Tim Keeley outlines the essential exercises to use in the rehabilitation of clients’ shoulder injuries and when establishing a solid foundation for scapula and rotator cuff stability and strength.
Personal trainers and physiotherapists continually encounter a range of upper body injuries and limitations in clients. All rehabilitation exercises for the upper limbs need to have an emphasis on making sure the shoulder blade, shoulder joint and arm are moving correctly and in the right movement sequence. Without this ‘scapula-humeral rhythm’ most clients will struggle to improve with any shoulder injury, or at best, still never reach 100 per cent.
After pain or injury, messages to the brain from tissue damage and inflammation activate a ’threat messaging system’. This is interpreted as pain, and quickly inhibits the stabilising muscles for the shoulder blade and the shoulder joint. The brain then starts to compensate with other muscles to get the arm moving. This, in turn, creates an irregular movement pattern in which, subconsciously, pulling and pushing movements start to change. If the postural and stabilising muscles are not rehabilitated early, the client can get stuck in an incorrect movement pattern, and returning to normal gym exercise and sport can prove difficult.
“If the postural and stabilising muscles are not rehabilitated early, the client can get stuck in an incorrect movement pattern, and returning to normal gym exercise and sport can prove difficult.”
The rehab program needs to start with exercises that activate the stabilising muscles of the shoulder blade, slowly building strength and stability for the shoulder. As the program progresses, the focus moves to the rotator cuff stability, strength and control. The key, as the exercises get harder and more advanced, is to maintain scapula stability throughout, and to continue this principle into your client’s overall training regime. It is crucial to make sure your client performs these exercises correctly in order to activate and stabilise the shoulder blade.
Prone scapula press
This is used for serratus anterior activation, to stop winging, and to build strength in scapula neutral setting, protraction awareness and pressing control. Firstly, push down through your hands and push your ribs into your shoulder blades to flatten your scapula. Make sure you get full protraction without hunching your shoulders or arching your thoracic spine.
If you experience wrist tightness in this position, try it in standing against a wall. To progress, try a single arm press against the wall or progress to the arm and leg raise exercise. This exercise could be chosen in place of an open chain serratus ball press.
Single arm skydive
This is great for isometric lower trapezius activation, building strength in a scapula depression setting, retraction and depression awareness, and pulling control. You need to beware too much retraction or over-use of the rhomboid or upper trapezius muscles, taking care to avoid neck pain or upper trapezius spasm.
Slowly pull your shoulder off the floor, moving down and back to the opposite hip. Hold this position and rotate your arm outwards and upwards. For an easier option, perform while seated, and to make it harder, position arm at 90 degrees.
4 point arm and leg raise
This works both the scapula muscles as well as activating the rotator cuff muscles isometrically. Start in the prone scapula press exercise position. Once you get into the full protracted position, slowly move all your upper body weight onto one arm, being careful not to move away from centre. Think of pushing the ground away from you. Raise the opposite arm forward. Hold this position and make sure you stay fully protracted at the shoulder blade. Next, slowly slide the opposite leg backwards, so your body weight is even between the leg and the arm. Hold this position for 10 seconds.
If this exercise is overly challenging, and you cannot maintain a neutral core or balance, try raising the arm only or try it in standing against a wall. To progress the exercise, add a theraband around the arm and/or perform in a full push up position. To watch a video of this important exercise being performed, go to www.physiofitness.com.au/arm-leg-raise-shoulder-rehab.htm
Single arm row
This exercise can be performed in place of single arm dumbbell rows and any form of seated row. Preferably use a theraband rather than a cable machine.
This exercise promotes and helps correct the scapulohumeral rhythm, strengthening the lower trapezius and posterior rotator cuff, and teaches you eccentric retraction control of the shoulder blade. Slowly pull your shoulder down and back, first with straight arm, then pull through with arm bending at the elbow, squeezing shoulder blade down and back. On the return of the arm, hold the shoulder blade back. Think ‘shoulder blade, arm, arm, shoulder blade’. Be careful that your shoulder doesn’t go into too much elevation, that you don’t bend your elbow before the movement of the shoulder blade, and that you don’t lose the eccentric holding of the shoulder blade on return. If you have shoulder impingement, lower the attachment of the band to a more horizontal position.
This is the classic physiotherapy exercise for the rotator cuff, and still one of the best. What most people don’t realise is that it also teaches isometric scapula stability during the dynamic rotation movement of the shoulder joint. When performed correctly it builds isokinetic lateral and medial rotator cuff strength. Keep your arm slightly away from your body, but don’t let your elbow move during the rotation. Your scapula must remain set wide and stabilised (still) through the movement. Be careful not to pull your shoulder blade back, hitch it or let it roll forward. Using a theraband is much more effective for the muscle than cable, or dumbbells. To advance this exercise, use heavier bands and then perform the exercise with your arm abducted out at 80 degrees for both internal and external rotation movements.
BOSU® push up
Once you have mastered the arm and leg raise, you can begin building protraction strength of serratus anterior in scapula dynamic setting by using the BOSU® in a push up. This also teaches protraction awareness and pressing control, and increases the rotator cuff isokinetic strength. Clients must be able to do this exercise before returning to any dumbbell press or bench press exercises in their ‘regular’ training program.
Set your shoulder blades in the same way as the prone scapula press. On the downward movement, slowly let your shoulder blades come together: to push up, think of pushing the ground away from you and raising your body to the ceiling, moving your shoulder blades apart. Be mindful of the position of your head, avoid upper trapezius overactivity, and always keep your lumbar spine in neutral. The top of the movement requires the shoulder blades to be fully protracted and flattened: if this is overly challenging, the action can be performed on the knees to lessen the load. Alternatively, use a box instead of a BOSU®.
If, after undertaking a rehabilitation program featuring these exercises, your clients need, or desire, more information on increasing their scapula and rotator cuff muscle strength, it is recommended you refer them to a physiotherapist for advice on further progression exercises.
Tim Keeley, BPhty, Cred.MDT, APA
The principal physiotherapist and director of Physio Fitness Australia, Tim has over 14 years experience in physiotherapy and the fitness industry. He is also an exercise rehabilitation expert, clinical educator and regular FILEX convention presenter. For more advice on this topic, email firstname.lastname@example.org or visit www.physiofitness.com.au.