Shoulder pain is one of the most common injuries I see during my clinical work roles (private practice musculoskeletal and sporting populations). Futhermore, in a number of sports, shoulder pain/injuries make up the most significant injuries seen in terms of time-loss and incidence/prevelance. These sports include hitting based sports (e.g. tennis), throwing sports (e.g. baseball), swimming, weightlifting, and more.
I recently delivered an inservice presentation on shoulder rehabilitation. The presentation was specifically on the principles guiding the rehabilitation process, and was highly evidence-based. This blog post will look to cover some of the principles mentioned during the presentation, however will not go into specific pathologies.
When structuring a rehabilitation plan for any injury, I always like to consider the principles of strength training that are recommended for “uninjured/healthy” populations. I’ve included the typical principles, as recommended in literature, textbooks and by the ACSM. See figure-1 for more information. I have also included basic training principles, which talk about starting with simple, slow, static type movements, often unloaded. The progressions then related to the complexity of the task, whether that is changes in speed, load, difficulty, movement, position etc (Giles et al., 2005).
After considering general strength training and rehabilitation principles, the consideration must be around shoulder rehabilitation parameters. Typically, the literature recommends the following:
Proximal to distal control: start with scapula control first
Exercise principles: motor control → endurance → strength → plyometric (if applicable)
Exercise type: pulls before pushes, OKC and CKC, master movement patterns before sport-specific skills.
(Blanch 2004; Cools et al., 2014; Cordasco et al., 1996; Forthomme et al., 2008; Podesta, 2013; Wilk & Hooks, 2015)
The rehabilitation process is usually divided up in the literature in a number of phases, varying between 3-6 steps (depending on the injury/literature/researcher preference). Progression through phases should be stepwise, and include gradual increases complexity (variety of variables involved). The phases often include:
Acute/early phase
Intermediate/strengthening phase
Advanced strengthening phase
Sport specific phase
Maintenance phase/exercises
(Blanch, 2004; Bleichert et al., 2017; Cardasco et al., 1996; Cools et al., 2014; Forthomme et al., 2008; Kokmeyer et al., 2016; McIntyre et al., 2016; van Dorssen et al., 2019; Warby et al., 2018; Watson et al., 2017; Wilk & Hooks, 2015)
There is strong consensus in the literature, and with expert opinion, that addressing and rehabilitating the scapula (shoulder blade) should form the first part of the rehabilitation plan/process (Bleichert et al., 2017; De Mey et al., 2012; Forthomme et al., 2008; Holmgren et al., 2012; Kibler et al., 2013; Kibler et al., 2019; Kokmeyer et al., 2016; Struyf et al., 2013; Warby et al., 2018; Watson et al., 2017).
Furthermore, it is recommended that initial scapula training include a “motor control” component (Cools et al., 2014; Ellenbecker & Cools, 2010; Wilk & Hooks, 2015).
Factor to consider in rehab:
Isometrics: short-term pain benefit for rotator cuff pathology (Bleichert et al., 2017; Dupis et al., 2018; Parle et al., 2017).
Pain during exercise / painful rehab: evidence is unclear (Littlewood et al., 2015), with low level studies showing promising results, but expert opinion recommending strongly against.
Position changes: changes from standing to sidelying, and 0degrees abduction to 90degrees abduction alters the muscle activation of scapula and rotator cuff muscles, and must be considered.
Exercises: consider the muscle activation of differing “scapula” and “rotator cuff” exercises. Keep in mind positions that may increase the load to certain muscles (e.g. supraspinatus) or reduce the subacromial space (e.g. empty can, upright row, abduction >90degrees etc). Note: most exercises (even if they are “scapula” or “rotator cuff”) will typically activate most muscles around the shoulder.
Posture: thoracic and cervical posture (e.g. FHP) are important considerations (Cools et al., 2014).
Core & Kinetic Chain: recommended to include in shoulder rehab. Primarily: address hip/trunk flexibility, hip abductor weakness, trunk/core weakness. This is particularly important for athletes, e.g. throwing/hitting/swimming athletes (Burkhart et al., 2003; Ellenbecker & Davies, 2001; Forthomme et al., 2008; Wilk & Hooks, 2015).
Include a high-level/sport conditioning phase (if appropriate for the athlete): this is a stage that may often be forgotten/brushed over in some shoulder rehab programs/plans.
Address patient education & expectations: especially important due to long rehab (typically) timeframes (Bleichert et al., 2017; Sgroi & Cilenti, 2018).
Consider compliance, especially barriers to compliance. This is important, as improved rehab compliance = better treatment outcomes (Deutscher et al., 2009). Time and rehab program duration are typically reported barriers for shoulder rehabilitation.
I have put these evidence-based principles and recommendations together into a graphic (see figure-2 below).
This blog hasn’t addressed specific exercises, as that would likely vary depending on the injury, patient, sport and goals. The principles presented are recommended in the literature & by experts in the field. It is important to consider these principles when completing shoulder rehabilitation, whether you’re the patient, or the treating health professional. As I always recommend, if you’re currently suffering from an injury, and haven’t had a proper assessment from a physiotherapist or sports physician, I’d recommend you to consider this. Accurate assessment and diagnosis significantly aids in the treatment and rehabilitation process.
Ky Wynne, DPT, APAM, BExSci
Bibliography: references provided upon request (due to large number included in the blog post).