Ah, the old rotator cuff dysfunction, among the most common injuries sported by people who come to see me in the clinic.
While common, rotator cuff injuries can be, frankly, a total pain to work with. They are sensitive and finicky, meaning that when they are injured they are easy to reinjure, and when they are injured, they also hurt!
Consider the ball and socket construction shown in Fig 1 below. In 1.a, we see the construction of the hip with its deep socket, the ball at the head of the femur (thighbone) sits snugly in the acetabulum (socket) on the pelvis. Compare that to the shoulder joint in 1.b. The socket on the shoulder blade is so much shallower, I call it the ball-on-wall construction rather than the ball and socket construction!
Fig 1 - Ball and socket of the hip (a), versus the shoulder in (b).
Because of this shallow ball and socket at the shoulder, we get a ton of mobility. The problem though is that it relies heavily on the muscles of the rotator cuff and more generally the whole shoulder girdle for stability. So along with this shoulder mobility, the muscles of the rotator cuff and their tendons are also vulnerable to friction and pinching compared to muscles around the hip. Repeated frictioning/pinching or some kind of traumatic incident can leave the rotator cuff tendons in a degraded state (tendinitis), and left long enough the body can slow down or stop the natural healing mechanism (the inflammatory response), leaving a crummy set of tissues that are not getting better. This sad state is known as tendinosis.
Not to worry though! Treatment for the vast majority of rotator cuff problems works! It usually consists of a combination of hands on manual therapy, modalities like heat or dry needling, and of course, exercise to strengthen the rotator cuff musculature and to train beautiful movement patterns!
Each case is unique so the specific treatment is also unique to the problem at hand, but strength training exercise is almost always a component that we start with early on.
Strength training most often looks like a series of open-chain movements executed against the pushback of a resistance band. Open-chain exercise is that where the end of the moving limb is not fixed against something. So a dumbbell chest press for example, would be open-chain, where a pushup would not be.
Common open chain exercises prescribed to treat a rotator cuff dysfunction might include flexion, abduction, internal rotation and external rotation as shown below in Fig. 2.
Fig 2. Commonly prescribed rotator cuff open-chain exercises with a resistance band.
And that’s great and all, but it’s not the only game in exercise town. Closed chain exercises have also been shown to activate the rotator cuff musculature, and I often consider them as an alternative to the traditional open-chain fare.
One reason for this is that sometimes people get frustrated with pen chain exercises. After all, they can be kind of boring, and don’t feel like “real gym exercises” (whatever that means). Now I could get on my soapbox and give my spiel about how “rehab is strength and conditioning, and strength and conditioning is rehab”, because it is. But I won’t this time. Because I get it…
There is an emotional satisfaction that comes with ripping out the traditional exercises, like pushups, presses, rows or dips. And 30 degree abductions with a piece of theraband just doesn’t scratch that itch now does it?
Thankfully as mentioned, closed kinetic chain exercises can also be used to effectively engage and activate the rotator cuff musculature. It just has to be done carefully, with an eye to pain tolerance and capacity to move beautifully! See the video above for a demonstration.
Consider these exercises:
Pushup - A pushup performed first against a countertop and then on progressive lines of incline as the shoulder improves has been shown to activate the posterior Rotator cuff musculature. Keep a straight line from your shoulder to you ankle, keep the depth shallow (not deeper than elbows at trunk to start with) and keep the abduction (winging) to less than 60 degrees.
BOSU pushup - To make life more challenging the pushup exercise can be done from the gound using the flat side of a BOSU to push against.
Mini Dip - Sitting at the edge of your chair, place your hands palm-down on the edge of the seat as shown push down through your hands so that your butt lifts off the chair by an inch or so.
Row - Rowing exercises, like a cable row, or TRX row compliment the pushup excercise well as the activate the anterior rotator cuff musculature preferentially. As with the piushup, keep a straight line between your shoulder and ankle. Elbows flared to no more than 60 degrees. To begin with don’t let your elbows pass further than your trunk as you pull.
BOSU Plank and circle - Here is an interesting alternative that riffs off the pushup. Assume a plank position on a BOSU trainer (as pictured below) with the flat side up. From your plank execute “circles” by loading your weight preferentially through all directions of the BOSU circumference. Execute 5 circles/side. 3 sets.
Fig 3 - Bosu Plank and circle
So what is “too much?”. Generally speaking try to keep the movement pain free. I am willing to accept a little bit of pain as long as it has returned to baseline within 24hrs. If your shoulder is more irritable/tender 24hrs or more post exercise then you’ve done too much and need to back of the depth or loading of movement.
Remember that closed kinetic chain exercises must be executed on top of an already sable shoulder girdle
Remember too that there are many great reasons to practice open chain exercises. They can be useful for practicing quality motor patterns in overhead athletes (think tennis players or swimmers), but as far as strength training goes, they aren’t the only game in town and the options described above will give some variety and good quality muscle activation to your workout.
So there you have it! If you have a rotator cuff dysfunction and are getting bored with your open chain home exercise protocol, and hour shoulder can tolerate it. Consider these fine closed chain exercises for a satisfying and effective strength training alternative in your rehab protocol!
Futher reading (if you really want to impress your friends)
Bang, M. D., & Deyle, G. D. (2000). Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome. Journal of Orthopaedic & Sports Physical Therapy, 30(3), 126-137.
Schory, A., Bidinger, E., Wolf, J., & Murray, L. (2016). A systematic review of the exercises that produce optimal muscle ratios of the scapular stabilizers in normal shoulders. International journal of sports physical therapy, 11(3), 321.
Tucker, W. S., Armstrong, C. W., Gribble, P. A., Timmons, M. K., & Yeasting, R. A. (2010). Scapular muscle activity in overhead athletes with symptoms of secondary shoulder impingement during closed chain exercises. Archives of physical medicine and rehabilitation, 91(4), 550-556.
Wattanaprakornkul, D., Halaki, M., Cathers, I., & Ginn, K. A. (2011). Direction-specific recruitment of rotator cuff muscles during bench press and row. Journal of Electromyography and Kinesiology, 21(6), 1041-1049.