Untitled

Effective Rotator Cuff Exercises

Table of Contents
Exercise Considerations.................................................................................................. 3
Disclaimer ....................................................................................................................... 3
Preface ............................................................................................................................ 4
Section 1: Introduction.................................................................................................... 5
Section 2: Shoulder Anatomy ......................................................................................... 9
Section 3: Functional Anatomy and Biomechanics ....................................................... 32
Section 4: Pathomechanics and Rotator Cuff Injuries ................................................... 37
Section 5: Diagnosing Rotator Cuff Injuries................................................................... 49
Section 6: Treatment and Management of Rotator Cuff Injuries ................................... 62
Section 7: Exercises for Rotator Cuff Injuries ................................................................ 69
Section 8: Effective Rotator Cuff Exercises .................................................................. 74
About Rick Kaselj ........................................................................................................ 201
About Healing Through Movement .............................................................................. 203
Other Books from Rick Kaselj ..................................................................................... 206
Ready-to-Download Webinars from Rick Kaselj .......................................................... 208
Rick Kaselj, MS, BSc, PK, CPT, CEP, CES 2

ExercisesForInjuries.com

Title:
Edition:
1st edition (November 2009)
2nd edition (August 2010)
Author: Kaselj, Rick, 1973 –
Key words: Rotator cuff, exercise
All rights reserved, except for use in a review. The reproduction or use of the content from this book in
any form (electronic, mechanical, or other) is prohibited. Photocopying or scanning any information into a
storage or retrieval system is forbidden without the written permission of the publisher and author.
Published by:
Healing Through Movement

#199- 19567 Fraser Highway
Surrey, BC V3S 9A4
E-mail: [email protected]
Webpage: http://www.HealingThroughMovement.com
Phone: (888) 291-2430

Fax: (604) 677-5425
Exercise Considerations
You and your client are encouraged to consult with his or her physician before beginning the exercises in
this book. Your client’s physician will determine which exercises are appropriate and if there are any
exercises to avoid or modify.
Disclaimer
Effective Rotator Cuff Exercises is primarily an educational resource and is not intended to take the
place of the advice and recommendations of a physician or qualified health care provider. If you suspect
or identify your client has a health problem, please have him or her seek the services of a physician or
qualified healthcare provider, first. It is recommended to have medical clearance to start an exercise
program for those clients that have been discharged from rehabilitation of their injury.
Exercise is an ever-changing science. As new research and clinical experience broaden our knowledge,
changes in exercise and exercise prescriptions are inevitable. The author has checked with sources
believed to be reliable in his effort to provide information that is complete and generally in accord with the
standards accepted at the time of publication. However, in view of the possibility of human error or
changes in exercise science, neither the author nor any other party who has been involved in the
preparation or publication of this work warrants that the information contained herein is in every respect
accurate or complete, and they are not responsible for any errors or omissions or for the results obtained
from the use of such information. Readers are encouraged to confirm the information contained herein
with other sources.


Preface
Thank you for supporting one of my dreams!
I have always dreamed of being a writer. Effective Rotator Cuff Exercises is one of those
writing dreams coming true. I hope you take from it as much as I have gotten out of researching
and writing it.
Pass this Book On
Feel free to take your personal printed copy and share it with your family and friends who suffer
from rotator cuff injuries. Let your colleagues know about this manual and how it has helped
your clients with rotator cuff injuries.
Your Clients Can Read This Manual
Most of the manual is written in a wording and tone that your clients with rotator cuff injuries will
understand. This allows you to share this manual with your clients. Feel free to make
photocopies of the exercises that you prescribe to your clients. This will ensure they remember
all the details of the exercises and get maximum benefit from them.
Guarantee
My passion is to use exercise to manage rotator cuff injuries. If this manual does not help you,
does not meet your expectation, or is not of value to you, I will refund your money. Please
contact me via email at [email protected] for your refund.
Contact Me
Please let me know what you think of this book. Visit www.ExercisesForInjuries.com or email
[email protected]. Your feedback and ideas will improve the content of future
editions and books.

Section 1: Introduction
Shoulder pain may not be one of the most severe and life-threatening medical
conditions known to man, but it is one of the most debilitating and frustrating
musculoskeletal injuries. A recent survey shows that shoulder pain is the third leading
cause of musculoskeletal disorders (MSD), following low back pain and neck pain. It
has an annual incidence of 10 cases per 1,000 people (Malanga, Visco, Andrus &
Bowen, 2009). Of those with shoulder pain, 20 to 30% suffer from a rotator cuff injury,
making it the most common cause of shoulder pain in the United States and in most
Western countries (Quintana & Sinert, 2009). Studies also reveal that its incidence is as
high as 25 cases per 1,000 population in individuals aged 42 to 46 years.
The rotator cuff is composed of the tendons of four muscles: the infraspinatus,
supraspinatus, subscapularis, and teres minor. The musculotendinous (part of the
muscle where the tendon and muscle connect) attachments of these muscles fuse
together and form a cuff or band surrounding the top of the humerus or upper arm bone.
The tendons are tough bands of fibrous tissues that connect the muscles to bones. The
job of the rotator cuff is to securely hold the humerus in place, allowing your arm to
rotate through a wide range of motion without difficulty or pain, while maintaining
stability of the shoulder joint.
Rotator cuff injuries involve tears or irritation of the rotator cuff muscles, or the
tendon. The injury may arise either from extrinsic (outside the body) or intrinsic (inside
the body) causes (Bilal, Duffy, Shafi and Hafi, 2007). Extrinsic causes include overuse
of rotator cuff muscles and tendons over a period of years, and traumatic shoulder
injuries resulting from a fall.
Individuals who participate in repetitive and forceful overhead or throwing

motions are vulnerable to injuries of the rotator cuff. Athletes who compete in overhead
sports like baseball, weight lifting, tennis, volleyball, swimming and golf are especially


susceptible to rotator cuff injuries. It is important, however, to emphasize that rotator
cuff injuries are not exclusively seen in athletes. People who are in building trades, like
carpenters and painters, or those who repeatedly lift heavy objects are also at risk for
rotator cuff injuries.
Structural damage to one of the structures of the rotator cuff often causes chronic
or recurrent shoulder pain, weakness in arm movement, and overall decreased range of
motion of the affected shoulder joint. More often than not, rotator cuff injuries are
regarded as benign musculoskeletal disorders and not very serious when it comes to
life and death. But when left untreated or inappropriately managed, rotator cuff injuries
can result in significant decreases in the shoulder range of motion, leading to an inability
to complete the simplest activities of daily living without pain. For an athlete suffering
from a rotator cuff injury, decreased physical performance and early retirement from
sports is possible. For a working individual, a rotator cuff injury may mean missed work
days, potentially a change of career, and financial hardship.
According to Vitale, Moskowitz, Pollack and Bigliani (1999), on average, the total
cost of a rotator cuff repair in the United States is USD $12,464. In Canada, a rotator
cuff repair may cost around USD $6,000. These figures do not include post-surgical
rehabilitation program fees. In another study by Webster and Snook (1993), the mean
compensation cost per case of upper extremity work-related musculoskeletal disease
was estimated at $8,070, leading to a total cost of $563 million in the 1993 workforce.
In order to prevent the lifelong complications of rotator cuff injuries, including

costly surgical procedures and post-surgical rehabilitation programs, regular rotator cuff
exercises are recommended. For individuals diagnosed with mild or uncomplicated
rotator cuff injuries, exercising the rotator cuff muscles leads to decreased shoulder pain
and tightness, increases range of motion, and prevents the progression of the rotator
cuff injury. For individuals who constantly use their shoulder joints for work, fun, or play,
exercising the rotator cuff is important to prevent future rotator cuff injuries. For those


who have had to have a rotator cuff surgery, overall success of surgery depends on a
post-surgical exercise rehabilitation program.
The Effective Rotator Cuff Exercises book will discuss specific, simple, and cost-
effective exercises and other conservative measures that can be of great help in
improving and preserving the functions of the rotator cuff and shoulder.

References
American Academy of Orthopaedic Surgeons. (n.d.). Rotator cuff tears. Retrieved

September 14, 2009, from http://orthoinfo.aaos.org/topic.cfm?topic=A00064
American College of Sports Medicine. (2004). ACSM’s resources for the personal
trainer (2nd ed.) Philadelphia, PA: Author.
Bilal, R., Duff, P., Shafi, B and Hafi, S. (2007, November 27). Emedicine.com: Rotator
cuff pathology. Retrieved September 14, 2009, from
http://emedicine.medscape.com/article/1262849-overview
France, R. (2004). Introduction to sports medicine and athletic training. Kentucky:

Thomson Delmar Learning.
Johnson, E. (2006). Treat your own rotator cuff. Indianapolis, IN: Dog Ear Publishing.
Malanga, G., Visco, C., Andrus, S. & Bowen J. (2009, January 29). Rotator cuff injury.
Retrieved November 20, 2009, Emedicine.com:
Quintana, E. & Sinert, R. (2009, January 29). Emedicine.com: Rotator cuff injuries.
Retrieved September 15, 2009, from http://emedicine.medscape.com/article/827841-
overview
Sports Media. (n.d.). Sports-media.org: Rotator cuff exercises. Retrieved September 15,
2009, from http://www.sports-media.org/rotator-cuff-exercises.html
Vitale, L. Geljin, A. Moskowitz, A., Bigliani, L. & Flatlow, E. (1999). Rotator cuff repair: a
prospective study of in-hospital costs and quality of life outcomes. Annual Meet
International Society of Technology Assessment in Health Care Meet, (15), 127.
Abstract retrieved September 19, 2009, from NLM Gateway.

Section 2: Shoulder Anatomy
The basics of shoulder anatomy, specifically the rotator cuff muscles, will help
you understand exactly how the shoulder works, why the rotator cuff is the site of most
common shoulder injuries, and demonstrate the importance of rotator cuff exercises for
injury prevention and rehabilitation.
The shoulder is one of the most intricate structures in the human body. This is
mainly because there are so many structures involved in the movement of the shoulder.
If one of these structures is injured or not functioning properly, the whole shoulder may
not function properly and the malfunction may put the shoulder at greater risk of injury.
The following structures are involved in the movement of the shoulder joint:
- Bones: the humerus, clavicle, scapula, sternum, and ribcage
- Joints: sternoclavicular (SC joint), acromioclavicular (AC joint), glenohumeral

(GH joint), and the scapulothoracic joint
- Muscles: infraspinatus, supraspinatus, teres minor, and subscapularis,

collectively known as the rotator cuff muscles, plus scapular stabilizing and
GH joint muscles
- Ligaments: a few examples are - capsular, conoid, coracoacromial, superior

transverse, and trapezoid ligaments
- Bursae: subdeltoid, subacromial, subscapular, and subcoracoid bursae
- Nerves: brachial plexus, subscapular nerve, axillary nerve, and

suprascapular nerve

- Blood vessels: anterior and posterior circumflex arteries
These structures work together statically and dynamically to assist in efficient

and effective completion of the most common and simplest movements of the shoulder,
including overhead reaching, throwing, lifting, pushing, and pulling. In this section, we
will focus only on the anatomy of the structures that are most important to rotator cuff
injuries, preventable exercises and rehabilitative exercises.
Coracoacromial
Ligament
Capsular
Ligament
Greater
Tubercle
of the
Humerus
Figure 10. Deep anterior view of the Left Shoulder highlighting the ligaments in the
shoulder and greater tubercle of the humerus.


Bones of the Shoulder
The shoulder is made up of

many different bones. Each one
has a significant function. Three
important bones relating to the
rotator cuff are the clavicle,
scapula, and humerus. These three
bones for the shoulder make up the
four joints in the shoulder, and the
Humerus scapula and clavicle make up the

pectoral girdle.
Figure 1. Pectoral Girdle.
Clavicle
Each clavicle is a double curved bone that attaches to the manubrium
(uppermost segment of the sternum) at its medial end to form the
sternoclavicular joint, linking the arms with the central axis of the body. At its
lateral end, the clavicle articulates with the scapula’s acromion process to form
the acromioclavicular joint, which also functions as an attachment site of muscles
and ligaments. Each clavicle functions as a supportive brace for elevating the
arms over the head; and the clavicles increase the stability of the shoulder by
helping to prevent dislocation of the shoulder.
Scapula
The scapula, or shoulder blade, is described as a flat, triangular bone which
connects the humerus, or upper arm bone, with the clavicle. The clavicle meets
the scapula through the acromioclavicular joint and the scapula meets the
humerus at the glenohumeral joint but the humerus does not connect to the


clavicle directly. The scapulae are commonly called wings because the upper
back seems to spread, like wings, every time the arms move.
Each scapula is composed of two processes (bony prominences) and a flattened

body. The acromion process is the enlarged tip of the spine of the scapula, which
sits right over the humerus. The acromion process mainly connects the clavicle
laterally at the acromioclavicular joint. The coracoid process is the small, beaklike
structure on the lateral edge of the scapula, anchoring some of the most
important muscles that are responsible for arm movements. Medial to the
coracoid process is the suprascapular notch, which acts as a passageway for
certain nerves to innervate the shoulder muscles. The scapula has three borders
- the superior, medial or vertebral, and lateral or axillary borders: and three
angles – the superior, inferior, and lateral angles. The lateral angle of the scapula
receives the head of the humerus, as it contains a shallow, round, basin-like
depression or socket called the glenoid fossa.


Figure 2. Lateral view of left scapula.

Clavicle
Acromion
Scapula
Figure 10. Posterior (Back) View of the scapula
Humerus
The upper arm is formed by a single bone called the humerus. Its proximal end is
a rounded head that fits into the glenoid fossa, forming the shoulder joint. The
head of the humerus is obviously larger than the glenoid fossa. Because of the
difference in size, in conjunction with the shallowness of the glenoid fossa, it


becomes possible for the shoulder joint to perform wider ranges of motion than
most of the other joints in the human body.
Figure 3. The left humerus, anterior view.
The upper limbs have the ability to perform a wide variety of movements mainly
because of the way the shoulder girdle is designed. According to Marieb (2004), the
following factors contribute to the remarkable mobility of the shoulder joints.
• Each shoulder girdle attaches to the axial skeleton at only one site – the
sternoclavicular joint. The axial skeleton is the central axis of the body, composed
of the skull, breastbone, and vertebral column.
• The shoulder blade is not directly attached to the axial skeleton; rather, it is
only loosely secured in place by the muscles of the upper torso.
• The glenoid fossa is a shallow, round depression. The shoulder joint is also
believed to be poorly reinforced by the ligaments (connective tissues that join one
bone to another at a joint).

Figure 4. Shoulder girdle, front (anterior) view.

Note: copyright ExercisesForInjuries.com
Figure 5. Shoulder, back (posterior) view.


The Shoulder Joints
There are four essential joints that make up the shoulder: the glenohumeral joint,
acromioclavicular joint, sternoclavicular joint, and scapulothoracic joint. These joints are
illustrated in Figure 6. The joints are the sites of union, or articulation, between two or
more bones. These junctions are designed to allow skeletal mobility within a certain
range of motion. Without the joints, even the simplest and easiest body movements are
not possible. The joints function differently and the range of motion or movement is
determined by the shapes of the articulating bone surfaces and the structures around
the joint.
Figure 6. A Medical Illustration of the Joints of the Shoulder. (2008).

Note: copyright Marty Bee
Glenohumeral Joint (GH)

The glenohumeral is where the glenoid fossa of the scapula and the head of the
humerus meet. The GH joint is classified as a ball-and-socket joint, since the
spherical head (ball) of the humerus fits into the socket of the scapula. Among all
the different types of joints in the human body, this joint has the greatest mobility.
The GH joint moves in all axes, including rotation; hence, it is termed a multi-
axial joint.

Although the glenohumeral joint is structurally similar to the other multi-axial

joints, it has an exceptional ability to move in wider and more extensive ranges of
motion than other joints. The hip joint is a ball-and-socket joint, but its range of
motion is limited as compared to that of the shoulder. The head of the femur, or
leg bone, meets with the pelvis at the acetabulum, which is a much deeper
socket compared to the glenoid fossa. The glenoid fossa is shallow in depth and
only covers 25 to 33% of the surface area of the humeral head. The shallow
depth of the GH joint allows for greater movement, but significantly reduces the
stability of the joint.
The GH joint ability to move in greater ranges of motion comes with a drawback.
The glenohumeral joint is considered one of the most unstable joints in the body.
Due to this decrease in stability, the GH joint is at greater risk of dislocation.
The labrum of the GH joint, is a fibrocartilage (ring of fibrocartilage around the

edge of the joint) that mainly functions to maintain normal glenohumeral
biomechanics (Iannotti & Williams, 2007) and increase the stability of the GH
joint. The labrum increases the joint's stability by deepening the concavity of the
socket by 5 to 9 millimeters and by increasing the humeral head contact area to
75% vertically and 56% transversely (Dutton, 2004).
The glenohumeral joint relies heavily on shoulder muscles, rather than the bones
and joints, for its stability. The joint capsule and glenohumeral ligaments are the
main static stabilizers of the GH joint, while the rotator cuff provides dynamic
stability.

Figure 7. Internal Structures of the Shoulder Joint

Acromioclavicular joint (AC)

The union of the scapula’s acromion process and the clavicle’s lateral end forms
the acromioclavicular joint (AC). The AC joint principally functions as the main
articulation site for scapular movement and connection of the upper extremity
with the trunk. The rotator cuff muscles are located just below (inferior to) the AC
joint.
Sternoclavicular joint (SC)

Considered one of the toughest joint capsules in the shoulder, the
sternoclavicular (SC) joint is the site where the medial end of the clavicle
articulates with the clavicular notch and the first rib. The SC joint is able to
perform five motions: clavicular protraction, retraction, elevation, depression, and
rotation.


The sternoclavicular joint has a strong and stable joint capsule. The articular
disc, or meniscus, of the SC joint functions as an effective shock absorber,
distributing the applied force between the two bones. Due to its stability, the SC
joint is not easily dislocated. Usually, clavicular fractures or dislocations of the AC
joint precede SC dislocation.
Scapulothoracic joint
The scapulothoracic joint is not classified as a true joint, which usually has a
synovial capsule (closed sac of synovial membrane situated between articular
surfaces). The scapulothoracic joint also lacks some anatomical characteristics
of a true joint, such as ligamentous support. The muscles attaching the shoulder
blade to the thorax are fully responsible for scapular movement and stability.
The scapulothoracic joint plays a crucial role in ensuring proper positioning of the
glenoid fossa and scapular stability for efficient arm movement. This joint is
capable of six scapular motions relative to the thorax: scapular elevation,
depression, adduction, abduction, and upward and downward rotation.
Subacromial Space
The subacromial space is the area of the shoulder that is involved in

impingement syndrome, one of the leading causes of shoulder pain. The subacromial
space is located below the acromion process and above the humeral head (Figure 6).
Within the subacromial space, the subacromial bursa and rotator cuff are located. When
the arm is in a relaxed and normal position, the size of the space is fairly wide. As the
arm is elevated, the greater tubercle of the humerus moves up into the subacromial
space, narrowing the size of the space. When the shoulder structures are functioning
optimally, the space has enough room for all the structures. If the structures of the
shoulder are not in optimal position, the risk of pinching the structures in the


subacromial space increases, which can lead to shoulder impingement and rotator cuff
injury.
The Bursae
A bursa is a small synovial fluid-filled sac, lined with synovial membranes. The
bursae are found in between the tendons and the bones, functioning as gliding surfaces
to reduce friction, and prevent tissue damage. There are 160 known bursae throughout
the body; nine are found in the shoulder area.
The subacromial or subdeltoid bursa, which is located over the greater tubercle
of the humerus and the supraspinatus tendon, is the shoulder bursa that is most
susceptible to injuries. It is also the largest bursa in the body. Due to the proximity of the
subacromial bursa and the supraspinatus tendon, anything that scars or accumulates
on the body of the tendon can also irritate and inflame the bursa, leading to bursitis.
Bursitis may also be caused by infection or an underlying rheumatic condition.
Scapular Muscles
The muscles in the shoulder are mainly divided into two major groups: the
dynamic stabilizers of the scapula, and the rotator cuff muscles. The scapular muscles,
also termed scapular pivoters, are mainly involved in movement and stability of the
scapulothoracic joint. The following scapular muscles are vital for the normal
biomechanics of the entire shoulder complex:
• Trapezius - The trapezius is the most superficial muscle of the neck and upper
trunk. It is vital in scapular stability.
Origin: Occipital bone and all cervical and thoracic vertebrae
Insertion: Scapular spine and clavicle


Action: Neck extension plus scapular movement of elevation, upward rotation,
adduction (retraction), and depression
• Serratus anterior – This muscle is mainly responsible for protracting and

upwardly rotating the scapula.
Origin: Upper component: first and second ribs; middle component: second, third
and fourth ribs; and lower component: fifth through ninth ribs
Insertion: Upper component: superior angle of the scapula; middle component:
anterior aspect of the medial scapular border; and lower component: medial
border of the scapula
Action: Abduction (protraction), upward rotation
• Levator scapulae – This muscle's line of pull is almost vertical, as it lies beneath
the upper trapezius and extends from the upper neck to the upper medial border
of the scapula.
Origin: Transverse processes of C1 to C4 or C5
Insertion: Medial superior angle of the scapula
Action: Cervical lateral flexion and rotation plus Scapular elevation, downward
rotation, and abduction (protraction)
• Rhomboids – A muscle group consisting of the rhomboid major and rhomboid

minor that works with the trapezius and controls the scapula’s medial border.
Origin: Major - second to fifth thoracic vertebrae and supraspinous ligament;
Minor - seventh cervical and first thoracic vertebrae
Insertion: Major and minor rhomboids - medial border of the scapula
Action: Scapular adduction (retraction) and downward rotation
A note on origins and insertions: the muscles are attached to the bones at no
less than two points. The origin refers to the end of the muscle attaching to an
immovable or less movable bone. Insertion refers to the end of the muscle that is


attached to a freely movable joint. Whenever a muscle contracts, its insertion site
moves toward the origin in open kinetic chain exercises.
The Rotator Cuff
In discussing the rotator cuff, it is important to include the four muscles that make
it up: supraspinatus, infraspinatus, teres minor, and subscapularis, or SITS muscles.
SITS is an abbreviation that stands for supraspinatus, infraspinatus, teres minor and
subscapularis. These muscles are collectively known as the rotator cuff muscles. The
rotator cuff is actually composed of the tendons of the rotator cuff muscles, fusing
together into the joint capsule to provide dynamic stability of the glenohumeral joint.
It was earlier discussed that there is minimal contact between the head of the
humerus and glenoid fossa. The muscles of the rotator cuff must, therefore, hold the
humerus in the right orientation to the glenoid fossa in order to stabilize the
glenohumeral joint (Hendrickson, 1999). The rotator cuff creates a fixed fulcrum for the
glenohumeral joint, functioning as a pivot on which a lever (the humerus) moves. This
way, the deltoid, the triangular-shaped muscle that forms the rounded shape of the
shoulder, can move the arm upward. Because of strong forces that are applied to it,
and because it is active in nearly all shoulder movement, the rotator cuff is a common
site of injury.

To further understand the pathomechanics of the most common types of rotator
cuff injuries, which will be discussed in the next section, it is important to understand
how each of these muscles works.

Figure 8. The Rotator Cuff Muscles (n.d.).

Note: copyright A.D.A.M.
Supraspinatus
Supraspinatus is located on the posterior and superior aspect of the scapula,
near the tip of the shoulder (superior angle of the scapula). The muscle fibers of
the supraspinatus come together to form the supraspinatus tendon that adheres
to the joint capsule. The supraspinatus tendon is the most commonly injured
tendon of the rotator cuff.
In spite of its small size, the supraspinatus muscle plays a key role in all shoulder
movements. Its main functions are to abduct the arm to the side, pull the
humerus into the glenoid cavity, and to prevent shoulder dislocation.
Infraspinatus and Teres Minor

The infraspinatus and teres minor muscles sit right next to each other on the
posterior side of the scapula. As with supraspinatus, the tendons of these
muscles adhere to the shoulder capsule, preventing the dislocation of the
shoulder. The infraspinatus and teres minor are both positioned at the same
angle and attach to the same area, creating the same shoulder motion. These
muscles are responsible in external rotation of the shoulder, and horizontal
abduction. These muscles actively participate in force couple, which is essential


for proper shoulder mechanics. The force couple is further discussed in the next
section.
Subscapularis
The subscapularis muscle is located under the anterior surface of the scapula. It
attaches on the anterior (front) part of the humerus, and thus performs inward
rotation of the arm. The subscapularis also gives the glenohumeral joint some
stability. Subscapularis, along with infraspinatus and teres minor, maintains a
horizontal line of pull to prevent the downward dislocation of the humerus
(University of Washington Medicine, 2005). Due to its location, it also assists in
the prevention of anterior dislocation of the humerus.

Subscapularis
Figure 9. Anterior (Front) Muscles of the Left Rotator Cuff – Subscapularis.

Supraspinatus
Infraspinatus
Teres Minor
Figure 10. Posterior (Back) Muscles of the Left Rotator Cuff – Supraspinatus,
Infraspinatus, Teres Minor.

Rotator Cuff
Muscle Origin Insertion Main Action
Supraspinatus Inner part of the Top of the greater Shoulder abduction

supraspinous fossa tubercle of the
of the scapula humerus Shoulder stabilization
Infraspinatus Medial portion of the Middle of the External rotation of

infraspinous fossa of greater tubercle of the shoulder
the scapula the humerus
Horizontal abduction
of the shoulder
SITS force couple

component
Shoulder stabilization
Teres minor Lateral border of the Middle of the External rotation of

scapula greater tubercle of the shoulder
the humerus
SITS force couple

component
Subscapularis Subscapular fossa Lesser tubercle of Internal rotation of the

the humerus shoulder
SITS force couple

component
Table 1. The Rotator Cuff Muscles.

The supraspinatus pulls the humerus into abduction and pulls the humeral head
in the medial direction, whereas the infraspinatus and subscapularis pull the humeral
head downward and in. During shoulder motion, the supraspinatus muscle controls the
elevation of the arm, with the support of the deltoid. The infraspinatus and teres minor
control the external rotation of the arm, whereas the subscapularis controls internal
rotation.
The rotator cuff muscles' main task as a group is to stabilize the glenohumeral
joint. They function like a strong ligament, securing the humeral head tightly in the
glenoid fossa during arm movements. The rotator cuff muscles work in conjunction with
the larger and more powerful superficial muscles of the glenohumeral joint during
shoulder motion.
Rotator Cuff Tissue Structure
The rotator cuff muscles receive their blood supply from different arteries.
However, a critical zone of hypovascularity (insufficient blood flow) may be identified in
the distal 1.0 to 1.5 cm of the supraspinatus tendon, close to its insertion in the greater
tubercle (Carr & Havvie, 2006). A similar hypovascular region is present in the
infraspinatus tendon. The hypovascularity of these areas is considered a significant
predisposing factor in rotator cuff pathology (injury), especially in older clients. Studies
show that the vascularity in these region decreases with age.
The rotator cuff is classified in good health if the tendon is predominantly made
up of Type I collagen fibers, which are highly tensile. These fibers are very resistant to
pulling forces and can withstand a great amount of stress without tearing. Type II
collagen is the most abundant protein in cartilage, providing its tensile strength. Type II
collagen fibers provide resistance to joint compressions. Repairing, aging, and
degenerating tendons are mostly made up of Type III collagen fibers. Type III collagen


fibers have lower tensile strength than Type I fibers, and are smaller in size. This
possibly explains why deteriorating and aging rotator cuff tendons are more susceptible
to injuries.

References
Bee, M (Artist). (2008). A Medical Illustration of the Joints of the Shoulder [Online
Image]. Retrieved September 21, 2009, from http://www.saatchi-
gallery.co.uk/illustrators/?inc=details&id=2129
Clippinger, K. (2004). Dance anatomy and kinesiology: principles and exercises for
improving technique and avoiding common injuries. Champaign, IL: Author.
Dutton, M. (2004). Orthopaedic: examination, evaluation & intervention. New York, NY:
The McGraw-Hill Companies, Inc.
Hendrickson, T. (2003). Massage for orthopedic conditions. Philadelphia, PA:

Lippincott-Williams & Wilkins.
Marieb, E. (2004). Essentials of human anatomy and physiology (7th ed.). San
Francisco, CA: Pearson Education Inc.
Matsen, F. & Warme, W. (2008, August 19). Orthop.Washington.edu: Anterior glenoid

reconstruction for unstable dislocating shoulders. Retrieved September 18, 2009, from
http://www.orthop.washington.edu/uw/surgerytodeepen/tabID__3351/ItemID__139/Articl
es/Default.aspx
Rotator Cuff Muscles [Online Image]. (n.d.). Retrieved October 4, 2009, from
http://www.nlm.nih.gov/medlineplus/ency/imagepages/19622.htm
Ryhanen, J. Niemela, E., Kaarela, O. & Raatikainen, T. (2003). Stabilization of acute,

complete acromioclavicular joint dislocations with a new C hook implant. Journal of
Shoulder and Elbow Surgery, 2(5).
University of Washington Medicine (2005). Mechanics of glenohumeral instability.

Retrieved September 28, 2009, from
http://www.orthop.washington.edu/uw/mechanicsof/tabID__3376/ItemID__258/PageID_
_557/Articles/Default.aspx

Section 3: Functional Anatomy and Biomechanics
Before discussing the most common injuries involving the rotator cuff, it is vital to
understand the functional anatomy and biomechanics of the shoulder. Understanding
exactly how shoulder motions occur will facilitate your understanding of the causes of
different types of rotator cuff injuries.
Functional Anatomy
Normal shoulder motion is considered a complex interaction of the bony anatomy

and the activity of muscles (MacFarland, 2006). The interaction of the static stabilizers
(bony structures, ligaments, and joint capsules) and dynamic components (shoulder
joint muscles, scapular stabilizers, and rotator cuff muscles) make it possible for the
shoulder to be flexible and create a wide variety of movements.
The articulations of the shoulder complex - which includes the sternoclavicular

joint, acromioclavicular joint, glenohumeral joint, and scapulothoracic joint - work
together in order to perform normal shoulder motion.
Full shoulder motion depends on normal and smooth movement of the scapula.
The scapula provides a contact point, the glenoid fossa, where the humeral head
articulates with the shoulder complex. The scapula slides or moves smoothly along the
chest wall (thoracic spine) during normal shoulder motion. The scapular motion is
directly controlled by the scapular stabilizers.
The study by Rundquist in 2007 revealed that increased scapular motion is one
way the shoulder compensates for any loss of joint motion, making the scapula an
essential structure in all shoulder movements. A common compensation strategy for an
injured rotator cuff is scapular elevation in order to assist with humeral movement.

Shoulder Stabilizers
The shoulder’s glenohumeral joint is classified as a ball-and-socket joint. It is one

of the most mobile joints in the human body, having the ability to move in a complex
three-dimensional pattern. However, having such remarkable mobility comes at a price;
this joint is also recognized as the most commonly dislocated joint in the body.
Additional stability is necessary to prevent shoulder injuries which will restrict work
tasks, recreational or sporting activities, and tasks around the house. This increase in
stability is provided by the shoulder stabilizers, which are further categorized into two
types: static and dynamic. Any breakdown in the function of the static or dynamic
stabilizers can greatly reduce the glenohumeral function (McCully, Kumar, Lazarus, &
Kadurna, 2005).
Static stabilizers
The static stabilizers include the bony structures, labrum, ligaments, and joint
capsules. These structures are mainly responsible for providing stability at the
end ranges of motion. The inferior glenohumeral ligament is considered the
main static stabilizer of the shoulder joint during abduction (Brukner & Khan,
2006). This ligament rotates toward the anterior during arm abduction and
external rotation, preventing partial anterior dislocation of the glenohumeral
joint. Shoulder stability is also enhanced by the glenoid labrum, which
surrounds the glenoid fossa. The labrum increases the joint’s stability by
deepening the concavity of the socket by five to nine millimeters and by
increasing the humeral head contact area to 75% vertically and 56%
transversely (Dutton, 2004).


Dynamic stabilizers
The dynamic stabilizers are classified into two groups: the rotator cuff and
scapular stabilization muscles. These muscles cross the glenohumeral joint,
producing motion and functioning to create dynamic stability. The active
contraction of the dynamic stabilizers is mainly responsible for maintaining
joint stability during the mid ranges of motion (McCully, Kumar, Lazarus, &
Karduna, 2005) and overhead movements.
The dynamic stability of the shoulder complex is mainly dependent on

optimal alignment of the scapula,
ideal glenohumeral orientation, and
quality of length-tension relationship (the force a muscle generates
while at a specific length) of the dynamic stabilizers.
Rotator cuff muscles

As stated, the rotator cuff muscles mainly control the position of the humeral
head in the glenoid fossa, which results in increased stability of the
glenohumeral joint. In order to achieve dynamic stability of the glenohumeral
joint, the deltoid and the rotator cuff muscles work together to exert a force
couple. The force couple involves the action of two equal forces moving in
opposite directions to create rotation around an axis. The force couples are
known to establish dynamic stability of the glenohumeral joint regardless of
the position of the humerus (Voight, Hoogenboom, & Prenctice, 2007).
During overhead activities, the deltoid muscle raises the arm, moving the
humeral head superiorly toward the acromion and coracoacromial arch. The
rotator cuff muscles, mainly the supraspinatus, compress the humeral head
on the glenoid, counterbalancing the forces of the deltoid muscle. Disruption
of the deltoid/rotator cuff balance could result in excessive superior


movement of the humeral head, leading to impingement upon the rotator cuff
muscles and tendons (Brukner & Khan, 2006).
Scapular stabilizers
Like the rotator cuff muscles, the scapular muscles also play an important role
in adding dynamic stability to glenohumeral movement. These muscles are
mainly responsible for controlling scapular rotation. Weakness, poor
activation, and low endurance of the scapular stabilizers commonly result in
altered scapulohumeral rhythm (synchronized, smooth, and symmetrical
motion between the scapula and the humerus). Normal rhythm is necessary
in order to decrease the shearing effect between the humeral head and the
glenoid fossa, and to resist the downward dislocation of the humerus. Normal
rhythm is achieved when the angulation between the glenoid and the humeral
head in motion is maintained within 30 degrees. Since the scapula is only
attached to the thorax through the scapular muscles, the scapular stabilizers
must have the activation, strength, and endurance to fix the position of the
scapula to the thorax, so the glenoid stays centered under the humeral head.
This position is essential for the rotator cuff to competently perform its
function with the humerus.
Electromyography (EMG) studies reveal that during the initial 30 degrees of arm
abduction, a high degree of supraspinatus activity has been demonstrated. According to
Malanga (2009), increased EMG activity is an indication of increased firing requirements
of the supraspinatus to stabilize the glenohumeral joint because the deltoid is activated.
Supraspinatus and deltoid form a force couple so the arm can reach overhead. If
supraspinatus is weak or injured, the deltoid muscle would elevate the shoulder and it
would bump against the clavicle limiting shoulder range of motion, especially overhead.


References
Bilal, R., Duff, P., Shafi, B and Hafi, S. (2007, November 27). Emedicine.com: Rotator
cuff pathology. Retrieved September 28, 2009, from
Brukner, P. & Khan, Khan, K. (2006). Clinical sports medicine (3rd ed). Australia:
McGraw-Hill Companies, Inc.
Ellenbecker, T. (2006). Shoulder rehabilitation: non-operative treatment. New York, NY:

Thieme Medical Publishers, Inc.
MacFarland, E. (2006). Examination of the shoulder. New York, NY: Thieme Medical
Publishers, Inc.
Malanga, G., Visco, C., Andrus, S. & Bowen J. (2009, January 29). Emedicine.com:
Rotator cuff injury. Retrieved September 28, 2009, from
McCully, S., Kumar, N., Lazarus, M., & Karduna, A. (2005). Internal and external
rotation of the shoulder: Effects of plane, end-range determination, and scapular motion.
Journal of Shoulder and Elbow Surgery, 14, 602-610.
Rundquist, P. (2007). Alterations in scapular kinematics in subjects with idiopathic loss

of shoulder range of motion. Journal of Orthopaedic and Sports Physical Therapy,
37(1), 19-25.
Voight, M., Hoogenboom, B., & Prentice, W. (2007). Musculoskeletal interventions:

techniques for therapeutic exercise. New York, NY: The McGraw-Hill Companies, Inc.

Section 4: Pathomechanics and Rotator Cuff Injuries
Section 4: Pathomechanics and Rotator Cuff Injuries_______
Rotator cuff tendon injuries are the most common cause of shoulder pain. It is
estimated that 20 to 30% of shoulder problems are related to the development of rotator
cuff injury (Quintana, 2009).
Rotator cuff injuries are brought about by extrinsic (from the outside) or intrinsic
(from within) factors. Falls on an outstretched hand, shoulder trauma, and injuries
incurred through repetitive movements such as lifting, throwing, pushing, and pulling are
classified as extrinsic causes. Athletes in sports which involve powerful and repetitive
overhead motions of the arms and shoulders, such as tennis, volleyball, golf, football,
swimming or baseball, are especially vulnerable to the development of a rotator cuff
injury. In addition, poor or inadequate blood supply, tendon degeneration with aging,
and calcification of the tendons are identified as intrinsic causes of rotator cuff injuries.
Neer (Neer 1983) pioneered the concept of primary compressive disease

impingement as a direct result of tendon compression, leading to rotator cuff
pathologies. Neer suggested that injuries to the rotator cuff are sustained when any of
the rotator cuff tendons is compressed between the humeral head and the acromion
during shoulder elevation. Repetitive and chronic compression results in tendon
irritation and inflammation which, in time, causes scarring and deterioration of the
rotator cuff tendons. Chronic degeneration of the tendon makes it susceptible to tearing
or rupture.
Injury Mechanisms of the Rotator Cuff
In general, rotator cuff injuries are caused by an underlying impingement

progression or an instability progression (Manske, 2006).


Primary compressive disease (primary shoulder impingement)
Primary compression results from direct compression of the superior aspect of
the rotator cuff. Any condition or structural alteration that causes narrowing of the
subacromial space can interfere with the normal gliding of the rotator cuff,
resulting in tendon abrasion.
The shape of the acromion is also believed to be a significant factor in the

development of impingement syndrome. Type I acromion is described to have a
flat acromial undersurface and is classified as the “normal” acromion. Type II
acromion has a curved and downward dipping. It is estimated that 17% and 43%
of clients with impingement syndrome demonstrate Type I acromion and Type II
acromion, respectively. Type III acromion is more hooked and downward dipping
which ends up obstructing the outlet of the supraspinatus tendon (Fongemie,
Buss, and Rolnick 1998). An individual with Type III acromion process is highly
susceptible to primary impingement. In fact, according to the study by Bigliani in
1986 (Dutton 2004), 70% of clients with rotator cuff tears have a Type III acromial
shape, which is characterized by a hooked acromion process (Figure 11).
Other causative factors of primary compressive disease are congenital thickening

of the coracoacromial ligament, and the presence of an os acromiale (failure of
an ossification centre in the acromial process). In middle-aged individuals,
narrowing of the subacromial space is also caused by degenerative spurring
(bony projections) that forms underneath the acromion process.

Figure 11. Types of Acromion Processes. (2001).

Note: copyright Mary Albury Noyes
Secondary compressive disease (secondary shoulder impingement)

The secondary impingement is a direct result of glenohumeral instability caused
by tensile overload and repeated overhead motion, which apply a high degree of
force and compress the structures in the subacromial space, including the rotator
cuff tendons.
Primary tensile overload

Previous shoulder instability is not associated with primary tensile overload.
Primary tensile overload usually affects younger individuals who engage in
repetitive overhead motions where a great amount of force is placed on the
rotator cuff. This condition involves impingement of the rotator cuff against the
posterior glenoid labrum and humeral head during activities that require forceful
elevation of the arm and internal rotation as seen during the deceleration phase
of throwing. Bankart lesions, characterized by tears in the glenoid labrum and
lesions in the posterior humeral head, usually occur from this primary overload.
Secondary tensile disease

Chronic primary tension overload results in secondary tensile disease. In this
condition, repetitive irritation of the rotator cuff, and subsequently its weakening,


causes subtle instability of the shoulder (Dutton, 2004). Greater amounts of
stress and more distractive forces are placed on the tendons, in contrast to
secondary compressive disease. Over time, the increasing tensile forces result in
tendon failure.
Macrotrauma failure
Macrotrauma failure is often a direct result of shoulder trauma, in particular from
falling on an outstretched arm. This type of injury is not typically seen in clients
with healthy rotator cuff tendons, suggesting that previous tendon damage or
disease has already occurred before the trauma.
Based on the mechanisms involved in injuries of the rotator cuff, the

pathophysiology of rotator cuff disorders can be traced back to intrinsic and extrinsic
factors. To sum up, the development of rotator cuff injuries is highly influenced by the
following factors:
Acromial shape and form. Type III acromial shape is strongly associated
with rotator cuff injuries.
Hypovascularity of the rotator cuff. Hypovascularity, or inadequate blood

flow to the rotator cuff, is influenced by arm positioning. Arm abduction to the
side causes insufficient supply of blood to the supraspinatus tendon.
Elevation of the arm above 30 degrees causes increased pressure on the
supraspinatus muscle, subsequently impairing the normal flow of blood in this
area. Additionally, studies reveal that hypovascularity of the rotator cuff
increases with age beginning as early as the second decade of life (Ling,
Chen & Wan, 1990; Lewis, 2008).
Weakened dynamic stabilizers. Weakened or injured rotator cuff and

scapular muscles, the shoulder’s dynamic stabilizers, result in increased


shoulder laxity. Since the muscles that secure the position of the humeral
head in the glenoid fossa are not strong enough to prevent the excessive
superior movement of the humerus, impingement of the tendons is likely.
Acromioclavicular joint degeneration. Degeneration of the

acromioclavicular joint causes narrowing of the subacromial space. Formation
of osteophytes (bone spurs) underneath the acromion process can also
cause impingement of the rotator cuff. Bone spurs form in response to
prolonged stress and manifest over time. Arthritis may also cause the
formation of osteophytes.
Increasing age. Aging is a significant risk factor of subacromial impingement

resulting from repetitive arm motions. Impingement related to aging
commonly begins during the third decade of life.
Arm position. Frequent and repetitive arm position during normal activities
can cause the impingement of the rotator cuff. The risk increases with
frequent arm movements between 60 and 90 degrees of humeral head
elevation.
Decreased endurance capacity of the scapular stabilizers. The scapular

stabilizing muscles are mainly responsible for maintaining the scapulohumeral
rhythm. Easily fatigued scapular stabilizing muscles result in unsynchronized
and asymmetric movement of the scapula and the humerus, increasing the
shearing effect between the humeral head and the glenoid fossa.
Capsular tightness. Impingement may also occur from disuse of the rotator
cuff. Individuals who avoid painful overhead movements could develop
tightness of the joint capsule over time. During the period of avoidance,
constant immobility of the joint capsule decreases the length of the


connective tissues, resulting in capsular tightness, joint stiffness, and limited
range of motion of the shoulder. Capsular tightness, weakness of the rotator
cuff, and decreased muscular strength of the depressors (muscles that move
the scapula downwards) result in excessive humeral migration, reinforcing the
impingement cycle.
Position of the humerus at rest. Rathbun and Macnab (1970) found that the
avascularity of the cuff is dependent on the position of the humerus. With the
arm in adduction, a consistent zone of poor filling was identified near the
tuberosity attachment of the supraspinatus tendon. Poorly vascularized zones
cause delayed healing of the microtrauma, which can further aggravate the
injury (Wilson 2001).
Scapular asymmetry. Warner and colleagues revealed that almost 60% of

individuals with impingement syndrome have static scapular postural
asymmetry (resting position of the scapula is different between left and right),
which usually occurs with weakness of the dynamic stabilizers and the deltoid
(Dutton, 2004).
Repetitive arm motion. Individuals who perform repetitive arm elevation

beyond 90 degrees in their daily activities are vulnerable to rotator cuff
injuries due to irritation of the rotator cuff tendon.
Postural imbalance. Postural imbalances that involve the scapulothoracic

dysfunction, for example thoracic kyphosis or cervical lordosis, can result in
acromial depression and scapular abduction. This increases the risk of
impingement.

Rotator Cuff Injuries
The rotator cuff injuries are usually classified into three categories: shoulder
impingement syndrome, rotator cuff tendinitis, and rotator cuff tears. In this section,
details about each injury type will be briefly discussed.
Shoulder Impingement Syndrome

The shoulder impingement syndrome occurs from direct compression of any of
the structures found in the subacromial space (the space between the acromion
and the humeral head). Compression of these structures increases the pressure
within the limited space, giving rise to the signs and symptoms associated with
impingement syndrome. The structures most commonly affected by shoulder
impingement syndrome are: subacromial bursae, supraspinatus muscle, joint
capsule, and long head of the biceps.
To describe and identify the progression of tendon degeneration occurring in

rotator cuff injuries, Neer outlined the stages of shoulder impingement syndrome.
These stages are also used to classify the three stages of tendon degeneration
based on the supraspinatus outlet.
• Stage I – Stage I is marked by acute inflammation and edema in the rotator cuff.
This stage is commonly seen in individuals younger than 25 years. Stage I is
usually reversible through conservative or non-operative treatments.
• Stage II – Stage II results from fibrosis (formation of scar tissue) and tendinitis
(inflammation of the tendon). These injuries do not respond to conservative
treatment or management and usually require surgical operation. Surgery is
frequently indicated to repair the damaged rotator cuff.

• Stage III – Stage III is characterized by bone spur formation and tendon rupture.
Full thickness or partial tears of the rotator cuff tendons are associated with this
stage. Bicep tendon lesions and bony alterations of the acromion and
acromioclavicular joint are also linked to the third stage. Anterior acromioplasty
(surgical removal of anterior hook of the acromion) and surgical repair of the
rotator cuff are usually advised.
Shoulder impingement syndrome usually occurs in individuals working in jobs

that require repetitive overhead activities on a daily basis. Athletes involved in
swimming, throwing sports, volleyball, and tennis are also susceptible to this
condition.
Clients with shoulder impingement initially report gradual onset of sharp pain and
a tearing sensation in the affected shoulder area. Other clients describe a
gradual increase of shoulder pain with overhead activities, or a feeling of
catching when moving the arm, also suggesting an impingement problem. The
pain is usually located in the deltoid region.
Rotator Cuff Tendinitis

Rotator cuff tendinitis (inflammation of the rotator cuff) is often associated
with shoulder impingement syndrome. The supraspinatus tendon is the
most commonly affected tendon in the rotator cuff. Inflammation of the
rotator cuff results from a variety of factors. Increased subacromial loading,
rotator cuff overload, muscle imbalances, and repetitive overhead motions
are believed to cause tendon irritation and inflammation.
Clients with rotator cuff tendinitis report dull and achy pain in the posterolateral
shoulder, which radiates into the deltoid muscle area. The pain usually occurs at


night and from sleeping on the affected side. Shoulder pain is elicited during arm
abduction of more than 90 degrees. Also some clients report having pain at rest
and with specific movements or activities. Weakness of the affected arm during
overhead activities is also commonly reported.
Rotator Cuff Tears

A rotator cuff tear is frequently the end result of a series of events that began
with an uncomplicated inflammation of the tendon. Over time, tendon injury
progresses to advanced inflammation or scarring, then to tissue micro-tearing,
and finally to partial or complete tearing (Whiting & Zernicke, 2008). Rotator cuff
tears (RCT) mainly develop from three mechanisms: extrinsic compression of the
cuff, tendon degeneration, and muscle imbalance. The tears usually occur at
tendon-to-bone junctions, where circulation is poor. One of the reasons why
healing is so slow in the rotator cuff is poor circulation.
The incidence of rotator cuff tears increases with age, occurring more commonly
in clients aged 40 years and older. Partial tearing or total rupture of the tendons
is frequently caused by chronic degeneration, although injuries may also be
acquired from acute trauma. Rotator cuff tears usually occur in the dominant arm.
Signs and symptoms of rotator cuff tears are similar to those of rotator cuff
tendinitis. The pain is usually located in the lateral area of the shoulder and upper
arm. Dull and achy pain occurs with overhead activities. Severe pain in the
shoulder occurring at night can be a sign of a large rotator cuff tear. Clients with
rotator cuff tears demonstrate an inability to perform some simple tasks that
involve raising the arm, such as combing hair, or fastening a garment at the
back. The tears of the rotator cuff can be partial or full-thickness.
• Partial thickness or incomplete tears involve the articular side or bursal

side of the affected tendon, or the intratendinous area. Bursal-sided tears


occur on the superior surface of the rotator cuff, whereas articular-sided
tears occur on the undersurface of the rotator cuff. Intratendinous tears
arise within the rotator cuff fibers. The tears on the superior side
commonly result from subacromial impingement, while undersurface tears
are associated with anterior instability and insufficiencies of the labrum
and joint capsules. Using an MRI arthrography, Stetson and colleagues
(2005) observed that the hypovascular zones are more prominent on the
articular side of the supraspinatus tendon.
• Full-thickness tears involve complete disruption of the tendon, both on

the bursal and articular. A tear is considered massive if it involves at least
two of the tendons. The tear usually starts on the critical zone of the
supraspinatus tendon and extends, causing tearing of the infraspinatus,
teres minor, and subscapularis tendons. Research shows that clients with
full-thickness tears have one or more coexisting intra-articular
abnormalities, mostly involving labral tears and biceps tendon tears. In
some cases, full thickness tears cause complete detachment of the
tendon from the humeral bone, resulting in significant impairment of the
shoulder. Clients with a full-thickness tear will not be able to raise their
arm past 90 degrees of abduction.
Full-thickness rotator cuff tears are also classified by their tear size. Tears
measuring less than 1 cm are classified small, medium tears measure 1 to
3 cm, large tears range from 3 to 5 cm, and severe tears are greater than
5 cm. Classifying the degree of the rotator cuff tear and measuring the
tear size are essential in creating the most appropriate rehabilitation
program for the injured client.

References
Bilal, R., Duff, P., Shafi, B and Hafi, S. (2007, November 27). Rotator cuff pathology.
Retrieved October 4, 2009, from Emedicine:
DeBerardino, T. (2006, June 8). Supraspinatus tendinitis. Retrieved October 4, 2009,

from Emedicine: http://emedicine.medscape.com/article/93095-overview
Fongemie, A., Buss, D., & Rolnick, S. (1998). Management of shoulder impingement
syndrome and rotator cuff tears. American Family Physicians. Retrieved from
http://www.aafp.org/afp/980215ap/fongemie.html
Krishnan, S., Hawkins, R, & Warren R. (2004). The shoulder and overhead athlete.
Philadelphia: Lippincott Williams & Wilkins.
Lewis, J. (2008). Rotator cuff tendinopathy. British Journal of Sports Medicine, 43:236-
241.
Ling, S., Chen, S, & Wan R. (1990). A study of the vascular supply of the supraspinatus
tendon. Surgical and Radiologic Anatomy, 12: 161.
Retrieved October 3, 2009, from Emedicine:
Neer C., Craig E., & Fukuda, H. (1983) Cuff-tear arthropathy. Journal of Bone and Joint
Surgery, 65(9):1232-1244.
Noyes, M. (2001). [Types of Acromion Processes] [Online Image]. Retrieved October 4,

2008 from http://www.creekayaker.com/shoulder/rotatorcuff-
injury/Rotator%20Cuff%20Injury.htm
Quintana, E. & Sinert, R. (2009, January 29). Rotator cuff injuries. Retrieved October 3,
2009, from Emedicine.com: http://emedicine.medscape.com/article/827841-overview
Radomski, M. & Latham, C. (2008). Occupational therapy for physical dysfunction.

Rathnub, J. & Macnab I. (1970). The microvascular pattern of the rotator cuff. Journal of
Bone and Joint, 52(3):543-553.


Stetson,W., Phillips, T., & Deutsch, A. (2005). The use of magnetic resonance
arthrography to detect partial-thickness rotator cuff tears. The Journal of Bone and Joint
Surgery, 87: 81-88.
Tuite, M. & Sanford, M. (2009, June 23) Shoulder, rotator cuff injury (MRI). Retrieved on
October 5, 2009, from Emedicine: http://emedicine.medscape.com/article/401714-
overview
Voight, M., Hoogenboom, B., & Prentice, W. (2007). Musculoskeletal interventions:

techniques for therapeutic exercise. New York, NY: The McGraw-Hill Companies, Inc.
Wilson, A. (2002). Effective Management of Musculoskeletal Injury: a clinical
ergonomics. Edinburgh: Hardcourt Publishers Limited.
Whiting, W. & Zernicke, R. (2008). Biomechanics of musculoskeletal injury (2nd ed.).

Illinois: Human Kinetic.

Section 5: Diagnosing Rotator Cuff Injuries

Clients complaining of a dull ache in the upper and outer region of the arm or
shoulder are considered as possibly having rotator cuff pathologies. Most of the clients
report minimal discomfort while performing below-shoulder activities.
An accurate diagnosis of rotator cuff injury requires a detailed medical history, a

thorough physical examination, and some laboratory and diagnostic imaging. These
approaches are important to help the doctor or specialist rule out other health conditions
that may present with the same signs and symptoms.
The purpose of this section is to give the fitness professional a better

understanding of the process that a physician or specialist uses to diagnose a rotator
cuff injury and the severity of the injury.
Administering these tests is outside the scope of practice for fitness

professionals. They were included in this manual so fitness professionals can have a
better understanding when communicating with physicians, orthopedic surgeons, and
other health care professionals about results that have been found with a client.
Client History
The importance of taking an accurate and detailed client history cannot be

stressed enough. A complete and accurate medical history helps direct a correct and
organized course for the physical examination, which leads to an accurate diagnosis.
Keep in mind that the treatment modalities prescribed for clients largely rely on the
diagnosis. In addition, timely and appropriate treatment approaches are crucial in
achieving increased chance of recovery, prevention of complications, reduced health
care costs, preserved joint function, and overall improved quality of life. Client history
should be viewed as one of the most important steps in diagnosing a rotator cuff injury.

A typical presentation of the rotator cuff injury due to tendon degeneration is a 40

year old individual with a progressive onset of shoulder pain. More advanced rotator cuff
disease usually presents with constant shoulder pain and markedly increased pain
during overhead movements and arm-length activities (reaching out front). Night pain in
the shoulder area is a common complaint. Weakness during shoulder elevation
commonly occurs as the rotator cuff injury progresses. Grating, crackling, and popping
sounds, termed crepitus, are often experienced by clients. Over time, neck and mid-
back pain may accompany the rotator cuff injury.
The fitness professional will need a complete health history on the client in order
to understand more clearly how the rotator cuff injury occurred, as well as what makes
the shoulder feel worse or better. This information will provide the fitness professional
with a better idea of the movements and range of motions to focus on, and which of
them to avoid.
Physical Examination
A systematic physical examination of the shoulder includes the following parts: a

careful inspection; palpation of the bones, joints, and soft tissues; assessment of
passive and active ranges of motion; and strength testing and special tests. The
physical assessment of the shoulder also includes examination of the neck or cervical
spine, and neurovascular examinations.
Observation
Inspection begins the moment the client enters the examination room. Inspection
is performed in the following order: anterior observation, lateral observation, and
posterior observation.


The symmetry of the shoulder joints and bones, movements of the upper arms,
and the gait are evaluated, taking note of any sign of painful positions and any
irregularity in shoulder movement. Deformities, swelling, redness, and muscle
wasting (decrease in the size of the muscle compared to the non-injured side) in
the shoulder area are documented.
The following observations during shoulder examination may signal common

shoulder pathologies:
• Atrophy or wasting of the supraspinatus and/or infraspinatus is a hallmark of a

rotator cuff tear (Dutton, 2004). This maybe difficult to see.
• Flattening of the deltoid muscle indicates dislocation of the glenohumeral

joint; and bulging of the anterior aspect of the deltoid indicates dislocation of
the humeral head
• Deltoid atrophy, especially on the posterior side, occurs in multidirectional

instability. Multidirectional instability is when the head of the humerus is able
to move outside normal limits in two of the three directions: anterior, posterior,
or inferior
• Scapular winging due to serratus anterior weakness, is a condition where the

shoulder blade sticks out at the back, especially when pushing something
stationary, such as a wall
• A significant finding usually observed in rotator cuff injuries is a prominent

scapular spine, indicating supraspinatus and/or infraspinatus wasting


• Biceps deformity, most especially during elbow flexion, suggests a ruptured
long head of the biceps: bunching of the biceps, also known as a Popeye
biceps, indicates rupture of the biceps
It is important for the fitness professional to observe the client during their first
session. The best way for the fitness professional to inspect or observe the client
is by performing a postural assessment of the shoulder area. It is outside of this
manual to cover details of a postural assessment of the shoulder area. Seek out
courses or books that my help you with this.
Palpation (by health care provider)
Palpation, or feeling with the hands during physical examination, is also done in
an organized and methodical manner. Tenderness localized over the greater
tuberosity or subacromial bursa is a common sign of a rotator cuff injury.
Range of motion or ROM testing
During the range of motion evaluation, both active (client’s own strength) and
passive (performed by the examiner) range of motion (ROM) of the shoulder are
assessed. Active and passive ROM tests can give the examiner some important
information regarding the overall functional capacity of the shoulder. The ROM
testing usually begins with evaluation of active movements.
Initiation or ending shoulder movement with pain or hesitation is a sign of

possible rotator cuff injury. Limited or restricted active ROM may be due to
structural alterations of the shoulder, such as capsule or muscle tightening or
formation of tissue adhesions incurred from trauma and prolonged
immobilization. Decreased ROM is also possibly caused by pain, muscle


spasms, or joint loosening resulting from trauma and overuse. The following table
lists the normal ranges of shoulder movements and the possible causes of
decreased ROM related to pain.

Shoulder Movement Normal Range of Motion in Possible Causes of Pain

Degrees
Flexion 160 – 180 • Impingement of the cuff
• Glenohumeral,
acromiocalvicular, and
sternoclavicular joints
Extension 50 – 60 • Glenohumeral joint
Abduction 170 – 180 • Impingement of the cuff
• Acromioclavicular
arthritis
External rotation 80 – 90 • Instability of the anterior
glenohumeral joint
Internal rotation 60 – 100 • Impingement of the cuff
• Instability of the
posterior glenohumeral
joint
Table 2. Normal ranges of shoulder movement and possible causes of decreased range
of motion related to pain.
Figure 12. Active range of motion of the shoulder.
Another useful technique in assessing the shoulder range of motion is the Apley
scratch test. In this examination, arm abduction and external rotation are


determined by reaching behind the head and touching the upper portion of the
opposite scapula. Arm adduction and internal rotation are measured by reaching
behind the back and touching the lower portion of the opposite scapula.

Figure 13. Apley’s scratch test (2000).

Note: copyright Marcia Harstock
The fitness professional observes the range of motion that a client has with their
shoulder in order to get an idea of which movements cause pain and which
movements are limited. This helps in selecting exercises for the client's program.
The fitness professional must select exercises that are in a range of motion that
the client can perform pain-free.
Special Tests (by health care provider)
Special tests are done to identify and assess each of the individual muscles that
make up the rotator cuff. These tests are done to assess the rotator cuff integrity,
determine the involvement of the biceps, and determine if there are signs of
impingement.
Rotator Cuff Integrity Tests

• Supraspinatus test. Also known as the empty can test, the supraspinatus test is
conducted by having the client abduct the shoulder to 90 degrees and
horizontally adduct 30 degrees. Then the arm is internally rotated so the thumb is


pointed to the floor. The examiner provides 5 to 10 lbs of pressure. If there is
weakness or pain it would be a positive test that there is a supraspinatus tendon
tear.
• Infraspinatus test. With arms at the sides, the elbows are flexed to 90 degrees
as the examiner applies an internal rotation force while the client resists by
creating an external rotation force. Inability to maintain the position and a lag
during external rotation are positive signs of infraspinatus test.
• Subscapularis test. This test involves internal rotation of the arm with the
dorsum (back) of the hand placed against the lower back. Inability to lift the hand
off the back is specific for subscapularis tendon tear.
Figure 14. Rotator Cuff Integrity Tests. A = Supraspinatus test; B = Infraspinatus test
(2001).
Note: copyright Marcia Harstock
Impingement Tests
• Neer impingement sign. This test involves forced passive forward flexion with
the arm completely internally rotated. If pain is experienced beyond 120 degrees
of forward flexion, the client is positive for subacromial impingement. Afterward, 5


to 10 ml of 1% lidocaine is injected into the subacromial space. Relief of pain
confirms impingement.
• Hawkins-Kennedy test. In this test, the examiner elevates the arm forward to 90
degrees, flexes the elbow to 90 degrees and then forcibly internally rotates the
arm. Pain with the maneuver indicates subacromial impingement or rotator cuff
tendinitis.
• Painful arc. Pain with active abduction of the arm between 60 to 120 degrees n
the coronal plane (frontal or side-to-side plane) indicates shoulder impingement.
The painful arc test is especially useful if combined with other tests assessing the
rotator cuff, like the Neer and Hawkins-Kennedy tests.
• Drop-arm test. A rotator cuff tear can be evaluated through the drop-arm test.
This examination involves passive abduction of the shoulder to 90 degrees, and
then slowly lowering it to the waist following the same arc of movement. A client
with a rotator cuff tear demonstrates arm drop to the side or inability to continue
the maneuver as far as the waist because of severe pain.
• Apprehension test. This test is done as the client lies supine (on back) or
seated with the arm abducted to 90 degrees and the elbow flexed to 90 degrees.
A slight posterior to anterior pressure is placed on the humerus or upper arm by
the examiner and then the arm is externally rotated. Pain, apprehension about
feeling shoulder dislocation, or resistance to further motion is specific for anterior
glenohumeral instability.

A B C
D E
Figure 15. Impingement tests. A = Neer’s test; B = Hawkins-Kennedy test; C =

Apprehension test; D = Painful arc test; E = Drop arm test
Imaging Techniques
In the last several years, rapid advances in the science and technology of
imaging techniques have led to more accurate diagnoses and overall improved quality
of health care. Advanced and more complex diagnostic imaging techniques have
enhanced physicians' skill in diagnosing, staging, and treating rotator cuff injuries. Note,
however, that no imaging modality is generally accepted as the diagnostic tool of choice
for diagnosing this condition. Thus, a detailed medical history and a thorough physical
examination continue to be vital elements in making the diagnosis.
In this section, the most commonly used imaging techniques are briefly discussed.
Plain Radiographs (X-Rays)

Routine radiographic imaging, one of the earliest methods used to diagnose
rotator cuff disorders, continues to be one of the most important components in
evaluating shoulder problems. Anteroposterior, axillary, and lateral views of the


shoulder are often taken. But plain radiographs have some limitations. During the
early stages of rotator cuff injury, often no abnormalities are seen in radiographs.
As the injury advances, radiographic abnormalities may be recognized. Further
study and investigation are often needed to confirm the abnormalities and
determine their severity.
Conservative Arthrography
For several years, conservative arthrography (x-ray using fluorscope with
contrast solution injected into the joint) was considered the gold standard
imaging technique for diagnosing rotator cuff full-thickness tears. However, this
diagnostic tool has demonstrated some limitations. Research shows that
conservative arthrography is only accurate in identifying and predicting the size
of tears in 50% of cases (Maffulli, 2005). Arthrography itself does not display
partial-thickness tears in the bursal side (Tuite & Sandford, 2009). In spite of
this, arthrography can accurately demonstrate partial-thickness tears on both
articular and bursal sides.
Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) has replaced arthrography as the main
imaging tool used to diagnose rotator cuff injuries. Research shows that aside
from being a noninvasive imaging modality, MRI is extremely specific and
sensitive (Malanga, 2009). In contrast to arthrography, MRI can detect the tear
size and location, and characteristics of the affected structures.
Ultrasonography
Ultrasonography is another diagnostic technique that can evaluate disorders of
the rotator cuff. It is known to be highly accurate in detecting full-thickness rotator
cuff tears, with the ability to characterize the extent of the damage. Dislocation of
the biceps tendon is also diagnosed through ultrasonography. Compared to MRI,


this modality is less expensive and more comfortable for individuals with
claustrophobia (fear of being in small and enclosed spaces). Ultrasonography
tests are largely dependent on the skills of the operator, however, increasing the
likelihood of inconsistencies and discrepancies in the results.
Electrodiagnostic test
Electrodiagnostic testing like electromyography and nerve conduction tests are
also helpful in assessing and evaluating rotator cuff disorders and their
complications. Through this test, other causes of shoulder pain and weakness,
such as cervical radiculopathy (nerve injury in the neck), can be ruled out,
increasing the chances of accurate diagnosis and appropriate treatment of
rotator cuff injury.
Again, these are not diagnostic tests that would be ordered by the fitness
professional, nor would the results of the test be interpreted by a fitness professional.
These tests are ordered by physicians, specialists, and other qualified health care
professionals. A listing of the diagnostic tests and their purposes is included in this
manual so that the fitness professional becomes familiar with common diagnostic tools,
as many clients will have had these tests prior to starting an exercise program. The
fitness professional will have a better understanding of the results of the diagnostic tests
when communicating with physicians, orthopedic surgeons, and other health care
professionals about client test results.


References
Doursounian, D. (2007). Clinical examination of the shoulder in disorders of the rotator

cuff. Retrieved October 6, 2009, from Maitrise Orthopedique: http://www.maitrise-
orthop.com/viewPage_us.do?id=1010
Goldberg, C. (2008). A comprehensive physical examination and clinical education site

for medical students and other health care professionals. Retrieved October 6, 2009,
from University of California San Diego http://meded.ucsd.edu/clinicalmed/joints2.htm
Harstock., M. (2000). Shoulder examination: special tests [Online image]. Retrieved

October 6, 2009, from AAFP.org: http://www.aafp.org/afp/20000515/3079.html
Maffulli, N. Renstrom, P., & Leadbetter, W. (2005). Tendon injuries: basic science and
clinical medicine. New York, NY: Springer Publishing Company.
Retrieved from Emedicine: http://emedicine.medscape.com/article/92814-overview
Renstrom, P. & Tjandra, J. (2002). Tennis: Olympic handbook of sports medicine (P.
Renstrom, Ed.). Massachusetts: Wiley Blackwell.
Tuite, M. & Sanford, M. (2009, June 23) Shoulder, rotator cuff injury (MRI). Retrieved on
November 9, 2009, from Emedicine: http://emedicine.medscape.com/article/401714-
overview
Woodward, T. & Best, T. (2000, May 15). The painful shoulder: part I. clinical
evaluation. American Family Physician. Retrieved October 6, 2009, from
http://www.aafp.org/afp/20000515/3079.html

Section 6: Treatment and Management of Rotator Cuff Injuries
The healing capacity of the rotator cuff tendons is limited. Researchers Wolff and
colleagues (2006) believe that the hypovascularity of the rotator cuff, specifically in the
critical zones found in the supraspinatus and infraspinatus, often results in irreversible
damage, which can significantly reduce one’s physical functioning and overall quality of
life. This is why it is important to apply immediate treatment and management of the
injured rotator cuff, in order to prevent further damage.
During the early stages, a rotator cuff injury is managed through conservative
and self-management measures. The initial phase of the treatment is guided by the
principles of PRICEMEM – Protection, Rest, Ice/Cold and Heat Applications,
Compression, Elevation, Manual Therapy, Early Motion, and Medication (Dutton, 2004).
It is also important to include lifestyle modifications to maximize recovery and to prevent
rotator cuff irritation or further injury.
Protection and Rest
Minimizing shoulder and arm movements is strongly recommended as soon as

the pain sets in. Rest prevents complications by protecting the surrounding muscles,
tendons, and ligaments from irritation. This will allow the body to focus on healing of the
rotator cuff injury. Repetitive, forceful lifting of weights and overhead movements must
be avoided during this initial phase in order to protect the injured site from developing
complications. If your client’s normal routine or everyday job requires frequent overhead
movements, like lifting, make sure they have plenty of rest periods between activities to
reduce the risk of irritation or further injury.


There is a fine balance between decreasing movement of the shoulder and
immobilizing the shoulder. Long term shoulder immobilization could lead to other
complications like muscle wasting, decreased shoulder function, and decreased range
of motion. Have your client rest the affected side in order to help with recovery, but
move it and use it as much as he or she can in a pain-free range of passively (with
assistance).
Ice/Cold and Heat Applications
Application of cold and hot compresses are important during the first 24 to 72
hours after an injury. Ice bags or even bags of frozen vegetables can be used to apply
cold to the affected area during the first 24 to 48 hours after an injury; heat should be
applied thereafter. Cold reduces blood flow to the injured area, which limits tissue
swelling and causes temporary relief of pain. Your client should not leave the cold
compress on for more than 15 to 20 minutes, to prevent any damage to the skin. It is
recommended to apply a cold compress for 15 to 20 minutes, and do not apply another
cold compress for at least 20 minutes. After icing, heat can be applied for 15 to 20
minutes. The heat causes dilation of your blood vessels, increasing the supply of blood,
which is rich in the nutrients and oxygen necessary for tissue healing.
The general thought is that ice is for inflammation, and heat is for promoting
blood flow. Each client will respond differently to ice or heat. How your client reacts will
determine which provides them benefit and which does not.
Clients that are performing a post injury fitness program for a rotator cuff injury
will still need to continue icing in order to keep inflammation down in the shoulder joint;
they will need heat to promote circulation to the rotator cuff and address muscular
tightness.

Massage (provided by qualified professional)
According to Pribicevic and Pollard (2005) deep tissue massage can disrupt the
formation of scar tissues and adhesions on the muscles and tendons, resulting in
increased muscle strength and improved joint functions. Weakness of the rotator cuff,
muscle stiffness, and tightening of the joint capsule are also treated with massage
therapy. Massage increases the circulation of the blood, which encourages tissue
repair.
Activity modifications
Lifestyle modifications are a must in decreasing rotator cuff irritation and further
injury. Individuals who have suffered from a previous injury of the rotator cuff tendons,
or who are at increased risk due to the nature of their work and activity, must be careful
in performing physical activities that place a stress on the rotator cuff.
To reduce the occurrence and recurrence of rotator cuff injuries and help speed
recovery, performing certain activities that require forceful overhead movements and/or
repetition must be avoided or kept at a minimum. Serving a tennis ball, javelin throwing,
football throwing, and baseball pitching can develop or aggravate a rotator cuff injury.
Be cautious about performing activities that are included in your everyday routine that
could place unnecessary stress on your rotator cuff: placing dishes in the cupboard,
combing hair, putting on or removing clothes, scrubbing the floor, reaching up to a shelf,
yard work or vacuuming.
Following are also some techniques for preventing rotator cuff irritation and
further injury as your clients do their normal activities.

Tips that can significantly decrease the occurrence and recurrence of rotator cuff
injuries in your clients:
• Activities that involve repetitive and/or stressful shoulder motion must be

spread throughout the day.
• Rest periods in between overhead activities.
• Alternate underhand activities with overhead motions.
• Warm up exercises of the upper body done before starting an exercise

session.
Medications (prescribed by health care professional)
Oral non-steroid anti-inflammatory drugs, or NSAIDs, like aspirin, naproxen, and

ibruprofen can alleviate pain and decrease tissue swelling. If NSAIDs do not provide the
desired therapeutic effects, steroid injections can be administered directly into the
painful structure in the shoulder. The medication that your client has been given must
be taken as directed by their physician, to prevent or minimize side effects. Keep in
mind that although certain medications can relieve the pain, they do not improve
shoulder functions. The way to improve the function of the rotator cuff is with exercise.
Exercise
Maintaining an exercise program is essential during the early stages of a rotator

cuff injury. Exercise improves blood flow to the rotator cuff and increases the strength of
the rotator cuff. The studies of Langberg and colleagues (1999) and Smith and Rennie


(2007) revealed that exercises can assist in the synthesis and organization of collagen
tissue, a type of protein that connects and supports other bodily tissues. Collagen is a
connective tissue that possesses great tensile strength, meaning it is highly resistant to
tissue damage when force is placed on it.
Exercising is one of the best ways to prevent the occurrence and progression of
a rotator cuff injury. During the early stages of a rotator cuff injury, exercises that
strengthen the rotator cuff muscles and the scapular stabilizers can significantly aid in
maintaining the stability of the shoulder joint, thereby increasing the chances of
recovery. The next section focuses on the different exercises that are most beneficial in
maintaining the strength, flexibility, and functions of the rotator cuff and its supporting
structures.
Surgery
Surgery is considered if conservative measures fail in relieving the pain and

weakness of the injured arm and shoulder. If the injury has not improved after a 6-week
assessment consisting of rigorous physical therapy, surgery most likely is indicated
(Quintana, 2009). Surgical therapy is indicated in the following cases:
• Clients younger than 60 years of age with a full-thickness tear

• Clients who fail to improve after 6 weeks of rehabilitation
• Clients who regularly and repeatedly perform activities that require shoulder use
and/or repeated overhead activities
Surgical treatment options vary. In some cases, debridement or removal of the

frayed or partially torn tendon is all that is needed to resolve the symptoms, along with
acromioplasty. Acromioplasty is an arthroscopic surgical procedure that smoothes the
undersurface of the acromion. For more significant and larger tears, an open repair
surgery or arthroscopy (less invasive type of surgery) may be indicated.

After the surgery is completed, the operated shoulder is supported in a sling or

brace for a short period of time to facilitate protection and healing.
Exercise is a key component of recovery from shoulder surgery. It is up to the

surgeon to determine when an exercise program should begin and what should be
included in it. Contact the surgeon to get guidelines which they would like you to follow
as the client's fitness professional.
If your client was under the care of a physical therapist after surgery, then
contact the physical therapist for guidance in designing an exercise program.
Who is a Qualified Health Care Provider?
This all depends on the country, state or province you live in. Each area has
guidelines on who can and can not do what when it comes to working with people with
injuries. In some provinces a massage therapist can provide medical clearance to start
an exercise program while in other provinces and states they can’t. Please research
who can do what in your region. In the region that I work in a (Province of British
Columbia in Canada.) surgeons, medical doctors, chiropractors, physical therapists and
massage therapists can all provide medical clearance for a client with an injury to start
an exercise program.



References
Krishnan, S., Hawkins, R, & Warren R. (2004). The shoulder and overhead athlete.
Langberg, H., Skovgaard, D., Petersen, L., Bulow J. & Kjær. (1999). Type I collagen
synthesis and degradation in peritendinous tissue after exercise determined by
microdialysis in humans. The Journal of Physiology, 521: 299-306.
Retrieved October 6, 2009, from Emedicine.com:
Pribicevic, M. & Pollard, H. (2005). A multi-modal treatment approach for the shoulder: a
4 client case series. Chiropractic & Osteopathy,13(1):20.
Quintana, E. & Sinert, R. (2009, January 29). Rotator cuff injuries. Retrieved October 6,
2009, from http://emedicine.medscape.com/article/827841-overview
Renstrom, P. & Tjandra, J. (2002). Tennis: Olympic handbook of sports medicine (P.
Renstrom, Ed.). Massachusetts: Wiley Blackwell.
Saidoff, D. & Apfel, S. (2005). The healthy body handbook: a total guide to the
prevention and treatment of sports injuries. New York: Demost Medical Publishing.
Smith, K. & Rennie, M. (2007). New approaches and recent results concerning human-
tissue collagen synthesis. Current opinion in clinical nutrition and metabolic care, 10:
582-590.
Wolff, A., Sethi, P., Sutton, K., Covey, A., Magit, D. & Medvecky, M. (2006). Partial-
thickness rotator cuff tears. Journal of the American Academy of Orthopaedic Surgeons,
14(13): 715-725.

Section 7: Exercises for the Rotator Cuff Injuries
Section 7: Exercises for Rotator Cuff Injuries___________
Types of Exercises
Exercising the shoulder region, more specifically the rotator cuff muscles and the
scapular stabilizers, is a crucial component of treating and managing rotator cuff
injuries. Together with other forms of conservative measures, maintaining an exercise
regimen of the shoulder can significantly increase the rate of tissue healing and prevent
re-injury of the rotator cuff.
There are different types of exercises recommended to resolve the symptoms

associated with rotator cuff injuries. Although each group of exercises has its own
specific functions, each one plays a part in regaining and maintaining the health of the
rotator cuff and helping in its recovery.
Range of Motion Exercises
Nagging shoulder pain due to a rotator cuff injury usually results in decreased
range of motion. Although resting the affected shoulder joint is recommended,
total and prolonged inactivity of the shoulder may result in more severe
complications, like a stiff or frozen shoulder.
Performing range of motion exercises within the pain free range of motion is
initially recommended to restore joint mobility and increase the joint’s range of
motion. Overhead exercises (greater than 90 degrees) may be limited, but can
be included once the individual becomes more tolerant of flexion and abduction
movements.


These exercises are done slowly and in a relaxed manner within non-painful
ranges of movement.
Strengthening Exercises
Improved shoulder strength is achieved through the use of dumbbells, tubing or

bands, pulleys, and your own body weight. Equipment resists the rotator cuff
muscles, leading to increased rotator cuff muscle strength in concentric and
eccentric movements.
An important and often ignored strengthening exercise is isometric strengthening.

Isometric strengthening exercises are a form of resistance training in which the
individual uses his muscles to exert a force against a stationary object. This
exercise involves holding the arm in a fixed position for a certain period of time.
Rotator cuff strengthening exercises are introduced once they are tolerated. It is
important that shoulder strengthening exercises are done only in a pain-free
range. Start these exercises with the introduction of isometric exercises, with the
arms positioned below 90 degrees of abduction and 90 degrees of flexion
(Dutton, 2004). Exercises of the scapular stabilizers – trapezius, rhomboids,
levator scapulae, and serratus anterior - are also initiated, together with isometric
exercises. These include scapular retraction, or movement of the scapula toward
the spine, and protraction, or movement of the scapula away from the spine.
Stretching or Flexibility Exercises
Flexibility exercises of the shoulder stretch the joint capsule and the muscles that
support the shoulder girdle. These exercises are an important component of
rehabilitation and recovery from rotator cuff injuries.

Stretching exercises result in more lengthening of soft tissue; such as muscles,

tendons, joint capsules, and fascia. Doing these exercises improves joint range
of motion, reduces risk of muscle injuries, reduces muscle stiffness, spasm,
relieves rotator cuff pain, provides muscle relaxation, and improves overall
shoulder function.
Warm Up and Cool Down Exercises
Warming up the shoulder is one of the most essential, yet frequently

underestimated exercises for the rotator cuff. Doing five to ten minutes of
shoulder warm up exercises increases the blood flow in the shoulder region,
lubricating and dynamically stretching the shoulder. Your client can do this with
arm range of motion exercises or by using a cardiovascular machine like the
elliptical machine with arms, a rowing machine, or an upper body bike
(ergometer).
After exercising, perform cool down exercises for five to ten minutes. Cooling
down regulates your heart rate and your breathing rate, and prevents muscle
injuries and lightheadedness. The exercises used to warm up are the same as
the exercises used to cool down.
Exercises after a Surgical Procedure
The rehabilitation progression after a surgical procedure largely depends on the

surgical technique, tear size, and the cuff tension of the repair (American
Academy of Orthopedic Surgeons, 2006). The exercises prescribed during
rehabilitation are similar to those that are found in this book. Have your client


consult with their surgeon or qualified health care provider to see which exercises
from this book they should be doing.
General Healthy Rotator Cuff Exercise Tips and Guidelines
• It is strongly recommended that your client consult their physician or qualified

health care provider in order to get medical clearance before starting any
exercises to manage the rotator cuff injury. It is also advised that they check with
their fitness professional from time to time, to assess if they are executing the
exercises correctly and to determine if they need to have their rotator cuff
exercise program progressed.
• Exercises should not elicit pain. If there is any pain, exercise should be stopped.
• Begin the exercise sessions with shoulder warm up exercises for five to ten
minutes.
• When performing the rotator cuff exercises in this manual, it is important to

breathe normally. Having your client hold their breath is not advised.


References
American Academy of Family Physicians. (2007). Rotator cuff exercises. Retrieved

October 7, 2009 from
http://familydoctor.org/online/famdocen/home/healthy/physical/injuries/265.html
Dutton, M. (2004). Orthopedic: examination, evaluation & intervention. New York: The
McGraw-Hill Companies, Inc.
Erstad, S. (2008, February 8). Rotator cuff problems: exercises you can do at home.
WebMd. Retrieved from http://www.webmd.com/a-to-z-guides/rotator-cuff-home-
rehabilitation-exercises
Hall, C. & Brody, L. (2005). Therapeutic exercise: moving toward function (2nd ed.).
Retrieved from Emedicine.com: http://emedicine.medscape.com/article/92814-overview

Section 8: Effective Rotator Cuff Exercises
Section 8: Effective Rotator Cuff Exercises_______________

Range of Motion Exercises
EXERCISE 1: PENDULUM - CIRCLES
Start End
Purpose: To improve circumduction (circular movement) of the shoulder joint while standing,
to lubricate and dynamically stretch the shoulder joint.
Starting Position: In a standing position, abdominals braced, feet hip width apart, knees and hips bent
to a 45 degree angle, non-injured arm supporting your body on a chair back, and
the injured arm hanging straight down.
How to Do the 1. Move your arm in a small circular movement in a counter-clockwise direction.
Exercise: The hanging arm is relaxed and use momentum to move the arm.
2. Repeat 10 times.
3. Perform the exercise in a clockwise direction.
4. This exercise can be done every day.
Progressions: - Perform the exercise with larger circles.

- Do the exercise 20 times in each direction.
Contraindication - Move your arm in a pain-free range. Do not push through the pain.
& Common - The exercise should be performed using very light weights (less than five lbs.)
Mistakes: or no weights at all.
- This exercise should be performed only by the injured shoulder as there will be
little or no benefit to the non-injured shoulder.

EXERCISE 2: PENDULUM - HORIZONTAL ABDUCTION-ADDUCTION
Start End
Purpose: To improve horizontal adduction and abduction of the shoulder joint while standing,
to lubricate and dynamically stretch the shoulder joint.
to a 45 degree angle, non-injured arm supporting your body on a chair back and the
injured arm hanging straight down.
How to Do the 1. Move your arm side to side in small movement. The hanging arm is relaxed and
Exercise: use momentum to move the arm.
2. Repeat 10 times.
Progressions: - Perform the exercise with larger side to side movements.

& Common - The exercise should be performed initially with no weight and then you can add
Mistakes: very light weights (less than five lbs.).


EXERCISE 3: PENDULUM - FLEXION-EXTENSION
Start End
Purpose: To improve flexion and extension of the shoulder joint in the standing position, to
lubricate and dynamically stretch the shoulder joint.
to a 45 degree angle, non-injured arm supporting your body on a chair and the
injured arm hanging straight down.
How to Do the 1. Move your arm in a small forward and back movement. The hanging arm is
Exercise: relaxed and use momentum to move the arm.
2. Repeat 10 times.
Progressions: - Perform the exercise with larger forward to back movements.

& Common - The exercise should be performed with very light weights (less than five lbs.) or
Mistakes: no weights at all.


EXERCISE 4: PULLEY – UP AND DOWN
Start End
Purpose: To improve flexion of the shoulder joint, lubricate the shoulder joint and improve the
range of motion in the shoulder joint.
Starting Position: Sit tall in a chair, each hand on one of the pulley handles and your injured shoulder
lower than your non-injured shoulder.
How to Do the 1. Gently pull down on the pulley using your non-injured (right) arm to lift your
Exercise: injured arm (left).
2. Lift the injured arm as high as you can. It should take two seconds to reach this
point.
3. Hold your arm for one second at this top position.
4. Now lower your arm back to the start. This should take two seconds.
5. Repeat this exercise 10 times.
Progressions: - Hold injured arm at the top position for two seconds and progress to five
seconds.
- If you feel a stretch in the shoulder muscles, you can hold the position for 20 to
30 seconds in order to stretch the muscle.
- Do exercise 20 times.
Contraindication & - Move your arm in a pain-free range. Do not push through the pain.
Common Mistakes: - Anyone with shoulder impingement should remain at a range of motion that
does not lead to a pinching feeling.
- Feeling a light stretch is normal, as long as there is no pain associated with it.


EXERCISE 5: PULLEY - SHOULDER FLEXION
End
Start
Purpose: To improve flexion of the shoulder joint, lubricate the shoulder joint and improve the
range of motion in the shoulder joint.
Starting Position: Sit tall in a chair, each hand on one of the pulley handles. Your non-injured shoulder
is bent at the elbow with the arm of your injured shoulder straight and lower than
your non-injured shoulder.
How to Do the 1. Gently pull down on the pulley using your non-injured arm (right) to lift your
Exercise: injured arm (left).
point.
Progressions: - Hold your injured arm at the top position for two seconds and progress to five seconds.
- Feeling a light stretch is normal, as long as there is no pain associated with it.


EXERCISE 6: PULLEY - SHOULDER ABDUCTION
Start End
Purpose: To improve abduction of the shoulder joint, lubricate the shoulder joint and improve
the range of motion in the shoulder joint.
Starting Position: Sit tall in a chair, each hand on one of the pulley handles. The non-injured shoulder
is bent at the elbow with the arm of your injured shoulder straight, out to the side,
and lower than your non-injured shoulder.
How to Do the 1. The injured arm is straight and at the side of the body (left). The non-injured shoulder is
Exercise: positioned to pull down (right).
2. Gently pull down on the pulley using your non-injured arm to lift your injured arm.
3. Lift the injured arm as high as you can. It should take two seconds to reach this point.
Progressions: - Hold injured arm at the top position for two seconds and progress to five
seconds.
- Feeling a light stretch is normal as long as there is no pain associated with it.

EXERCISE 7: PULLEY - INTERNAL ROTATION
Start End
Purpose: To improve internal rotation of the shoulder joint, lubricate the shoulder joint and
improve the range of motion in the shoulder joint.
Starting Position: Stand in front of a door with each hand on one of the pulley handles. The non-
injured arm holds the handle in front of the body, while the injured arm reaches
behind your back to grasp the other handle.
How to Do the 1. Gently pull down on the pulley using your non-injured arm (right) to lift your injured
Exercise: arm (left) up your back.
point.
Progressions: - Hold injured arm at the top position for two seconds and progress to five seconds.
- If you feel a stretch in the shoulder muscles, you can hold the position for 20 to 30
seconds in order to stretch the muscle.
Contraindication - If you are not able to get into the starting position without pain, do not do this
& Common exercise.
Mistakes: - Move your arm in a pain-free range. Do not push through the pain.
- Feeling a light stretch is normal as long as there is no pain associated with it.
- This exercise should be performed only by the injured shoulder as there will be little
or no benefit to the non-injured shoulder.


EXERCISE 8: WAND - SHOULDER FLEXION
Start End
Purpose: To improve flexion of the shoulder joint with an active range of motion exercise.
Starting Position: Stand and hold a wand (broom, cane, stick) in your hands about shoulder width
apart.
How to Do the 1. Use both arms to lift the cane as high up as you can. It should take two seconds
Exercise: to complete this movement.
2. Hold your arm in this position for one second.
3. Return your arms to the starting position. This should take two seconds.
4. Repeat five times.
6. This exercise can also be done in supine (lying on your back).
Progressions: - Increase the hold at the top to three to ten seconds.

Contraindication - Anyone with shoulder impingement should remain within a range of motion that
& Common does not lead to a pinching feeling.
Mistakes: - Avoid arching in the lower back in order to get full shoulder flexion.
- Move your arm in a pain-free range. Do not push through the pain.


EXERCISE 9: WAND - SHOULDER EXTENSION

Start End
Purpose: To improve extension of the shoulder joint with an active range of motion exercise.
Starting Position: Stand and hold a wand (broom, cane, stick) in your hands about shoulder width
apart, behind your back with arms straight.
How to Do the 1. Use both arms to lift the cane away from you as far as you can. It should take
Exercise: one second to complete this movement.
2. Hold your arms in this position for one second.
3. Return your arms to the starting position. This should take one second.
Progressions: - Increase the hold at the end range to three seconds.

& Common
Mistakes:


EXERCISE 10: WAND - EXTERNAL & INTERNAL ROTATION

Start Middle End
Purpose: To improve internal and external rotation of the shoulder joint with an active
range of motion exercise.
Starting Position: Stand and hold a wand in your hands about shoulder width apart, with elbows
bent.
How to Do the 1. Keep elbows tight against the body and use both hands to move the
Exercise: wand to the right as far as you can. It should take one second to
complete this movement.
3. Now move both hands to the other side (left). It should take two seconds
to complete this movement.
6. Repeat five times on each side.
8. This exercise can also be done in supine (lying on your back).
Progressions: - Do exercise 10 times.
Common Mistakes:


EXERCISE 11: WAND PULL DOWN - EXTERNAL ROTATION

Start End
Purpose: To improve external rotation of the left shoulder joint and internal rotation of the right
shoulder joint with an active range of motion exercise, and stretching the triceps and
latissiumus dorsi.
Starting Position: Stand and hold a wand at your back, with one hand grasping the wand behind the
neck and the other hand holding it below and behind the pelvis.
How to Do the 1. Use the bottom hand (right) to move the wand and the top hand downwards. It
Exercise: should take one second to complete this movement.
3. Now move both hands to the starting position. It should take one second to
complete this movement.
5. Repeat 5 times
& Common - Those with anterior shoulder instability should be cautious with this exercise.
Mistakes: - This exercise should be performed only by the injured shoulder as there will be

EXERCISE 12: WAND PULL UP - INTERNAL ROTATION

Start End
Purpose: To improve internal rotation of the right shoulder joint and external rotation of the left
shoulder joint with an active range of motion exercise and stretching the deltoid and
rotator cuff.
Starting Position: Stand, holding a wand at your back, with one hand grasping the wand behind the
neck and the other hand holding below at the lower back.
How to Do the 1. Use the top hand to move the wand and the bottom hand upwards. It should
Exercise: take one second to complete this movement.
& Common - Those with posterior shoulder instability should be cautious with this exercise.
Mistakes: - This exercise should be performed only by the injured shoulder as there will be

EXERCISE 13: WAND – HORIZONTAL ABDUCTION AND ADDUCTION

\
Start Middle End
Purpose: To improve horizontal abduction and adduction of the shoulder joint with
an active range of motion exercise plus stretch the triceps, posterior
deltoid and rhomboids.
Starting Position: Stand and hold a wand in your hands about shoulder width apart, with
elbows straight.
How to Do the Exercise: 1. Use both hands to move the wand to the left as far as you can. It
should take one second to complete this movement.
3. Now move both hands to the other side. It should take two seconds
to complete this movement.
5. Return your arms to the starting position. This should take two
seconds.
Common Mistakes:

EXERCISE 14: WAND - ABDUCTION AND ADDUCTION

Start End
Purpose: To improve abduction and adduction of the shoulder joint with an active
range of motion exercise.
Starting Position: Stand and hold a wand in your hands about shoulder width apart, with
elbows straight and in front of your body.
How to Do the Exercise: 1. Use both hands to move the wand to the right as far as you can. It
should take one second to complete this movement.
3. Return your arms to the starting position. This should take one
second.
4. Repeat five times on each side.
Common Mistakes: - If you feel pinching in the shoulder when doing this exercise, grab the
wand with the hands turned out and the thumbs out.



EXERCISE 15: SHOULDER FLEXION
Start End
Purpose: To improve flexion range of motion of the shoulder joint; to activate the deltoid,
supraspinatus, and scapular stabilizing muscles.
Starting Position: Stand with your arms to your side and legs hip width apart.
How to Do the 1. Raise your arm toward the ceiling as far as you can while keeping your elbow
Exercise: straight. It should take two seconds to reach the top of the movement.
2. Hold your arm at the top of the movement for one second.
3. Return to your arm to the starting position. It should take two seconds to do this.

- Add dumbbells and resistive tubing to the exercise.
Contraindication - Anyone with shoulder impingement should remain at a range of motion that
Mistakes: - Avoid any arching in the lower back in order to get full flexion.


EXERCISE 16: SHOULDER EXTENSION
Start End
Purpose: To improve extension range of motion of the shoulder joint to activate latissimus
dorsi and scapular stabilizing muscles.
How to Do the 1. Move your arm back behind you as far as you can while keeping your elbow
Exercise: straight. It should take two seconds to reach the top of the movement.
3. Return to your arm to the starting position. It should take two seconds to do this.

Contraindication - Limit shoulder extension to 45 degrees in order to decrease excessive stress on

& Common the rotator cuff.
Mistakes: - Avoid bending forward in order to get greater shoulder extension.


EXERCISE 17: SHOULDER ABDUCTION
Start Middle End
Purpose: To improve abduction of the shoulder joint in order to activate the deltoid,
supraspinatus, and scapular stabilizing muscles.
How to Do the 1. Move your left arm out to your side while keeping your elbow straight and palm
Exercise: down. It should take two seconds to move your arm to shoulder height.
2. If you are able to move your arm further, rotate your arm so the palm is up and
continue to move your arm upward. It should take two seconds to move your
arm from shoulder height to the top position.
4. Return your arm to the starting position. It should take two seconds to reach
shoulder height and another two seconds to reach your side.
Progressions: - Increase the hold at the top to three seconds.

& Common - Anyone with shoulder impingement should remain within a range of motion that
Mistakes: does not lead to a pinching feeling.

EXERCISE 18: SHOULDER ADDUCTION
Start End
Purpose: To improve adduction of the shoulder joint in order to activate the pectoralis major
and latissimus dorsi.
How to Do the 1. Move your left arm from your side towards the middle of your body while
Exercise: keeping your elbow straight. It should take two seconds to complete this
movement.
3. Return to your arm to the starting position. This should take two seconds.

& Common - Anyone with AC joint injury or pain should remain within a range of motion that
Mistakes: is pain free.

EXERCISE 19: SHOULDER INTERNAL ROTATION
Start End
Purpose: To improve internal rotation of the shoulder joint and stretch the rotator cuff.
Starting Position: Stand with your left arm behind your back, right arm at your side and legs hip width
apart.
How to Do the 1. Move your left arm from behind your back at your hip level towards your
Exercise: opposite (right) shoulder blade. It should take two seconds to complete this
movement.
3. Return to your arm to the starting position. This movement should take two
seconds.

- If you feel a stretch, you can hold the end position for 20 to 30 seconds in order
stretch the muscle.
& Common - Those with anterior and posterior shoulder instability should be cautious with this
Mistakes: exercise.
- This exercise should be performed only by the injured shoulder as there will be little
or no benefit to the non-injured shoulder.

EXERCISE 20: SHOULDER EXTERNAL ROTATION
Start End
Purpose: To improve external rotation of the shoulder joint, activate the scapular stabilizing
muscles, and stretch latissimus dorsi, triceps and pectoralis major
Starting Position: Stand with your right arm behind your head and your left arm at your side, and legs
hip width apart.
How to Do the 1. Move your right arm from behind your head towards your opposite (left)
Exercise: shoulder blade. It should take two seconds to complete this movement.
3. Return to your arm to the starting position. This movement should take two
seconds.

- If you feel a stretch, you can hold the end position for 20 to 30 seconds in order
stretch the muscle
Mistakes: - Any one with shoulder impingement should remain within a range of motion that


Notes on Range of Motion Exercises
Your client may have other range of motion exercises that their doctor, physical
therapist, and health care providers have recommended.
Your client may be given other range of motion exercises prior to seeing you. Often,
these are passive range of motion exercises, i.e., exercises where the client uses the
non-injured arm to take the injured arm through shoulder ranges of motion. Passive
range of motion exercises are not included in this manual. The next step for your client
is to work towards active range of motion exercises, i.e., using the shoulder muscles to
move the injured shoulder. This manual includes active range of motion exercises.
Should your client do each exercise with each arm?

With range of motion exercises, your client does not need to perform every exercise
with each shoulder. If the non-injured shoulder has full range of motion, it is not
necessary. Your client may perform the exercise on both sides if doing it on the non-
injured side gives the injured side a rest, so it can recover from the exercise performed.
A second reason for exercising both sides is that there is bilateral learning between the
two sides of the body. The body feels and sees how the non-injured side does the
movement, and it works to transfer that movement pattern to the injured side.
Where can your client get a pulley that attaches to the door?
Any medical supply store and some larger pharmacies will have them.

Stretching and Flexibility Exercises
EXERCISE 1: POSTERIOR STRETCH

Start End
Purpose: To improve horizontal adduction of the shoulder joint and to stretch deltoid,
rhomboids, middle trapezius, and posterior capsule.
How to Do the 1. Move your right arm across your chest at a height just below the shoulder.
Exercise: 2. Move your left arm across your body to your right elbow and lightly pull your
right arm to intensify the stretch.
3. You should feel a light stretch in the back of your shoulder.
4. Hold the stretch in your left arm for 30 seconds.
5. Return your arm to the starting position.
6. Perform the exercise on the left arm.
7. Repeat two times on each side.
Progressions: - If you are not feeling a stretch, you can move the arm up and down until you
feel a light stretch in the back of your shoulder.
Contraindication - Move your arm to a point that is pain free. Do not push through the pain.
& Common - Anyone with AC joint injury or pain should remain within a range of motion that
Mistakes: is pain free.

EXERCISE 2: POSTERIOR SHOULDER II STRETCH

Start End
Purpose: To improve internal rotation of the shoulder joint and stretch supraspinatus,
infraspinatus, teres minor, deltoid, and the posterior capsule.
Starting Position: Stand with your left arm behind your back, left elbow against the corner of a wall
and legs hip width apart.
How to Do the 1. Step back with your left leg and let the wall lightly push the left elbow forward.
Exercise: 2. You should feel a light stretch in the back of your left shoulder blade.
3. Hold the stretch for 30 seconds.
5. Perform the exercise on the other arm.
Progressions: - If you are not feeling the stretch, move the hand behind your back more towards
the opposite shoulder blade.
& Common - Those with anterior and posterior shoulder instability should be cautious with
Mistakes: this exercise.
- The stretch should be light. If you have to force the elbow forward to feel the
stretch, skip this exercise.


EXERCISE 3: ANTERIOR SHOULDER STRETCH
Start End
Purpose: To improve internal rotation of the shoulder joint, and to stretch supraspinatus,
anterior deltoid and pectoralis major.
Starting Stand with your left arm behind your back, left elbow against the corner of a wall and
Position: legs hip width apart.
How to Do the 1. Step forward with your left leg and let the wall lightly push the left elbow back.
Exercise: 2. You should feel a light stretch in the front of your left shoulder.
Progressions: - If you are not feeling the stretch, move the hand behind your back more towards
the opposite shoulder blade.
Mistakes: - The stretch should be light. If you have to force the elbow back to begin to feel
the stretch, skip this exercise.


EXERCISE 4: SUPRASPINATUS STRETCH

Start End
Purpose: To improve internal rotation of the shoulder joint and stretch supraspinatus.
Starting Position: Stand and place both of your hands on your hips.
How to Do the 1. Move both of your elbows forward.

Exercise: 2. You should feel a light stretch around the top of your shoulders.
4. Return your arms to the starting position.
5. Repeat 2 times.
Progressions: - If you are not feeling the stretch, make sure you stand up tall and with good
posture.
& Common - Those with posterior shoulder instability should be cautious with this exercise.
Mistakes: - The stretch should be light. If you have to force the elbows forward to begin to
feel the stretch, skip this exercise.

EXERCISE 5: DOORWAY STRETCH - ANTERIOR CAPSULE STRETCH
Start End
Purpose: To improve external rotation and horizontal extension of the shoulder joint by
stretching pectoralis major, pectoralis minor, and the rotator cuff.
Starting Position: Stand in a doorway or at the end of a wall, with your right forearm on the wall, elbow
bent to 90 degrees, and elbow below shoulder height.
How to Do the 1. From the starting position, step through the doorway with your right leg.
Exercise: 2. You should feel a light stretch around the front of your shoulder.
4. Return to the starting position.
5. Repeat two times and switch sides.
Progressions: - If you are not feeling the stretch, make sure you stand up tall and that your
forearm is against the door frame.
Contraindication - Move to a point that is pain free. Do not push through the pain.
Mistakes: - Do not arch your lower back.


EXERCISE 6: SUPERIOR CAPSULE STRETCH

Start End
Purpose: To improve adduction of the shoulder joint and stretch supraspinatus.
Starting Position: Stand, bend the left elbow, and place a rolled up towel between your elbow and
torso.
How to Do the 1. Reach with your right hand and grab your left elbow and use the right arm to
Exercise: pull the left elbow towards the body.
2. You should feel a light stretch around the top of your shoulder.
4. Return your right arm to the starting position.
5. Repeat two times.
posture.
& Common - The stretch should be light. If you have to force the elbow towards your body to
Mistakes: feel the stretch, skip this exercise.

EXERCISE 7: TRICEPS STRETCH - INFERIOR CAPSULE STRETCH

Start End Anterior End Posterior
Purpose: To improve flexion of the shoulder joint by stretching triceps.
Starting Position: Stand and take your left hand and reach over your shoulder to touch your back.
How to Do the 1. Reach with your right hand and push your left elbow back.
Exercise: 2. You should feel a light stretch in the back of your left arm.
4. Return your arms to the starting position.
posture.
& Common - Avoid any arching in the lower back or upper back (keep rib cage down) when
Mistakes: attempting to move your elbow further back.

EXERCISE 8: WALL SHOULDER STRETCH

Start End
Purpose: To improve horizontal abduction of the shoulder joint by stretching the anterior
deltoid and pectoralis major.
Starting Position: Place your right arm against the wall just below shoulder height.
How to Do the 1. Keep your right arm where it is and rotate your body further away from your
Exercise: right arm.
2. You should feel a light stretch in the front of your chest.
Progressions: - None.
Mistakes:

Notes on Stretching
At what intensity should the shoulder stretches be performed?
The stretch should be light. Your client will get the greatest benefit form the stretch if it
is light. Pain or discomfort should not be felt during the stretch. If the stretch is too
strong, the muscle may not relax and allow the muscle to lengthen.


Strengthening Exercises - Isometrics
EXERCISE 1: SHOULDER FLEXION

End
Purpose: To improve shoulder flexion strength of the shoulder joint in a standing position by
isometrically activating the deltoid and scapular stabilizing muscles.
Starting Position: Stand with your right arm in 30 degrees of flexion in front of your body against a wall
or another immovable object.
How to Do the 1. Press your right arm into the wall at 10% of your maximum strength for six
Exercise: seconds.
2. After the first repetition, keep the arm where it is but rest for one second.
3. Repeat six times.
Progressions: - Progress to maximum flexion isometric exercise.
& Common - Don't push at more than 10% of your maximum strength. You should be
Mistakes: pushing lightly so the lower intensity muscle fibers are activated.

EXERCISE 2: SHOULDER EXTENSION
End
Purpose: To improve shoulder extension strength of the shoulder joint in a standing position
by isometrically activating the latissimus dorsi muscle, long head of the triceps and
scapular stabilizing muscles.
Starting Position: Stand with your left arm in 30 degrees extension behind your body, elbow bent to
90 degrees and pushing against a wall or another immovable object.
How to Do the 1. Press your left arm into the wall at 10% of your maximum strength for six
Exercise: seconds.
2. After the first repetition of six seconds, keep the arm where it is but rest for one
second.
Progressions: - None
& Common - Don't push at more than 10% of your maximum strength. You should be
Mistakes: pushing lightly so the lower intensity muscle fibers are activated.

EXERCISE 3: SHOULDER ABDUCTION

End
Purpose: To improve shoulder abduction strength of the shoulder joint in a standing position
by isometrically activating the deltoid, supraspinatus, and scapular stabilizing
muscles.
Starting Position: Stand with your right arm in 30 degrees abduction to the side of your body against a
wall or another immovable object.
How to Do the 1. Press the back of your left hand into the wall at 10% of your maximum strength
Exercise: for six seconds.
second.
Progressions: - Progress to maximum abduction isometric exercise.
Mistakes: - Don't push at more than 10% of your maximum strength to begin. You should
be pushing lightly so the lower intensity muscle fibers are activated.

EXERCISE 4: SHOULDER ADDUCTION
End
Purpose: To improve adduction strength of the shoulder joint in a standing position by

isometrically activating the pectoralis major, and scapular stabilizing muscles.
Starting Position: Stand with your right arm in 30 degrees flexion against a wall or another immovable
object.
How to Do the 1. Press the palm of your right hand into the wall at 10% of your maximum
Exercise: strength for six seconds.
second.
Mistakes: - Don't push at more than 10% of your maximum strength. You should be
pushing lightly so the lower intensity muscle fibers are activated.

EXERCISE 5: INTERNAL ROTATION

End
Purpose: To improve shoulder internal rotation strength of the shoulder joint in a standing
position by isometrically activating the subscapularis, latissimus dorsi muscle, and
Starting Position: Stand with your left elbow at your side and place the palm of your left hand against
a wall or another immovable object.
How to Do the 1. Press the inside of your left wrist into the wall focusing on rotating in at your
Exercise: shoulder. Press 10% of your maximum strength for six seconds.
second.
Contraindication - Don't push at more than 10% of your maximum strength. You should be
& Common pushing lightly so the lower intensity muscle fibers are activated.
Mistakes:

EXERCISE 6: EXTERNAL ROTATION

End
Purpose: To improve shoulder external rotation strength of the shoulder joint in a standing
position by isometrically activating the infraspinatus, teres minor muscle, and
Starting Position: Stand with your right arm at your side and the back of your right hand and forearm
against a wall or another immovable object.
How to Do the 1. Press your right wrist against the wall while rotating out at your shoulder, using
Exercise: 10% of your maximum strength for six seconds.
second.
Progressions: - Progress to maximum external rotation isometric exercise.
Contraindication - Don't push at more than 10% of your maximum strength. You should be
& Common pushing lightly so the lower intensity muscle fibers are activated.
Mistakes: - Focus on moving the whole arm out to the side compared to rotating the
shoulder out.


EXERCISE 7: Elbow Below Shoulder Into Wall
End
Purpose: To improve the isometric activation and endurance of the scapular stabilizing
muscles with an emphasis on middle trapezius.
Starting Position: In a standing position about 1 foot from the wall, move your arm to the side until it is
below shoulder height and bend the elbow to 90 degrees. Now place a soft plastic
Pilates or toy ball between your forearm and the wall.
How to Do the 1. Move your arm back, pressing into the ball at 10 percent of your maximum
Exercise: strength for 6 seconds, focusing on the muscle around your shoulder blade to
perform the movement.
2. Relax for 1 second and then move into the next repetition.
3. Perform 6 repetitions.
Contraindication - Pressing too hard into the ball leads to activating the wrong muscles. It is
& Common important to only press 10% of your maximal strength into the ball.
Mistakes: - Focus on moving the whole arm out to the side compared to rotating the
shoulder out.


EXERCISE 8: Y into Ball

End
Purpose: To improve the isometric activation and endurance of the scapular stabilizing
muscles and external rotators of the shoulder with an emphasis on lower trapezius.
Starting Position: In a standing position about 1 foot from the wall, move your arm to the side until it is
120 degrees out to the side (abduction). Now place a soft plastic Pilates or toy ball
between your forearm and the wall.
How to Do the 1. Move your arm back, pressing into the ball at 10 percent of your maximum
Exercise: strength for 6 seconds, focusing on the muscle around your shoulder blade to
perform the movement.
2. Relax for 1 second and then move into the next repetition.
3. Perform 6 repetitions.
Contraindication - Pressing too hard into the ball leads to activating the wrong muscles. It is
& Common important to only press 10% of your maximal strength into the ball.
Mistakes:


Notes on Strengthening Exercises – Isometrics
What is a maximum isometric exercise?
Some of the isometric exercises progress from using 10% of maximum strength to
maximum strength. Maximum strength is when the client performs the exercise
applying 100% maximal force with their arm with pain-free range of motion. The
maximum isometric exercises are performed to activate the scapular stabilizing muscles
at a higher level.
What are lower intensity muscle fibers?
Performing a muscle contraction at a lower muscle contraction level (10% of maximum)

targets the slow twitch muscles. Slow twitch muscles are important for stabilizing and
protecting a joint.
What if I perform the exercises at a level greater than 10% of maximal strength?
If you perform the exercise at a level of greater than 10% of maximal strength, you end
up focusing on the fast twitch muscles. In most cases with a shoulder injury, the
muscles that need to be worked on are slow twitch muscles, like the rotator cuff and
scapular stabilization muscles.
How important is breathing when doing isometrics?
It is important to breath normally when performing isometric exercises. If you hold your
breath, it increases your blood press which can be an issue for some people and
holding your breath is not the way we move our bodies throughout the day. If you take
too deep of a breath, this changes your chest position which changes the position of
your shoulder which affects the muscles being targeted during the exercise.


Strengthening Exercises – Bodyweight
EXERCISE 1: Four Point Arm To Side Leading with Pinkie

Start End
Purpose: To improve horizontal abduction (extension) strength of the shoulder joint in four
point position by concentrically and eccentrically strengthening the posterior deltoid,
rhomboids, and middle trapezius muscles. This exercise emphasizes the
rhomboids while the opposite shoulder has its scapular stabilizers activated and the
core is active in order to prevent trunk rotation.
Starting Position: In a four point position (hands under shoulder and knees under hips). Make sure to
chin tuck, align your body in perfect alignment, set your shoulder blades and brace
your abdominals.
How to Do the 1. Separate your hands and move right arm out to the side while still keeping it
Exercise: below shoulder height. The movement is being lead by the pinkie of your hand.
2. It should take two seconds to reach the end position. Hold the end position for
a second and then take two seconds to return back to the start position.
3. Rest for 1 second and move into the second repetition.
4. Perform 12 repetitions of the exercise and then switch to the left.
Progressions: - Add resistive tubing or dumbbells.

- Progress to two sets and then three sets.
Contraindication - Dropping your head. This will take away from the work being done by the
& Common rhomboids and emphasize the upper trapezius.
Mistakes: - Shrugging your shoulder shifts the emphasis on the upper trapezius which is
overactive in most people.


EXERCISE 2: Four Point Arm To Side Leading with Thumb

Start End
Purpose: To improve horizontal abduction (extension) strength of the shoulder joint in a four
point position by concentrically and eccentrically strengthening the posterior
deltoid, rhomboids, and middle trapezius muscles. This exercise emphasizes the
middle trapezius and posterior rotator cuff muscles, while the opposite shoulder
has its scapular stabilizers activated and the core is active in order to prevent trunk
rotation.
Starting Position: In a four point position (hands under shoulder and knees under hips). Make sure
to chin tuck, align your body in perfect alignment, set your shoulder blades and
brace your abdominals.
How to Do the 1. Separate your hands and move right arm out to the side while still keeping it
Exercise: below shoulder height. The movement is being lead by your thumb.
3. Rest for 1 second and move into the second repetition
4. Perform 12 repetitions of the exercise and then switch to the left.

over active in most people.
- Arching at the lower back to get more range of motion. The back is upright and
not moving during the exercise.


EXERCISE 3: Four Point with ½ Y

Start End
point position by concentrically and eccentrically strengthening the posterior
deltoid, rhomboids, and trapezius muscles. This exercise emphasizes the lower
trapezius, while the opposite shoulder has its scapular stabilizers activated and the
core is active and working to prevent trunk rotation.
Starting Position: In a four point position (hands under shoulder and knees under hips). Make sure
to chin tuck, align your body in perfect alignment, set your shoulder blades and
brace your abdominals.
How to Do the 1. The right arm is straight, turn out to the side (externally rotated) 45 degrees
Exercise: and the hand in a fist.
2. In a controlled and slow manner, move your right arm to about a 45 degree
angle (120 degrees of abduction) until it is slightly behind the right shoulder. In
the end position, the elbow will be just below the shoulder and the hand above
the shoulder.
5. Perform 12 repetitions of the exercise and then switch to the left hand.



EXERCISE 4: Four Point with ½ W

Start End
rhomboids, and middle trapezius muscles. This exercise emphasizes the middle
Starting Position: In a four point position (hands under shoulders and knees under hips) with the
elbow bent to 25 degrees. Make sure to chin tuck, align your body in perfect
alignment, set your shoulder blades and brace your abdominals.
How to Do the 1. In a controlled and slow manner, move your right arm out to the side in a
Exercise: horizontal abduction (extension) movement until it is slightly behind the right
shoulder. In the end position the elbow will be just below the shoulder and the
hand above the shoulder.



Notes on Strengthening Exercises – Bodyweight
What is a concentric contraction?
This is when the muscle is shortening during a muscle contraction.
What is a eccentric contraction?
This is when the muscle is trying to shorten but the resistance to the muscle is causing
the muscle to lengthen.

Strengthening Exercises - Tubing
EXERCISE 1: Tubing Row

Start End
Purpose: To improve shoulder extension strength of the shoulder joint and scapular retraction
in sitting position by concentrically and eccentrically strengthening the posterior
deltoid, rhomboids, latissimus dorsi, rotator cuff and middle trapezius muscles.
Starting Position: In a sitting position with tubing looped around your feet and tubing handles in your
hands.
How to Do the 1. Pull back on the tubing and move the elbows just past the shoulders, squeezing the
Exercise: shoulder blades together.
2. It should take two seconds to reach the end position. Hold the end position for a
second and then take two seconds to return back to the start position.
4. Perform 12 repetitions of the exercise.
Progressions: - Increase the resistive tubing resistance.

Contraindication - Shrugging up in the shoulder focuses on the upper trapezius which is over active in
& Common most people. Relax your shoulders and focus on the muscle in the back of the
Mistakes: shoulder blades.
- The elbows are slightly bent and lead the movement, not the hands. It is like your
elbows are pulling your elbows back.
- Make sure your wrists are neutral (straight) in order to decrease the stress on your
wrists.

EXERCISE 2: Low Tubing “T” Row

Start End
Purpose: To improve horizontal abduction (extension) strength of the shoulder joint in sitting
position by concentrically and eccentrically strengthening the posterior deltoid,
rhomboids, rotator cuff and middle trapezius muscles. With the arms further away
from the body, there is an increase in the emphasis on the rotator cuff.
hands.
How to Do the 1. Separate your hands by squeezing your shoulder blades towards your spine
Exercise: and moving your arms out to the side while still keeping your arms well below
shoulder height.

Contraindication - Shrugging up in the shoulder. Relax your shoulders and focus on the muscle in the
& Common back of the shoulder blades.
Mistakes: - The elbows are slightly bent and lead the movement, not the hands. It is like your
elbows are pulling your elbows back.
wrists.

EXERCISE 3: High Tubing “T” Row
Start End
rhomboids, rotator cuff and middle trapezius muscles. This exercise puts greater
emphasis on the rhomboids. With the arms further away from the body, there is
greater emphasis on the rotator cuff.
hands.
How to Do the 1. Separate your hands and move your arms out to the side while keeping your arms
Exercise: below shoulder height.

Contraindication - Shrugging up in the shoulder puts emphasis on the upper trapezius which is over
& Common active in most people. Relax your shoulders and focus on the muscles in the back
Mistakes: of the shoulder blades.
- Let the elbows lead the movement and not the hands. It is like your elbows are
pulling your elbows back.
wrists.


EXERCISE 4: Standing Thumbs Out to the Side

Start End
Purpose: To improve external rotation strength of the shoulder joint in standing position by
concentrically and eccentrically strengthening the rotator cuff muscles.
Starting Position: In a standing position with tubing in your hands, palms facing up, elbows bent and
at your side.
How to Do the 1. Separate your hands focusing on rotating out with your shoulders.
Exercise: 2. It should take two seconds to reach the end position. Hold the end position for
Progressions: - Decrease the amount of tubing between your hands.

- Increase the resistive tubing resistance.
Contraindication - Shrugging your shoulder shifts the emphasis on the upper trapezius which is
& Common over active in most people.
Mistakes: - Make sure your wrists are neutral (straight) in order to decrease the stress on
your wrists.
- Do not straighten the elbows, this leads to the triceps compensating.
- Ensure your elbows are tight against your body.


EXERCISE 5: Standing Pinkie Out to the Side

Start End
Purpose: To improve external rotation strength of the shoulder joint in standing position by
concentrically and eccentrically strengthening the rotator cuff muscles. With the
palms down, this decreases the help from the wrist and challenges the rotator cuff
more.
Starting Position: In a standing position with tubing in your hands, palms facing down, elbows bent
and at your side.
How to Do the 1. Separate your hands focusing on rotating out with your shoulders.

Contraindication - Shrugging your shoulder, shifts the emphasis on the upper trapezius which is
& Common over active in most people.
your wrists.
- Do not straighten the elbows, this leads to the triceps compensating.
- Ensure your elbows are tight against your body


EXERCISE 6: Open Up with Palms Down

Start End
Purpose: To improve horizontal abduction (extension) strength of the shoulder joint in

standing position by concentrically and eccentrically strengthening the posterior
deltoid, rhomboids, rotator cuff and middle trapezius muscles. This exercise
emphasizes the rhomboids.
Starting Position: In a standing position with tubing in your hands, arms just below shoulder height
and palms down.
How to Do the 1. Separate your hands and move your arms out to the side while still keeping
Exercise: your arms below shoulder height.



- Make sure your wrists are neutral (straight) in order to decrease the stress on
your wrists.
- Try to keep your arms straight as bending them will change the muscles being
used.

EXERCISE 7: Low Diagonal Tubing with Palms Down

End
Start
Purpose: To improve shoulder extension strength of the shoulder joint at varying degrees of
shoulder flexion in standing position by concentrically and eccentrically
strengthening the posterior deltoid, rhomboids, latissimus dorsi, rotator cuff and
scapular stabilizers. When the arm is overhead the emphasis is the scapular
stabilizers while when the arm is below shoulder height the focus is rhomboids and
latissimus dorsi.
Starting Position: In a standing position with tubing in your hands, one arm just below shoulder height,
the other arm below shoulder height and palms down.
How to Do the 1. Separate your hands and move your arms out to the side while still keeping one
Exercise: arm just below shoulder height and the other arm just above shoulder height.
5. Then switch sides.



your wrists.
used.



EXERCISE 8: High Diagonal Tubing with Palms Down

Start End
strengthening the posterior deltoid, rhomboids, latissimus dorsi, rotator cuff and
scapular stabilizers. When the arm is overhead the emphasis is the scapular
stabilizers while when the arm is below shoulder height the focus is rhomboids and
latissimus dorsi.
Starting Position: In a standing position with tubing in your hands, one arm just below shoulder height,
the other arm below shoulder height and palms down.
How to Do the 1. Separate your hands, moving your arms across your body at a 45 degree angle
Exercise: so one arm is well above the shoulder while the other is below.



your wrists.
used.



EXERCISE 9: Three Way

End 1 Start 2
Start 1

Start 3 End 3
End 2
strengthening the posterior deltoid, rhomboids, latissimus dorsi and scapular
stabilizers. When the arm is overhead the emphasis is the scapular stabilizers while
when the arm is below shoulder height the focus is rhomboids and latissimus dorsi.
Starting In a standing position with tubing in your hands, arms just below shoulder height and
Position: palms down.


How to Do the 1. Separate your hands and move your arms out to the side while still keeping your
Exercise: arms below shoulder height.
3. Rest for 1 second.
4. Move your hands so one arm is just above the shoulder and the other just
below. Separate your hand and move them back so your arms move at a 45
degree angle. You stop moving your hands when they become in line with your
shoulders.
6. Switch which arm is above and below the shoulder. Perform the movement
again.

- Increase the resistive tubing resistance
- Perform the exercise with the palms up.
Mistakes: - Shrugging your shoulder, shifts the emphasis on the upper trapezius which is
- Arching at the lower back to get more range of motion. The back is upright and
not moving during the exercise.
your wrists.
used.


EXERCISE 10: Open Up with Palms Up

Start End

middle trapezius.
and your arms rotated out (90 degrees external rotation) so thumbs are pointing
away from each other.
3. Rest for 1 seconds and move into the second repetition.



your wrists.
used.


EXERCISE 11: Low Diagonal with Palms Up

Start End

middle trapezius.



your wrists.
used.


EXERCISE 12: High Diagonal Tubing with Palms Up

Start End

middle trapezius.
How to Do the 1. Separate your hands and move your arms out to the side.



your wrists.
used.


EXERCISE 13: Four Point Arm Back

Start End
Purpose: To improve extension strength of the shoulder joint in four point position by
concentrically and eccentrically strengthening the posterior deltoid, rhomboids,
latissimus dorsi and middle trapezius muscles. This exercise emphasizes the
latissimus dorsi, while the opposite shoulder has its scapular stabilizers activated
and the core is active in order to prevent trunk rotation.
Starting Position: In a four point position (hands under shoulders and knees under hips), abdominals
are active, one hand is pressing on the tubing and the other hand gripping the
tubing. One can kneel on a mat for comfort.
How to Do the 1. Move the arm back so it is in line with your body.
4. Perform 12 repetitions of the exercise on each side.



Mistakes: - Shrugging your shoulder, shifts the emphasis on the upper trapezius which is
your wrists.
used.


EXERCISE 14: Four Point Arm To Side Leading with Pinkie and Tubing

Start End
Purpose: To improve horizontal abduction (extension) strength of the shoulder joint in four
rhomboids, and middle trapezius muscles. This exercise emphasizes the
rhomboids while the opposite shoulder has its scapular stabilizers activated and the
Starting Position: In a four point position (hands under shoulder and knees under hips), abdominals
tubing. Make sure to chin tuck, align your body in perfect alignment, set your
shoulder blades and brace your abdominals. One can kneel on a mat for comfort.
Exercise: your arms below shoulder height. The arm movement is lead by your pinkie.
3. Rest for 1 second and move into the second repetition



your wrists.
used.


EXERCISE 15: Four Point Arm To Side Leading with Thumb and Tubing

End
Start
Starting Position: In a four point position (hands under shoulders and knees under hips), abdominals
tubing.
Exercise: your arms below shoulder height. The arm movement is lead by the thumb.



- Arching at the lower back or upper thoracic to get more range of motion. The
back is upright and not moving during the exercise.
your wrists.
used.


EXERCISE 16: Four Point with ½ Y with Tubing

Start End
Purpose: To improve horizontal abduction (extension) and flexion strength of the shoulder
joint in a four point position by concentrically and eccentrically strengthening the
posterior deltoid, rhomboids, and lower trapezius muscles. This exercise
emphasizes the lower trapezius. While the opposite shoulder has its scapular
stabilizers activated and the core is active in order to prevent trunk rotation.
Starting Position: In a four point position (hands under shoulders and knees under hips). Resistive
tubing is in your hands with the hand of the arm performing the movement in a fist.
Make sure to chin tuck, align your body in perfect alignment, set your shoulder
blades and brace your abdominals. The right arm is straight, turn out to the side
(externally rotated) 45 degrees and the hand in a fist.
How to Do the 1. In a controlled and slow manner, move your right arm to about a 45 degree
Exercise: angle (120 degrees of abduction) until it is slightly behind the right shoulder. In
the end position the elbow will be just below the shoulder and the hand above
the shoulder.



your wrists.
used.


EXERCISE 17: Four Point with ½ W with Tubing

Start End
Purpose: To improve horizontal abduction (extension) strength of the shoulder joint in a four point
trapezius, while the opposite shoulder has its scapular stabilizers activated and the core
is active in order to prevent trunk rotation.
Starting Position: In a four point position (hands under shoulders and knees under hips). Resistive
tubing is in your hands with the hand of the arm performing the movement in a fist
and the elbow bent to 45 degrees. Make sure to chin tuck, align your body in
perfect alignment, set your shoulder blades and brace your abdominals.
How to Do the 1. In a controlled and slow manner, move your right arm out to the side in a
Exercise: horizontal abduction (extension) movement until it is slightly behind the right
shoulder. In the end position the elbow will be just below the shoulder and the
hand above the shoulder.



your wrists.



EXERCISE 18: Bow and Arrow

Start End
trapezius while the core is active in order to prevent trunk rotation of the right side.
Starting Position: In a sitting position on a stability ball with tubing in your hands. Your left arm is
straight and gripping the tubing while the right arm is gripping the tubing with the
right elbow bent to 90 degrees.
How to Do the 1. The right elbow pulls back at a height just below the shoulder with the right
Exercise: shoulder focusing on the muscles around the scapula performing the movement
and stopping with the right elbow just passing the right shoulder.

- Decrease the amount of tubing between your hands
- Progress to two sets and then three sets on each side.


your wrists.



EXERCISE 19: Rotator Cuff Pull

Start End
Purpose: To improve external rotation strength of the shoulder joint in sitting position by
concentrically and eccentrically strengthening the posterior deltoid, rhomboids,
rotator cuff and middle trapezius muscles. This exercise emphasizes the rotator
cuff of the right arm while the core is active in order to prevent trunk rotation.
Starting Position: In a sitting position on a stability ball with tubing in your hands and arms straight just
below your shoulders.
How to Do the 1. The right shoulder pulls back and external rotates until the elbow is bent to 90
Exercise: degrees and the right elbow is in line with the right shoulder.

your wrists.


EXERCISE 20: One Palm Down Arm Retraction

End
Start
rhomboids, and middle trapezius muscles. This exercise emphasizes the right
rhomboid while the core is active in order to prevent trunk rotation.
Starting Position: In a sitting position on a stability ball with tubing in your hands and arms straight just
below your shoulders.
How to Do the 1. Keeping the left shoulder where it is, move the right arm straight out to the side
Exercise: until it is in line with the right shoulder.

Mistakes: - Shrugging your shoulder shifts the emphasis on the upper trapezius which is over
active in most people.
wrists.


EXERCISE 21: One Palm Up Arm Retraction

Start End
trapezius while the core is active in order to prevent trunk rotation.
Starting Position: In a sitting position on a stability ball with tubing in your hands, arms are straight,
right palm is down and left palm is up.
How to Do the 1. Keeping the left shoulder where it is, move the right arm straight out to the side
Exercise: until it is in line with the right shoulder.

your wrists.


Notes on Strengthening Exercises – Tubing
What speed should I do the exercise with tubing?
You should perform the exercise in a slow and controlled manner. There should be
tension on the tubing during the whole movement.


Strengthening Exercises - Dumbbell
EXERCISE 1: DUMBBELL - EXTERNAL ROTATION
Start End
Purpose: To improve external rotation strength in the shoulder joint while lying down, by
concentrically and eccentrically strengthening the infraspinatus and teres minor
muscles.
Starting Position: Lie on your side with your right arm bent at the elbow to 90 degrees, your shoulder
rotated in, and elbow at your side. Make sure your body is in a straight line and your
head is supported.
How to Do the 1. Move your right wrist away from the floor as far as you can rotating at your
Exercise: shoulder. It should take two seconds to reach the end of the movement.
2. Hold your arm for one second at this position.
3. Now return your arm back to the start. It should take two seconds to return to
the start.
4. Switch arms and perform this exercise with the left arm.
5. Repeat this exercise, 12 times for one set.
Progressions: - Progress to two sets and then three sets.

- Increase weight of the dumbbell.
& Common - If it is painful to lie on your side, do not do this exercise on the side that is painful.
Mistakes: - The action is from the shoulder. Your body should remain stationary and your elbow
tucked into your side.
- If you feel a stretch on the top of your shoulder with your arm at your side, you can
put a rolled up towel under your elbow against your body.
wrists.


EXERCISE 2: DUMBBELL - INTERNAL ROTATION
Start End
Purpose: To improve internal rotation strength of the shoulder joint while lying down, by
concentrically and eccentrically strengthening the subscapularis and latissimus
dorsi muscle.
Starting Position: Lie on your side with your left arm bent at the elbow to 90 degrees, your shoulder at
0 degrees of rotation, and elbow at your side. Make sure your body is in a straight
line and your head is supported.
How to Do the 1. Move your left wrist away from the floor and towards your abdomen rotating at
Exercise: your shoulder. It should take two seconds to reach the end of the movement.
3. Now return your arm back to the start. It should take two seconds to return to
the start.
4. Switch arms and perform this exercise with the right arm.
Progressions: - Progress to full internal rotation. Start with your left arm fully rotated away from
your abdomen.
Contraindication - Move your arm to a point that is pain free. Do not push through the pain. Move
& Common the arm to a point just below feeling any pain.
Mistakes: - If it is painful to lie on your side, do not do this exercise on the side that is
painful.
- The action is from the shoulder. Your body should remain stationary and your
elbow tucked into your side.
- If you feel a stretch on the top of your shoulder with your arm at your side, you
can put a rolled up towel under your elbow against your body.
your wrists.


EXERCISE 3: DUMBBELL - EMPTY CAN
Start End
Purpose: To improve scaption (plane of movement of the scapula) strength of the shoulder
joint in a standing position by concentrically and eccentrically strengthening the
supraspinatus muscle.
Starting Position: Stand and internally rotate your shoulders so your thumbs are pointing towards the
floor, as you hold the dumbbells at thigh height.
How to Do the 1. Lift both arms from your thighs forward at 30 degrees off center. Lift your arms
Exercise: as high as you can just below your shoulders. It should take two seconds to
reach the end of the movement.
3. Now return your arms back to the start. This should take two seconds.

- Increase the weight of the dumbbells.
Contraindication - Move your arms to a point that is pain free. Do not push through the pain.
& Common - Anyone with shoulder impingement should remain at a range of motion that
- Perform this exercise with a light weight. Do not exceed 10 lbs. per hand.
- The full can exercise is more effective than the empty can exercise and
presents less risk of injury.
your wrists.


EXERCISE 4: DUMBBELL - FULL CAN
Start End
Purpose: To improve scaption (plane of movement of the scapula) strength of the shoulder
joint in a standing position by concentrically and eccentrically strengthening the
supraspinatus muscle.
Starting Position: Stand with your thumbs pointing upwards, as you hold the dumbbells at thigh
height.
How to Do the 1. Lift both arms from your thighs forward at 30 degrees off center. Lift your arms
Exercise: as high as you can to just below your shoulders. It should take two seconds to

- Increase weight of dumbbells.
- Perform this exercise with a light weight. Do not exceed 10 lb. dumbbells.
- The full can exercise is more effective than the empty can exercise and
presents less risk of injury


EXERCISE 5: DUMBBELL - PRONE SHOULDER EXTENSION
Start End
Purpose: To improve extension strength of the shoulder joint in a lying position by

concentrically and eccentrically a strengthening the latissimus dorsi, teres major,
and scapular stabilizing muscles.
Starting Position: In a prone lying position on a bench, let your right arm hang straight down, holding a
dumbbell in your hand on the floor.
How to Do the 1. Move your right arm from just above the floor to your side. It should take two
Exercise: seconds to reach the end of the movement.
3. Now return your arm to the floor but do not touch. This should take two
seconds.

- Increase weight of the dumbbells.
& Common - Keep your body in a straight line by looking straight down and placing a towel
Mistakes: under your face or forehead.
your wrists.


EXERCISE 6: DUMBBELL - PRONE HORIZONTAL ABDUCTION
Start End
Purpose: To improve horizontal abduction (extension) strength of the shoulder joint in a lying
rhomboids, and middle trapezius muscles.
Starting Position: In a prone lying position on a bench, extend your right arm straight at 85 degrees of
abduction with a dumbbell in your hand on the floor.
How to Do the 1. Lift the dumbbell off the floor and move it straight back so it is in line with your
Exercise: body. It should take two seconds to reach the end of the movement.
3. Now return your arm back to the start. This should take two seconds.

- Increase the weight of the dumbbell.
Mistakes: - If starting at 85 degrees of abduction is too difficult begin at 45 degrees of
abduction.
- Anyone with shoulder impingement should remain at a range of motion that
does not lead to a pinching feeling or try the thumb turned up.
your wrists.


EXERCISE 7: DUMBBELL - 90/90 EXTERNAL ROTATION
Start End
Purpose: To improve external rotation strength of the shoulder joint in a lying position by
concentrically and eccentrically strengthening the infraspinatus and teres minor
muscles while stabilizing the scapula with the scapular stabilizing muscles.
Starting Position: Lie prone on a bench with your right arm abducted to 85 degrees, elbow bent to 90
degrees and dumbbell in your hand just above the floor.
How to Do the 1. Rotate your right arm moving the dumbbell to just below your shoulder so it is in
Exercise: line with your body. It should take two seconds to reach the end of the
movement.

- Increase weight of dumbbell.
& Common - If starting at 85 degrees of abduction is too difficult begin at 45 degrees of
Mistakes: abduction.
- Anyone with shoulder impingement should remain at a range of motion that
your wrists.


EXERCISE 8: DUMBBELL SHOULDER SHRUG
Start End
Purpose: To improve shoulder elevation strength of the scapularthoracic joint in a standing

position by concentrically and eccentrically strengthening the upper trapezius
muscle.
Starting Position: Stand, arms at your side, with dumbbells in your hands.
How to Do the 1. Lift both shoulders towards your ears. It should take two seconds to reach the
Exercise: end of the movement.
2. Hold your arms for one second at this position.

- Increase weight of dumbbells.
& Common - Make sure your wrists are neutral (straight) in order to decrease the stress on
Mistakes: your wrists.


EXERCISE 9: DUMBBELLS FRONT RAISES
Start End
concentrically and eccentrically strengthening the deltoid and supraspinatus
muscles.
Starting Position: Stand, arms at your sides, and dumbbells in your hands.
How to Do the 1. Lift arms in front of the body as far as you can or to a height just below your
Exercise: shoulders. It should take two seconds to reach the end of the movement.

- If moving to 85 degrees of flexion is too difficult move only as far as you can
without pain.
your wrists.


EXERCISE 10: DUMBBELL LATERAL RAISE
Start End
by concentrically and eccentrically strengthening the deltoid and supraspinatus
muscles.
Starting Position: Stand with your arms at your sides, and dumbbells in your hands.
How to Do the 1. Lift arms out to the sides as high as you can, focusing on lifting from the
Exercise: shoulders and not the wrists until you reach a height just below your shoulders.
It should take two seconds to reach the end of the movement.

- Increase the weight of the dumbbells.
- If moving to 85 degrees of abduction is too difficult move only as far as you can
without pain.
your wrists.


EXERCISE 11: DUMBBELL MILITARY PRESS
Start End
Purpose: To improve shoulder abduction strength of the shoulder joint above shoulder height
in a sitting position by concentrically and eccentrically strengthening the deltoid,
trapezius, triceps and supraspinatus muscles while activating the scapular
stabilizing muscles.
Starting Position: In a sitting position, hold your arms at shoulder height, with dumbbells in your
hands.
How to Do the 1. Push the dumbbells over your head. It should take two seconds to reach the
Exercise: end of the movement.

- Increase weight of the dumbbells.
your wrists.


EXERCISE 12: DUMBBELL BENT OVER ROW
Start End
Purpose: To improve shoulder extension strength of the shoulder joint in a four-point position
by concentrically and eccentrically strengthening the deltoid, latissimus dorsi,
trapezius and rhomboids muscles and activating the scapular stabilizing muscles in
the opposite arm.
Starting Position: Place your left hand and left knee on a bench, right foot on the floor, and right arm
hanging straight down, holding a dumbbell.
How to Do the 1. Lift the dumbbell up by focusing on pulling your right elbow up until your elbow
Exercise: just passes your right shoulder. It should take two seconds to reach the end of
the movement.

& Common - Make sure your wrists are neutral (straight) in order to decrease the stress on
Mistakes: your wrists.
- Make sure to keep your shoulder in line with the other shoulder and don’t let the
shoulder of the working arm drop or sag towards the floor.
- Keep the elbow and arm close to the body when doing the movement.


EXERCISE 13: DUMBBELL BENCH PRESS
Start End
Purpose: To improve horizontal flexion strength of the shoulder joint in a supine position by
concentrically and eccentrically strengthening the pectoralis major muscle.
Starting Position: In a supine position on a bench, place your elbows just below your shoulders, rib
cage in neutral and hands holding dumbbells in front of your shoulders.
How to Do the 1. Push the dumbbells up until your arms are straight. It should take two seconds
Exercise: to reach the end of the movement.
Contraindication - Move your arms to a point that is pain free. Do not push through the pain. Move
& Common the arms to a point just below feeling any pain.
your wrists.
- You can place your feet on the bench in order decrease the stress and arch on
your lower back.


EXERCISE 14: DUMBBELL REVERSE FLY
Start End
Purpose: To improve shoulder horizontal extension strength of the shoulder joint in a seated
position by concentrically and eccentrically strengthening the posterior deltoid and
rhomboids muscle.
Starting Position: In a seated position on a bench, activate the core (abdominals), bend forward at
your waist, with dumbbells in your hands below your thighs.
How to Do the 1. With a slight bend in your elbows, lift your elbows back, focusing on the
Exercise: contraction of the middle back muscles. It should take two seconds to reach the
end of the movement.
your wrists.


EXERCISE 15: CHAIR PRESS UP
Start End
Purpose: To improve scapular depression strength in the scapulothoracic joint in a sitting

position by activating the lower trapezius and serratus anterior muscle.
Starting Position: Sit with both your hands beside your thighs and fingers wrapped over the edge of
the chair, table or bench.
How to Do the 1. Straighten your arms and lift your buttock off the bench. It should take two
Exercise: seconds to complete this movement.
2. Hold position for one second.
3. Return your seat to the starting position. It should take two seconds to return to
the start.

Mistakes: - Make sure you have good upright posture and are not dropping your head
forward or rounding your mid-back.
your wrists.

Notes on Strengthening Exercises – Dumbbell
What is scaption?
It is the plane of movement that is in line with the scapula. To reach scaption, you
abduct (move are out to the side) the your arm to 90 degrees, then move your arm 30
degrees in to horizontal flexion (out front, horizontal adduction or transverse flexion). If
you keep your shoulder in this position and move your arm in flexion and extension, you
are now moving the scaption plane, or scaption.

STRENGTHENING EXERCISES - PULLEYS
EXERCISE 1: PULLEY EXTERNAL ROTATION

Start End
Purpose: To improve shoulder external rotation strength of the shoulder joint in a standing
position by concentrically and eccentrically strengthening the infraspinatus and
teres minor muscle.
Starting Position: Stand with your left arm bent at the elbow to 90 degrees, your shoulder at 0
degrees of rotation, keeping elbow at your side. Adjust the pulley arm so when you
perform the exercise the pulley cable is parallel to the floor.
How to Do the 1. Move your left hand away from the pulley machine as far as you can while
Exercise: keeping the wrist in alignment and rotating at your shoulder. It should take two
seconds to reach the end of the movement.
5. Repeat this exercise 12 times for one set.
- Progress to full external rotation. Start with your right arm fully rotated in with
Progressions: your forearm against your abdomen.


- Move your arm to a point that is pain free. Do not push through the pain. Move
Contraindication the arm to a point just below feeling any pain.
& Common - This action is from the shoulder. Your body remains stationary keeping the
Mistakes: elbow at your side.
- If you feel a stretch on the top of your shoulder with your arm at your side, put a
rolled up towel under your elbow, against your body.
your wrists.

EXERCISE 2: PULLEY INTERNAL ROTATION

Start End
Purpose: To improve shoulder internal rotation strength of the shoulder joint in a standing
position by concentrically and eccentrically strengthening the subscapularis and
latissimus dorsi muscle.
Starting Position: Stand with your right arm bent at the elbow to 90 degrees, your shoulder at 0
degrees of rotation, and elbow at your side. Adjust the pulley arm so when you
perform the exercise the pulley cable is parallel to the floor.
How to Do the 1. Move your right wrist toward your abdomen by rotating at your shoulder. It
Exercise: should take two seconds to reach the end of the movement.
Progressions: - Progress to full internal rotation. Start with your left arm fully rotated away from your
abdomen.
Contraindication - Move your arm to a point that is pain free. Do not push through the pain. Move the
& Common arm to a point just below feeling any pain.
Mistakes: - This action is from the shoulder. Your body remains stationary keeping the elbow at
your side.
- If you feel a stretch on the top of your shoulder with your arm at your side, put a
rolled up towel under your elbow, against your body.
wrists.


EXERCISE 3: PULLEY SHOULDER ABDUCTION
Start End
by concentrically and eccentrically strengthening the deltoid and supraspinatus
muscle.
Starting Position: Stand with your left arm at your side. Adjust the pulley arm to its lowest setting.
How to Do the 1. Hold the pulley handle and move your left arm away from your side as far as
Exercise: you can or to a height of just below shoulder height. It should take two seconds
to reach the end of the movement.
Mistakes: - Anyone with shoulder impingement should remain at a range of motion that
your wrists.


EXERCISE 4: PULLEY SHOULDER ADDUCTION
Start End
Purpose: To improve adduction strength of the shoulder joint in a standing position by

concentrically and eccentrically strengthening the latissimus dorsi and pectoralis
muscles.
Starting Position: Stand with your right arm extended out to your side, at a level just below your
shoulder. Adjust the pulley arm so that in the starting position has your arm below
your shoulder.
How to Do the 1. Hold the pulley handle and move your right arm down next to your side. It
- If starting at 90 degrees of abduction is too difficult begin at 45 degrees of
abduction.
your wrists.


EXERCISE 5: PULLEY SHOULDER EXTENSION

Start End
Purpose: To improve extension strength of the shoulder joint in a standing position by

concentrically and eccentrically strengthening the latissimus dorsi muscle.
Starting Position: Stand, facing the pulley, with your left arm out front just below your shoulder. Adjust
the pulley arm so that in the starting position the cable is parallel to the floor.
How to Do the 1. Hold the pulley handle and move your left arm down to your side. It should take
Exercise: two seconds to reach the end of the movement.
- If moving to 85 degrees of flexion is too difficult move as far as you can without
pain.
your wrists.


EXERCISE 6: PULLEY FLEXION

Start End
concentrically and eccentrically strengthening the deltoid and supraspinatus
muscles.
Starting Position: Stand, facing the away from the pulley, with your right arm at your side. Adjust the
pulley arm to its lowest position.
How to Do the 1. Hold the pulley handle and move your right arm from your side forward as far as
Exercise: you can or to a height of just below your shoulder. It should take two seconds to
- If moving to 85 degrees of flexion is too difficult for you, move as far as you can
without pain.
your wrists.


EXERCISE 7: PULLEY HORIZONTAL ABDUCTION

Start End
Purpose: To improve shoulder horizontal extension strength of the shoulder joint in a standing
position by concentrically and eccentrically strengthening the rhomboid muscle and
activate the scapular stabilizing muscles.
Starting Position: Reach with your arm across your body and grab the pulley handle. Adjust the pulley
arm so that in the starting position the cable is parallel to the floor.
How to Do the 1. Hold the pulley handle and move it from your right side to your left. It should
Exercise: take two seconds to reach the end of the movement.
- If moving to 85 degrees of flexion is too difficult move as far as you can without
pain.
your wrists.

EXERCISE 8: STANDING BILATERAL PULLEY ROWS
Start End

concentrically and eccentrically strengthening latissimus dorsi and rhomboids.
Starting Position: Stand with both arms out front, just below shoulder level. Adjust the pulley arm so
that in the starting position the cable is parallel to the floor.
How to Do the 1. Holding the pulley handles, pull your elbows back and to a position below and
Exercise: just past your shoulders. It should take two seconds to reach the end of the
movement.
your wrists.

EXERCISE 9: STANDING UNILATERAL PULLEY ROWS
Start End

concentrically and eccentrically strengthening latissimus dorsi and rhomboids.
Starting Position: Stand with your left arm extended out front just below shoulder level. Adjust the
pulley arm so that in the starting position the cable is parallel to the floor.
How to Do the 1. Hold the pulley handle and pull your left elbow back to a position just past your
Exercise: left shoulder. It should take two seconds to reach the end of the movement.
your wrists.

EXERCISE 10: SUBSCAPULARIS DYNAMIC HUG
Start End
Purpose: To improve horizontal adduction strength of the shoulder joint in a standing position
by concentrically and eccentrically strengthening subscapularis.
Starting Position: Tubing is securely fixed. Stand with your arms in an open hug position holding
handles of the tubing.
How to Do the 1. Move your arms in a hug movement forward while rotating your shoulders in. It
4. This exercise is performed with both arms at the same time.
your wrists.

3 Month Rotator Cuff Exercise Program


Notes on the 3 Month Rotator Cuff Exercise Program
This is a 3 month rotator cuff exercise program that you can use with your clients.
It brings together the exercises from the Effective Rotator Cuff Exercises Manual and
put them in program that you can use with your rotator cuff clients.
If you would like receive a digital copy of the exercises in the Effective Rotator Cuff
Exercises Manual, feel free to email me at [email protected] . I will gladly
send you a digital copy that you can print and give out to your clients.
What takes priority over the exercise program that follows are the guidelines given by
the medical physician and health care providers.
Note that not all of the exercises from the Effective Rotator Cuff manual are in the 3
month program. I have selected the ones that I have gotten the best results with.
Rick Kaselj


Rotator Cuff Exercise Program - Month 1 - Movement
Goal: To get the shoulder moving and improve range of motion

Frequency: Everyday
Equipment Needed: Over the door pulley
Estimated Time to Complete: 10 minutes
Range of Motion Sets & Reps

PENDULUM - CIRCLES 1 set of 10 repetitions
PENDULUM - HORIZONTAL ABDUCTION-ADDUCTION 1 set of 10 repetitions
PENDULUM - FLEXION-EXTENSION 1 set of 10 repetitions
PULLEY – UP AND DOWN 1 set of 10 repetitions
PULLEY - SHOULDER FLEXION 1 set of 10 repetitions
PULLEY - SHOULDER ADDUCTION 1 set of 10 repetitions
PULLEY - INTERNAL ROTATION 1 set of 10 repetitions
*Note – The pulley used is an over the door pulley that helps with passive range of motion.


Rotator Cuff Exercise Program - Month 1 - ROM
Goal: To increase range of motion

Frequency: Everyday
Equipment Needed: Wand

WAND - SHOULDER FLEXION 1 set of 5 Repetitions
WAND - SHOULDER EXTENSION 1 set of 5 Repetitions
WAND - EXTERNAL ROTATION 1 set of 5 Repetitions
WAND PULL DOWN - EXTERNAL ROTATION 1 set of 5 Repetitions
WAND PULL UP - INTERNAL ROTATION 1 set of 5 Repetitions
WAND - ABDUCTION AND ADDUCTION 1 set of 5 Repetitions
Strength Sets & Reps

ISOMETRIC - SHOULDER FLEXION 1 set of 6 Repetitions
ISOMETRIC - SHOULDER EXTENSION 1 set of 6 Repetitions
ISOMETRIC - SHOULDER ABDUCTION 1 set of 6 Repetitions
ISOMETRIC - SHOULDER ADDUCTION 1 set of 6 Repetitions
ISOMETRIC - INTERNAL ROTATION 1 set of 6 Repetitions
ISOMETRIC - EXTERNAL ROTATION 1 set of 6 Repetitions

Rotator Cuff Exercise Program - Month 2
Goal: To improve smoothness of range of motion, address tight muscles and work on
strength
Frequency: Range of motion and stretching can be done everyday and strengthening
can be done every other day.
Equipment Needed: Dumbbells, bench

SHOULDER FLEXION – ACTIVE RANGE OF MOTION 1 Set of 5 Repetitions
SHOULDER EXTENSION – ACTIVE RANGE OF MOTION 1 Set of 5 Repetitions
SHOULDER ABDUCTION – ACTIVE RANGE OF MOTION 1 Set of 5 Repetitions
SHOULDER ADDUCTION – ACTIVE RANGE OF MOTION 1 Set of 5 Repetitions
SHOULDER INTERNAL ROTATION – ACTIVE RANGE OF MOTION 1 Set of 5 Repetitions
SHOULDER EXTERNAL ROTATION – ACTIVE RANGE OF MOTION 1 Set of 5 Repetitions
Stretching Sets & Reps

POSTERIOR STRETCH 2 times for 30 seconds
ANTERIOR SHOULDER STRETCH 2 times for 30 seconds
SUPRASPINATUS STRETCH 2 times for 30 seconds
DOORWAY STRETCH - ANTERIOR CAPSULE STRETCH 2 times for 30 seconds
TRICEPS STRETCH - INFERIOR CAPSULE STRETCH 2 times for 30 seconds
Strength Sets & Repetitions

DUMBBELL - EXTERNAL ROTATION 1 set of 12 repetitions
DUMBBELL - PRONE SHOULDER EXTENSION 1 set of 12 repetitions
DUMBBELL - PRONE HORIZONTAL ABDUCTION 1 set of 12 repetitions
DUMBBELL - FULL CAN 1 set of 12 repetitions
DUMBBELL SHOULDER SHRUG 1 set of 12 repetitions
DUMBBELL LATERAL RAISES 1 set of 12 repetitions
DUMBBELL MILITARY PRESS 1 set of 12 repetitions
DUMBBELL BENT OVER ROW 1 set of 12 repetitions
CHAIR PRESS UP 1 set of 12 repetitions

Goal: To address tight muscles and work on strength

Frequency: Stretching can be done everyday and strengthening can be done every
other day.
Equipment Needed: Pulleys
Stretching Sets & Reps

POSTERIOR STRETCH 2 times for 30 seconds
POSTERIOR SHOULDER II STRETCH 2 times for 30 seconds
SUPRASPINATUS STRETCH 2 times for 30 seconds
DOORWAY STRETCH - ANTERIOR CAPSULE STRETCH 2 times for 30 seconds
TRICEPS STRETCH - INFERIOR CAPSULE STRETCH 2 times for 30 seconds
Strength Sets & Reps

PULLEY EXTERNAL ROTATION 1 set of 12 repetitions
PULLEY INTERNAL ROTATION 1 set of 12 repetitions
STANDING UNILATERAL PULLEY ROWS 1 set of 12 repetitions
PULLEY SHOULDER ABDUCTION 1 set of 12 repetitions
PULLEY SHOULDER ADDUCTION 1 set of 12 repetitions
PULLEY SHOULDER EXTENSION 1 set of 12 repetitions
PULLEY FLEXION 1 set of 12 repetitions
PULLEY HORIZONTAL ABDUCTION 1 set of 12 repetitions
STANDING BILATERAL PULLEY ROWS 1 set of 12 repetitions

3 Months Rotator Cuff Exercise Program

- Client Handouts -

Notes on the 3 Month Rotator Cuff Exercise Program – Client

Handouts
These are the client handouts for 3 month rotator cuff exercise program that you can
give to your clients.
It brings together the exercises from the Effective Rotator Cuff Exercises Manual and
put them in handouts that you can use with your rotator cuff clients.
Feel free to copy them and give them out to your client. If you would like receive a
digital copy of the handouts, feel free to email me at [email protected] . I
will gladly send you a digital copy that you can print out and give out to your clients.
Rick Kaselj


Rotator Cuff Exercise Program - Month 1 – Movement
Exercise Day
PENDULUM - CIRCLES 1 set

of 10
reps
PENDULUM - HORIZONTAL 1 set

ABDUCTION-ADDUCTION of 10
reps
PENDULUM - FLEXION- 1 set

EXTENSION of 10
reps
PULLEY – UP AND DOWN 1 set

of 10
reps
Notes:


PULLEY - SHOULDER 1 set

FLEXION of 10
reps
PULLEY - SHOULDER 1 set

ADDUCTION of 10
reps
PULLEY - INTERNAL 1 set

ROTATION of 10
reps
Notes:


Rotator Cuff Exercise Program - Month 1 – ROM
Exercise Day
WAND - SHOULDER FLEXION 1 set

of 5
reps
WAND - SHOULDER 1 set

EXTENSION of 5
reps
WAND - EXTERNAL 1 set

ROTATION of 5
reps
WAND PULL DOWN - 1 set

EXTERNAL ROTATION of 5
reps
WAND PULL UP - INTERNAL 1 set

ROTATION of 5
reps


WAND - ABDUCTION AND 1 set

ADDUCTION of 5
reps
ISOMETRIC - SHOULDER 1 set

FLEXION of 6
reps

EXTENSION of 6
reps

ABDUCTION of 6
reps

ADDUCTION of 6
reps


ISOMETRIC - INTERNAL 1 set

ROTATION of 6
reps
ISOMETRIC - EXTERNAL 1 set

ROTATION of 6
reps
Notes:


Exercise Day
SHOULDER FLEXION – 1 set

ACTIVE RANGE OF MOTION of 5
reps
SHOULDER EXTENSION – 1 set

reps
SHOULDER ABDUCTION – 1 set

reps
SHOULDER ADDUCTION – 1 set

reps
Notes:


SHOULDER INTERNAL 1 set of 5

ROTATION – ACTIVE reps
RANGE OF MOTION
SHOULDER EXTERNAL 1 set of 5

ROTATION – ACTIVE reps
RANGE OF MOTION
POSTERIOR STRETCH 2 times for

30 seconds
ANTERIOR SHOULDER 2 times for

STRETCH 30 seconds
SUPRASPINATUS 2 times for

STRETCH 30 seconds


DOORWAY STRETCH - 2 times for

ANTERIOR CAPSULE 30 seconds
STRETCH
TRICEPS STRETCH - 2 times for

INFERIOR CAPSULE 30 seconds
STRETCH
DUMBBELL - EXTERNAL 1 set of 12

ROTATION repetitions
DUMBBELL - PRONE 1 set of 12

SHOULDER EXTENSION repetitions
DUMBBELL - PRONE 1 set of 12

HORIZONTAL ABDUCTION repetitions


DUMBBELL - FULL CAN 1 set of 12

repetitions
DUMBBELL SHOULDER 1 set of 12

SHRUG repetitions
DUMBBELL LATERAL 1 set of 12

RAISES repetitions
DUMBBELL MILITARY 1 set of 12

PRESS repetitions
DUMBBELL BENT OVER 1 set of 12

ROW ROTATION repetitions


CHAIR PRESS UP 1 set of 12

repetitions
Notes:


Exercise Day
POSTERIOR STRETCH 2 times for 30

seconds
POSTERIOR SHOULDER II 2 times for 30

STRETCH seconds
SUPRASPINATUS 2 times for 30

STRETCH seconds
DOORWAY STRETCH - 2 times for 30

ANTERIOR CAPSULE seconds
STRETCH
Notes:


TRICEPS STRETCH - 2 times for 30

INFERIOR CAPSULE seconds
STRETCH
PULLEY EXTERNAL 1 set of 12

PULLEY INTERNAL 1 set of 12

STANDING UNILATERAL 1 set of 12

PULLEY ROWS repetitions
PULLEY SHOULDER 1 set of 12

ABDUCTION repetitions



ADDUCTION repetitions

EXTENSION repetitions
PULLEY FLEXION 1 set of 12

repetitions
PULLEY HORIZONTAL 1 set of 12

ABDUCTION repetitions
STANDING BILATERAL 1 set of 12

PULLEY ROWS repetitions


About Rick Kaselj
Rick Kaselj, M.S. (Exercise Science), B.Sc. (Kinesiology), PK, CPT, CEP, CES
Rick Kaselj specializes in active rehabilitation and fitness. He

works in one-on-one and group rehabilitation settings, educating
and training people who have been injured at work, in car
accidents, and during sport activities.
Rick has combined his rehabilitation experience and passion for

research to develop a variety of courses and presentations for
fitness professionals, Kinesiologists, and healthcare providers. Rick has given over 263
presentations to 5031 fitness professionals across Canada and USA. These courses
include:
• Core stability of the shoulder

• Exercise rehabilitation for the shoulder, lower back, hip, or knee
• Foam roller essentials
• Intro and advanced core stability
• Intro and advanced stability ball exercises
• Postural assessment and exercise prescription
• Injury-free running
• Save your shoulders
• Training for better golf
Rick strives to balance his work life with his personal fitness endeavours and travel. He
has trained for and competed in the Manitoba Marathon, the 225 km Ironman Canada
Triathlon, and the 160 km Sea2Summit Adventure Race in Whistler, BC.
He recently hiked 4,300 km along the Pacific Crest Trail from Mexico to Canada and


mountain biked the 5,000 km Great Divide Mountain Bike Route over the Rocky
Mountains from Mexico to Canada. An avid traveler, Rick has toured three continents
and visited 17 countries.
In 1997 he graduated with his Bachelor of Science degree in Kinesiology from Simon
Fraser University. Rick recently completed his Masters of Science degree focusing on
corrective exercise and therapeutic exercise for the rotator cuff. Rick currently works as
a lecturer, Kinesiologist, personal trainer, and exercise rehabilitation specialist in and
around Vancouver, British Columbia, Canada.
To learn more about Rick Kaselj, please visit www.ExercisesForInjuries.com


About Healing Through Movement
Healing Through Movement has been helping people reach their health, fitness, rehabilitation
and sport goals since 1999.
How Healing Through Movement can help you:
Active Rehabilitation – This individualized program is designed to help you overcome injury by
using flexibility, endurance, strength and cardiovascular exercises.
Adaptive Fitness – A personalized exercise program designed for youth and adults with
special needs. The types of special needs may include cerebral palsy, multiple sclerosis, brain
injury and/or developmental disability.
Adventure Travel Presentations – A full sensory experience including music, images, and
storytelling on the experience and adventure of hiking the 4,300 km Pacific Crest Trail, cycling
Cuba, and cycling the Rockies from Mexico to Canada.
Corrective Exercise – An exercise program designed to address your muscle imbalances and
areas of tightness and pain.
Endurance Training – An individualized training program created to help you complete your
desired running, cycling, duathlon, triathlon, or adventure race.
Exercise Rehabilitation – An exercise program designed to help you recover from your injury
or medical condition in a safe and effective manner.


Exercise Rehabilitation Courses – Education and training for registered Kinesiologists,
exercise therapists, and personal trainers on the use of exercise as a safe and effective tool to
recover from back, shoulder, knee, hip, ankle, elbow and wrist injuries.
Expedition Training – Forming a complete plan including gear selection, route preparation,
nutrition guidelines and a training program to help accomplish your hiking, biking or kayaking
dream.
Personal Training – An exercise program to help you reach your weight loss, strength gain,
and body shape improvement goals.
Post Rehabilitation – After you have completed physical therapy, chiropractic or massage
therapy treatment, this is an exercise program designed to help you recover from your injury
and return your body back to where it was before your injury.
Pool Therapy – Use the pool environment to decrease stress on joints and to help your body
recover from injury by improving range of motion, strength, endurance and balance.
Where can Healing Through Movement meet me:
In Person – Healing Through Movement can meet you at your home, local community centre or
fitness centre to help you achieve your health, fitness, training, sport, travel or rehabilitation
goals.
Phone/Online Training – More clients are meeting with Healing Through Movement over the
phone or through email to reach their health, fitness, training, sport, travel or rehabilitation goals.

Founder of Healing Through Movement - Rick Kaselj
Rick Kaselj is a Registered Kinesiologist and Personal Trainer with a

passion for exercise rehabilitation. Rick designs effective exercise
programs that safely and rapidly help his clients recover from an injury,
medical condition, and/or musculoskeletal pain, and reach their health,
rehabilitation, and sport goals. Rick presents courses on
exercise rehabilitation and adventure travel across Canada and USA. To
reach Rick, call (888) 291-2430 or visit
www.HealingThroughMovement.com .
#199 – 19567 Fraser Highway

Surrey, BC V3S 9A4
Phone: (888) 291-2430 Fax: (604) 677-5425
E-mail: [email protected]
Webpage: HealingThroughMovement.com


Other Books from Rick Kaselj
To order these books, visit www.FitnessRehabPublishing.com
Core Stability for the Rehab Client DVDs
Core stability muscles assist in stabilizing the lower back and pelvis; when ignored they
weaken, and the risk of lower back and pelvis related injuries increase. This course will cover
anatomy of the core and introduce functional core exercises which focus on strengthening core
muscles and stabilizing the lower back and pelvis.
Core Stability of the Back
Core stability muscles play an important role in all activities of daily living. They enable us to
perform the simplest of activities and help us maintain good posture. When ignored, core
stability muscles become weak and the risk of lower back pain and instability increases. In the
Core Stability of the Back book you will learn about the key muscles of the core, how to locate
these muscles in the body, how to activate them and an effective program to create a strong
and stable back.
Core Stability of the Back - Home Program -
This a complete Core Stability of the Back program that you can use to get your back onto the
road of being pain-free. I the home program you will get the Core Stability of the Back book
plus a home DVD, audio workout and audio book. Core stability muscles play an important role
in all activities of daily living. They enable us to perform the simplest of activities and help us
maintain good posture. When ignored, core stability muscles become weak and the risk of
lower back pain and instability increases. In the Core Stability of the Back book you will learn
about the key muscles of the core, how to locate these muscles in the body, how to activate
them and an effective program to create a strong and stable back.
Your Stability Ball Exercise Guide
You bought a stability ball, now what? This guide will take you through 23 exercises that target
your legs, chest, back and abdominals. The guide includes two stability ball workouts you can
follow based on your fitness level and a stretch routine you can do with the stability ball.


Most Effective Gluteus Maximus Exercises
A common area that people want to exercise is their gluteus. There are a number of common
exercises people do but recent research has determined which gluteus exercises are the most
effective. This guide will help you learn about the most common gluteus exercises and which
ones are the most effective in working your gluteus maximus, hamstrings and gluteus medius.

- Fitness Professional’s Guide to Rotator Cuff Exercises -
Rotator cuff injuries are the most common shoulder injuries fitness professionals will face.
Exercise is recommended by physicians for people with rotator cuff injuries and therefore it is
vital for the fitness professional to be educated and prepared to work with these clients.
Exercise can help safely alleviate pain, decrease stiffness, increase range of motion, and
improve rotator cuff strength. Gain a comprehensive understanding of rotator cuff injuries, how
to design an appropriate exercise program for your clients with a rotator cuff injury and discover
the most effective exercises for the rotator cuff. If you are ready to increase your confidence
working with clients with rotator cuff injuries, would like to understand how to safely train clients
with rotator cuff injuries and empower yourself with the best exercises to help your clients with
rotator cuff injuries, then Effective Exercises Rotator Cuff Exercises is a must take course for
you.
The Most Effective Exercises For Scoliosis

- Fitness Professional’s Guide to Exercise and Scoliosis -
Exercise is recommended by physicians for people with scoliosis. With more people with
scoliosis leaning towards exercise to help improve their condition, it is vital for the fitness
professional to be educated and prepared to work with these clients. Exercise can help safely
alleviate pain, stiffness, de-conditioning, and muscular weakness associated with scoliosis.
Gain a comprehensive understanding of scoliosis, how to design an appropriate exercise
program for your clients with scoliosis and discover the most effective exercises for scoliosis. If
you are ready to increase your confidence working with clients with scoliosis, would like to
understand how to safely train clients with scoliosis and empower yourself with the exercises to
help your clients with scoliosis, then Effective Exercises for Scoliosis is a must take course for
you.
Interested in receiving over $299 worth of

fitness education information?
Visit www.ExercisesForInjuries.com
To order these books, visit www.ExercisesForInjuries.com


Ready-to-Download Webinars from Rick Kaselj

Scapular Stabilization Exercise Program
Shoulder injuries lead to pain, prevent people from doing the things they love and make the
simples tasks challenging. Many will learn strength exercises to help them recover from their
shoulder injury. But too often these strength exercises will lead to slower recovery from a
shoulder injury. What needs to be done before strengthening the shoulder is activating, building
endurance and strengthening the scapular stabilization muscles. Adding this one step will
speed up the recovery from a shoulder injury and prevent re-injury of the shoulder.
For more details visit - http://scapularstabilizationexercises.com/
Exercise and Plantar Fasciitis
The role of exercises for plantar fasciitis is vital in helping with a speed up recovery, decreases
pain, decreases the risk of reoccurrence and helps creates an action plan on what to do if
symptoms return. The focus of the plantar fasciitis and exercise webinar will be exercise
program design and exercises for a client that has plantar fasciitis.
For more details visit - http://exercisesforinjuries.com/plantar-fasciitis-exercises/
The Most Effective Rotator Cuff Exercise Program
After the back, the second most common injury a fitness professional will encounter is the
shoulder. Most times shoulder injuries directly and indirectly involve the rotator cuff. When
fitness professionals hear that their client has a rotator cuff issue, they end up focusing on
strengthening. Strengthening is important for your rotator cuff client but it is only one part of an
effective rotator cuff conditioning program. The fitness professional must address all five areas
of a rotator cuff conditioning program in order to fully rehabilitate the rotator cuff. If not, they will
only band-aide the injury and not fully help their client overcome their rotator cuff injury. In this
webinar, fitness professional will learn how to avoid common rotator cuff exercise mistakes, the
5 components of a rotator cuff condition program and exercises to help their client’s rotator cuff
injury.
Corrective Exercises for Running Injury-Free
Running is one of the most popular recreational activities amongst adults but most will have to
stop due to an injury. Along with a solid running program that prevents over training, there are
a number of key exercises that a fitness professional must include in a recreational runners
program in order to keep them running injury-free. In the corrective exercises for running injury-
free webinar, the fitness professional will learn a comprehensive list of assessment techniques
and exercises to keep their clients running injury-free.
For more details visit - http://exercisesforinjuries.com/running-corrective-exercises/


Exercises for Prevention, Rehabilitation & Overcoming Knee Injuries
The knee is the focus of an exercise program when it is injured but often ignored any other time.
More and more research has come out showing that the goal of the client should determine the
knee exercise program compared to the presence or absence of injury. If your client’s exercise
goal is prevention of knee injuries, the exercises program differs from a client that is recovering
from a knee injury. If the client has had a knee injury and would like prevent a future knee
injury, there is an exercise program that focuses on overcoming knee injuries. It is important
that the fitness professional know which exercises and exercise programs are best for their
client depending on the goal of the client. In this exercise and knee injury webinar, the fitness
professional will learn three different knee exercise programs to help their clients that want to
prevent a knee injury from occurring, rehabilitation a knee injury and overcome knee injuries by
preventing them from happening in the future.
For more details visit - http://exercisesforinjuries.com/acl-injury-exercises/
Core Stability of the Hip
In this webinar, fitness professionals will learn a progressive exercise program that they can use
with their personal trainer and group fitness clients in order to improve the core stability in their
hip in order to prevent and recovery from back, hip and knee injuries.
Fore more details visit - http://exercisesforinjuries.com/hip-injury-exercises/
Lower Back Spinal Fusion & Exercise
In many situations, a lower back condition can lead to lower back spinal fusion surgery. It is
estimated 126,000 spinal fusion surgeries occur a year in the USA and since 1996 the number
of surgeries has increased 116%. The group that has had the greatest increase in lower back
spinal fusion are adults over 60. Lumbar compression fractures, spinal deformities,
spondylolisthesis, lumbar instability, disc herniation and degenerative disc disease are common
conditions that can lead to lower back spinal fusion. A key component in the recovery from
lower back spinal fusion surgery is exercise. The role of exercise after spinal fusion is important
in speeding up recovery, strengthening the muscles supporting the vertebrae and improving the
endurance of core stability muscles. The focus of the spinal fusion and exercise webinar will be
the exercise program design and exercises for a client that has had a lower back spinal fusion.
For more details visit - http://exercisesforinjuries.com/lumbar_fusion_exercises/
Upcoming Webinars
- Exercises for Shoulder Impingement

- Exercises for Shoulder Dislocation
Interested in receiving over $299 worth of

fitness education information?
Visit www.ExercisesForInjuries.com


Untitled

Uploaded by

Document Informationclick to expand document information

Document Informationclick to expand document information

Copyright:

Available Formats

Untitled

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Untitled

Uploaded by

Copyright:

Available Formats

Effective Rotator Cuff Exercises

Section 2: Shoulder Anatomy ......................................................................................... 9

Section 3: Functional Anatomy and Biomechanics ....................................................... 32

Section 4: Pathomechanics and Rotator Cuff Injuries ................................................... 37

Section 5: Diagnosing Rotator Cuff Injuries................................................................... 49

Section 6: Treatment and Management of Rotator Cuff Injuries ................................... 62

Section 7: Exercises for Rotator Cuff Injuries ................................................................ 69

Section 8: Effective Rotator Cuff Exercises .................................................................. 74

About Rick Kaselj ........................................................................................................ 201

About Healing Through Movement .............................................................................. 203

Other Books from Rick Kaselj ..................................................................................... 206

Ready-to-Download Webinars from Rick Kaselj .......................................................... 208

Rick Kaselj, MS, BSc, PK, CPT, CEP, CES 2

Effective Rotator Cuff Exercises

Author: Kaselj, Rick, 1973 –

Key words: Rotator cuff, exercise

Healing Through Movement

Phone: (888) 291-2430

Rick Kaselj, MS, BSc, PK, CPT, CEP, CES 3

Pass this Book On

Your Clients Can Read This Manual

Rick Kaselj, MS, BSc, PK, CPT, CEP, CES 4

Individuals who participate in repetitive and forceful overhead or throwing

Rick Kaselj, MS, BSc, PK, CPT, CEP, CES 5

In order to prevent the lifelong complications of rotator cuff injuries, including

Rick Kaselj, MS, BSc, PK, CPT, CEP, CES 6

Rick Kaselj, MS, BSc, PK, CPT, CEP, CES 7

American Academy of Orthopaedic Surgeons. (n.d.). Rotator cuff tears. Retrieved

France, R. (2004). Introduction to sports medicine and athletic training. Kentucky:

Rick Kaselj, MS, BSc, PK, CPT, CEP, CES 8

Section 2: Shoulder Anatomy

- Bones: the humerus, clavicle, scapula, sternum, and ribcage

- Joints: sternoclavicular (SC joint), acromioclavicular (AC joint), glenohumeral

- Muscles: infraspinatus, supraspinatus, teres minor, and subscapularis,

- Ligaments: a few examples are - capsular, conoid, coracoacromial, superior

- Bursae: subdeltoid, subacromial, subscapular, and subcoracoid bursae

- Nerves: brachial plexus, subscapular nerve, axillary nerve, and

Rick Kaselj, MS, BSc, PK, CPT, CEP, CES 9

- Blood vessels: anterior and posterior circumflex arteries

These structures work together statically and dynamically to assist in efficient

Rick Kaselj, MS, BSc, PK, CPT, CEP, CES 10

The shoulder is made up of

Humerus scapula and clavicle make up the

Figure 1. Pectoral Girdle.

Rick Kaselj, MS, BSc, PK, CPT, CEP, CES 11

Each scapula is composed of two processes (bony prominences) and a flattened

Rick Kaselj, MS, BSc, PK, CPT, CEP, CES 12

Figure 2. Lateral view of left scapula.

Rick Kaselj, MS, BSc, PK, CPT, CEP, CES 13

Figure 10. Posterior (Back) View of the scapula

Rick Kaselj, MS, BSc, PK, CPT, CEP, CES 14

Figure 3. The left humerus, anterior view.

Rick Kaselj, MS, BSc, PK, CPT, CEP, CES 15

Figure 4. Shoulder girdle, front (anterior) view.

Figure 5. Shoulder, back (posterior) view.

Rick Kaselj, MS, BSc, PK, CPT, CEP, CES 16

The Shoulder Joints

Figure 6. A Medical Illustration of the Joints of the Shoulder. (2008).