I am going to attempt to provide the reader a generic blue print for individuals suffering from an acute shoulder problem to a chronic condition. In most cases the diagnosis is usually impingement syndrome or traumatic shoulder instability. Resolution of these conditions will require rotator strength, proprioceptive training in the open and closed chain positions, neuromuscular training, functional training capsular restrictions, and posterior cuff stretching. This article will not answer everyone�s questions but it will give the athlete a good place to start and safe progressions.

Rotator cuff training is common place in almost every training environment. Modern trainers and lifters know numerous exercises to improve shoulder girdle strength. The success of rehabilitation may be in the patience and organization of the exercises.

When initiating rotator cuff rehabilitation programs starting in the side lying position is recommended. This position offers good firing of the external rotators while limiting the strain on the anterior joint capsule. I would only externally rotate to the point just before the pain begins. If the pain is constant, you stop at the point just before the pain starts to increase. The load should be kept light and the volume high.

This exercise is progressed to standing external rotation at 0� with a towel between the body and arm. A towel between the body and arm is used to keep the strain on the capsule low, allow for a good balance between the muscles that adduct the arm and externally rotate the arm and finally it increases the firing of the posterior rotator cuff muscles.

Internal rotation is started in the standing position with the arm at 0�. This position gives good upper and lower subscapularis firing while protecting the supraspinatus.

Dynamic stabilization is initiated from the quadruped position (on hands and knees). This allows for global stability via dynamic stabilization through increasing the compression of the humeral head by forces of the rotator cuff muscles acting in synchrony. One exercises is a push up plus (push the hands into the floor and round the shoulders). Other simple exercises are weight shifting side to side and back and forth. The goal is to keep the scapula from winging and work on shoulder endurance.

For those of you that have suffered an acute shoulder problem. You will notice that your movement may be limited a nd painful with flexion, external rotation, abduction and reaching behind your back. In most situations the individual will have an empty end feel. The joint does not feel tight. It just hurts like a mother to get to end range. You can stretch into the pain or you can check your motion once a week. You will normally find as the pain is reducing the motion will concurrently improve. I prefer this option.

If you are performing the first three exercises side lying external rotation, standing internal rotation and quadruped. Biceps and rowing below shoulder level are usually safe. If pain is produced with rowing when the pull is at end range you may find stopping three inches or so before end range helpful. As pain reduces you will resume pulling through a full range of motion.

In these early stages I do not perform scaption (good position of front raise) or abduction/lateral raises even with light weights. In most cases the sub acromial space is irritated and normal biomechanics are disrupted. When long arm exercises are performed the deltoid activity cannot be balanced by the decreased activity of the infraspinatus and subscapularis force couple. So instead of having humeral head compression you have superior migration causing impingement.

When you feel you are ready to progress you would stop side lying external rotation and progress to standing external rotation at 0�. Internal rotation can stay the same (standing at 0�). Quadruped exercises can be progressed to tripod isometric holds and weight shifts or if possible push up plus from the elbows and toes. Lift your body off the floor so your back is parallel, now relax shoulder blades then drive the elbows into the floor pushing your chest away from the floor and trying to round your shoulders (the plus component). I would now add T�s (prone horizontal abduction with external rotation) from the quadruped position. Lift the arm to 100� of abduction. The thumb will always face the ceiling. I like this position because as the non involved arm is working the involved arm is getting proximal global firing and glenohumeral compression (you are actually performing a tripod exercises).

As your pain is reducing you will notice you can now move your arm further into planes of motion. You will most likely just have pain at the end range of one, two or all planes of motion; flexion, abduction, external rotation, internal rotation and horizontal adduction.

Assuming that the pain is getting less and you have had no consistent setbacks with the previous exercises you can progress to external and internal rotation in standing with the arm at 45�. These will eventually progress to 90�/90� in standing and the prone 90�/90� external rotation. Push ups and push up plus can be done from the regular push up position. From the push up position you can walk side to side and backwards and forwards with your hands. Scaption and Y�s are added as well as chair press ups. These are like mini dips from a chair.

From here you can progress to more challenging exercises. Some of your choices are push ups on unstable surfaces, wheel barrel walking (partner holds feet), medicine ball toss with light balls and heavy balls, ball dribbles against a wall at shoulder level and overhead, isometric push ups holds and push ups on a unstable surfaces, depth drop push ups( 4-6 inches), and standing and kneeling PNF D2 done from 150� to 180�. Some of these neuromuscular stability exercises are going to be trained to failure and for speed.

Stretching that will most likely be beneficial are pec minor, and posterior capsule. For those that are big chested and can�t lift their arms overhead would probable benefit from lat and pec major stretching.

Pressing is always a question. Push ups are a good choice and they can be done in a variety of ways. If you are working with throwing or overhead athletes the stress on the shoulder girdle from benching and military pressing is questionable.

Floor dumbbell pressing may be the safest exercise and at the same time keeping your pressers mentally sane. Floor pressing can go from two arms to alternating arms to one arm presses. This sequence can then be repeated on a stability ball.

It has been my experience that when an individual does a workout that does not hurt they want to quickly progress it. This may be ill advised. It will be okay to repeat the exact workout for a few weeks. Quick jumps likely end up in flare ups and frustrations. If you adhere to the rules and the resolution is fast then go a head and skip the progressions. Our goal is to resolve the problem while having as little impact on the current level of preparedness.