Selecting exercises for rotator cuff-related shoulder pain – Interview with Hilkka Virtapohja

Physiotools Shoulder flexion+ ext rotation“Creating an exercise program for a client with rotator cuff pain is more an art than a protocol. Exercise templates offer evidence- and function-based possibilities to correct the biomechanics and strengthen the muscles and tendons. Every exercise can be used as an assessment. When creating an exercise program using a template as a base, some exercises may need to be deleted or modified as not all would be suitable for every client. Some exercises may need to be modified individually to provide suitable progression for improvement of functional activity.”

Rotator cuff tendinopathy has been considered as the most common cause of shoulder pain. It refers to pain and weakness, usually experienced with shoulder elevation. Evidence suggests that tendinopathy is associated with excessive load of rotator cuff tissues. Aging is also a normal and predominant factor in the development of rotator cuff degeneration.

What kind of exercises can be used at the irritable phase of rotator cuff tendon-related shoulder pain?

Acute irritable RC tendinopathy is characterized by almost constant night pain. Relative rest and finding the correct amount of loading at work and activities is essential to calm the irritation.

Usually it takes at least a month before the tissues calm down and before the real strengthening exercises can be started. If there is tendon or bursa swelling, gentle isometric contractions towards the painful direction may be helpful. They increase the mechanoreceptor activity and maintain the tissue strength and metabolism during recovery with respect of the irritated tissues. Exercises also guide the pressure from the localized area, from anteriorly and superiorly translated humeral head, to more centered and spacious place at glenoid fossa. Exercises may help the pressure to be spread toward the whole shoulder circle and assist the muscle activation in proximal and distal kinetic chain. Submaximal isometric contractions are suggested to be performed with 30 seconds hold (the duration can be modified), repeated 3 times with 3-5 minutes relaxation between the repetitions. Exercises are repeated from three to five times per day, if helpful.

After the symptoms calm down with exercises and pain education or with help of bursal injections or medication, the gradual reloading exercises can be started.

How does shoulder biomechanics help to choose valuable exercises for the client?

Movement is energy and it is most efficient when flowing freely. For balanced and smooth shoulder biomechanics, all body parts need to support that functioning. It’s important to explore, if the rotator cuff is affected by compensatory compression, torsion or translation forces due to movement restrictions or muscle weakness in other areas of the body. The body always functions as a whole and shoulder tissues can be affected e.g. by lack of body awareness or restricted spine mobility. Also often the muscle strength or length in different body areas don’t meet the demands of the task or work. The shoulder acts best like a tunnel for the movement forces, without angulations or catches. Rotator cuff muscles play an important part of maintaining the ‘tunnel’ open, by centering the humeral head to the glenoid in every arm position.

Anatomical studies have shown that rotator cuff muscles are not really separate muscles, but overlay each other as an expansion of the joint capsule, activated and fine-tuned by the mechanoreceptors of the capsule. Also, there is no separation of rotator cuff activation and scapula muscle activation, rotator cuff exercises are scapular exercises, scapular exercises are rotator cuff exercises and can be played accordingly.

The exercise program usually includes different movement directions and scapular and rotator cuff muscle strengthening. The posterior rotator cuff is addressed and facilitated, because it controls the anterior translation of the humeral head during flexion.

How do you select exercises for rotator cuff strengthening?

Specific exercises may show high rotator cuff muscle EMG-activation, because there is a demand to stabilize the glenohumeral joint and prevent the translation of the humeral head. Sometimes the exercise with highest EMG-activation is not the best one, if there is tendon swelling. The biomechanics of the exercise isn’t necessarily beneficial for the client either. E.g. ‘push up plus’ exercise activates effectively serratus anterior and subscapularis, but doesn’t help a client, who is lifting or hammering above shoulder level. Shoulder extension activates the subscapularis to prevent forward translation of the humeral head, but doesn’t necessarily meet the client’s functional needs. Clinical reasoning and sensitivity are important to find the best exercises and shoulder research is a valuable tool to be used.

Closed chain exercises increase the shoulder mechanoreceptor activity through compression and may be used to activate rotator cuff. Closed chain during the movement, wall slides or four-point kneeling or plank positions may be beneficial, if the scapular rotation or stability needs to be addressed or advanced through core stability.

Body assessment or screening can be used to examine any deficits, which affect the shoulder function. Exercises to correct the dysfunctions related to other body parts can be added individually.

Can you give some clinical tips on how to use an exercise template?

You can use the template by assessing and selecting correct exercises for the client, modifying the dosage and removing other exercises. Try the exercise with the client as if you were trying on new shoes. How does it fit, how does it feel? It doesn’t need to feel the most comfortable at first, and the use can be progressed gradually and paced for shorter periods. Some exercises may not fit at all or can be postponed. At the beginning of reloading, one exercise set per day, every three days may be enough. At the next follow-ups you can use the template again, remove the easier exercises and progress with advanced ones.

The load, repetitions, sets and recovery time should be progressed to meet the exercise physiology and strength training principles. For example, an eccentric shoulder external rotation exercise with a dumbbell may be repeated at the beginning five times, using two sets and repeated 3-5 times per day in order to respect the tissue recovery and to strengthen the tendons. Functional and integrated movements are also recommended to be added based on the client’s needs.

There is strong evidence that the psychosocial factors play a big role in shoulder, knee, neck and back pain. Adding an individual note to the template can be valuable to encourage relaxed use of the body and to address useful thought patterns and proper life style to help the recovery.

Hilkka Virtapohja is a Finnish physiotherapist and has studied exercise physiology, anatomy, sport coaching and sports medicine at Jyväskylä and Kuopio Universities. She has over 30 years of experience helping people to recover from shoulder pain and surgery using therapeutic exercise.

Hilkka has created a template Rotator Cuff Strengthening (Exercise Progression) for all Physiotools users.  To view the exercises in Physiotools online, go to the Exercises page, select Templates and type the template name in the free text search.


  • Lewis J et al. Rotator Cuff Tendinopathy: Navigating the Diagnosis- Management Conundrum. J Orthop Sports Phys Ther 2015;45(11):923-937
  • Thorpe AM et al. Are Psychologic Factors Associated With Shoulder Scores After Rotator Cuff Surgery? Clin Orthop Relat Res 2018;476:2062-2073