However, re-injury rates can be as high as 50%. As a fitness professional, balancing risk management with progress hinges on your education to help this population. Have questions on navigating this balance? Keep reading!

When we think of rotator cuffs, we might picture band external rotation exercises. However, this image creates a limited picture of what the rotator cuff does. The rotator cuff is composed of four muscles: supraspinatus, infraspinatus, teres minor, and subscapularis. These muscles work together to slurp the humeral head toward the scapular glenoid fossa, creating stability. This stability allows big movers like deltoids to do their job without shearing the humeral head upward in the socket. Without this compressive stability, the humeral head would drift upwards, pinching the supraspinatus under the acromion. This pinch sets the stage for injury.

Managing training risk involves addressing the factors that contribute to re-injury. Training risks related to rotator cuff safety fall into three categories: poor healing, trauma, and early overuse. Each factor has a different management strategy, which presents the opportunity for client education and collaboration toward a healthy lifestyle.

Poor Healing — Some factors, like older biological age, cannot be altered, but many other risk factors can be modified through your coaching. Smoking cessation, blood sugar control, adequate protein intake, and micronutrient absorption all create a physiological environment that can either support or hinder healing. Free resources like MyPlate or Dietaryguidelines.gov provide solid foundations to answer questions like “how much protein does my client need at a basic level?” Partnering with certified nutrition coaches or registered dietitians can help create custom plans for a thriving healing environment. Clients may benefit from hearing that the tissue healing quality will only be as good as the environment from which it can grow.

Trauma — While the word “trauma” might evoke images of a person falling on outstretched arms, it also includes taking on a speed or load for which the body has not rebuilt adequate capacity. Many patients leave therapy before rebuilding the capacity to achieve goals like playing tennis, cleaning the garage or caring for small children. While the standard 3 x 20 basic muscle endurance exercises set a helpful foundation, multi-directional, load, and speed capacity to meet goals has yet to be developed. This is why activities like starting a pull lawnmower, playing pickleball, doing jumping jacks or simply getting set up for an exercise could spark a traumatic re-injury. Fitness professionals can help fill the gap by designing programs that gradually incorporate progressive levels of motor control, speed and load through multiple planes of motion. Clients may also need reminders of how to safely transition into and out of upper body exercises by keeping weights close to the center of the chest on transitions versus grabbing a weight or cable handle positioned away from the body.

Early Overuse — The rotator cuff’s endurance matters most for activities that involve overhead motion or reaching sideways away from the body. Freestyle swimming, golf, tennis, pickleball, playing with kids, overhead lifting, bench press and chest fly all present vulnerable positions. When reintroducing these movements, starting small helps manage risk. For example, clients can start with doubles tennis instead of singles tennis. They can start with drills before trying a game. In the gym, clients can start with 1 x 10 dumbbell chest press before progressing sets and reps, or to the longer lever arm chest fly.

Prior to beginning the post-rehab program design, fitness professionals should check on any long-term restrictions issued by the client’s surgeon or rehabilitation team. Many times, clients are allowed to progress to all activities, but over-generalizing without checking could introduce unexpected risk and liability.

Next, fitness professionals should include a movement screen to check available ranges of motion. Asking the client to raise both arms overhead, touch hands to the back of their head and touch hands together behind their back provides a solid foundation of understanding. Missing motion is not necessarily an indication for stretching; instead, it is a flag to collaborate with the rehabilitation professional on the underlying cause of the motion restriction. Once the client has medical clearance and full motion, fitness professional program design can progress into three phases:

This phase presents a wonderful opportunity for hands-on scapular cueing to focus on neuromuscular control and scapulohumeral coordination. This phase places a huge emphasis on quality versus quantity with acute variables such as 1 x 5-8 with no or low load. Common exercises include:

Speed and momentum can be scary! However, starting light with load close to the body’s center provides the foundation for fun in re-exploring movement safely. Common exercises based on timed duration progressions include:

At this point, the client demonstrates excellent scapulohumeral rhythm as illustrated by their ability to maintain space between their shoulder and ear during exercise. The client can also reach through all planes at various speeds without compensation. Now the client is ready to focus on building load capacity, resilience, and dynamic power for return to sport or other life activities. Common exercises, scaled then progressed to the client capability, include:

While the above progressions focus on building rotator cuff capacity, the rotator cuff is one part of a whole body. The rotator cuff’s function depends on the foundations set in the body’s posterior chain and thoracic mobility. It also depends on rotator cuff endurance. Including each of the following at all phases prepares the client for success:

In all phases, quality outweighs quantity. If clients compensate, show signs of fatigue or experience local soreness or motion loss, fitness professionals can help educate clients on the importance of listening to the body and the value of non-linear progress.

If you train active adults recovering from rotator cuff repairs or serious injuries, include the pearls above to help educate clients for a safe return to all that they enjoy.