In this article, we’re going to cover the most common root issues that result in a strained rotator cuff. Addressing how you load your shoulder can help you avoid surgery. Then we’ll break down the three keys to help you rehab your rotator cuff tear and prevent those long-term wear and tear injuries from happening again.
If your shoulder hurts right now, skip down to the section on Acute Pain Strategies to get Dr. B’s favorite methods of easing the pain.
You can also follow along with the exercises on the YouTube video 3 Keys to Rehab a Rotator Cuff.
Basic Shoulder Anatomy
Your shoulder is a ball-and-socket joint that is formed where the “ball” of your humerus head and the “socket” of your scapula’s glenoid cavity come together, hence the name “glenohumeral”.
The glenoid cavity is quite shallow, and while the joint allows for a great deal of mobility, as with anything the greater something is designed for mobility the less the stability – this is known as an inverse relationship, btw.
Because of this, it must depend on surrounding musculature, including the rotator cuff, to provide support.
Your rotator cuff is made up of the supraspinatus, infraspinatus, subscapularis, and teres minor muscles, which all run from your scapula to your humerus.
The Real Role of the Rotator Cuff
The name rotator cuff implies that these muscles are all about rotation. And yes, that’s true – but only to an extent.
Your rotator cuff muscles do work to rotate your arm both internally and externally, and to lift it.
But their real function is DYNAMIC stabilization of the humeral head in the socket. .
Without the stabilizing force, there would be no point to rotation, as it wouldn’t take much movement of the humeral head in that shallow glenoid cavity to dislocate your shoulder joint.
Your rotator cuff is at work during overhead movements of all kinds – including the swing of a tennis racket, the stroke while swimming and the overhead lift of a set of weights .
It isn’t only working to stabilize, rotate and lift your arm during these activities – it also works to accelerate and decelerate your arm during high velocity movements, like pitching .
Root Causes of a Strained Rotator Cuff
If you train heavy overhead movements, the Olympic lifts or play sports like baseball, volleyball and tennis with any of the following issues…
- Poor posture, especially kyphosis and rounded shoulders
- Any of the 3 types of scapular dyskinesis
- Winged scapula
- Shoulder mobility restrictions
- Consciously or not moving with improper movement patterns (especially keeping scapulae retracted and depressed during overhead movements!)
… you’re at risk for a strained rotator cuff!
Getting the Whole Story of Shoulder Pain
If your doctor hands you a rotator cuff tear diagnosis, it’s not the be-all-end-all of shoulder pain. It doesn’t even tell you the whole story.
The most important thing to understand about rotator cuff pathology is that it’s a progression.
We have a tendon, which attaches the muscle to bone. The initial pathology, or wear and tear, is called tendinosis.
(You have probably heard of tendinitis before. The difference between that and tendinosis is that tendinitis is a temporary inflammation that typically goes away after a period of rest. Tendonosis is a chronic inflammation of the tendon.)
Tendonosis can progress to a partial thickness tear and eventually a full-thickness tear.
Rotator cuff tears are a surprisingly normal part of aging. The vast majority of rotator cuff injuries are age-related tears. They start early in life, depending on your activity level.
If we took a random sample of people off the street and did MRIs on their shoulders, we would statistically see some age-related changes in their 20s and 30s – especially if they’ve been particularly active.
At a later stage, that tendinosis may become a partial tear and turn into a full tear even later on in life.
Think of it like how holes develop in your pants. Most of the time, you’ll wear a spot thin, then it will start with a small hole, which will turn into a bigger hole. You have to be doing something pretty traumatic (to the pants) to create a sudden tear in brand new jeans.
In your shoulder, the wear and tear on the tendon will increase the size of the partial tear over time.
This tear happens so slowly that we have seen bunches of studies showing pathology in the rotator cuff without any symptoms or pain.  People adapt, compensate, and change activities to avoid pain.
This is why it’s so important to compare your symptoms to MRI results. For many people, having a partial tear on an MRI doesn’t mean you need surgery. It does mean you will need to change something before your partial tear becomes a full tear.
The best way to do that is by finding and fixing the root cause.
Dr. B says:
“After I started working with the [Toronto] Jays, my waiting list for surgery got crazy. It was over two years.
So somebody would come to see me with a sore shoulder and an MRI proving rotator cuff tear, and I’m like, “Okay, you’ve done your physio, you’ve had your cortisone injection, you’re still having symptoms that are interfering with the quality of your life – I guess we need to do an operation.
Patients would say, “Yeah, let’s do it.”
They’re ready to do it the next day. Unfortunately, my surgery list was two years down the road. And they’d say, “What the heck am I going to do for two years?”
So I started to get them to work on exercises to change how they were loading their rotator cuff. To my amazement, 70% of the people got better and didn’t want surgery.
It got me thinking that we had to fix why the rotator cuff got damaged in the first place before we even considered surgery.”
Next, we’ll cover when surgery is the best option and break down the 3 keys to having a healthy, functional rotator cuff.
When To Consider Surgery?
Not all rotator cuff tears are created equal.
First off, the tendon is about one centimeter thick. A full-thickness tear means that the full depth of the tendon is torn.
Partial tears only go through 25% to 50% of the tendon. Generally, these tears don’t require surgery.
Image by www.wjgnet.com
Anyone with tendinosis does not need an operation.
The main consideration for choosing surgery is a full-thickness tear AND pain.
Now, that doesn’t mean that you can forget about a partial tear or rotator cuff strain, even if there is no pain. Monitoring your rotator cuff tear is part of focusing on preventing a full tear and minimizing pain down the road.
Say, for example, you’re doing exercises to get to the root cause of why your tendon is tearing in the first place. You have a documented ½ centimeter tear. Six months after you’ve had the diagnosis, you should have a repeat ultrasound to check if the tear is getting bigger.
But most of the time, you’ll know that you have a problem because the pain will persist.
ALWAYS consult with your doctor. If you fall into the surgery category, you have a full-thickness tear of the rotator cuff tendon, then work with your doctor and your surgeon to make sure you’re taking the appropriate next steps.
Acute Pain Strategies
But what if you don’t have a full tear and still have pain? Maybe a 4/10, or it just hurts too much to lift your arm over your head.
First thing? Ice.
15 minutes, 3 times a day, can help settle down your pain.
One of the most effective things Dr. B recommends is what’s called the pendulum. All you do for this is bend over at the waist and let your arm hang. The goal is to let gravity distract and open your shoulder joint.
You can get your body swaying a little bit, so you don’t use your arm and shoulder muscles too much. Do little circles clockwise and counterclockwise. The motion will help settle down the pain.
Next, cuff isometrics can help too, if you have a partner handy, and if you don’t have a partner, use a wall as resistance.
Let your upper arm hang at your side with a fist out from a 90-degree elbow bend. Have your partner put their hand on your outer wrist, push into their hand for a slow count of five (don’t forget to breathe), then relax. Repeat this with the partner’s hand on your fist out front, your inner wrist, and the back of your elbow.
Isometrics allow you to activate all four of the rotator cuff muscles in a way that they aren’t vulnerable. But the muscles contracting and relaxing can really help the pain.
Doing the isometrics three times a day in the beginning just to help out the muscles. As you start to feel better, you can gradually begin to do the same at different angles of your shoulder and elbow to work your shoulder muscles in different directions.
Remember that the rotator cuff’s entire job is to keep the joint centered no matter what position it’s in. As you wake up the muscles and strengthen them, it will help train your body to keep your shoulder in place no matter what activities you’re doing.
3 Keys to a Healthy Functional Rotator Cuff
Each key focuses on proper alignment and its common dysfunction.
These are perfectly normal to have. Dysfunctions develop over years of activity and inactivity. While many rotator cuff issues develop in people who were active in their younger years, they can develop in anyone as part of the aging process.
Key #1 The posture and alignment of the shoulder girdle.
If you have poor posture, say you’re hunched over in front of your desk, it affects the space that your rotator cuff travels through. That rounding of the shoulder decreases the space of the rotator cuff, and you’re leading to increased chances of wear of your rotator cuff tendon.
It’s super important that you mobilize your thoracic spine and get your forward head posture corrected.
Dr. B says the most common problem she’s seen in her practice is a posterior capsule contracture – or tightness at the back of the shoulder.
The capsule that joins the humerus ball and the glenoid (the saucer) is made up like a shirt sleeve. If the back of that capsule gets too tight, it changes the alignment of the shoulder.
So when you go to lift your arm over your head, the tight posterior capsule actually pushes the humeral head up and leads to impingement of your rotator cuff. It literally shuts off your rotator cuff.
You can’t even activate the rotator cuff when you have this posterior capsular contracture.
You can test this by having a friend put their hand on top of your scapula (shoulder blade). The goal is to hold your shoulder blade in place to check how much it can actually move your shoulder without compensatory mechanisms.
Have your friend lift your arm out to the side until it’s even with your shoulders, then move it in front of you. When the posterior capsule is tight, your arm won’t be able to move in front of your body without your shoulder blade moving to give it the extra range of motion.
Don’t worry if you aren’t perfectly symmetrical. Most people aren’t. You’re good as long as your arm can move in front of your body.
If you find that you do have a tight posterior capsule, click the link to the YouTube video below. Do the exercise for the next 4 to 6 weeks to correct it, but you’ll start feeling better right away.
Key #2: Maintaining your scapula (shoulder blade) in the correct position.
The most common problems with scapula position are:
- Anterior tilt
- Too low
Anterior tilt means that the top of your shoulder blade is tipped too far to the front. Having your shoulder blade too low is self-explanatory.
A protracted shoulder blade is pulled toward the front – typically from a rounded shoulder posture.
The position of your shoulder blade is in large part affected by the mobility of your thoracic spine. If your goal is rotator cuff rehab, paying attention to what your shoulder blades are doing throughout the day is a good place to start before moving on to the exercises.
Key #3: Strengthening the rotator cuff and ensuring it’s active throughout the full range of motion
When there is pain in the shoulder, particularly if there is poor scapula or glenohumeral joint alignment, the rotator cuff can’t turn on. That leads the brain to find compensatory mechanisms, and it gets in the habit of using those instead of the rotator cuff.
Undoing those compensations is key to solving the tendinosis and tears. Getting the rotator cuff to work with the muscles around your shoulder and scapula will take time because you’re replacing bad habits in your neuromuscular patterning.
The more activity you want to do, the stronger you have to be—no time like the present to start.
Exercises to Rehab a Strained Rotator Cuff
Exercise #1: Upper Serratus Anterior Release
One of the other areas that can be tight is the pec minor and the upper fibers of the serratus anterior. Releasing tension on those fibers will help.
- Elevate your scapula
- Place your fingers on top of your clavicle (collarbone)
- Push your fingers back toward your scapula
- Roll your scapula up, back and down, in a clockwise direction 2-3 times
- Then roll your scapula counterclockwise 2-3 times
This can be sensitive or even mildly painful, like a deep tissue massage. Slowly keep at it, and don’t push any harder than you can comfortably tolerate.
Do this for 1 – 2 minutes per side.
Exercise #2: Pec Minor Release
The pectoralis minor is another tight area that often needs some ASMR as the first step to getting back in working order.
- Place your hand behind your back and the ball on the front of your shoulder just below your clavicle
- Support the ball against a wall and roll your shoulder over the ball
- Roll 3 times clockwise, then 3 times counterclockwise
- Open your shoulder by tilting your scapula posteriorly – the bottom of your shoulder blade should be angled into your body – and rolling over the ball 2-3 times with the ball in 2-3 different places
Spend 1 – 2 minutes per side.
Exercise #3: Standing Robot Stretch
The key point for the standing robot stretch is maintaining a posterior scapula tilt (tucking your shoulder blade tips into your body) during the whole movement.
- Stand with your back against a wall
- Raise your elbows up about 30 degrees
- Externally rotate one arm (lift your hand away from the wall to a waving position, keeping your elbow in place)
- Hold for 5 seconds
- Switch sides
When you get comfortable with the movements above, you can add an extra challenge by sliding your arms up and down against the wall in the direction of your fingertips. Always revert to the original position before switching sides.
Aim for 2 sets x 5 cycles per set, 5 second hold.
Exercise #4: “4S” Shoulder Saver
We like this exercise because it will help correct any dysfunctions in your shoulder, spine, scapula, and serratus anterior muscle.
You won’t need anything for this one except space to move your arms while you stand.
- Extend your shoulders where you reach your arms behind you, palms facing each other
- Simultaneously, posteriorly tilt your scapula.
- Hold for 5 seconds, with the goal of increasing your end range
- Move to shoulder flexion, reach your arms in front of you and overhead
- Simultaneously, posteriorly engage the pelvis (tuck your butt down), engage your abs, and keep your rib cage down
- Hold for 5 seconds, again trying to increase your end range
Remember to maintain deep, even breathing while performing the shoulder saver.
Perform 2 sets x 6 steps per direction.
Exercise 5: Shoulder Circle Crossovers
The shoulder circle crossover will integrate the rotator cuff into the full range of shoulder movement.
- Start off by internally rotating the shoulder, putting the backs of your hands toward your thighs
- Extend the shoulder, reaching back behind you as high as you can
- Once you get stuck, start to externally rotate your shoulder as you keep reaching up overhead
- When you get to the overhead position, move your arms in front of the body on the way down
- Cross your arms over in front of you with the elbows straight until to return to the start position.
The goal is to keep the backs of your hands pointing toward each other as much as possible when your arms are behind you. Reach as high as you can at the top.
Do 2 sets x 3 reps.
Exercise #6: Side-lying External Rotation
The side-lying ER is a great exercise for building strength in the rotator cuff muscles, strengthening the tendon.
Remember, build up your strength to the level that you need. Suppose you’re doing extreme movements like serving a tennis ball or throwing a baseball. In that case, you’ll need more strength than if you’re looking to maintain movement longevity and enjoy less demanding activities like light hiking or gardening.
- Lay on your side and place something between your elbow and your body (a rolled-up towel, for example)
- Hold a dumbbell in a strong grip making sure your wrist stays in a neutral position
- Externally rotate through the whole range of motion
- Pull the shoulder into the body at the end range and go slow.
- Pause for a second at the top
- Lower the dumbbell slowly, under control
Do 2 sets x 8-10 reps per side.
Final Thoughts on Rotator Cuff Tears & Tendonosis
For many people, following the exercises and strategies on this page and in the YouTube video will grant some relief from rotator cuff pain in 1 or 2 weeks. Don’t forget to use the methods at the beginning of the article to settle down any pain between sessions.
For a long-term solution, we developed Shoulder Control Course to address these three key areas and take it to the next level.
This article was reviewed and updated on April 28, 2022 by our Chief Medical Officer, Dr. Erin Boynton, MD, FRCS to include new research and information on latest surgical developments. Read more about Dr. B here.