Rotator Cuff Physio Rehabilitation

Rotator Cuff Physio Rehab for shoulder pain

The fundamentals of rotator cuff physio rehab

In a previous blog post we have outlined the anatomy and mechanics of the rotator cuff. We also discussed the ways these muscles can be overloaded and injured. Forming a clear understanding of the muscles and tendons at play is important so we can adequately address the problem. More important perhaps, is identifying the activities and loading that may be contributing to the problem. The focus of this blog is around a rotator cuff physio rehab approach.

Load on the rotator cuff tendon

The following are the different types of loads that can impact the rotator cuff tendons – particularly when dealing with a rotator cuff injury:
  • Compressive load: Compressive loads occur when the rotator cuff tendons are compressed between the humeral head and the acromion. This type of load is most commonly associated with subacromial impingement. This compression can occur acutely with impact like falls or tackles; or can occur repetitively over time. Forceful compressive loading can result in acute damage to the tendon. Or change can occur over time – with a thickening of the tendon as it adapts to better withstand the compressive loading.
  • Tensile load: Tendons love tensile load. The tendon is designed to transfer tension from the muscle into the bone on which it is attaching. That said – too much of a good thing… Our tendons respond and adapt to the loads we consistently apply to them. If we are inconsistent, or add too much too quickly, then our tendon can struggle to adapt healthily to the load. This can result in a process called tendinopathy, where the fibers of the tendon undergo a disordered healing process. The outcome of which can be pain, stiffness in the tendon, and increased risk of tears.
  • Compression + tension loading: In particular we want to avoid sharp increases in tensile loading while holding tendons in a compressed position. In the shoulder this predominantly occurs when we load the tendons in particularly bad postures, or in the presence of sub-acromial impingement.
  • Shear load: Shear load occurs when there is a sliding or shearing force across the rotator cuff tendons. This type of load is most associated with traumatic injuries such as dislocations or fractures.

Change in load

As mentioned above, change to loading is one of the most important variables to understand. Rotator cuff physio rehab will always seek to find changes to loading that preceded pain or rotator cuff injury. A common example is when an athlete moves from gym-based exercise to swimming or throwing sports. Or it could be other factors that have recently caused impingement or acute impact, resulting in more compression to the tendon. Most commonly however, the most relevant change is a rapid increase in loading of the tendons. This includes a sudden return to sport. Or most commonly a ramping up in overall volume. Think of the swimmers who go from one weekly session to swimming five times a week through summer. Or the increase in load in a cricketer’s shoulder between off-season and competition.

Rotator cuff injury and strain – Increased volume is a common culprit

Rapid increases in volume create an imbalance in our tendon’s normal wear and repair cycle. Like muscular strength training, exercise creates small amounts of change in the tendon from which, under healthy conditions, the tendon adapts. With too much loading that we aren’t accustomed to, the tendon struggles to keep up with repair. This generally doesn’t cause an acute breakdown of the tendon. Rather the tendon undergoes a disordered healing process that we call tendinopathy (formerly referred to as tendinitis). Over time this process can make the tendon weaker, less tolerant of stretching, and sometimes painful. Often this tendinopathy process precedes an acute rotator cuff injury.

Building a rotator cuff physio rehab training plan

Establishing a baseline of safe and consistent loading is the first step in the rehabilitation process. This will focus on a few key points:
  • Minimising load in positions of compression. This will involve identifying if impingement is occurring, or improving posture to minimise compressive forces in the tendons as they encircle the shoulder.
  • In the early stage of rehab, we want to avoid positions of acute impingement.
  • A relative reduction in training load.
  • This will often be a small decrease to somewhere around 60-75% normal volume.
  • This may look like one less session of exercise a week. Or reducing sets of reps in the gym with certain exercises.
  • Ensuring there is adequate rest happening between sessions.
  • Often a normal exercise routine can be maintained with minimal decrease in load if the sessions can be adequately spaced. This amount of rest is different depending on training experience. Anywhere from 24-72 hours can be necessary for shoulder tendons to respond and adapt to training in a sustainable way.
Including adequate warm-up exercises:
  • Shoulders love a good warm-up. The normal day of an office worker does so little to stimulate, stretch or strengthen the shoulder. Spending a few minutes with a theraband to warm-up the muscles around the shoulder blade can be a lovely addition to a session.
Rotator cuff physio rehabilitation exercises: Rehab and warm-up exercises should be specific to the movements required in the sport. That said, we have a heap of simple exercises we recommend as a base on which a more personalised program can be built.
    1.Rows, band rows, inverted rows, seated rows, single arm rows. You name it, if it involves pulling weight in towards the body, we love it. Rowing movements recruit lots of big and small muscles around our shoulder blade that are crucial in creating a strong platform on which the cuff muscles can act. Also, rowing movements are often one of the least irritating of all strengthening exercises for shoulders with rotator cuff problems. This often means they are the foundation of our rotator cuff physio rehab programs.
    2.Straight-arm theraband pull-aparts are a great step up from the humble row. The pull-aparts require the muscles of the shoulder to act on a longer lever, across a larger range than the row. This means it is a great way to increase work for the muscles. Simply stand and hold a band tight between your hands, at arm’s length. It can be performed from waist height to overhead. Keeping shoulder blades square – pull the band apart. Easy as that.
    3.Theraband rotation: Boring old physio 101. This exercise is so over done we almost feel sinful when we give it to patients. You know the drill: Band tied to a pole or door-knob. Elbow by your side. Physio poking you in the shoulder to tell you to “retract” your shoulder blades. Rotating your forearm in a seemingly obscure movement. And fatiguing a seemingly miniscule, previously unheard-of muscle. Sounds eerily familiar. New age physios will scoff at us, but we still use and love this exercise. Theraband external rotation is a great way to build up a consistent and comfortable load in some very specific tendons. Tendons that often have a hard time getting specific strengthening work without overdoing it in positions of impingement.

Making your rotator cuff physio rehab work sports specific

Importantly, these exercises should be progressed as able into a range of motion relevant to sport. This often means performing rotation overhead for swimming and throwing sports.
  • Closed-kinetic chain (CKC) strength work: This is often overlooked, and under-utilised. Closed-kinetic chain exercise is where the joint is working in a position between body-weight and the ground. For example, with shoulders – push-ups are a closed kinetic chain exercise. But overhead pressing is not.
    1. CKC exercises create a gentle force through the shoulders that creates a natural approximation of the joint surfaces. In this position we can often load muscles more comfortable than we could in open-kinetic chain movements.
    2. CKC movements are fundamental to a lot of sports and gym activities. We need to train safely in these movements before a return to sport conditions.

Rotator cuff physio rehab at The Movement Centre Randwick

The above is a general approach that describes how we work with these injuries. It is useful for us to identify the factors that lead to pain and injury. An provides a blueprint from which we build individual rehab plans. The plan is always specific to the individual, their injury, and their needs. This blog is not intended as a rotator cuff injury treatment plan on its own. And lots of factors change how we approach each patient. Some rotator cuff injury patients require imaging, or a surgical referral. Come and see our team if you wish to discuss an approach suitable for you. Don’t let a rotator cuff injury keep you out of the sport you love. If you are experiencing pain, weakness or stiffness in your shoulder, you may benefit from a rotator cuff physio rehab program. Understanding the structures and loading is the first step in the process. Implementing a consistent program is the next step. Our physios at Movement Centre Randwick can help you. We love helping our patients with rotator cuff physio programs.
Disclaimer: The Movement Centre provides this information as an educational service. The information contained on this website and in this blog is not intended to serve as or replace actual medical advice. Anyone seeking specific advice or assistance should consult their local Randwick Physio, general practitioner, medical specialist, or otherwise appropriately skilled practitioner.