My Shoulder Hurts! Now What?

Shoulder Rehab Protocol

My shoulder hurts! Now what? If your are in an extreme amount of pain and/or have numbness and tingling in your upper extremities, it is time to call in a professional like myself. That said, if your pain is mild and you haven’t lost a tremendous amount of range of motion, you may be able to deal with this injury on your own. However, short of a rotator cuff repair, immobilizing a shoulder is a very bad idea. The most important concept to remember when dealing with shoulder pain is that shoulders need to move and without movement they can get pathologically painful very quickly. Progressive movement and exercises are essential to making shoulder pain go away and restoring functional movement.

The shoulder joint can reasonable be viewed through a dichotomous model of mobility and instability. In the context of freedom of movement, the mobility of the shoulder allows us an almost unlimited scope of movement with which to interact with the outside world. In the context of stability, the shoulder is inherently unstable relative to every other joint in the body. The shoulder joint owes both its mobility and instability to the relationship of the scapula(shoulder blade) and the humerus(upper arm). Both of these bones move together and relative to each other when expressing the full range of motion of the shoulder. For you to reach overhead to slam a shot in pickleball or grab a juggy hold on a rock wall, the scapula must function as a mobile foundation. As your humerus changes positions the scapula must at once, change positions to protect the integrity of the joint but also allow the humerus the freedom to move. This is a delicate dance referred to as, “scapulohumeral rhythm.” This rythm refers to the precise movement required of the scapula relative to the humerus.

Shoulder pain is always related, in one way or another, to a dysfunction in scapulohumeral rythm. The movements at this joint are dictated by the deltoid muscles and the rotator cuff(RTC). The deltoid muscles cap the shoulder joint and move the upper arm when we need to use our upper extremities to interact with the outside world. This set of muscles provide the power for much of our arm movements and, as such, provide much of the stress to the shoulder joint that the RTC must manage. The RTC manages the relationship between the shoulder blade and the humerus, mitigating the demands on the joint placed on it by the deltoid. As the demands of the deltoid raise our elbow to the height of our shoulder and then overhead, our shoulder joint becomes less stable and the demands on our RTC become greater. The relationship between elbow positioning, driven by the deltoid muscles, and joint stability, provided by the RTC, guides the progression of therapeutic exercises when the shoulder is injured.

General Protocol

Rotator Cuff Exercises with elbow close to the ribs → Rotator Cuff Exercises with elbow at 90 degrees → Horizontal Push/Pull Exercises → Vertical Push/Pull Exercises.

Generally speaking, when your shoulder hurts we have to start by considering the function and health of the RTC. Again, the RTC is the conductor of the movement between the scapula and humerus. If we focus on the prime movers of the shoulder, the deltoids, at the expense of the RTC, we are only going to make the injury worse. Thus we have to start by exercising the shoulder joint in positions that are the least demanding on but most stimulating to the RTC. That is to say, we have to start with exercises that keep the elbow as close to your ribs as possible.

Shoulder External Rotation

With this exercises the elbow is bent, and the humerus holds a towel against the ribs. The patient holds a band in their hand for resistance and moves their hand from the neutral position of directly in front of the body, away from their midline.

Bilateral External Rotation

Progress to bilateral external rotation. Grasp a band with both hands, palms up, and pulling your hands away from each other. These two exercises stimulate the RTC in a safe position, and begin to stimulate the RTC in a way that improves the scapulohumeral rhythm.

To progress, we then focus on gentle range of motion exercises for the shoulder. This can be done by using your fingers to, “crawl,” up a wall until your shoulder is overhead.

Wall Crawl

Prone Shoulder External Rotation

If the standing RTC exercises cause pain, lay on your stomach on a bed with your involved arm hanging off the bed. Now with your thumb up, gently lift your arm overhead or out to the side. Both, the RTC external rotation exercises and the range of motion exercises can be progressed by adding resistances and changing your body orientation.

Once you can progress through the RTC specific exercises in a pain free manner, the next set of exercises involve pressing away from the body and pulling towards the body. Begin with a horizontal press and pull type exercise. These can be done with free weights, bands or cables. It’s important that you begin with horizontal motions, as the shoulder is inherently more stable with these movements.

Floor Press

Shoulder Row

Once you have progressed both your repetitions and resistance with horizontal press and pull exercises it is time to add vertical pressing and pull to your routine. These exercises require you to drive stress through the shoulder joint with your elbow overhead, an inherently unstable position for the shoulder. Go slow with this last set of movements.

Overhead Press

Pull Down

Therapeutic exercises are essential to healing a joint because they drive an appropriate amount of stress through the muscles and surrounding connective tissue to prompt an improvement in strength and movement. However, when a joint is dysfunctional, the body will often hold too much stress in the surrounding muscles as a way to stabilize the joint. The body’s response to injury is natural and helpful, up to a point. But, after the acute inflammatory response has ended, it is time to start removing the tension in the surrounding musculature to improve joint mechanics.

Removing the tension from muscles in a therapeutic context is best done with trigger point massage. Trigger points in a muscle are areas of acute, painful and specific muscle tension. By placing firm and sustained pressure on these points, the muscle cells will release their tension. While the release of tension comes with a noticeable and desirable decrease in pain, the real benefit is improved joint mechanics. For shoulder dysfunction, the muscle to target are often the pectoralis minor, upper trapezius, scalenes, and selected muscles of the rotator cuff. Removing tension from these muscles allows for better positioning of the humerus relative to the shoulder blade. With improved mechanics restored, active movement of the joint can begin.

Are there exercises to avoid? When I suggest exercises that people should avoid, it is always in the context of an injury, poor posture or a movement habit that will predispose a person to getting hurt. There are a few exercises that involve the shoulder that I think people should avoid or approach with caution. Shoulder raises, a lift where weight is lifted either straight our in front of your body or straight out the side, is one such exercise. Because of the long lever arm involved, the mechanics of a shoulder raise have to be perfect to avoid irritating or injuring the rotator cuff. As the weight gets heavier or the lifter gets fatigued, the scapulohumeral rhythm is invariably compromised, impinging the RTC tendon between the head of the humerus and the acromion process of the shoulder blade. Pressing and pulling exercises are genenerally enough to develope adequate shoulder strength, rendering lateral raises redundant in your exercise routine. That said, if your goal is shoulder aesthetics, then the front and lateral raise is the exercies of choice. To modify this lift, reduce your weight and be precise in your movements, no jerking the weight to shoulder height.

Bench pressing is another lift that I counsel my patients to modify or dramatically reduce the weight they are lifting. Again, the rotator cuff tendon is put in a precarious position when the weight is close to the chess. In this position the shoulder is at an extreme internal rotation range of motion, putting the RTC in danger of being impinged or torn. Again, if your goal is aesthetics, then the bench press is indispensable in achieving a larger, more defined pectoralis muscle. Modifying this exercise for to be safer involves not allowing your elbows to go past your torso when lowering the weight. Additionally, the closer your elbows are to your torso, the more stable the shoulder joint will be throughout the movement.

In summary, if you are experiencing shoulder pain start with addressing rotator cuff weakness using exercises that keep the elbow close to the ribs. Then progress in weight and exercises that require the elbow to move away from the ribs and higher relative to your torso. Then move on to horizontal pressing and pull, finishing up your rehab with vertical pressing and pulling.