As a so called shoulder ‘expert’ I often get asked what are my favourite rehab exercises for them. But this is a tricky question to answer as there are so many different variables that make me choose an exercise. However, there are some exercises that I do seem to find myself regularly falling back on, so I thought I’d write a little bit about them, and for a change, I thought I would base this piece more on my 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 patient groups, with different presenations of shoulder pain, so I class them as multi purpose exercises. Next, they are simple, easy to coach/teach and require little or no equipment. Finally they can be adapted and progressed easily. However, they are not the most exciting, fancy, or cutting edge exercises, as I tend to find with most things in this profession you cant go wrong if you focus on doing the simple this well, and leave the fancy sh*t for the guru’s and show offs!
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 prescriping 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 any performance or functional improvements. And talking of function I’m sure some of the functional movement nazi’s will have a few comments on these exercises! It seems these days you just cant just give an exercise to get someone stronger, its has to be bloody ‘functional’ all the freaking time!
Ok disclaimers done, let’s get started…
No 1: Rotator Cuff Isometrics
Ok, I’m cheating here with my No 1 exercise as it’s really three exercises, but the simple, basic isometric exercise is too often over looked and under used. This is a shame as I find it very effective in reducing a lot of shoulder pains in many people that it rightly deserves my No 1 spot despite them being perceived as boring and simplistic nature. Although recently they are gaining some popularity and credibility again.
Isometric exercises for those non therapists reading, 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!!! 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 beleive have 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 they do produce some significant forces and tension in the cuff, so can be thought of beginning the needed loading program.
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, 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 30° of abduction (see images below)
Next is ‘External Rotation in Neutral Press’ used for when I suspect more postero-superior cuff tendinopathy, 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 if to painful to reduce compression effects (see images below)
Finally is the ‘Belly Press’ used for when I suspect more antero-superior cuff tendinopathy, 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 from me for them to do lots throughout the day, usually in groups of 3-5 at a time, holding each one for a long duration, usually 15-30 seconds plus, with strong-ish intensity. This parameters have been found to produce the greatest pain relieving effect (source) albeit in healthy subjects. Isometrics 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 fastidious and at time over 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 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 and not a diagnosis). I usually 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 I think have poor scapular movement, although links to scapular position and movement causing pain and pathology is tenuous (see Chris Littlewoods piece on this here), as is our ability to spot it. 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). I also place a big emphasis on the eccentric action of this an most all other shoulder exercises. Eccentrics are known to produce higher forces in musculotendious units than concentric actions and maintain or increase myofibril length, all essential and positive effects of rehab.
Prone Y Lift
Now before the ‘functional exercise nazis‘ start jumping up and down and explode with rage that I’ve dared to get someone lying down doing a shoulder exercise, I say… 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 all target similar muscles, but as they ask both arms to move together and symmetrically, which really get the functional exercise nazis twitching.
Anyway, this exercise can be progressed into standing positions with the use of cable machines, dumbells or therabands (see image below), some times referred to as the PNF diagonal patterns of movement, and to keep the ‘functional exercise nazis‘ even happier, you could get your patient doing them standing on one leg, or combined with trunk rotation, or when doing a lunge or squat, or…. well you get the idea!
Keeping the functional movement nazis happy
I think 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 scapula kinematics, as well as in the supraspinatus tendon key in humeral head control, as well as encouraging thoracic extension, usually lacking in most.
The final reason I like this exercise is that I find a lot of 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 a little surprised when they try it. 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 the Lat pull down 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 in restricting over head movement of the shoulder when it becomes stiff and tight. Also as it is an internal rotator of the shoulder it also can contribute, with the pecs in overpowering the weaker external rotators and so develop shoulder joint imbalances.
Now all the above can be true, but I think the poor old Lats are normally the victim rather than the culprit in poor shoulder movements or imbalances, and simply stretching them or using manual therapy techniques to loosen them off does bugger all.
Instead I find giving a Lat Dorsi strengthening exercise is a great way to actually help improve restricted shoulder elevation, counter intuitive eh? If the focus is again on the eccentric action of the movement, not the pull down, but the return back to it’s starting position over head slow and deliberate, this is what I think helps improve and encourage better overhead shoulder mobility. This maybe through sarcomereogenisis, the addition of sarcomeres (smallest units in muscle) in series to the Lats, and / or via reducing stretch mechanoreceptor firing rates so improving an individuals stretch tolerance.
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’ exercise in a different way, that will hopefully placate the ‘functional exercise nazis‘ a little, I can feel you guys all twitching from here!
Just 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. 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, so generating more torque 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
Another reason I like this exercise is that it really helps those with classical sub acromial pain who present with a painful abduction arc. I find when they do resisted adduction exercises such as this, it can in a lot eliminate their painful arc immediatly, and they think you are magician and they love you for it… and BOOM, you’ve got your way in, their attention and hopefully their compliance to do some rehab! I think there is a HUGE psychological effect in eliminating someones painful arc which shouldn’t be over looked!
Now the magic removal of the painful arc with resisted adduction exercises is not due to them producing greater rotator cuff co contraction as I’ve heard some therapists explain, that’s a myth. In fact this exercise is pretty useless for cuff activation. Instead Lat Pull Downs work by reducing the deltoids activity of superior humeral head migration, so eliminating the painful arc (source)
No 4: Overhead Shoulder Press
Again probably thought of 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.
The over press is a great movement that uses a lot of shoulder, scapula and trunk muscles and of course can be thought as functional as most people want to, need to, reach over head. The weights used don’t need to be great and even to begin with it can be unweighted just to develop the movement pattern.
There are many variations of the overhead shoulder press but my favourite is the ‘Arnie’ shoulder press, 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 based myths bro!
The Arnie press is great as it works the shoulder through a greater range and through multiple planes of movement and it’s harder and more challenging to perform. Also as its harder the weights don’t need to be to as high to get the desired strengthening effects.
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 fine corrections having to be made all the time so working all the shoulder muscles, developing greater speed or quickness of muscle/tendon reaction, not to mention working proprioception. The other benefit of the bottoms up press is you need to have a much stronger grip and there is a correlation to grip strength and rotator cuff strength (source) and using strong gripping when perfoming all exercises is something I encourage!
Bottoms Up Kettlebell Press
No 5: Press Up
My final favourite shoulder rehab exercise for this piece, is the good old press up, for a number of reasons. First it’s a great all round upper limb strengthener, and not just of thr anterior shoulder and chest as known, but its also good for producing high levels of activity in the posterior rotator cuff (source) which is commonly lacking. Next it’s a closed chain exercise so has adavantages in providing increased joint proprioception, cuff co-contraction as well as reducing joint shearing forces. And finally it has multiple variations and simp,e adaptations to change and progress and it is 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 type exercise into your shoulder rehab programs you are missing a trick!
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 well informed, physiotherapist blah, blah, blah, that sometimes it doesn’t matter WHAT exercises we give people, they get better regardless!
Time and graded exposure to any movement is all that it needs sometimes to reduce pain. It can be the easiest and simplist way to rehab a painful shoulder, or any other joint for that matter. Simoly getting your patient to do a movement that aggravates their symptoms a little bit and by reassuring them they aren’t doing any harm and encouraging them to gradually increasing their exposure and tolerance to that movement, it can reduce 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? All constructive comments gladly received!
As always thanks for reading
Adam
