What are the best exercises for rotator cuff syndrome?

Best Exercises for Rotator Cuff Syndrome

For rotator cuff syndrome, initiate a supervised physical therapy program emphasizing loaded strengthening exercises, specifically the "full can" exercise (scaption with external rotation), side-lying abduction at 45 degrees, and progressive resistance training targeting both rotator cuff and scapular stabilizers. 1

Initial Treatment Framework

Physical therapy with supervised exercise is the recommended first-line treatment for rotator cuff problems, superior to unsupervised home programs for optimal outcomes 1. While home exercise programs can provide significant improvements in pain and function after 3 months, supervised therapy ensures proper technique and progression 2.

Specific Exercise Recommendations

Primary Strengthening Exercises

The "full can" exercise (scaption with external rotation) should be prioritized over the "empty can" exercise because it:

• Produces similar or higher supraspinatus activation 3
• Generates greater infraspinatus and subscapularis activity 3
• Reduces subacromial impingement risk by promoting scapular external rotation and posterior tilt 3
• Increases subacromial space width compared to internal rotation positions 3

Side-lying 45-degree abduction demonstrates the greatest muscle activation across all rotator cuff muscles (supraspinatus, infraspinatus, subscapularis) and deltoid, making it highly effective for comprehensive rotator cuff rehabilitation 4.

Exercise Types and Loading Parameters

Loaded resistance exercises (against gravity or resistance) are supported by systematic review evidence for reducing pain and improving function in rotator cuff tendinopathy 5. Three effective approaches show similar outcomes 6:

• Open chain resisted band exercises: Progressive resistance using elastic bands
• Closed chain exercises: Weight-bearing upper extremity exercises (push-ups, wall slides)
• Both demonstrate significant SPADI score improvements at 6 weeks 6

Loading parameters should follow these principles:

• Perform 3 sets of 8-12 repetitions for isotonic exercises 7
• Use loads of 8 repetition maximum, adjusted every 2-3 weeks 7
• Total time under tension of approximately 96 seconds per session 7
• Progress resistance as tolerated while maintaining proper form 5

Essential Scapular Stabilization Exercises

Scapular muscle training is critical because the serratus anterior and trapezius control scapular upward rotation, posterior tilt, and external rotation—all necessary for optimal shoulder function 3. Include:

• Scapular retraction exercises (rowing variations) to increase subacromial space and enhance supraspinatus force production 3
• Serratus anterior activation (scapular punch, push-up plus) to prevent scapular winging 3
• Lower trapezius strengthening (prone horizontal abduction at 100 degrees with external rotation) 3

Additional Effective Exercises

High to very high rotator cuff and scapular muscle activity occurs with 3:

• Prone horizontal abduction at 100 degrees with external rotation
• Standing shoulder extension from 90 to 0 degrees
• External and internal rotation at 0 and 90 degrees abduction
• D1 and D2 proprioceptive neuromuscular facilitation patterns

Critical Technical Considerations

Scapular position dramatically affects exercise safety and effectiveness:

• Perform exercises with scapular retraction rather than protraction to maximize subacromial space 3
• Avoid exercises promoting scapular internal rotation and anterior tilt, which increase impingement risk 3
• Maintain external rotation during elevation exercises whenever possible 3

The teres minor shows minimal activation with standard exercises, so specific isolated strengthening may be unnecessary for most patients 4.

Integration with Pain Management

Combine exercise therapy with 8:

• Regular paracetamol (acetaminophen) and NSAIDs for pain control
• Single corticosteroid injection if needed for short-term symptom relief to facilitate exercise participation 1
• Avoid multiple repeated injections that may compromise rotator cuff integrity 1

Common Pitfalls to Avoid

• Do not use "empty can" exercises as they increase impingement risk compared to "full can" 3
• Avoid unsupervised home programs initially—supervised therapy produces better outcomes 1
• Do not neglect scapular stabilizers—focusing only on rotator cuff muscles ignores critical kinetic chain components 3
• Avoid exercises in protracted or internally rotated scapular positions that narrow subacromial space 3

Evidence Limitations

Current guidelines acknowledge insufficient evidence exists for specific postoperative rehabilitation protocols, including timing of ROM exercises and resistance training after surgical repair 9. However, for non-operative rotator cuff syndrome, the exercise approaches outlined above have moderate-quality supporting evidence 5, 6.