Traditionally rotator cuff (RTC) exercises have consisted of internal(IR) and external rotation (ER), rows, shoulder extensions, T/Y/W’s, and maybe if your PT was adventurous, and there was no impingement, bicep curls. But just looking at what “movements” the rotator cuff muscles do is definitely not enough; the FUNCTION of these four small muscles are what truly need to be examined for proper rehabilitation. The main functions of the RTC are:
1. Depressing the arm bone (humerus) in the shoulder joint so you can raise your arm above shoulder level
2. Stabilizing the shoulder joint so proper scapulo-humeral rhythm can be maintained
3. During closed chain exercises, assisting in the stabilization of the scapula and humerus to allow for mobility in the shoulder
4. Oh yeah, ASSISTING with internal and external rotation.
The rotator cuff muscles can be remembered by the acronym SITS.
Subscauplaris
Infraspinatus
Teres Minor
Supraspinatus – most commonly torn
If you look at the functions above, you don’t see a heavy emphasis for the rotator cuff muscles being the prime movers of the arm. They are role players, part of the supporting cast, and that is how they should be rehabbed and trained. When rehabbing a rotator cuff injury I will often surprise my patients by only using bands to provide variations of the following exercises, or for warm ups involving PNF rotary movements such as D1/D2 flexion and extension. I will definitely do internal and external rotation in this WARM UP, but only if it can be performed with proper scapular positioning and control, which is more difficult than you think.
- The Farmer’s Walk – What better way to get your RTC contracting than to perform an exercise designed to rip your arm out of your shoulder joint. No joking, these should be done with heavy weight. Leave the 5 pounders on the rack. Your weakness with this exercise should be your grip strength if anything. Shoulders are down and back (packed), chin is packed, and arms are straight. To prevent your arms from being torn from your sides, those four muscles above have to work their hearts out to stabilize the shoulders. And an added bonus; to prevent your scapula from comic forwards your other periscapular muscles need to fire like crazy!
- Deadlifts – Once again leave the tiny weights at home. The deadlift pulls on your arm like a Farmer’s walk, but also requires mobility within your shoulder. Shoulders blades should be back, chin is packed, elbows are locked, back is straight, and your feet should have arches. Use your glutes to lift the weight, not your back or arms (your shoulders will passively move properly if your form is good).
- Arm Bars – Traditionally, these are done with a kettle bell while laying on the floor, but because my patient population can have some difficulty getting up from the floor I will use a heavy band. This is once again a progression on the previous two exercises because it requires more mobility from the shoulder but continues to require stability in the shoulder blade. Grab the band with your elbow locked, and keep your shoulder blade down and back through the entire exercise. Your fist should always face the anchor of the band, and then you rotate your body/chest away from the anchor point and then return to the start. The heavier the band the better.
I would love to include Turkish Get Ups on this list, but their complexity and fact that it requires getting on on the floor prevent me from including this in many peoples’ rehab programs.
Obviously proper prep work needs to be done prior to performing any of these exercises as well. Mobility work where it’s needed in the thoracic spine, AC joint, shoulder, and accompanying musculature, as well as making sure the client even possesses the motor control to retract their shoulder blade needs to be done.
One final thought for those of you having patients do IR/ER or those of you who actually are the ones doing IR/ER. When performing these exercises I want you to try to keep your shoulder blade stable (not in a rolled forwards position) to allow the RTC to perform true IR and ER. You will see that these muscles get fatigued even easier this way, and it also works on scapular control.
Hope you are starting to take a new look at how you train or rehab. Remember that it is not always how a muscle moves, but actually what a muscle does that should be addressed with your rehab/training.
Always Evolve (your rotator cuff rehab),
Mike
Mike Scott, DPT 
Good post, I’ve evolved my shoulder rehab in a similar way. Do you use shoulder packing (down/back) for individuals who are already in a downward rotation position? If so, why? If not, what cues do you give these individuals? Have you tried palpating the pec minor when cued to pull down/back (could just be my dysfunctional scapulae)?
Hutch,
First off thanks for reading. I’m glad to see that “outside the traditional PT box” shoulder rehab is becoming the norm. People who already have a downward rotation position that I have seen are usually stuck there due to their subscap or SA being bogged down. At the end of my post I mentioned having some tissue prep done if needed, and usually these patients will need quite a bit. I’m glad that they are already in a “packed” position, but they can’t do anything with their shoulder blade. They won’t be able to perform proper Scap-humeral rhythm meaning impingement is imminent. I’m always looking for mobility before stability, so once I get proper mobility in these downward rotated shoulder blades I can then cue them on how to control it with the usual cues. I will usually go from open chain unweighted to closed chain, back to open chain weighted, incorporating the exercises above when mechanics determine they are ready. The deadlift and farmer’s walks are also great assessments at seeing how the T/S and C/S are working together. And finally, because the pec minor is a scap depressor, I will use tactile cuing if someone is having difficulty with scap depression. We also need to remember that it is not our goal to ALWAYS be in scapular packed position, but to be able to get there, control it and also elevate when needed.
Hutch, I appreciate the readership!
Always Evolve,
Mike
Good stuff, keep it coming. That subscap / serratus intersection is always a good spot in most dysfunctional shoulders. If you haven’t read Evan Osar’s work on shoulders, I’d highly recommend his book and videos.
I’m glad that I have never injured my rotator cuff. Rehabilitation is the worst. Good luck with your rotator cuff rehab.
Mike,
I like the post, however don’t the RTC mms stablize the most in the functional mid range? So with the arms hanging from the side you of course have to have muscular activity, but would it be an optimal position? How about mid range (or for that matter multiple range) carry with perturbations when appropriate. Great work as always.
Dan,
Thanks for reading as always. You are indeed correct about the RTC firing the most in functional midrange (another reason IR/ER aren’t worth doing many of with your elbow at your side) . Farmers walks require a good deal of RTC involvement but are definitely not working on stability through a range of motion. Deadlifts require some movement and stability through a small range, and the band arm bar I provided is through a larger
amount of midrange. Each is progressively harder on the RTC.
Push ups, chop/lifts, and many more are included in my rehab as well. Perturbations are a definite requirement along the way. Thanks for getting me to dive a little deeper into my reasoning
Always evolve,
Mike