In the last article of this series we looked at Assessing Rotator Cuff Related Shoulder Pain (RCRSP) and differential diagnosis. In this article we will take those assessment findings and look at treatment options to use. Part of this is based off the research, and part of it is based off my anecdotal experience.
One of the ways that I look at rehab, that is influenced by both Dr. Stuart McGill and by Mike Reinold, is to look at what the patient’s deficits and goals are and to try to bridge the gap between where they are now and where they need to be. In terms of that – the most common issues I see in people with RCRSP are:
- Limited shoulder range of motion – particularly in flexion, abduction, external rotation and hand behind back (HBB)
- Decreased strength in the affected shoulder (1) and in the scapular muscles (2)
- Increased tone in the neck accessory muscles (2)
- Limited thoracic extension & rotation mobility
- (For throwing and/or rotational athletes) limited hip abductor & external rotator strength
Everyone is different and these may not apply to all, but I think most readers can agree these apply to a lot of our clients in this demographic.
Before we get too far into any treatment options – two of the cornerstones of my philosophy to rehab are education & empowerment. With respect to education, activity modification is a crucial component of these cases. Activity modification can take two forms:
- Reducing activity levels to a tolerable level that allows symptoms to calm down and then slowly building things up (i.e. Greg Lehman or Tim Gabbett). For most cases I do like to keep things relatively pain-free.
- However, if you’re dealing with a case that is more fear avoidant, activity modification may involve getting people to slowly ease into activity. This can be tough, especially if you’re dealing with a client who is highly sensitized and/or has a lot of anxiety surrounding activity. This is where things like pain science education can be useful. My approach is more simple for most of these cases – I educate people that it’s safe to do activity with a bit of pain as long as it’s within a tolerable level and comes back down shortly after the activity is done.
From an empowerment perspective – if you show people ways to do things that can help alleviate their symptoms (similar to that of a McGill or McKenzie approach), this can help for many cases with confidence and self-management in my opinion. I’d also like to point out the study in 2016 that showed 75% of people with full thickness rotator cuff tears who were able to rehab their shoulder without surgery (3)!
Working through the problem list now from bottom to top…
Decreased hip abductor & external rotation strength
In rotation-based athletes, decreased rotary power generated from the hip means more is asked of the shoulder to generate this rotary power. I see this as an issue commonly in throwers (particularly baseball players) and golfers. Don’t get me wrong – I do like clamshells as a starting point but they do tend to be overused and can only go so far. I usually like to progress from clamshells to banded clamshells to monster walks to hip airplanes. I also like to incorporate the element of corkscrewing the legs into the floor when doing squat or deadlift variations to incorporate these muscles in a less “isolationist” manner.
Decreased thoracic extension & rotation ROM
Limited thoracic ROM can play a big factor in limiting the ability of the client to get their arms overhead and/or out to the side. Simple PPIVMs can be helpful with improving thoracic mobility. I don’t do manipulations but they (if done safely and on the right people) can be helpful as well with shoulder pain (4). I also like using a thoracic extension PNF drill that I learned from Dr. McGill (video here https://www.youtube.com/watch?v=RDQaZVRG4hI).
From an exercise perspective some of the common thoracic mobility exercises such as Eric Cressey’s Back To Wall Shoulder Flexion or the Quadruped Rotation are very helpful for general mobility, but in my experience are difficult for people limited by shoulder pain. Simple thoracic rotation in sitting with the arms crossed can improve thoracic mobility. Thoracic extension in sitting or on a foam roller can help as well.
Increased tone in neck accessory muscles
Assuming they are just tight and not painful (and there are no medical concerns), stretches, soft tissue work and contract/relax techniques can help to reduce tone in the neck accessory muscles. Self soft tissue techniques can also help as well.
Research isn’t very positive on the effectiveness of kinesiotaping in people with shoulder pain (5), but I do find it anecdotally helpful for people with neck tightness who tend to shrug their shoulders excessively when lifting their arm up and/or when sitting.
Decreased strength in shoulder & scapular muscles
A recent article in JOSPT (6) questioned the idea of needing to strengthen the shoulder. I agree with the sentiment that we shouldn’t be telling patients they have a “weak” shoulder – but there is still value in strengthening as many people I see do have limitations in scapular and shoulder strength.
For rotator cuff strengthening, simple exercises like shoulder flexion, abduction, internal rotation and external rotation within a tolerable range of motion are reasonable enough to do. Over time the goal should be to progress the ROM of the exercises.
I don’t get too fancy with scapular strengthening, as some of the fancier stuff is initially pain limited in people I work with, but things like very light dumbbell or band rows can be a good place to start and are well tolerated by most people. Wall pushups (progressing to incline and then floor) with scap protraction are a great way to train the serratus muscles.
Limited shoulder range of motion
Some people use pulleys or broomstick exercises to help improve ROM. While I’m not against this, particularly for chronic cases who may not have moved their shoulder much, I don’t use this approach for most people as:
- The exercises tend to be quite provocative and the ROM is pain-limited
- I don’t like the idea of giving people 10 million exercises
I’ve found anecdotally that in patients with a directional preference (refer to my last article on Assessing RCRSP for a deeper explanation for what that is), that repeated movements in that direction will improve ROM in the other directions as well.
That said – not everyone has a directional preference. If people are moving through a range of motion I’d just as much rather have them do strengthening exercises through a tolerable ROM and work to increase it over time. This often does the trick for most motions.
Hand behind back can be a very stubborn movement to improve in people with shoulder pain. Usually as the condition improves, it improves, but sometimes everything else can improve while it stays limited. Some tools I’ve found helpful are:
- Education that this may take a long time to improve! This is key.
- Combination of internal rotation PROM and posterior gliding of the shoulder
- Soft tissue work of the external rotators
- Cross body stretch combined with a pin of the external rotators (props to Mike Reinold for these ideas (7))
- External rotator strengthening with the arms elevated at 90 abduction or 90 flexion with a focus on a slow eccentric. This essentially does the same as a sleeper stretch but kills two birds with one stone as there’s strengthening involved.
I also like the combination of glides with PROM in people who have limited ROM in other directions.
As an aside, if you have access to an arm bike/crank in your facility I like the idea of having your clients do a few minutes on it (if they can tolerate it) at low resistance to help warm up the shoulders beforehand.
RCRSP can be tricky to treat, and as we’ve shown above there can be a lot of different factors involved, but I hope this article provides some useful tips for managing the common issues seen with this condition. As always – thanks for reading!