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Chapter 16 · Shoulder

Shoulder Pain protocol

For pain at the top, side or front of the shoulder and pain reaching overhead or away from the body—rotator cuff tendinopathy/tears, impingement (SAPS) and bursitis. Passive range first, then active control, then cuff and scapular strength.

CompleteSource: Rehab Science · Ch 16 · PDF pp. 360–396📖 Rehab ScienceBuild my programme →
AMBER — get assessed before starting rehab
Screen for red flags before starting any protocol (safety check). Progress by symptoms and function, not by the calendar: > 3/10 pain → start phase 1; < 3/10 → phase 2 (PDF p. 205).
Follow this programme to treat
  • Pain at the top, side, and/or front of the shoulder
  • Pain when reaching away from the body and overhead
  • Rotator cuff injury (tear/tendinopathy)
  • Shoulder impingement (subacromial pain syndrome)
  • Shoulder bursitis
Conditions in this protocol
Questions the book answers
1

Phase 1

Source: Rehab Science · PDF p. 370

Why these exercises · Calm pain and tension in the posterior cuff, scapular muscles, chest and mid-back; isometrics begin low-load tendon strengthening; PROM keeps range without making the cuff work (active lifting too early can flare pain and worsen tears).

Good for
  • Alleviating shoulder pain
  • Relieving muscle tension
  • Improving shoulder range of motion
  • Warm-up for phase 2 and 3 exercises
Guidelines
  • Perform every day
  • Tools: small massage ball, foam roller, dowel
  • Add phase 2 when you have no pain at rest and no more than mild pain (3/10) with the exercises
Avoid / modify in this phase: Reaching overhead under load · Sleeping on the painful side · Active lifting that flares pain

Soft tissue mobilizations

▶ 1–2 min per area, any order, both sides; pause 10–20 s on tender points; avoid flaring arm movements

STARTInternal rotation over the ball
Posterior rotator cuff mobilisation
Reduce pain and tension in the back of the shoulder.
PDF p. 371
STARTLift hips and reach
Levator scapulae mobilisation
Ease tension at the top inner corner of the shoulder blade.
PDF p. 371
STARTArm reaches over the ball
Rhomboid mobilisation
Relieve tension between the shoulder blade and spine.
PDF p. 372
STARTLean into the ball
Upper trapezius mobilisation
Reduce tension across the top of the shoulder.
PDF p. 374
STARTReach overhead
Pectoral mobilisation
Release tension at the front of the shoulder and chest.
PDF p. 374
STARTRoll the mid-back
Thoracic mobilisation (foam roller)
Loosen the mid-back so the shoulder can move more freely.
PDF p. 375

Isometric exercises

▶ 4–5 reps × 30–45 s holds; as much force as tolerated with ≤ mild pain; elbow at 90° pushing into a wall or rack

View from abovehand to belly = internal · hand away = external rotationSTARTPush and hold — no movement
Shoulder isometrics (multi-direction)
Reduce tendon pain and begin very low-load strengthening.
PDF p. 376

Mobility exercises (PROM → AAROM)

▶ 3 × 10–15; move slowly to ≤ mild pain; pause 2–3 s at end range; add AAROM as pain decreases

STARTHealthy arm lifts the injured arm
Shoulder flexion PROM/AAROM (dowel)
Restore overhead range while the injured muscles stay relaxed.
PDF p. 377
STARTDowel pushes the arm sideways
Shoulder abduction PROM/AAROM (dowel)
Restore sideways and overhead range passively.
PDF p. 377
View from abovehand to belly = internal · hand away = external rotationSTARTOne shoulder rotates out
Internal/external rotation PROM/AAROM (dowel)
Restore rotation—the first direction lost in frozen shoulder.
PDF p. 378
Progress to the next phase when: No pain at rest and no more than mild pain (3/10) with the exercises
2

Phase 2

Source: Rehab Science · PDF p. 379

Why these exercises · Mid-back and shoulder-blade mobility complement phase 1; the arm now moves actively (use the dowel for AAROM if needed, sharing 50/50). The angel opens the chest; the prone T is the first strengthening exercise for the scapular retractors.

Good for
  • Improving range of motion
  • Building early scapular strength
  • Warm-up for phase 3 exercises
Guidelines
  • Perform every day
  • Tools: foam roller, bench
  • Add phase 3 when you can do the exercises with no more than mild pain (3/10)

Mobility exercises (AROM)

▶ 3 × 10–15; move as far as you can with ≤ mild pain; pause 2–3 s at end range

STARTRound then arch the mid-back
Thoracic flexion and extension (quadruped)
Restore mid-back movement that supports shoulder elevation.
PDF p. 379
View from abovehand to belly = internal · hand away = external rotationSTARTShoulder blades forward then back
Shoulder protraction and retraction mobility
Improve shoulder-blade control forward and back.
PDF p. 380
STARTLead with the thumb
Shoulder flexion mobility (AROM)
Actively restore overhead range with control.
PDF p. 380
STARTLift out to the side
Shoulder abduction mobility (AROM)
Actively restore sideways elevation.
PDF p. 381
View from abovehand to belly = internal · hand away = external rotationSTARTRotate out then in
Internal and external rotation mobility (AROM)
Active rotation control.
PDF p. 382
STARTSweep arms overhead
Angel (foam roller)
Dynamically stretch the chest and encourage a more upright posture.
PDF p. 383
STARTLift arms into a T
Prone T
First strengthening exercise for the shoulder-blade retractors.
PDF p. 383
Progress to the next phase when: Exercises performed with no more than mild pain (3/10)
3

Phase 3

Source: Rehab Science · PDF p. 385

Why these exercises · Build cuff and scapular strength to reduce re-injury: rows (retractors) → external rotation (arguably most important for cuff health; side-lying is a good start, 90/90 for throwers) → internal rotation (subscapularis) → one raise variation per session, rotated across sessions → one press variation (floor press if full-range pressing stresses the biceps tendon) → supinated curl for the biceps.

Good for
  • Strengthening the shoulder and surrounding muscles
  • Preventing shoulder pain and injury
Guidelines
  • Perform 3 or 4 days a week
  • Do 3 sets of 10–15 reps
  • Push sets to fatigue
  • When there are multiple exercise options, choose a variation based on your injury type, equipment availability, and personal preference
  • Tools: bench, dumbbells, resistance bands, towel
  • All banded exercises can be done using a cable machine

Row (choose one)

choose one
STARTPull elbow back
Dumbbell row
Strengthen the muscles that pull the shoulder blades back.
PDF p. 385
STARTPull handle to the armpit
Banded row (kneeling)
Strengthen the scapular retractors with a band.
PDF p. 386

External rotation (choose one)

choose one
View from above (lying on your side)hand to belly = internal · hand away = external rotationSTARTRotate the forearm upward
Side-lying dumbbell external rotation
Strengthen the external rotators of the cuff.
PDF p. 387
STARTRotate forearm up to horizontal
Prone 90/90 external rotation
Strengthen external rotation with the arm away from the body.
PDF p. 388
View from abovehand to belly = internal · hand away = external rotationSTARTPull band outward
Banded external rotation
Strengthen external rotators standing.
PDF p. 389

Internal rotation

View from abovehand to belly = internal · hand away = external rotationSTARTPull handle in to the stomach
Banded internal rotation
Strengthen the subscapularis—the only cuff muscle that rotates the arm inward.
PDF p. 390

Raise (choose one — rotate between sessions)

choose one
STARTDiagonal up and out
D2 raise / D2 flexion
Strengthen a diagonal "sword from sheath" pattern combining elevation and external rotation.
PDF p. 391
STARTRaise to shoulder height in a V
Scaption raise
One of the best exercises for activating the supraspinatus.
PDF p. 391
STARTLift to shoulder level
Lateral raise
Strengthen lifting the arm out to the side.
PDF p. 392
STARTRaise forward to shoulder height
Frontal raise
Strengthen lifting the arm forward.
PDF p. 392

Press (choose one)

choose one
STARTLower then push the floor away
Push-up plus
Strengthen pressing plus the serratus anterior, an upward rotator of the shoulder blade.
PDF p. 393
STARTPress up from the floor
Floor press (dumbbell)
Press while limiting shoulder extension at the bottom.
PDF p. 394
STARTFull-range press
Dumbbell bench press
Full-range pressing strength.
PDF p. 395
STARTPress and reach forward
Banded press with protraction
Press and finish with shoulder-blade protraction.
PDF p. 395

Curl

STARTCurl and supinate
Single-arm supinated curl
Strengthen the biceps and its tendons.
PDF p. 396
Source: Rehab Science · Ch 16 · PDF pp. 360–371· 8 original research citationsshow sources ▾
Also cited by the book on these pages:
  1. [Ch 16·1] Zhao J, Luo M, Liang G, et al. Risk factors for supraspinatus tears: a meta-analysis of observational studies. Orthop J Sports Med. 2021;9(10):23259671211042826. find original ↗
  2. [Ch 16·2] Yamamoto A, Takagishi K, Osawa T, et al. Prevalence and risk factors of a rotator cuff tear in the general population. J Shoulder Elbow Surg. 2010;19(1):116-120. find original ↗
  3. [Ch 16·3] Matthewson G, Beach CJ, Nelson AA, et al. Partial thickness rotator cuff tears: current concepts. Adv Orthop. 2015;2015:458786. find original ↗
  4. [Ch 16·5] Kim HM, Dahiya N, Teefey SA, Keener JD, Galatz LM, Yamaguchi K. Relationship of tear size and location to fatty degeneration of the rotator cuff. J Bone Joint Surg Am. 2010;92(4):829-839. find original ↗
  5. [Ch 16·6] Eajazi A, Kussman S, LeBedis C, et al. Rotator cuff tear arthropathy: pathophysiology, imaging characteristics, and treatment options. AJR Am J Roentgenol. 2015;205(5):W502-W511. find original ↗
  6. [Ch 16·7] Diercks R, Bron C, Dorrestijn O, et al. Guideline for diagnosis and treatment of subacromial pain syndrome: a multidisciplinary review by the Dutch Orthopaedic Association. Acta Orthop. 2014;85(3):314-322. find original ↗
  7. [Ch 16·8] Pieters L, Lewis J, Kuppens K, et al. An update of systematic reviews examining the effectiveness of conservative physical therapy interventions for subacromial shoulder pain. J Orthop Sports Phys Ther. 2020;50(3):131-141. find original ↗
  8. [Ch 16·9] Haik MN, Alburquerque-Sendín F, Moreira RF, Pires ED, Camargo PR. Effectiveness of physical therapy treatment of clearly defined subacromial pain: a systematic review of randomised controlled trials. Br J Sports Med. 2016;50(18):1124-1134. find original ↗

Page numbers are those of the uploaded PDF edition. "Find original" opens a PubMed search for the cited study.