abduction and internal rotation! Now does this position look familiar? Yep it's the same position as one of our most common sub acrominal pain povocation tests, the good old Hawkins Kennedy Test, when we try to push the humeral head up against the acromial arch squeezing the structures beneath it to see if they cause pain, but I. The upright row we are doing it repeatedly, with speed and with weight, can you begin to see a potential issue here!

Hawkins Kennedy Test

However, there are modifications of the upright row that I do like, as this exercise does create high forces in the upper trapezius and a stack load of other muscles which can be desirable. The modification I like is in a single arm snatch movement (see image below), where you pull a weight up from the floor infront of you and end up with it above your head, doing it this way and doing it with a single arm produces much less force and less time in the 'danger zone' of combined abduction and internal rotation and incorporates a whole body movement, so giving more 'bang for your buck' per rep.

Single Arm Snatch

No 3 & 4: Theraband Rotations in Neutral

Now those that know me, will not be surprised that these two exercises are in my least favourite catergory, with me often criticising (some say whinging and moaning) on there over use and application, not just beacuse the exercises have issues, but also for some other reasons.

These exercises are performed by pulling a theraband either across the body for internal rotation bias, or away from the body for external rotation bias, with the elbow bent at 90 degrees and the upper arm down by the side of the trunk (see images below).

Theraband Rotations in Neutral

The main reason I don't like these exercises is simply due to their lazy, over prescribed use by so many therapists for every shoulder pain they encounter, giving them out routinely to all patients with any shoulder issue, no matter the condition or the diagnosis, not thinking, not fully assessing, not clinically reasoning.

Many argue that these exercises do have a role with many shoulder issues as they are simple to do and easy to teach and as they get some force into the rotator cuff muscles and tendons and so strengthening them, but what most don't know is they don't get as much force into the cuff as they do in the deltoid and pecs. Studies have show high EMG activity in the delt and pec during neutral rotational exercises, so they get your delts and pecs strong, but not really your rotator cuff (source)

Another reason I don't like or use these exercises is they lack the co contraction of the cuff needed to dynamically stabilise the humeral head as they target all the torque producing muscles of the shoulder in one direction so creating potential shearing forces in the joint (source)

There are, in my opinion, far better alternatives than doing rotational movements in neutral positions, for example, simply elevating the arm into unsupported elevated position targets the cuff more specifically (source) although again they don't produce much better cuff co contraction which is often needed!

Finally another reason I'm not a fan of these exercises is they could compound some shoulder problems rather than help solve them, for example the external rotation exercises in neutral also targets the rhombiods heavily and this muscle acts as a strong scapular downward rotator, usually not advantageous in sub acromial pain

So in summary I don't like shoulder rotation rubber band exercises in a neutral postion and when I see a therapist giving out both internal and external exercises to the same patient at the same time a little piece of me starts to cry quietly inside as I see our profession losing its credibility, one rubber band exercise at a time… please stop!

No 5: Anything on a Bosu, Swiss Ball or Wobble Board

Finally the idiocy that is unstable surface training gets my last spot. When it comes to shoulder rehab (and most other rehab) training on unstable surfaces is just bonkers and a gigantic waste of time and energy, it's usually done more for the therapists benefit than the patients, giving an illusion of complexity and 'thinking out side the box'

Bonkers…

There is absolutely no sound clinical reason to do any shoulder rehab exercises on an unstable surface, unless perhaps you are thinking of doing over head weights standing in on a rowing boat in the middle of the open sea.

Studies have shown that there is no increased muscle activation in any muscle groups so no gains in strength by exercising shoulders on unstable surfaces (source) (source), as for the argument that it improves 'core' activation, that also has been shown to be not true (source).

However if in closed chain positions then perhaps, the role of unstable thingys could be useful in some instances, such as a press ups action on Swiss balls, as this does show in some research increased muscle activation (source) but then in others it doesn't (source) and the reasoning and functionality of doing such exercises again has to be questioned strongly (source).

So there you go, my five least favorite shoulder rehab exercises, please let me hear your comments and opinions and if you have any others you would of like to have seen added to the list.

As always, thanks for reading

Enjoy your sport

Adam