My Top 5 Shoulder Rehab Exercises

https://thesportsphysio.wordpress.com/2014/02/14/my-top-5-shoulder-rehab-exercises/

I often get asked what are my favourite rehab exercises for shoulders, but this is a tricky question to answer as there are so many different variables that make me choose an exercise, but there are some exercises I do seem to find myself regularly falling back on, so I thought I'd write a little piece on them, and for a change, I thought I would base this piece more around my own clinical experience and opinion rather than just what research and evidence says (although it always influences my choices and is never far away), and for the sake of brevity I thought it best to keep it to just five exercises.

So why have I have chosen these five exercises? Well firstly, I seem to use them a lot with different conditions so I class them as multi purpose exercises, they are also simple, easy to coach/teach and require little or no equipment, finally they can be adapted to suit the client you have and progressed easily. They are however, not the most exciting, or fancy, or cutting edge exercises, as I find with most things, get the simple things right, and leave the fancy stuff for the show offs!

However, before I get started let me make it clear that I have come up with this list based on 'MY' experience and these are the five exercises I find 'MYSELF' regularly falling back on due to the shoulder issues 'I' encounter, your clientele maybe different, and although they can be used with a lot of shoulder problems they may not be suitable for some. 

I am also NOT saying these exercises are the best for injury prevention or strength or function, and talking of function I'm sure the functional movement aficionados will have some comments, and on this note, I am actually hoping this piece will create some debate and discussion and I truly encourage this, I think the more we can discuss different rehab ideas and approaches the more we can learn from each, other so please leave your thoughts and comments below!

Ok are you ready, let's get started…

No 1: Rotator Cuff Isometrics

Ok, ok I'm cheating here with my No 1 exercise as it's really three exercises, but the simple, basic isometric rotator cuff exercise is too often over looked and under used, which is a shame as I find it very effective in reducing a lot of shoulder pains in so many people that it deserves my No 1 spot despite it's perceived boring and simplistic nature.

Isometric exercises for those non therapists reading this is when a muscle/tendon is asked to contract but there is no movement of the joint and so no change in the length of the muscle/tendon, just like when you flex your pecs and biceps in the mirror after a shower… No!!! Its just me that does that then, ok moving on…!

In my clinic I see a lot of people with acute shoulder pains brought on usually after an increase in activity, sport or training and most I diagnose with a reactive cuff tendinopathy. Most of these shoulders have quite high pain levels for the first few weeks and we know that isometrics are great for reducing pain (source) and although they may not be the best for producing overload they do still produce some significant force and tension in the cuff and so prevent weakening and further degeneration.

There are lots of variations and I don't think it matters too much how you do them, it's more important how hard and how much you do them, more on this in a bit. 

The isometric exercises I usually give are a 'Back of the hand Wall Press' used when I suspect a more superior cuff tendinopathy, mainly effecting the supraspinatus tendon, it's done simply by standing next to a wall and pressing the back of the hand into the wall in the scapular plane (called Scaption) at approx 20° of abduction (see images below)

Next is 'External Rotation in Neutral Press' used for when I suspect more postero-superior cuff tendinopathy, mainly effecting the supra and infraspinatus tendons, this is done by resisting external rotation by pressing the back of hand into a wall again with the arm bent at 90° or by simply using the other hand, this can also be done in different angles of shoulder elevation (see images below)

Finally is the 'Belly Press' used for when I suspect more antero-superior cuff tendinopathy, mainly effecting the subscapularis tendon, this is done by placing the hand against the belly, elbow and wrist in line and push the belly in (see images below)

Isometric rotator cuff exercises

The sets, reps and frequency of these exercises that I advise are simply self directed by the patient, with an emphasis by me for them to do lots, holding each one for a long duration, usually 5-10 seconds plus, with strong-ish intensity, as this has been found to produce the greatest pain relieving effect (source) albeit in healthy subjects. The exercises are also guided by pain levels, in that it shouldn't produce more than 4-5/10 discomfort when doing them (10/10 being worst possible pain imaginable).

The reason for this rather lazy prescription technique which usually goes against my own strict exercise prescription ethos, is due to there being evidence that by allowing patients with tendinopathy pain to self guide how many exercises they do is just as effective as when given set amounts (source) ok this is only seen in Achilles tendinopathy but there is also some early evidence that self managed rehab is just as effective as set prescribed amounts for cuff tendinopathy (source). Finally I think self managed exercises when in pain produces better compliance to the regime, and as our primary goal with these exercises is for pain modification via neuro modulation rather than physical tissue adaption for strength or endurance (although these are positive side effects if they do occur, which is debatable) basically it doesn't really matter how much they do or don't do, just as long as pain reduces.

No 2: Prone Y Arm Lift

This next exercise is also one I find myself regularly giving to most of my classical sub acromial pain patients (I don't use impingement as I think it's a misleading term) be it a tendinopathy or a sub acromial bursitis or even both. I commonly give this exercise when the patient has a clear reduction in pain with the use of the Scapular Assistance Test as described by Jeremy Lewis (source) or in those that demonstrate poor scapular position and movement with either an anteriorly tilted or downward rotated scapular, or both, although links to scapular position, pain and pathology is tenuous (see Chris Littlewoods piece on this here). However, most people I see with classical sub acromial pain tend to have weak posterior shoulder muscles and this is a great exercise to start addressing this.

The prone Y lift is simply done by lying on your front, on a bed or bench, with your arm hanging over the edge, then lift the arm up and out to raise it above your head, and I like to instruct that the thumb is on top pointing upwards to ensure the shoulder is in external rotation (see image below). Again as with the isometrics the exact angle of the lift can be varied, but for best results the research says 120° of abduction produces the stongest contraction in the supraspinatus (source) and upper/lower trapezius muscles (source). 

Prone Y Lift

Now before the 'functional exercise police' start jumping up and down and explode with rage that I've dared got someone lying down doing an exercise, let me first say, come on guys… give me some credit for getting them doing it with just a single arm. These can be done with both arms and there are the group of exercises called the I, Y, T, W lifts that do this, but as they ask both arms to move together and symmetrically, I argue, when does this occur in activity or sports, not a lot, apart from maybe a butterfly stroke swimmer or a 1970's disco dancer! Anyway, this exercise can be quickly progressed into a standing position with the use of cable machines, dumbells or therabands (see image below), some times referred to as diagonal patterns of movement or PNF patterns, and to keep the 'functional exercise police' even happier, you could get your patient doing them standing on one leg, or with trunk rotation, or when doing a lunge or squat, or…. well you get the idea!

Keeping the functional movement police happy

The Y lift exercise gives a lot of 'bang for your buck' targeting two commonly weak areas in one exercises, producing high forces in the upper and lower trapezius muscles both key in producing scapular upward rotation, important in good scapular kinematics, as well as in the supraspinatus tendon key in humeral head control.

The final reason I like this exercise is that I find most patients like the challenge of this tough little exercise, most look at me when I demonstrate it and I can see them thinking… “pah easy” only to be surprised when they try. This I think increases compliance as most patients I meet like to be challenged and work on something they thought they could do, but can't!

No 3: 'Lat' Pull Downs

Now this is a bit of a curve ball for No 3, and you maybe a little surprised that a physio is recommending what's traditionally thought of as a gym based strengthening exercise for shoulder rehab, but let me explain why I like Lat pull downs for a lot of shoulder problems.

The 'Lats' or Latissimus Dorsi muscle has a bit of a image crisis, with it being seen by many therapists and coaches as a contributor to a lot of shoulder issues, with it often being blamed as a key factor in restricting over head movement of the shoulder as it becomes stiff and tight, and also as it's an internal rotator of the shoulder it's thought to contribute with the pecs in overpowering the weaker external rotators and so develop shoulder joint imbalances.

Now the above can be true, but I think the Lats are normally the victim rather than the culprit, and simply stretching them or using manual therapy techniques to loosen them off, or even working adjacent muscles or antagonist groups to counteractdoesn't seem to help that much. Instead I find giving Lat exercises a great way to actually help improve restricted shoulder elevation movement, counter intuitive eh, but if the focus is on the slow controlled eccentric part of the movement, not the pull down but rather when the hand returns back to it's starting position over head, this is what I think helps improve and encourage better overhead shoulder mobility.

Now when I say 'Lat pull downs' I don't mean the tradional type you are probably thinking, as seen in a gymnasium, sitting down on a machine pulling a bar behind your neck with both hands oh no, no, no… I have a couple of techniques that target the 'Lat pull down' in a different way, and will hopefully placate the 'functional exercise police' a little, I can feel you all twitching from here!

First as with the Y lifts, single arm movements I think are far better for most, and in a standing position is also better if able, but this can be a challenge due to the height needed, if not able then I find leaning forward at the trunk or even kneeling is a good alternative. As I said earlier the focus of this exercise is not on the pull down, but on the slow controlled rise back up of the hand above the head, and I also think it can be done with the elbow straight throughout the movement, so producing a longer lever and so generating more force away from the centre of mass, encouraging co contraction of other lumbar and abdominal muscles as well (see image below)

Single arm Lat pull downs

The other reason I like this exercise is for all those with classical sub acromial pains who present with a painful abductionarc, because when they do resisted adduction exercises such as this, it eliminates their painful arc. Now this is not due to greater rotator cuff co contraction as I've heard some therapists explain, that's just a myth, in fact this exercise is pretty useless for cuff activation or re training, instead it's actually due to this movement reducing deltoid activity, and so reduces deltoid action of superior humeral head migration, and so eliminates the painful arc (source) I also think there is a huge psychological effect of eliminating a painful arc when doing this exercise which shouldn't be over looked!

No 4: Overhead Shoulder Press

Again probably thought as another strange exercise for a physio to use in shoulder rehab, but the standard weighted overhead shoulder press I don't think is used nearly enough or early enough in shoulder rehab.

There are many variations of the shoulder press but my favourite is the 'Arnie' press as it works the shoulder through a greater range and through multiple planes of movement and as it's harder and more challenging to perform, the weights used don't need to be to as high to get the desired effect, and yes it's named after Arnold Schwarzenegger, whose credited with designing the exercise, although I can find no reliable source to confirm this so it could be just one of those gym legends!

Anyway, to perform an 'Arnie shoulder press', simply hold a dumbell in your hand just in front of your shoulder with palm facing towards you, then press/push the weight up over your head and as you do, twist your hand so that when your arm is straight above your head your palm is now facing away from you, reverse this movement as you bring the weight back down in front of your shoulder (see images below)

Arnie Shoulder Press

For an added dimension of difficulty and fun try doing an Arnie press with a kettlebell, up side down, what's called a 'Bottoms Up Kettlebell Press' (see image below) The unstableness of the kettlebell makes for a much harder press movement with corrections having to be made all the time so working all the shoulder muscles and developing greater speed or quickness of muscle/tendon reaction, not to mention working joint and limb proprioception, the other benefit is that doing the bottoms up press means you need to have a much stronger grip and there is a correlation to grip strength and rotator cuff strength (source)

Bottoms Up Kettlebell Press

The over press is a great movement that uses a lot of muscles and of course can be thought as functional as most people want to, need to reach over head, the weights used as I said don't need to be great and even to begin with it can be unweighted just to develop the movement pattern.

On this subject of movement patterns the 'Arnie' press isn't the only over head reaching pattern, it's just a favorite of mine, but if we look at the movement pattern of any over head reaching movement we will see that it can be wide and varied dependant on the task or individual performing it, so spare some time and consideration for this fact, ask, look and rehearse with your patient their over head reaching pattern and look to try and reproduce it or if it's painful find other ways around it, as always there is never one way is right way!

No 5: Press Up

My final favourite shoulder rehab exercise is the good old press up for a number of reasons, it's a great all round upper limb strengthener, particularly of the posterior rotator cuff (source) which is commonly lacking, it's a closed chain exercise so has adavantages in providing increased joint proprioception, cuff co-contraction as well as reducing joint shearing forces, it has multiple variations and adaptations and it is also a great all round body exercise.

Press Ups

As I said variations of press ups are almost limitless and restricted by only your own imagination, they can be done standing, kneeling, inclined, declined, hands wide apart, close together, asymmetrical, explosive, static, weighted, assisted etc etc etc, I have my 45 year old housewife with superior cuff tendinopathy doing them, I have my 80 year old post op shoulder replacements doing them, I have my 23 year old type II anterior shoulder instability patient doing them, I even eventually have my rarer posterior shoulder dislocators doing them, obviously with caution and only when ready to do so!

Simply put if you haven't got some form of a press up exercise into your shoulder rehab programs your missing a trick in my humble opinion!

So there you go, my top five shoulder rehab exercises!

However, with all of that just said I need to spend a little time in the summary to discuss the non specific effects of all rehab exercises! 

It does occasionally pain me to admit this as a so called experienced, educated and informed, physiotherapist blah, blah, blah, but sometimes it doesn't matter WHAT exercises we give people, they get better regardless!

Time and graded exposure is sometimes the easiest and simplist way to rehab a painful shoulder, or any other joint for that matter, getting your patient to do the movement that provocates their symptoms a bit and by reassuring them they aren't doing any harm and gradually increasing their exposure and tolerance to that movement, it reduces their sensitivity and pain to that movement… it can be that simple!

So let me know what you think of my favourite rehab exercises, good? bad? let's get the discussion going, all comments gladly received!

As always thanks for reading

Adam