What exercises are recommended for a patient with a rotator cuff injury to promote healing and improve range of motion?

Rotator Cuff Exercise Program

Despite inconclusive evidence from the American Academy of Orthopaedic Surgeons regarding specific exercise protocols for rotator cuff tears, supervised physical therapy incorporating loaded resistance exercises targeting the rotator cuff and scapular stabilizers is recommended based on the best available evidence showing improvements in pain and function. 1, 2, 3

Initial Exercise Approach

Supervised vs. Home Exercise

• Supervised physical therapy is superior to unsupervised home exercise programs for optimal outcomes in patients with rotator cuff pathology. 2, 4
• While the American Academy of Orthopaedic Surgeons cannot definitively recommend for or against exercise programs due to limited quality evidence, available studies show improvements with both supervised and home physical therapy without evidence of harm. 1

Exercise Type and Loading

Loaded resistance exercises are the cornerstone of rotator cuff rehabilitation:

• Open chain resisted band exercises and closed chain exercises both demonstrate significant improvements in pain and function, with SPADI score improvements documented at 6 weeks. 2, 3
• Perform 3 sets of 8-12 repetitions for isotonic exercises, using loads of 8 repetition maximum, adjusted every 2-3 weeks, with total time under tension of approximately 96 seconds per session. 2
• All three exercise types (open chain, closed chain, and range of motion exercises) show effectiveness, though more patients may deteriorate with minimally loaded range of motion exercises alone. 3

Target Muscle Groups

Focus rehabilitation on these specific areas:

• Rotator cuff muscles (supraspinatus, infraspinatus, teres minor, subscapularis) through progressive resistance training. 1
• Scapular stabilizers to address scapular dyskinesis, which contributes to rotator cuff injury. 1
• Posterior shoulder musculature to counterbalance overdeveloped anterior musculature and prevent injury progression. 1

Exercise Progression Protocol

Follow this structured timeline:

• Initial phase (0-4 weeks): Complete rest from aggravating activities until asymptomatic, focusing on pain-free range of motion restoration. 1
• Strengthening phase (4-12 weeks): Progressive loaded resistance exercises targeting rotator cuff and scapular stabilizers, re-establishing proper shoulder and spine mechanics. 1, 2
• Return to activity (1-3 months): Functional, progressive, individualized program emphasizing proper mechanics, initiated only after achieving pain-free motion and strength. 1

Pain Management During Exercise

Integrate these strategies with your exercise program:

• Start paracetamol (acetaminophen) immediately and continue regularly for pain management. 2, 4
• Add NSAIDs or COX-2 inhibitors concurrently with paracetamol for more effective pain control. 2, 4
• Consider a single corticosteroid injection with local anesthetic for short-term improvement in pain and function if needed to facilitate exercise participation. 2, 4
• Avoid multiple corticosteroid injections as they may compromise rotator cuff integrity and affect subsequent repair attempts. 2, 4

Critical Pitfalls to Avoid

• Do not rely on unsupervised home exercises without proper instruction as supervised therapy demonstrates superior outcomes. 2, 4
• Avoid exercises that reproduce pain during the initial healing phase, particularly overhead activities. 1
• Do not progress too rapidly - ensure pain-free motion and adequate strength before advancing to the next phase. 1
• Recognize when conservative management fails - if symptoms persist despite 3-6 months of supervised physical therapy and appropriate pain management, surgical consultation is warranted. 4

Evidence Quality Considerations

The American Academy of Orthopaedic Surgeons acknowledges that insufficient evidence exists for specific postoperative rehabilitation protocols, including timing of ROM exercises and resistance training. 2 However, the available evidence from systematic reviews and randomized trials supports loaded resistance exercises for reducing pain and improving function in rotator cuff tendinopathy. 2, 3, 5 The evidence is strongest for supervised exercise programs incorporating progressive resistance training targeting both rotator cuff and scapular stabilizer muscles. 2, 3