Rehabilitation exercises for rotator cuff injury
This topic has been touched on before by Marc (Shoulders - Rotator cuff) however, there wasnt a detailed discussion into what exercises are involved in the rehabilitatino process. Ive had people PM me about what exercises to do for different stages of the injury (i.e. chronic vs acute injury etc). Ive put together this thread to list some of the exercises that i found useful when i tore my rotator cuff and also exercises that the physiotherapists and doctors instruct patients to do.
The principles of rotator cuff injury management come down to these things:
1) Activity modification - People with acute pain can stay active but should avoid extremely painful movements. Activity can be increased as pain settles.
2) Analgesia - Simple pain killers or Non-steroidal anti-inflammatory drugs (NSAIDs) provide short-term pain relief.
3) Rehabilitation - There is some evidence that supervised exercise is beneficial.
4) Referral - Refer people to an orthopaedic specialist at six months if there is a poor response to treatment. However, if there is a massive tear it is best to refer immediately for orthopaedic evaluation. Delay compromises optimal outcomes for patients.
For an acute injury (one thats happened recently):
- Basic first aid measures – RICE (rest, ice, compression and elevation)
- Apply ice to decrease swelling. Wrap the ice in a cloth to avoid freezing the skin. Apply the wrapped ice 10-15 minutes at a time. This is most helpful in the first 1-2 days.
- Support the arm in a sling to rest the rotator cuff muscles. The sling may be taken off at night. Anti-inflammatory medications may help reduce pain and swelling.
- Make an appointment with your doctor for assessment. The physician may ask you to be seen for follow-up, either by a primary care doctor or an orthopedic surgeon (specialist).
- Further imaging may be required to determine the degree and involvement of muscle tear. This is often done via magnetic resonance imaging (MRI).
- Early surgery (within 3 weeks) to repair the tendon is often needed, especially for younger, more active people with larger tears.
- Indications for surgical treatment:
o Usually for people younger than 50 years with complete or significant tears
o An option after failure to improve after 6 weeks of proper rehab
o If the person has a job that requires constant shoulder use
The major objectives of rehabilitation from a rotator cuff injury are to increase flexibility, obtain pain-free range of motion, and strengthen the muscles of the shoulders, upper back, front chest, and upper arms. In severe cases, you should avoid activity that causes shoulder pain altogether. In these cases, you can still maintain cardiovascular fitness by cycling, unless otherwise prescribed by your doctor.
Stretching and stregthening of the 4 shoulder rotator cuff muscles (subscapularis, infraspinatus, supraspinatus and teres minor - for diagram, see link ive given to Marc's post. There he gives a good website outlying the basic anatomy of the shoulder musculature), as already mentioned the foundation of rehabilitation of rotator cuff injuries. Initially, soon after injury, after the pain has died down a little, it is best to start performing shoulder exercises to maintain the range of motion inthe shoulder and prevent scarring from the inflammation. This is best performed initially by isolating each muscle group and selectively training that muscle (known as Isometrics) - with no weights.
Phase 1 - Isometric exercises.
The subscapularis is the anterior stabilizer of the rotator cuff and responsible for internally rotating the shoulder. It is best strengthened by holding your arm in front of the body, with the arm flexed to 90 degrees, and rotating the hand to touch the belt. The exercise can be performed while lying on your back with the elbow close to your side and flexed ninety degrees. Lift the weight until it is pointing toward the ceiling and then lower it slowly. Add small amounts of weight as you progress, making sure you are in minimal pain at all times. If it gets too painful, stop and rest.
The supraspinatus is strengthened by holding out your arm straight in front of the body, with the thumbs pointed toward the floor. Slowly elevate the weight to above the head. Stop if pain is produced in any portion of this motion, as the rotator cuff is under maximal stress in this position. As you feel better, you can slowly introduce small amounts of weight to continue strengthening of the muscles.
The infraspinatus is strengthened by holding you arm (and later on, a weight) in the position of the ski pole just prior to planting the pole. By rotating the arm from the neutral straight ahead position, to the externally rotated (out to the side) position, the infraspinatus and teres minor are strengthened. Again, this exercise can also be performed while lying on your side with the elbow close to your hip, and flexed ninety degrees. Rotate the weight until it is pointing toward the ceiling. Shoulder exercises are best performed with relatively light weights and multiple repetitions.
The logic behind stretching and strengthening the inflamed rotator cuff in order to speed healing and functional performance is as follows: the inflamed tissue is characterized by increased fluid between the cells, increased numbers of new blood vessels and inflammatory type cells. As a result of this inflammatory reaction, new collagen tissue is laid down in an effort by the body to heal the injured tissue. If the shoulder is immobilized during this time, the new collagen is laid down in a disorganized fashion, creating scar. The goal of gentle stretching, strengthening and anti-inflammatory medication, is to stimulate the cells to lay down collagen along the lines of stress, forming normal strong tendons. The combination of a good warm up, gentle stretching, strengthening below the limits of pain, icing after working out and anti-inflammatory medication has been consistently shown to speed recovery time in the strongest possible fashion.
After you are comfortable with these stretches and have minimal pain and good/fair range of motion in your shoulder, you can move onto resistance exercises. These usual start with what is known as tubing exercises. The 'tubing' is also known as a theraband, which is just a big rubber elastic band that you tie, at one end, to something and you hold the other end and pull the band thereby stretching it and providing resistance for your shoulder.
Phase 2 - Tubing exercises
External rotation: Stand resting the hand of your injured side against your stomach. With that hand grasp tubing that is connected to a doorknob or other object at waist level. Keeping your elbow in at your side, rotate your arm outward and away from your waist. Make sure you keep your elbow bent 90 degrees and your forearm parallel to the floor. Repeat 10 times. Build up to 3 sets of 10.
Internal rotation: Using tubing connected to a door knob or other object at waist level, keep your elbow in at your side and rotate your arm inward across your body. Make sure you keep your forearm parallel to the floor. Do 3 sets of 10.
Extension: Same principles as the other two. Keep the arm parallel. 3 sets of 10. See attached picture
As you feel more confident and you find your strength increasing, you can add more resistance - either in terms of shortening the length of the theraband so you need more resistance to stretch it or by increasing hand held weights in small increments.
Ofcourse, these arent the only exercises for shoulder rehabilitation. There are many more. Ive listed a few more below that ive found from a good website:
Lie on your back with your arms at your sides. Lift one arm straight up and over your head. Grab your elbow with your other arm and exert gentle pressure to stretch the arm as far as you can.
Stand and lift one arm straight out to the side. Keeping the arm at the same height, bring it to the front and across your body. As it passes the front of your body, grab the elbow with your other arm and exert gentle pressure to stretch the shoulder.
Drape a towel over the opposite shoulder, and grab it with your hand behind your back. Gently pull the towel upward with your other hand. You should feel the stretch in your shoulder and upper arm.
Stand with hands at sides with no weight in either hand. Raise shoulders to the point of pain and hold for five seconds. Relax for five seconds. Perform this sequence 10 times, 3 times daily. As pain permits, hold dumbbells of equal weight in each hand while performing this exercise. Add weight by using hand-held dumbbells as pain permits.
Stand with arms fully extended at sides while grasping 2- to 5-pound weights in each hand, held palm forward. Flex the arms at the elbow to approximately 100 degrees, or to the point of pain, whichever comes first. Hold this position for 5 to 10 seconds. Return to the start position. Rest for 5 seconds. Repeat this exercise 10 times. You can increase the weight as pain allows and strength develops.
Stand with elbows directed upward over the shoulders and with arms relaxed. Extend arms at the elbow so that the hands proceed upward to the point of pain. Hold this position for five seconds. Return to the starting position and relax for five seconds. Perform this sequence 10 times, 3 times daily. As pain permits, add weight by using hand-held dumbbells.
Lie on belly with hands extended along sides of the body. Raise the upper chest from the floor to the point of pain and hold this position for 5 seconds. Return to the start position and relax for 10 seconds. Repeat this sequence 10 times, 3 times daily.
Reach out and place the unaffected side hand on a corner of a table. Bend at the waist. Flex the injured side arm at the elbow and pull the injured side arm backward and upward as if sawing wood. Slowly bring the shoulder blades as close together as pain will permit. Slowly bring the injured side arm down to its beginning position. Repeat this sequence 10 times, at least three times daily.
Stand with the hand of the unaffected arm resting on the corner of a table and supporting some of the body weight. Slightly bend the knee on the unaffected side and extend the other leg sideways. Allow the injured arm to hang loosely over the unaffected side foot. By shifting the body weight, cause the relaxed injured arm to swing in circles to the fullest extent possible as limited by pain. Perform 25 swings in a clockwise direction. Allow the injured arm to cease swinging. Perform 25 swings of the injured arm in a counterclockwise direction. Repeat this sequence at least three times daily.
Flexed elbow pull
Bend and raise the injured side elbow to shoulder height. Grasp the injured side elbow with the uninjured side hand. Gently pull the injured side elbow toward the opposite shoulder until limited by first significant pain. Hold this position for 10 seconds. Relax for 10 seconds. Repeat this sequence 10 times at least three times daily.
Im sure there are other exercises that i havent mentioned.
Now people often say, when can i start weight training again? or when can i return to sport? There is no definite answer for that. It depend on the degree of your injury, how dedicated you are to your rehab and the rate at which your body heals. some people with minor tears can return to full contact sports in as short as 4 weeks. Other with larger tears have to have surgery and can be out for a year.
My advise to you is, dont rush it. Let your body take its time to heal. Be religious in doing your exercises and the results will come with time. Impatience is one of the biggest causes of re-injury.
And most importantly, always consult your physician for advice. While we can help you on these forums and point you in a right direction, nothing can replace a one-on-one physical examination and a good chat with your physician. This is essential.
If anything ive said is unclear or ive made a mistake (im only human) - let me know. If there is anything more you want to know, dont hesitate to ask and ill do my best to help you.
post edited by Lynx100 - 2005/08/13 20:01:20
RE: Rehabilitation exercises for rotator cuff injury
I was doing the bench press, without warming up. I felt a bothering pain in my shoulder, but I chose to ignore it.
After doing my last set, something snapped in my shoulder and it was VERY painful. I went to a doctor, and he asked me if I could lift my arm. I barely did. Then he said I proboably have just partly torn one of my rotator cuff muscles, and I should re-heal in about 2 months.
It's been 2 months now and while I can move my arm all around, I still feel uneasy slight pain when I put my arm in certain positions, such as the driving 'streering wheel' position. I went to doctor again, asking to do an MRI. He said that he's pretty sure I don't need an MRI, but he said if it doesn't go away in 3 weeks, he'll send me to a shoulder specialist.
I am beginning to worry if it's normal to have this uncomfort and how long it's going to take me to get back to working out. Could you all lift your arm when you injured your rotator cuff? Do you think I can do these exercises, and how often am I supposed to do them?