Southern Sports & Orthopaedics
Rehabilitation guide
Rotator Cuff non-operative rehabilitation protocol
This handout describes details of the exercise program to improve the function of your shoulder.
Through proper rehabilitation, the intact muscles around the shoulder can compensate for the
impingement pain or weakness caused by a rotator cuff tear. In fact, up to 70% of patients with a
symptomatic cuff tear can gain satisfactory results with a non-operative rehabilitation program.
The main facets of rehabilitation are:
1. Decreasing pain and protecting the shoulder from ongoing injury
2. A stretching program to restore shoulder motion
3. A strengthening program the strength and function of the intact muscles
The rehab program should be performed each day. Starting with the stretching, then doing the
strengthening program, followed by another set of stretching to finish.
Decrease pain and ongoing injury
The dysfunction in your shoulder causes pain through rubbing of the tendons on the thickened bursa,
ongoing irritation of the tendon or abnormal movement of the ball in the socket. The rehab program is
designed to correct those problems.
In the meantime, and during the program:
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Keep your shoulder as mobile as possible
Avoid doing things that cause painful catching in your shoulder this applies to both the
exercises in this program and to your sporting and work activities. You can’t really “work
through” rotator cuff pain and can make things worse.
Regularly use ice therapy if the shoulder is sore. A plastic bag of crushed ice, or frozen peas,
wrapped in a damp towel and resting on the front of the shoulder for 5-10 mintues, 3-5 times
per day.
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Southern Sports & Orthopaedics
Rehabilitation guide
Stretching program
This program is made up of a series of stretches; each designed to improve the flexibility of a specific
region of the shoulder capsule and shoulder girdle. Proper performance of the stretching program
should ensure balanced shoulder flexibility.
Frequency
Each stretch should be performed 3-5 times during a session of exercises. Stretching sessions should
be performed 3 times per day to prevent scar tissue from reforming between sessions.
If too much time is allowed between sessions, the shoulder will tighten back up, resulting in little
progress.
Duration
When the limit of a stretch is reached, it should be held for a minimum of 30 seconds. Remember to
relax and breathe as the stretch is held. Do not bounce at the end range, rather apply persistent gentle
pressure during the count. Repeat each stretch 3-5 times and try to push a little farther with each
repetition.
Exertion
At the beginning of a stretching program, the shoulder may initially ache more as a result of the
exercises. This should not cause concern and you should continue to work through the discomfort,
which should subside with continued efforts. If stretching results in moderate to severe pain that lasts
for greater than 15 minutes following the program, you should back off on the exertion.
The directions of stretch you need to concentrate on are:
1.
2.
3.
4.
5.
6.
7.
Pendulums
External rotation
Forward flexion (reaching up overhead)
Cross body reaching
Internal rotation (reaching up behind the back)
Abduction (reaching out to the side)
“Sleeper “ stretch
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1. Pendulums
Stand next to a table or support and lean forward.
Gently let the involved arm hang down freely and relaxed.
Swing your arm forwards, backwards, sideways and in circles,
using gravity to help you. Initially perform this exercise for 1
minute, 3-4 times (rest between sets).
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Rehabilitation guide
2. External rotation
External rotation at waist height:
Lie on your back.
Hold a pole (eg broom handle or ski pole) with your arms by your sides and elbows bent to 90°.
Support the elbow on the involved side throughout the movement on a rolled towel (about 15cm high).
With your uninvolved arm gently push the affected arm outwards into external rotation as far as it will
comfortably go. Do not let your elbow move away from the side of your body.
Hold for 30 seconds. Repeat 3-5 times.
This can also be done standing.
With your stiff arm at your side and your elbow bent 90°, stabilize the
arm by placing your hand against a wall or door frame.
Turn your body away so that your stiff arm rotates out to the side. Keep
your elbow tucked in against your side.
External rotation at shoulder height:
Place your hand against the wall at shoulder height or above, with the
elbow bent. Turn your body away from the wall, so that your arm turns
outwards.
Hold for 30 seconds. Repeat 3-5 times
3. Forward flexion
Lying
Lie on your back and use your good arm to grasp your
involved elbow.
Gradually lift your involved arm upwards over your head. The
aim is to get to at least 90°. This movement may be tight,
but should not be painful.
Hold for 30 seconds, then slowly lower the arm to the
starting position.
Repeat 3 times.
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Rehabilitation guide
Seated overhead stretch:
Sit in a chair beside a table or flat surface that supports your arm in a
comfortable amount of forward elevation.
By leaning your body forward and allow your arm to slide forward, to a
gentle elevation pressure can be applied to the arm.
Hold for 30 seconds to several minutes as tolerated.
Standing overhead stretch:
Place the hand on the wall and gently leaning your body forward as
indicated to raise the arm relative to the body.
Hold for 30 seconds. Repeat 3-5 times.
4. Cross - body reaching
With your thumb pointed down and elbow straight, use your good arm to pull the arm of your stiff
shoulder across your chest. Hold for 30 seconds, then slowly release. Repeat 3-5 times.
Perform this stretch at three different levels:
1. Slightly below shoulder height
2. At shoulder height
3. Slightly above shoulder height
5. Internal rotation
Place the arm of your stiff shoulder behind your back.
Using a towel or a stick in your good arm, pull the arm of your stiff
shoulder up your back.
Initially hold for 15-20 second, building up to 30 seconds.
Repeat 3-5 times
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6. Abduction
Either lying down or standing with you back against a wall, use your good arm holding a broomstick or
similar to elevate the arm away from the body to the side.
Concentrate on keeping the shoulders relaxed. Avoid leaning sideways or hunching the shoulder to
increase the movement achieved.
Hold 30 seconds, repeat 3-5 times.
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✗ 7. “Sleeper” stretch
Side lying sleeper stretch:
Lie on a flat surface on your side with the stiff shoulder side
down, the arm in front of you with the elbow bent 90° and the
hand pointing up.
Use your good arm to lever down on the forearm of your stiff
shoulder (push your hand toward the ground).
Hold for 30 seconds then release. Repeat 3-5 times.
To increase the intensity of the stretch, roll your body forwards
about 30° onto the affected arm and repeat the stretch.
Standing sleeper stretch:
Standing about 20cm from a wall, lean against the wall, with the
affected side closest to the wall.
Use your good hand to push your affected hand towards the
ground, allowing the arm to rotate.
Similar to cross body reaching, this exercise should be performed
in 3 positions: with arm at shoulder height, slightly above and
slightly below
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Southern Sports & Orthopaedics
Rehabilitation guide
Strengthening program
In the strengthening program, you are trying to improve the function of the intact muscles to
compensate for the weakness of the damaged ones. There are 3 groups of muscle to concentrate on:
The rotator cuff muscles (forward flexion, internal and external rotation)
The postural or scapular muscles (Rhomboids, Latissimus dorsi)
The Periscapular muscles (Pectorals and Deltoid muscles)
At the same time as strengthening these muscles, you want to avoid making the impingement
symptoms or muscle irritation worse. Do all of the exercises as tolerated, within what is comfortable for
you. Movement should always be smooth, slow and under control. Concentrate on good form with the
exercise, rather than on increasing the resistance or number of repetitions.
Start with one set of 10 repetitions, increase reps and number of sets as tolerated
Perform strengthening exercises equally on both arms, not just the problematic one.
After exercising, your shoulder may feel fatigued and ache. This is okay, but severe discomfort is not.
Using an ice pack and anti-inflammatory medication is okay as part of your rehab after exercising. If still
having significant discomfort in spite of this, back off on the intensity and/or number of repetitions of
exercises you are doing.
Once you are comfortably doing the exercises in phase one, progress to phase 2, continuing to do the
exercises from phase 1. Once comfortable with phase 2, stop phase 1 and start phase 3 exercises.
Gradually progress through the phases until able to perform them all easily.
Phase 1 Strengthening
1. Wall push ups
A. Stand about 20cm from the wall.
Place your hands against the wall palms flat and fingers up.
Lean towards the wall by bending your elbows. Slowly
alternate pressure from one shoulder to the other by rocking
from side to side.
Hold for 30 seconds, repeat 3 times
B. Once performing this easily, move your feet further away
from the wall.
2. Seated Stabilization
Sit on a bench or chair firm chair with your hands on the chair. Lean from one side to the other, putting
gradually increasing weight through each arm to support you on either side as you slowly rock side to
side. 3 sets of 10 repetitions
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Rehabilitation guide
3. Internal rotation
Isometrics (Exercises where you use the muscles without moving the arm).
Standing with inner forearm against the wall and your elbow at your side. Push
your hand against the wall trying to rotate your forearm into your body.
Keep pushing for 10 seconds then relax. 3 sets of 10 repetitions.
4. External rotation
Isometrics
In this case stand beside a wall with the outside of your bent forearm against the
wall. Push outwards against the wall. Keep pushing for 10 seconds and then
relax. Repeat 3 sets of 10 repetitions.
Side-lying ER
Lying on your unaffected side, rotate your arm outwards as far as comfortable,
slowly return it to the starting position.
Repeat as tolerated, slowly building up to 3 sets of 10 repetitions.
This can be repeated with your arm held in front of you, with your elbow at the
same level as your shoulder, supported on pillows or books.
Rotate your arm outwards towards the ceiling. Aim for 3 sets of 10 repetitions
5. Shoulder blade circles:
Shrug your shoulder blades forward, up back and then down in a circle.
Repeat with both forward and backward circles. Perform for 1-2 minutes, 3 times daily.
6. Shoulder Blade Retraction:
Stand in the pendulum position, bending forwards from the waist with both arms hanging forward.
Draw your shoulders blades back to squeeze them together behind your back. Hold for 5 seconds and
then slowly release. Repeat 10 times, 3 times daily.
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Southern Sports & Orthopaedics
Rehabilitation guide
Phase 2 strengthening
1. Forward flexion
Elevate your arm forwards as far as comfort allows, hold for 5 seconds, then slowly lower to the starting
position. Repeat as tolerated, slowly building up to 3 sets of 10 repetitions.
2. Scratching the Itch: part 1
Reach up behind your back as far as you can go comfortably. From the push
it a little further – you’ll feel it pulling in your shoulder, which may be a bit
uncomfortable. Hold for a few seconds and then back off until it is
comfortable. Repeat this 10 times. Do 3 sets.
3. Scratching the Itch: part 2
Reach over your opposite shoulder and try to reach across your shoulder
blade. Start at the edge of what is comfortable and then push a bit further,
hold for a few seconds and then back off. Repeat this 10 times. Do 3 sets.
4. Drawing the Sword:
This movement mimics the action it is named for.
Imagine you have a sword in its scabbard by your
opposite hip.
Reach down and grasp it with your hand, then lift
your arm up, out to the side and back so that
your hand moves diagonally from beside one hip
to above the other shoulder.
3 sets of 10 repetitions.
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Southern Sports & Orthopaedics
Rehabilitation guide
Phase 3 strengthening
1. 2 point kneeling
Kneel on all fours. Lift your good shoulder and opposite knee so that your weight is going through your
sore shoulder. Hold for 30 seconds. Repeat 3 times. Gradually increase the duration of the pose as you
get stronger.
2. Cobra pose
This exercise promotes good posture and strengthens the back muscles to place the shoulder in a
better position for pain-free function.
Lying face down, turn the hands so your palms face down (or outwards if you are really flexible) thumbs
are facing out away from your body. Open out and extend using your back muscles to lift your chest
from the floor. Hold for 30 seconds. 3 repetitions. Gradually increase the duration of the pose as you get
stronger.
3. Swiss ball Stability
Kneeling down, place both hands on the sides of a Swiss ball and lean forwards. Hold this position for
30 seconds. 3 repetitions. To increase the intensity, increase the duration of the pose and move your
knees further away from the ball. Once comfortably performing two-handed, do the same exercise onehanded.
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Southern Sports & Orthopaedics
Rehabilitation guide
4. Theraband strengthening
Using a progressive resistance elastic (Theraband) to provide resistance for four movements.
In each movement aim for 3 sets of 10 repetitions.
Increase the resistance of the band if completing the exercises easily.
As for the stretching exercises. Take the movement to the end of your comfort zone, then push a little
further and hold for several seconds before backing off.
1. External rotation.
Have the band secured at waist height (a door
handle is good) on the side opposite the exercising
shoulder. Keeping the elbow to the side, rotate the
hand outwards as far as you can comfortably go.
Slowly return to the start position
2. Internal rotation
Keep the band in the same place, but turn around, so the
band in under tension with your arm rotated outwards in
the finishing position of external rotation. Rotate the arm in
to touch your belly. Slowly return to the starting position.
3. Forward flexion
Have the theraband secured around your foot. Start with
your arm straight, about waist height. Raise your arm
against the resistance of the band. Raise your arm as far as
is comfortable plus a bit more, hold for several seconds,
then slowly lower.
4. Abduction
Again, the theraband is secured at foot level. Have your arm
about 30° forwards of being straight out to the side. Raise your
arm against the resistance of the band. Raise your arm as far as
comfortable plus a bit more, hold for several seconds, then
slowly lower.
Once performing this comfortably, your can take your arm fully
out to the side and repeat the exercise.
is
30°
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Southern Sports & Orthopaedics
Rehabilitation guide
Phase 4 strengthening
1. Theraband Drawing the Sword
Secure the theraband under your foot or at ground level. Repeat the Drawing the Swords exercise with
the theraband. 3 sets of 10 repetitions.
2. External rotation at shoulder height
Have the band secured at shoulder height on the side
opposite the exercising shoulder. Start with the elbow at
shoulder height. Without moving your elbow, rotate your hand
outwards (back and upwards) as far as you can comfortably
go. Slowly return to the start position.
3 sets of 10 repetitions.
3. Internal rotation at shoulder height
Keep the band in the same place, but turn around, so the band in
under tension with your arm rotated outwards in the finishing position
of external rotation. Now, without moving your elbow, rotate your hand
downwards until it is facing directly forwards. Slowly return to the
starting position.
3 sets of 10 repetitions.
Once doing this easily, progress the movement by raising the elbow
above shoulder height.
4. Seated push-ups
Sit on a firm chair and using your arms raise your body off the chair.
Hold for 5 seconds and lower. Repeat 3 sets of 3 repetitions. Progress
the exercise by increasing the duration of the hold.
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Southern Sports & Orthopaedics
Rehabilitation guide
5. Cable rows
Secure the theraband at ground level. Keeping the elbow close to your body draw you arm
backwards.
3 sets of 10 repetitions.
This exercise can be varied by rotating your arm outwards, so your forearm and palm are facing
forwards. Repeat the same motion of extending the arm back, while keeping the elbow close to the
body.
6. Ball throwing
This is mimicking the motion of throwing a ball overhand in slow motion. Start gently and gradually
increase the range of movement and speed of the action as you feel comfortable. 3 sets of 10
repetitions.
Once you are comfortable with this exercise, it can be progressed by using a theraband to provide
resistance to the movement. Again aim for 3 sets of 10 repetitions.
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