Are overhead pulley exercises suitable for an adult patient with shoulder pain who has recently received a corticosteroid injection?

Overhead Pulley Exercises for Shoulder Pain After Corticosteroid Injection

Overhead pulley exercises should NOT be used in patients with shoulder pain who have received a corticosteroid injection. 1

What Are Overhead Pulley Exercises?

Overhead pulley exercises involve using a rope-and-pulley system mounted above the patient's head to perform shoulder range of motion exercises. The patient pulls down on one end of the rope with the unaffected arm, which causes the rope to lift the affected arm overhead through the pulley mechanism, creating passive or assisted shoulder abduction and elevation.

Why They Are Contraindicated

The American Heart Association/American Stroke Association explicitly recommends against overhead pulley exercises (Class III recommendation, Level C evidence). 1 The mechanism of harm is clear:

• Overhead pulley exercises encourage uncontrolled abduction that can worsen underlying shoulder pathology 2, 3
• They create forces that may aggravate inflamed or injured rotator cuff structures, particularly after corticosteroid injection when tissues may be temporarily weakened 2
• The passive nature of the exercise removes protective muscular control, potentially causing further damage to compromised shoulder structures 3

Recommended Alternatives After Corticosteroid Injection

Instead of overhead pulley exercises, focus on:

Controlled Range of Motion

• Stretching and mobilization techniques targeting external rotation and abduction to prevent frozen shoulder, performed within pain-free ranges 3
• Active-assisted exercises where the patient maintains muscular control rather than relying on passive pulley systems 3

Strengthening Program

• Rotator cuff strengthening exercises to improve joint stability once acute inflammation subsides 3
• Scapular stabilizer exercises to restore proper shoulder mechanics 3

Supportive Measures

• Positioning and supportive devices (including slings when appropriate) to prevent subluxation during the acute phase 1, 3
• Patient education on proper positioning and range of motion techniques before discharge 1, 3

Evidence on Corticosteroid Injection Effectiveness

While overhead pulley exercises are contraindicated, understanding the injection's expected timeline helps guide rehabilitation:

• Corticosteroid injections provide greatest pain relief at 1-6 weeks after administration 4, 5
• Exercise therapy combined with injection shows superior outcomes at 6 weeks compared to injection alone, but this benefit equalizes by 12 weeks 4
• Physiotherapist-led exercise programs are significantly more effective than exercise leaflets alone (mean difference -8.23 points on SPADI at 6 months) 5

Critical Timing Considerations

Consider repeat injection only if the patient achieved ≥50% pain relief lasting at least 2 months from the first injection. 2 This prevents overuse of corticosteroids while identifying true responders who may benefit from additional treatment.