General Guidelines — Shoulder Pathologies
- Poor posture and abnormal scapulohumeral rhythm improve by strengthening back muscles and stretching anterior structures.
- Emphasize scapular stabilization — key focus is the Lower Trapezius and Serratus Anterior.
- Avoid overhead exercises for most diagnoses, unless in an advanced/asymptomatic stage.
- Incorporate lots of closed-chain exercises to stabilize the inherently unstable shoulder joint.
- Be careful with, or avoid, positions of vulnerability (combination of abduction and external rotation).
- Foam Roll is a great adjunct to a scapular stabilization program.
Impingement Syndrome
A painful condition due to inflammation, irritation, and degradation of structures within a narrowed subacromial space (under the coracoacromial arch). With impingement, the bursa, rotator cuff tendons, and the long head of biceps come under direct compression, causing inflammation that can lead to bursitis or tendinitis. Believed to be the most common cause of shoulder pain — 44–65% of all shoulder complaints. Contributing factors include an abnormally shaped acromion, vascular and neurological factors, hypermobility, forward-head/rounded-shoulder posture, poor scapulohumeral rhythm, and training errors.
- Most common cause of shoulder pain (44–65%)
- Compression under the coracoacromial arch
- Hallmark: a painful arc raising the arm
- Worsened by overhead reaching; often gradual onset
Symptoms: Pain raising the arm overhead — a 'painful arc'. Usually a 'toothache' discomfort, but sharp with overhead or backward reaching. Generally gradual onset with no specific mechanism. May radiate into the upper lateral arm. In advanced cases, pain becomes continuous and worse at night. Sometimes a 'catching' sensation when lowering the arm from overhead.
- Keep arm work at 90° of shoulder flexion (shoulder height) and below.
- Emphasize closed-chain exercises to promote joint stability.
- Focus on the middle and lower traps, rhomboids, and serratus anterior.
- Foam Roll is a great adjunct to a scapular stabilization program.
- Note: Triceps Press Sit (reaching back) is flagged in studio notes as not good for impingement.
- Avoid overhead exercises.
- Work at shoulder height (90°) and below.
- Avoid positions of vulnerability (combined abduction + external rotation).
Focus on the middle and lower traps, rhomboids, and serratus anterior, and incorporate lots of closed-chain exercises to promote joint stability.
Scapular Stabilization (Lower Trap & Serratus)
Closed-Chain Stability
Rotator Cuff & Arm Strengthening
Bursitis & Tendinitis
Inflammation of the bursa (bursitis) and/or tendon (tendinitis); the two often inflame together due to their proximity. Bursitis is inflammation of the slippery bursa where tendons pass over bone. Tendinitis is inflammation of a tendon. (Terminology: tendinosis = microtears from overuse; tendinopathy = tendon disease including both inflammation and microtears.) Precautions and recommendations are the same as for Impingement.
- Inflammation of bursa and/or tendon
- Often occur together (proximity)
- Managed the same as Impingement
- Tenderness over long head of biceps (tendinitis)
Symptoms: Bursitis: pain with overhead activity, pain sleeping on the affected side, pain over the outside of the shoulder/upper arm. Tendinitis: pain in the shoulder/upper-bicep area when moving the arm up and down, spreading across the rotator cuff as it develops; tenderness over the long head of biceps, possible swelling, and loss of ROM in acute cases.
- Treat as for Impingement — keep arm work at 90° and below.
- Emphasize closed-chain stability and scapular control (mid/lower traps, rhomboids, serratus).
- Avoid sleeping/loading positions on the affected side during flare-ups.
- Use Foam Roll for scapular stabilization.
- Avoid overhead exercises (as for Impingement).
- Work at shoulder height and below.
- Avoid positions of vulnerability (abduction + external rotation).
As for Impingement — scapular stabilization (mid/lower traps, rhomboids, serratus) with lots of closed-chain work.
Scapular Stabilization (Lower Trap & Serratus)
Closed-Chain Stability
Rotator Cuff & Arm Strengthening
Rotator Cuff Tear
A partial or full tear — essentially a hole in one of the rotator cuff tendons (supraspinatus is most commonly torn). Separated into overuse tears (repetitive motion wearing the cuff down over time; common in older people or those with high shoulder demand) and traumatic tears (sports, falls on an outstretched arm, MVAs). Partial tears thin the tendon but keep it attached; full-thickness tears detach it from bone. Surgical repair is common; post-op protocols vary significantly — always consult the PT/surgeon.
- Supraspinatus is the most commonly torn tendon
- Overuse vs traumatic mechanisms
- Full-thickness tear: tendon detaches from bone
- Post-op: follow surgeon's specific protocol
Symptoms: Same as Impingement but worse. Sharp pain elevating the arm overhead or reaching backward; night pain; radiating pain to the lateral arm; catching sensation when lowering from overhead. With a complete tear, difficulty or inability to hold the arm out to the side at 90°, plus shoulder (and often arm) weakness.
- Treat conservatively as for Impingement — no overhead work, stay at 90° and below.
- For post-op clients, follow the surgeon's specific protocol exactly (these vary widely).
- Build closed-chain stability and scapular control before any loaded overhead progression.
- Progress slowly; respect weakness and pain.
- No overhead exercises (as for Impingement).
- Post-op: follow the specific surgeon's protocol.
- Avoid positions of vulnerability (abduction + external rotation).
As for Impingement — scapular stabilization with closed-chain emphasis; for post-op, follow the surgeon's protocol.
Scapular Stabilization (Lower Trap & Serratus)
Closed-Chain Stability
Rotator Cuff & Arm Strengthening
Adhesive Capsulitis (Frozen Shoulder)
Restriction of shoulder motion as the joint capsule contracts and forms scar tissue. Most often insidious (no clear cause); occasionally after trauma. A common subjective finding is recent emotional/psychological trauma (divorce, bereavement, job loss). More common in women (2:1), ages 40–60, and with endocrine disorders (diabetes, thyroid), hormonal changes, prior shoulder trauma, and conditions like heart disease and Parkinson's. Three stages: Freezing (most painful, 6–12 weeks), Frozen (pain eases, stiffness worsens, 4–6 months), Thawing (gradual recovery, can take over a year).
- Capsule contracts & forms scar tissue
- More common in women (2:1), ages 40–60
- Three stages: Freezing → Frozen → Thawing
- Most limited in abduction & external rotation
Symptoms: Loss of active and passive range of motion. Pain at the extremes of motion. Difficulty or inability with ADLs (brushing hair, putting on shirts/bras). Pain when lying on the affected shoulder.
- Work only within the range the client has — these clients have very limited ROM.
- Keep the shoulder mobile but in a tolerable, pain-free range.
- Pain and limitation are greatest in abduction and external rotation — avoid forcing these.
- Choose exercises that can be performed successfully without pain; adapt to the current stage.
- Avoid exercises in extreme ranges of motion.
- Do not force abduction or external rotation.
- Stay within the client's available, pain-free range.
Keep the shoulder mobile but in a tolerable range; choose exercises that can be performed successfully without pain.
Scapular Stabilization (Lower Trap & Serratus)
Rotator Cuff & Arm Strengthening
Shoulder Instability
Occurs when the shoulder capsule and ligaments are stretched out and no longer keep the humeral head centered in the socket. Often caused by severe trauma (a collision or fall on an outstretched arm) that tears ligaments, labrum, and/or rotator cuff; sometimes from connective-tissue disorders or general laxity. A loose joint may sublux (partial) or dislocate (complete). Prior dislocation often leads to chronic instability — in patients under ~35, chronic instability follows ~80% of traumatic dislocations. Overhead athletes may have multi-directional instability (MDI). Even without full dislocation, apprehension can limit function.
- Capsule/ligaments stretched — head not centered
- Subluxation (partial) vs dislocation (complete)
- Under-35 traumatic dislocation → ~80% chronic instability
- Apprehension alone can limit function
Symptoms: An uncomfortable sensation that the shoulder may be about to slide out of place. History of subluxation or dislocation.
- Keep the arm below 90° of shoulder flexion.
- Choose closed-chain over open-chain work — co-contraction promotes joint stability.
- Avoid positions of vulnerability where the client feels the joint might slip.
- Build confidence gradually; apprehension itself limits function.
- Avoid positions of vulnerability (especially combined abduction + external rotation).
- Keep arm below 90° of shoulder flexion.
- Favor closed chain over open chain.
Keep the arm below 90° of shoulder flexion and choose closed-chain over open-chain exercises, because co-contraction promotes joint stability.
Closed-Chain Stability
Scapular Stabilization (Lower Trap & Serratus)