[ research report ]

PETER K. EDWARDS, MSc1 • JAY R. EBERT, PhD1 • CHRIS LITTLEWOOD, PhD2

TIM ACKLAND, PhD1 • ALLAN WANG, FRACS, PhD3,4

A Systematic Review of Electromyography

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Studies in Normal Shoulders to Inform

Postoperative Rehabilitation Following
Rotator Cuff Repair

R
otator cuff tears are generally considered to be normal, age- after surgery often depends on the size of
related degenerative disorders, with full-thickness rotator cuff the tear; tissue quality; the location, type,
tears evident in approximately 20% of patients over 65 years and chronicity of the tear; previous and/
or concomitant surgery; and individual
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

of age.11,50,58 When rotator cuff tears become symptomatic and

conservative management fails, they are typically repaired surgically.
Reports of the incidence of surgery to re-
pair the rotator cuff show an increase of
238% from 1995 to 2009 in the United
States9 and of 204% from 1998 to 2011 in
a Finnish population.42 Despite positive
UUSTUDY DESIGN: Systematic review.
Journal of Orthopaedic & Sports Physical Therapy®
clinical results, reports of repair failure
after surgery can range from 16% to 94%,
and those that do fail, or fail to heal, tend
to do so within the first 3 to 6 months
postsurgery.26,39 A successful outcome
UURESULTS: A search identified 2159 studies.
patient factors such as smoking, body
mass, and physical activity.1,12,13,15,17,19,20,36,47
However, the postoperative rehabilita-
tion protocol remains one of the more
important factors in determining a suc-
cessful outcome following rotator cuff
surgical repair.25 Several studies have in-
dicated that avoiding early motion may
protect the repaired tendon(s) without

UUBACKGROUND: Electromyography (EMG) has
previously been used to guide postoperative reha-
bilitation progression following rotator cuff repair to
prevent deleterious loading of early surgical repair.
UUOBJECTIVE: To review the current literature
investigating EMG during rehabilitation exercises
in normal shoulders, and to identify exercises
that meet a cut point of 15% maximal voluntary
isometric contraction (MVIC) or less and are
unlikely to result in excessive loading in the early
postoperative stages.
UUMETHODS: An electronic search of MEDLINE via
Ovid, Embase, CINAHL, SPORTDiscus, PubMed, and
the Cochrane Library for all years up to June 2016
was performed. Studies were selected in relation to
predefined selection criteria. Pooled mean MVICs
were reported and classified as low (0%-15%
MVIC), low to moderate (16%-20% MVIC), moderate
(21%-40% MVIC), high (41%-60% MVIC), and very
high (greater than 60% MVIC).
After applying the selection criteria, 20 studies
were included for quality assessment, data extrac-
tion, and data synthesis. In total, 43 exercises
spanning passive range of motion, active-assisted
range of motion, and strengthening exercises were
evaluated. Out of 13 active-assisted exercises, 9
were identified as suitable (15% MVIC or less) to
load the supraspinatus and 10 as suitable to load
the infraspinatus early after surgery. All exercises
were placed in a theoretical-continuum model, by
which general recommendations could be made
for prescription in patients post rotator cuff repair.
UUCONCLUSION: This review identified passive
and active-assisted exercises that may be appro-
priate in the early stages after rotator cuff repair.
J Orthop Sports Phys Ther 2017;47(12):931-944.
Epub 13 Jul 2017. doi:10.2519/jospt.2017.7271
UUKEY WORDS: electromyography, exercise,
rehabilitation, shoulder
detrimental postoperative stiffness,33,44
while conversely, other studies advocate
early passive and active-assisted motion
of the operated shoulder to regain func-
tional mobility.31 As such, both surgeons
and therapists alike remain uncertain and
conflicted about how to best manage and
rehabilitate a patient after rotator cuff re-
pair, particularly, when to introduce and
progress passive and active-assisted exer-
cises throughout the early postoperative
period without risk of an adverse outcome.
Exercise prescription following rota-
tor cuff repair could be based on known
muscle activity levels elicited during
each respective exercise, as these are the
best available estimate of stress placed
on the rotator cuff tendon.51 A number of
studies have investigated muscle loading

The School of Human Sciences, University of Western Australia, Crawley, Australia. 2Keele Clinical Trials Unit and Research Institute for Primary Care and Health Sciences, Keele
1

University, Staffordshire, United Kingdom. 3Department of Orthopaedic Surgery, The University of Western Australia, Perth, Australia. 4St John of God Hospital, Subiaco, Australia.
The authors certify that they have no affiliations with or financial involvement in any organization or entity with a direct financial interest in the subject matter or materials
discussed in the article. Address correspondence to Mr Peter Edwards, School of Human Sciences (M408), University of Western Australia, 35 Stirling Highway, Crawley, WA 6009
Australia. E-mail: peter.edwards@uwa.edu.au t Copyright ©2017 Journal of Orthopaedic & Sports Physical Therapy®

journal of orthopaedic & sports physical therapy | volume 47 | number 12 | december 2017 | 931

 [ research report
during an array of therapeutic rotator cuff
rehabilitation exercises.10,16,35,38,54 These
studies have evaluated the challenge to
individual rotator cuff musculature in
nonpathological, asymptomatic shoul-
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ders using electromyography (EMG)
via a percentage of maximal voluntary
isometric contraction (MVIC). Electro-
myography has previously been used as a
pragmatic tool to guide postoperative re-
habilitation progression by categorizing
activation levels as low (0%-20% MVIC),
moderate (21%-40% MVIC), high (41%-
60% MVIC), and very high (greater than
60% MVIC).16,38,54 From the perspective
of rehabilitation following rotator cuff
tendon repair, it is essential to consider
the spectrum of all rotator cuff loading
exercises, given their importance in the
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
early postoperative stages to improving
range of motion (ROM) and motor per-
formance of the shoulder without over-
loading the early surgical repair. Previous
reviews have evaluated strengthening
exercises that optimally load the rotator
cuff, deltoid, and scapular muscles.10,14
However, these reviews have failed to
include passive and/or active-assisted
Journal of Orthopaedic & Sports Physical Therapy®
activities in conjunction with active
strengthening exercises, and thus do
not provide the information required for
therapists to better prescribe exercises
throughout the entire postoperative re-
habilitation timeline.
The objective of this systematic re-
view was to identify and synthesize the
current literature regarding rotator cuff
muscle activation in a normal, uninjured
cohort during common rehabilitative ex-
ercises routinely prescribed after rotator
cuff repair, and to understand how these
exercises may load a newly repaired ro-
tator cuff tendon. In the absence of de-
finitive evidence regarding postoperative
rehabilitation, the aim of this review is to
define an optimal postoperative loading
protocol within the parameters currently
deemed not to expose the repairing cuff
to loads that might cause structural fail-
ure, and to see whether EMG evidence
can help us design more progressive re-
habilitation protocols.
932 | december 2017 | volume 47 | number 12 | journal of orthopaedic & sports physical therapy
]
METHODS
Data Sources and Search Strategy
A comprehensive search of all relevant
literature was undertaken in 5 data-
bases: MEDLINE via Ovid, Embase,
CINAHL, SPORTDiscus, PubMed, and
the Cochrane Library for all years up to
June 2016. Search terms were related to
rotator cuff muscles (supraspinatus OR
infraspinatus OR subscapularis OR teres
minor OR rotator cuff OR cuff muscles),
exercise (exercis* or eccentric or concen-
tric or iso* or resist* or rehab* or physical
therapy or strength* or load* or training
or activ* or passive*), and electromyogra-
phy (electro* or EMG) (TABLE 1). Electro-
myography was chosen because this is the
most reliable and valid method of mea-
suring muscle activation, and has been
used in previous reviews as a measure to
establish loading during rehabilitation
exercises.10,14 A manual review of refer-
ences in key articles was also performed
to ensure that no relevant articles had
been overlooked or not located in the ini-
tial search.
Selection Criteria and Quality Appraisal
Two reviewers (P.E. and J.E.) indepen-
dently applied selection criteria to the
titles and abstracts of the manuscript
yield. It was required that studies used
EMG as a primary tool to detect muscle
activity in the rotator cuff during reha-
bilitation exercises, as this is the gold
standard method of measuring such ac-
tivity.14 Included studies were required
to undertake EMG analysis of at least 1
rotator cuff muscle, to compare the inten-
sity between different rehabilitation exer-
TABLE 1 Search Terms in the MEDLINE Database
Search Term
1 supraspinatus OR infraspinatus OR subscapularis OR teres minor OR rotator cuff OR cuff muscles [Title /
Abstract] AND
2 exercis* OR resist* OR rehab* OR physical therapy OR strength* OR load* OR training OR activ* OR passive*
[Title / Abstract] AND
3 electromyo* OR EMG [Title / Abstract]
cises to ensure that a comparison could
be made between each study. Exercises
were considered relevant and deemed
eligible if a minimum of 2 repetitions of
each exercise was performed, to further
differentiate between a clinical test and
an exercise for rehabilitation, and were
designed specifically to either load the
rotator cuff or to rehabilitate and restore
function following rotator cuff repair.
This included passive, active-assisted,
and active exercises, as these exercises are
commonly performed movements in the
early stages following rotator cuff repair.
No restriction on time period or level of
evidence was applied to the search; how-
ever, studies must have been published in
a peer-reviewed journal.
Studies whose sample included pa-
tients with a history of shoulder patholo-
gy, injury, or pain were excluded to reduce
the unknown influence of these factors on
EMG outcomes. However, control groups
in studies evaluating differences dur-
ing exercises between pathological and
healthy participants were included. To
reduce the potential effects of shoulder
pathology on EMG findings, studies that
had a mean age or upper age limit range
above 50 years were excluded, because-
asymptomatic rotator cuff tears increase
with age.50 Any study with a specific aim
to evaluate a clinical test was excluded, as
were studies in which rotator cuff mus-
cle activity was examined during activi-
ties such as occupational tasks, sporting
tasks, or specific hand grips, as these were
not considered to be exercises that could
be implemented in a clinical rehabilita-
tion program. While studies evaluating
2 or more different rehabilitation exer-
 cises were included, individual exercises
not meeting the inclusion criteria were
omitted from this evaluation. Exercises
that required the addition of external
load (eg, dumbbells or resistance bands)
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were included, provided the load could be
replicated or performed within an inde-
pendent home-based setting (eg, not re-
quiring the use of machine equipment).
In studies that presented their results
graphically, data values were estimated
from the graph. Studies that did not nor-
malize the EMG activity of exercises to an
MVIC were excluded, as were studies that
recorded supraspinatus activity via sur-
face EMG. Non-English studies, review
articles, conference abstracts, non–peer-
reviewed studies, case reports, and opin-
ion pieces were excluded, as were articles
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
for which the full text was not available.
Study Review Process
and Quality Appraisal
The full text of an article was sourced for
review when the title and/or abstract ap-
peared to meet the selection criteria, or
did not provide sufficient information
to determine its eligibility and required
Journal of Orthopaedic & Sports Physical Therapy®
closer investigation. The full text of the
articles was appraised for quality using a
standardized quality assessment tool for
observational studies, as used by Gan-
derton and Pizzari14 in a previous review,
that reported each aspect of the qual-
ity assessment in a raw form instead of
in a summarized score. Each study was
evaluated by its respective category, such
that quality and validity were not com-
promised. Two reviewers (P.E. and J.E.)
independently assessed the methodologi-
cal quality of the included studies, and
disagreement was resolved by consensus.
Data Extraction and Analysis
One reviewer (P.E.) independently ex-
tracted data in relation to study char-
acteristics, methodological details,
method of EMG analysis and normal-
ization procedure, and the results from
studies (mean muscle amplitude data
for each rotator cuff muscle during each
exercise).
journal of orthopaedic & sports physical therapy | volume 47 | number 12 | december 2017 | 933
Data Synthesis
As differences existed in methodology be-
tween the included studies (eg, individual
muscles analyzed, exercises tested, exer-
cise procedure variations, normalization
procedures), data were not combined
in a meta-analysis or directly compared
between studies.7,14 Rather, a qualitative
analysis was carried out to identify the
exercises within each study that elicited
maximum muscle activity. As previously
stated, a comparison of EMG data from
each of the 4 rotator cuff muscles during
each exercise is presented as a percent-
age of the MVIC (percent MVIC) for that
muscle. For the purpose of this review, in
studies where different resistance loads
were included, the maximal load was an-
alyzed to record maximal average muscle
activation during the exercises.
Previous studies have previously
categorized activation into levels (low,
0% to 20% MVIC; moderate, 21% to
40% MVIC; high, 41% to 60% MVIC;
and very high, greater than 60%
Database Search
Potentially relevant publications, n = 2159
• MEDLINE, n = 477
• Embase, n = 586
• PubMed, n = 619
• CINAHL, n = 186
• SPORTDiscus, n = 256
• Cochrane Library, n = 33
Titles and abstracts screened, n = 914
Retrieved for full-text evaluation, n = 48
Articles included for review, n = 20
FIGURE 1. A flow chart of the search strategy used in this review. Abbreviation: MVIC, maximal voluntary isometric
contraction.
MVIC).6,16,38,54 In their biomechanical
study, Long et al35 designated muscle
activation greater than 15% MVIC to
be potentially indicative of higher loads
than desirable in a newly repaired rota-
tor cuff. Therefore, to permit meaningful
comparisons of EMG activation levels
between exercises and to improve the
clinical relevance of load stratification,
we chose to employ the following clas-
sification system for the safe and pro-
gressive implementation of the reported
rehabilitation exercises: low, 0% to 15%
MVIC; low to moderate, 16% to 20%
MVIC; moderate, 21% to 40% MVIC;
high, 41% to 60% MVIC; and very high,
greater than 60% MVIC.
RESULTS
T
he comprehensive search of the
electronic databases identified 2157
studies, and 2 additional studies
were included for evaluation after manu-
ally searching through reference lists of
Additional articles identified through
reference checks, n = 2
Duplicates removed, n = 1245
Results excluded based on title and abstract,
n = 866
Full texts excluded, n = 28
• Exercise criteria not met, n = 12
• No full text available, n = 2
• Age >50 y, n = 1
• Evaluated clinical test position, n = 5
• Pathological cohort, n = 3
• Did not evaluate rotator cuff, n = 1
• Not normalized to % MVIC, n = 3
• Improper electrodes, n = 1
 [ research report ]
retrieved papers and systematic reviews
Supine bar-assisted ER38 3
(FIGURE 1). After screening all titles and Upright bar-assisted ER30 3
abstracts and removing duplicates, 48 Washcloth press-up (hands close)54 3
publications were subsequently assessed Washcloth press-up (hands apart)54 4
Supine press-up54 4
in full text. Of these, 20 satisfied the se-
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Wall-assisted ER30 4
lection criteria, were rated as “good qual- Scapular protraction on ball54 5
ity,” and were included for full review. For Forward bow54 5
exercises examined in a single study, we Supine therapist-assisted elevation38 5
reported their individual mean, and for Prone shoulder extension: 0° of ABD56 6
Sidelying elevation16 7
exercises examined in more than 1 study, Standing IR: 0° of ABD38,41 7 (7-10)
we reported the pooled mean and the Incline press-up54 8
range of mean MVIC values. A summary Towel slide (sagittal)16,30 8 (4-12)
of the characteristics and methodological Upright-assisted IR38 9
Supine self-assisted elevation16,38,54 11 (1-17)
quality of the 20 included studies is pro-
Pendulum38 11
vided in TABLE 2 and TABLE 3, respectively. Towel slide (medial)16 12
Electromyographic activity of the 4 rota- Towel slide (scapular)16,54 13 (7-13)
tor cuff muscles was compiled, summa- Supported vertical wall slide57 13

rized, and ranked from lowest to highest

activation to allow for a comparison of
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Ball roll16 16
exercises. Upright bar-assisted elevation16,21,30,38 16 (11-19)
FIGURE 2 depicts the pooled means for Unsupported vertical wall slide57 17
Pulley-assisted elevation16,21,30,38 17 (3-19)
supraspinatus muscle activations dur-
Supported diagonal wall slide57 18
ing passive, active-assisted, active, and Active flexion: elbow bent38 20
strengthening exercises. Overall, 20 ex- Wall walk/slide16,38 22 (21-22)
ercises reported low-level (less than 15% Unsupported diagonal wall slide57 22
Standing resisted shoulder extension41 24
MVIC) muscle activation, and therefore
Supine assisted ER38 27
were deemed appropriate to implement in Standing press-up54 29
early-stage rehabilitation following rota- Active flexion/elevation: elbow straight16
Journal of Orthopaedic & Sports Physical Therapy®

29
tor cuff repair. FIGURE 3 depicts the pooled Standing ER in scapular plane46 32
Standing IR in scapular plane ABD4 33
means for infraspinatus muscle activations
Seated row/pull24 33
during passive, active-assisted, active, and Standing ER: 0° of ABD without towel38,41,46 35 (20-41)
strengthening exercises. Overall, 23 ex- Standing resisted shoulder flexion/elevation41 35
ercises reported low-level (less than 15% Prone flexion: 180° of ABD56 38
MVIC) muscle activation and were there-
fore deemed appropriate to implement in
Standing IR: 90° of ABD41 41
early-stage rehabilitation following rota- Standing ER: 0° of ABD with towel46 41
tor cuff repair. FIGURE 4 depicts the pooled High row41 42
means for the teres minor, the muscle least Low row41 46
Standing row/pull28 46
evaluated, with 15 exercises selected across
Forward punch5,28,41 46
4 studies, all of which were strengthening Sidelying ER46 51
exercises. Only 6 studies evaluated the sub- Standing ER: 90° of ABD41,46 54 (39-57)
scapularis, which is shown in FIGURE 5. Jung Diagonal4 54
et al30 was the only study that measured Dynamic hug4 62
Full-can shoulder ABD3,45 73 (62-90)
the subscapularis (upper) during passive Prone ER: 90°3,46 74 (68-91)
and active-assisted exercises, 3 of which Empy-can shoulder ABD3,45 75 (63-92)
were classified as truly passive. Decker et Prone horizontal ABD: 90°3,45 77 (67-88)
al4 was the only study that compared both Prone horizontal ABD: 100°45 82
Push-up plus4 99
the upper and lower portions of the sub-
0 15 30 45 60 75 90 105
scapularis. The mean amplitudes evaluat- % MVIC
ed in the lower portion of the subscapularis
were not pooled and subsequently exclud- FIGURE 2. Supraspinatus pooled means (range) of percent MVIC ranking of exercises. Abbreviations: ABD, abduction;
ER, external rotation; IR, internal rotation; MVIC, maximal voluntary isometric contraction.
ed from FIGURE 5. The lower portion of the

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TABLE 2 Characteristics of Included Studies

Study Sample Muscles Assessed Electrode Type Exercises Evaluated

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Boettcher et al3 n = 15 (9 male, 6 female) healthy, asymptomatic participants Supraspinatus, Intramuscular Full-can shoulder abduction
Mean age, 28.4 y; age range, 19-47 y infraspinatus Empty-can shoulder abduction
Dominant shoulder Prone horizontal abduction
Prone ER: 90°
Decker et al4 n = 15 (9 male, 6 female) healthy, asymptomatic participants Supraspinatus, Intramuscular, Dynamic hug
Male mean ± SD age, 28.0 ± 5.1 y; height, 180 ± 10 cm; infraspinatus, surface Forward punch
weight, 87.4 ± 14.6 kg subscapularis Diagonal
Female mean ± SD age, 25.0 ± 2.4 y; height, 160 ± 10 cm; Standing IR: 0°
weight, 58.0 ± 6.9 kg Standing IR: scapular plane
Standing IR: 90°
Push-up plus
Gaunt et al16 n = 15 (7 male, 8 female) healthy, asymptomatic participants Supraspinatus, Intramuscular, Towel slide (sagittal)
Mean age, 23.9 y; age range, 22-28 y; mean ± SD height, 173.4 infraspinatus surface Towel slide (medial)
± 10.6 cm; weight, 74.4 ± 15.9 kg Towel slide (scapular plane)
Supine self-assisted elevation
Pulley-assisted elevation
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Wall walk/slide
Ball roll
Upright bar-assisted forward elevation
Active flexion/elevation, elbow straight
Gurney et al21 n = 28 (15 men, 13 women) healthy, asymptomatic partici- Supraspinatus, Intramuscular Pulley-assisted elevation in sagittal plane
pants infraspinatus, Pulley-assisted elevation in scapular plane
Men mean ± SD age, 33.5 ± 16.4 y subscapularis, Self-assisted elevation
Women mean ± SD age, 26.5 ± 5.0 y teres minor Self-assisted bar elevation
Randomly assigned Therapist-assisted elevation
Ha et al22 n = 30 (24 men, 6 women) healthy participants Infraspinatus Surface Prone ER
Mean ± SD age, 22.6 ± 1.7 y; height, 176.2 ± 4.5 cm; weight, Sidelying wiper
Journal of Orthopaedic & Sports Physical Therapy®

65.6 ± 7.4 kg Sidelying ER

Standing ER
Hintermeister n = 19 healthy males Supraspinatus, Intramuscular, Standing IR: 0°
et al24 Mean ± SD age, 30 ± 6.2 y; height, 179.3 ± 4.6 cm; weight, infraspinatus, surface Seated rowing (middle grip)
78.2 ± 8.4 kg subscapularis Seated rowing (wide)
Dominant shoulder Forward punch
Illyés and Kiss28 n = 16 (12 male, 4 female) healthy participants from control Supraspinatus, Surface Standing row/pull
group infraspinatus Forward punch
Male mean ± SD age, 22.1 ± 1.1 y; height, 182.9 ± 23.9 cm; Active flexion/elevation: elbow straight
weight, 72.1 ± 3.4 kg
Female mean ± SD age, 22.6 ± 2.12 y; height, 164.1 ± 33.3 cm;
weight, 61.1 ± 4.5 kg
Dominant shoulder
Illyés et al27 n = 25 (16 male, 9 female) healthy participants from control Infraspinatus Surface Standing row/pull
group Forward punch
Male mean ± SD age, 28.1 ± 3.1 y; height, 172.9 ± 14.9 cm; Shoulder elevation
weight, 77.1 ± 8.4 kg
Female mean ± SD age, 26.6 ± 3.7 y; height, 168.9 ± 12.3 cm;
weight, 63.1 ± 5.5 kg
Dominant shoulder
Jung et al30 n = 16 healthy male participants Supraspinatus, Intramuscular Towel slide
Median age, 25 y; age range, 21-30 y; median height, 175 cm; infraspinatus, Pulley-assisted elevation
height range, 165-184 cm; median weight, 71 kg; weight subscapularis Upright bar-assisted forward elevation
range, 55-106 kg Upright bar-assisted ER
Wall-assisted ER
Table continues on page 936.

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 [ research report ]

TABLE 2 Characteristics of Included Studies (continued)

Study Sample Muscles Assessed Electrode Type Exercises Evaluated

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Kim et al32 n = 32 healthy participants (18 male, 14 female) Infraspinatus Surface Sidelying ER without towel
Mean ± SD age, 24.7 ± 3.3 y; height, 173.4 ± 10.6 cm; weight, Seated ER at 90° of abduction
74.4 ± 15.9 kg Seated ER at 0° of abduction
Dominant shoulder Prone ER at 90°
Marta et al37 n = 15 (7 male, 8 female) healthy, asymptomatic participants Infraspinatus, teres Surface Prone horizontal abduction at 90° with full ER
Mean age, 23.9 y; age range, 22-28 y minor Prone horizontal abduction at 90°
Prone horizontal abduction at 100° of abduction
Prone ER at 90°
Sidelying ER without towel
Standing ER: scapular plane
Standing ER: 0° with towel
McCann et al38 n = 10 healthy, asymptomatic participants Supraspinatus, Intramuscular Supine self-assisted elevation
Age range, 18-33 y infraspinatus Supine therapist-assisted elevation
Supine bar-assisted ER
Supine assisted ER
Pendulum
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Pulley-assisted elevation
Upright bar-assisted elevation
Wall walk/slide
Upright assisted extension
Upright assisted IR
Active forward flexion/elevation (elbow bent)
Active forward flexion/elevation (elbow straight)
Active abduction
Standing ER at 0° without towel
Standing IR at 0°
Myers et al41 n = 15 healthy male participants Supraspinatus, Intramuscular, Standing IR at 0°
Journal of Orthopaedic & Sports Physical Therapy®

Mean ± SD age, 24.53 ± 2.77 y; height, 177 ± 8 cm; weight, infraspinatus, surface Standing IR at 90°
78.31 ± 8.20 kg subscapularis, Standing ER at 0°
Dominant shoulder teres minor Standing ER at 90°
Standing resisted shoulder flexion/elevation
Standing resisted shoulder extension
High scapular rows
Standing rows/pull
Low scapular rows
Forward punch
Reinold et al46 n = 10 (5 male, 5 female) healthy, asymptomatic participants Supraspinatus, Intramuscular Standing ER at 0° with towel
Mean age, 28.1 y; range, 22-38 y infraspinatus, Standing ER at 0° without towel
Dominant shoulder teres minor Standing ER in scapular plane
Standing ER at 90°
Sidelying ER
Prone ER at 90°
Prone horizontal abduction at 100°
Reinold et al45 n = 22 (15 male, 7 female) healthy, asymptomatic participants Supraspinatus Intramuscular Full-can shoulder abduction
Mean ± SD age, 26.7 ± 7 y; height, 175 ± 10 cm; weight, Prone horizontal abduction at 90°
79 ± 18 kg Empty-can shoulder abduction
Dominant shoulder
Sakita et al48 n = 20 male participants Infraspinatus Surface Standing ER at 0° with towel
Mean ± SD age, 26.0 ± 3 y; height, 180 ± 7 cm; weight, Standing ER at 0° without towel
77 ± 10 kg Sidelying ER with towel
Dominant shoulder Sidelying ER without towel
Table continues on page 937.

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TABLE 2 Characteristics of Included Studies (continued)

Study Sample Muscles Assessed Electrode Type Exercises Evaluated

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Uhl et al53 n = 18 healthy males Supraspinatus, Intramuscular, Prayer

Mean ± SD age, 22 ± 3 y; height, 175 ± 10 cm; weight, infraspinatus surface Quadruped
73 ± 17 kg Tripod
Dominant shoulder Pointer
Push-up
Push-up with feet elevated
One-armed push-up
Uhl et al54 n = 10 (3 male, 7 female) healthy, asymptomatic volunteers Supraspinatus, Intramuscular Supine self-assisted elevation
Mean ± SD age, 25.0 ± 5 y; height, 171 ± 7 cm; weight, infraspinatus Forward bow
78 ± 15 kg Washcloth press-up (hands close)
Dominant shoulder Washcloth press-up (hands apart)
Towel slide (scapular plane)
Scapular protraction on ball
Supine press-up
Incline press-up
Standing press-up
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Wattanaprakornkul n = 15 (10 male, 5 female) healthy, asymptomatic participants Supraspinatus, Intramuscular Prone flexion at 180° of abduction
et al56 Mean ± SD age, 21.9 ± 3.0 y; height, 170.5 ± 12.2 cm; weight, infraspinatus, Prone extension at 0° of abduction
67.1 ± 13.9 kg subscapularis
Dominant shoulder
Wise et al57 n = 20 healthy participants Supraspinatus, Intramuscular Supported vertical wall slide
Mean ± SD age, 21.7 ± 2.8 y; height, 168.6 ± 23.8 cm; weight, infraspinatus Unsupported vertical wall slide
73.7 ± 17.1 kg Supported diagonal wall slide
Dominant shoulder Unsupported diagonal wall slide
Abbreviations: ER, external rotation; IR, internal rotation.
Journal of Orthopaedic & Sports Physical Therapy®

subscapularis was found to be moderately
activated during the dynamic hug (39%
MVIC), diagonal exercise (38% MVIC),
and internal rotation in 0° (40% MVIC)
and 45° of abduction (26% MVIC). The
push-up plus exercise showed the highest
activation levels, with very high activation
in the upper subscapularis (121% MVIC)
and high-level activation in the lower sub-
scapularis (46% MVIC).
TABLE 4 depicts a continuum of re-
habilitation exercises based on muscle
activation (percent MVIC) for the supra-
spinatus and infraspinatus, modified to
match suggested phases of rehabilitation
for both early and delayed postoperative
motion pathways.
DISCUSSION
better inform clinicians in prescribing
rehabilitation exercises early postsurgery.
In the case of rotator cuff repair, exercise
prescription respecting tissue healing
and repair maturation, particularly with-
in the first 3 to 6 months, when the repair
is most vulnerable,26,39 is vital to prevent
excessive loading at the repair site. Pre-
vious studies have used EMG studies to
guide postoperative rehabilitation pro-
gression in the rotator cuff following
surgery,55 with 15% MVIC considered to
be the upper limit of a safe loading range
during exercises in the early stages fol-
lowing repair. In this review, the pooled
means of 20 and 25 exercises for the su-
praspinatus and infraspinatus, respec-
tively, generated activation levels below
this 15% cutoff. The exercises, both pas-
sive and active assisted, were intended
ymptomatic limb to move the operated
limb also generated low-level activation
in both the supraspinatus and infraspi-
natus. However, active-assisted exercises
using a bar or a pulley to elevate the op-
erated limb tended to generate over 15%
MVIC, suggesting that their use early in
rehabilitation may be inappropriate. The
pendulum exercise, a passive exercise
commonly employed early in rehabilita-
tion, demonstrated low levels of supra-
spinatus and infraspinatus activation,
suggesting that it may be appropriate for
inclusion as an early-stage exercise after
rotator cuff repair. However, it has been
shown that incorrectly performed pendu-
lums, especially large pendulums, gener-
ated more supraspinatus muscle activity
in the shoulder than smaller, correctly
performed pendulum exercises.35 Fur-

T
he goal of this systematic re-
view was to highlight rotator cuff
muscle activation during routinely
prescribed rehabilitation exercises, to
to restore glenohumeral ROM. The bulk thermore, the amount of supraspinatus
of passive ROM exercises demonstrated muscle activation during incorrect pen-
activation levels below the cutoff, and dulum exercises has also been found to
active-assisted exercises using the as- be higher in pathological shoulders when

journal of orthopaedic & sports physical therapy | volume 47 | number 12 | december 2017 | 937

 [ research report ]
compared to healthy shoulders.8 Given
Forward bow54 2
the greater activity observed in patho- Towel slide (sagittal)16,30 4 (1-8)
logical shoulders and the importance Scapular protraction on ball54 4
of correct technique during pendulums Supine therapist-assisted elevation38 5
Supine self-assisted elevation38,54 6 (4-8)
with respect to how the supraspinatus
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Prone shoulder extension: 0° of ABD56 6

may be loaded, other exercises to restore Washcloth press-up (hands close)54 7
ROM postoperatively may be more ap- Towel slide (medial)16 7
propriate, especially during times of lack Towel slide (scapular)16,54 7 (4-9)
of supervision, such as with home-based Upright bar-assisted ER30 9
Pendulum38 9
rehabilitation programs. Supine assisted ER38 9
The use of a wall to passively exter- Supine press-up54 9
nally rotate the shoulder activated the Incline press-up54 9
supraspinatus less than passive exter- Supported vertical wall slide57 9
Unsupported vertical wall slide57 10
nal rotation performed in supine with
Supported diagonal wall slide57 10
a bar or stick or by a therapist. Though Sidelying elevation16 10
supraspinatus activity was generally low Pulley-assisted elevation16,30,38 11 (3-20)
for the 3 passive supine external rota- Washcloth press-up (hands apart)54 11
Supine bar-assisted ER38 12
tion exercises, higher activity was ob-
Seated ER: 0° of ABD32 13
served in the infraspinatus and more so
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Standing press-up54 14
in the subscapularis. Therefore, caution Unsupported diagonal wall slide57 15
must be exercised when administering Wall walk/slide16,38 15 (9-19)
these exercises to individuals with tears
involving the infraspinatus and sub- Upright bar-assisted elevation16,30,38 16 (11-27)
scapularis. While the 3 passive external Seated ER: 90° of ABD32 17
rotation exercises imparted low levels of Ball roll16 18
muscle activation on the supraspinatus, Wall-assisted ER30 18
Standing IR: 0° of ABD38,41 20 (3-32)
the supraspinatus tendon was still sub- Self-assisted IR38 22
ject to passive tension, particularly in
Journal of Orthopaedic & Sports Physical Therapy®

Standing IR: 90° of ABD41 24

the anterior region.23 In a cadaver study, Active flexion/elevation16,38 26 (21-29)
Hatakeyama et al23 suggested that ex- Low rows41 29
High rows41 31
ternal rotation up to 60° with the arm
Active flexion: elbow bent38 35
elevated to 30° in the scapular or coro- Standing ER: 0° of ABD with towel37,46,48 39 (39-50)
nal plane can be safely performed dur- Standing ER: 45° of ABD37,46 39
ing postoperative rehabilitation without
excessive tension on the repair site. In
Standing resisted shoulder extension41 41
another cadaver study, external rotation Sidelying ER with towel48 42
increased supraspinatus tension in the Forward punch4,27,28,41 42 (28-50)
anterior tendon region and relaxed the Sidelying ER without towel32,37,46,48 45 (18-62)
posterior region, thus contributing to Prone shoulder flexion: 180° of ABD56 45
Push-up53 49
increased gap formation anteriorly, with Standing ER: 0° of ABD without towel38,41,46,48 50 (40-77)
strain peaking at 30° of external rota- Standing ER: 90° of ABD41,46 50 (50-51)
tion.43 Therefore, clinicians may need to Standing row/pull27,28,41 51 (28-60)
restrict passive external rotation below a Prone ER: 90°3,32,37,46 54 (30-135)
Standing resisted shoulder flexion41 55
range threshold of 30° during the acute
Prone horizontal ABD: 90°3,37,46 64 (39-122)
postoperative phase to avoid compro- Empy-can ABD3 75
mising the integrity of the repair tissue. Full-can ABD3 82
Passive internal rotation was found to Push-up plus4 104
Pendant ER3 125
generate low activation and, along with
0 15 30 45 60 75 90 105 120 135
active internal rotation, has been sug- % MVIC
gested to place excessive tension on the
repair and should be avoided in the early FIGURE 3. Infraspinatus pooled means (range) of percent MVIC ranking of exercises. Abbreviations: ABD,
abduction; ER, external rotation; IR, internal rotation; MVIC, maximal voluntary isometric contraction.
stages of rehabilitation.23

938 | december 2017 | volume 47 | number 12 | journal of orthopaedic & sports physical therapy

 Active ROM exercises are contraindi-
cated during the early postoperative stag-
es, with some evidence of disruption to
the healing process.34 However, the pres-
ent review found that a series of progres-
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sive, active elevation exercises in different
body orientations and below 15% MVIC,
such as the supine and incline press-up,
Standing ER: 0° with towel37,46
Standing ER: scapular plane37,46
Prone horizontal abduction: 100°37,46
Prone ER at 90°37,46
Standing ER: 0° without towel37,41,46
Prone horizontal abduction: 90°37
Sidelying ER37,46
Internal rotation: 90° of ABD41
Standing ER: 90°41,46
Forward punches41
Internal rotation: 0° of ABD41
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Middle row41
Low row41
High row41
Resisted shoulder flexion41
0 20
FIGURE 4. Teres minor pooled means (range) of percent MVIC ranking of exercises. Abbreviations: ABD, abduction;
ER, external rotation; MVIC, maximal voluntary isometric contraction.
Journal of Orthopaedic & Sports Physical Therapy®
Pulley-assisted elevation30
Table slide30
Prone shoulder flexion56
Seated row24
Wall-assisted external rotation30
Upright bar-assisted elevation30
Upright bar-assisted external rotation30
Forward punch4,24,41
Internal rotation: 0° of ABD4,24,41
Internal rotation: 45° of ABD4
External rotation: 0° of ABD41
External rotation: 90° of ABD41
Dynamic hug4
Diagonal4
Internal rotation: 90° of ABD4,41
Low row41
High row41
Standing row41
Resisted shoulder extension41
Resisted active elevation/flexion41
0 20
FIGURE 5. Subscapularis pooled means (range) of percent MVIC ranking of exercise. Abbreviations: ABD,
abduction; MVIC, maximal voluntary isometric contraction.
may also be considered appropriate. Re- on the glenohumeral joint.54 As this study
habilitation programs have also been rec- highlights, in the study by Uhl et al,54 for
ommended to progress from short–lever the supraspinatus, supine and incline
arm activities to longer–lever arm activi- press-ups did not generate muscle activa-
ties, as well as to initiate activities from tion levels above our cutoff of 15% MVIC,
supine and progress through to incline which allows for a gradual progression
and then upright postures, adjusting the that is likely to be safe, though somewhat
effect of gravity, and subsequently load, more demanding, before progressing to
the standing press-up, which was found
29 (17-46) to generate moderate EMG activity. Fur-
39 (31-55) thermore, by unloading and supporting
the shoulder throughout active ROM,
41 (39-44)
exercises such as the table slide, ball roll,
45 (43-48)
46 (17-84) and supported vertical wall slide were
47 found in the present review to impart
56 (33-80) low and low-to-moderate muscle acti-
63
vation on the supraspinatus and infra-
69 (39-89)
69 spinatus alike; therefore, these could be
93 considered as a progression toward tran-
98 sitioning toward active press-up, flexion,
101
and elevation exercises. Activity during
109
112
active external rotation exercises ranged
from moderate to high in the supraspina-
40 60 80 100 120
% MVIC tus (31%-69% MVIC), the infraspinatus
(13%-50% MVIC), and the teres minor
(29%-69% MVIC), and should be pro-
gressed from a seated position to posi-
tions of standing, sidelying, prone in 90°
8 of abduction, and, finally, standing in 90°
10 of humeral abduction.
12
The rehabilitation program depicted
14
15 in TABLE 4 groups exercises based on EMG
activity level of the supraspinatus and
infraspinatus, to anticipate the projected
24
stress on the repaired rotator cuff, into
27
35 (8-69) phases aligned with tissue healing and
repair site strength.51,52 This is consistent
with a recent consensus statement sug-
40 (13-74)
gesting that rehabilitation after rotator
53
57 cuff repair should include a 2-week peri-
57 od of strict immobilization followed by a
58 staged introduction of protected, passive
60
ROM to 6 weeks after surgery, followed
65
69
by restoration of active ROM, and then
74 progressive strengthening beginning at
81 postoperative week 12.51 Fibers respon-
97 sible for binding and healing tendon to
99
the bone are not present in any consid-
40 60 80 100 120
% MVIC
erable number between 6 and 12 weeks,
with repair strength considered only 19%
to 30% of normal at 6 weeks and 29%
to 50% of normal at 12 weeks,18 and not
journal of orthopaedic & sports physical therapy | volume 47 | number 12 | december 2017 | 939
 [ research report ]

TABLE 3 Quality Appraisal of Included Studies

Internal Validity
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External Validity Performance Selection Bias/Control of Confounding

Appropriate Appropriate Appropriate
Participation Direct Electrode Randomization Randomization Familiarization Normalization Statistical
Representation* Rate Observation Blinding Choice† of Exercises of MVIC Trials of Exercises‡ Procedure Tests
Boettcher et al3 Y Y Y N Y Y N N Y Y
Decker et al4 Y Y N N Y Y N Y Y Y
Gaunt et al16 Y Y Y N Y Y N N Y Y
Gurney et al21 Y Y Y N Y Y N Y Y Y
Ha et al22 Y Y Y N Y Y N Y Y Y
Hintermeister N Y Y N Y Y N Y Y N
et al24
Illyés and Kiss28 Y Y Y N N N N Y Y Y
Illyés et al27 Y Y Y N Y N N Y Y Y
Jung et al30 N N Y N Y Y N N Y Y
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Kim et al32 Y Y Y N Y Y N Y Y Y
Marta et al37 N Y Y N Y Y N Y Y Y
McCann et al38 N Y Y N Y N N N Y Y
Myers et al41 N Y Y N Y Y N N Y N
Reinold et al46 Y Y Y N Y Y N N Y Y
Reinold et al45 Y Y Y N Y Y N N Y Y
Sakita et al48 N Y Y N Y N N Y Y Y
Uhl et al53 N Y Y N Y Y N Y Y Y
Uhl et al54 Y Y N N Y Y N Y Y Y
Journal of Orthopaedic & Sports Physical Therapy®

Wattanaprakornkul Y Y Y Y Y Y Y Y Y Y
et al56
Wise et al57 N Y Y Y Y Y Y N Y Y
Abbreviations: MVIC, maximal voluntary isometric contraction; N, no; Y, yes.
*Representation indicates whether the study sample was representative of a normal, apparently healthy population (eg, both male and female participants, no
pathology, nonathletes).
†
Appropriate electrode choice indicates whether there were intramuscular electrodes on the supraspinatus, infraspinatus, subscapularis, and teres minor, and
surface electrodes on the infraspinatus.
‡
Familiarization indicates whether participants received practice on performing exercise prior to testing.

suitable for moderate or large, repetitive
loads. Therefore, exercises must still be
applied cautiously throughout this phase
to almost full maturity at 15 weeks,49 at
which time the repair site can tolerate
greater loads. In this phase, we advocate
strengthening exercises that elicit be-
tween 21% and 50% MVIC, consistent
with previous recommendations.51 Be-
cause exercises are progressed from pas-
sive ROM to active-assistive ROM, active
ROM, and resisted exercises, it is impor-
tant to recognize that these exist along a
continuum51,52,54 and that individual dif-
ferences between patients and repairs
must be respected, including stratifying
those patients presenting with risk fac-
tors shown to negatively influence tendon
healing and subsequently increase the
risk for retearing. It has been reported
that large, massive tears are nearly at 2
times greater risk for structural failure
in studies that used an initiation of early
motion,52 thus conservative progression
and initiation of load should be applied.
Consistent with the recommendations of
Thigpen et al,52 which outlined 2 reha-
bilitation pathways adjusting the rate of
rehabilitation progression to account for
individual variation in patient age, as well
as the rotator cuff tear size, tissue qual-
ity, and repair integrity, our rehabilitation
guideline similarly includes 2 pathways,
based on early and delayed time points to
progress exercises.
A limitation of our review is that re-
sults are solely based on reported values
from younger (under 40 years), healthy
individuals performing selected rotator
cuff exercises. The bulk of EMG stud-
ies available used nonpathological, or
healthy, shoulders to investigate cuff ac-
tivation during rehabilitation exercises.
The common rationale provided was
that EMG amplitudes and muscle acti-

940 | december 2017 | volume 47 | number 12 | journal of orthopaedic & sports physical therapy

 Summary and Suggested Continuum of Rehabilitation Exercises, Based on
TABLE 4 Muscle Activation (Percent MVIC) for the Supraspinatus and Infraspinatus,
for Both Early and Delayed Postoperative Motion Pathways
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Time Point Exercises

Phase 1: protection and early Early: weeks 2-6 Passive ROM: flexion
motion phase Delayed: weeks 5-8 Forward bow, supine therapist-assisted flexion, supine self-assisted flexion, sidelying flexion, towel slides, washcloth press-up
EMG activation: ≤15% MVIC Passive ROM: rotation (no IR; ER to 30°)
Wall-assisted ER, supine bar-assisted ER, upright bar-assisted ER
Phase 2: active-assisted to Early: weeks 7-9 Active-assistive ROM: flexion
active motion phase Delayed: weeks 9-12 Ball roll, upright bar-assisted flexion, supported wall walk/slide (progression into unsupported), pulley-assisted flexion
EMG activation: ≤20% MVIC Active ROM: flexion
Supine active press-up, reclined active press-up
Active-assistive ROM: rotation
Continue ER exercises as above. Commence self-assisted IR, bar-assisted IR
Phase 3: strengthening phase Early: week 10 Active ROM: flexion
EMG activation: 21%-50% MVIC Delayed: week 13 Progress to standing press-up/active flexion (short lever, progressing to long lever), resisted active flexion
Active ROM—strengthening: rotation
Progress from seated to standing (in slight abduction to 45° of abduction) to sidelying (with and/or without pillow)
Seated row exercises, progressing to standing row/pulls: forward/scapular punches
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Phase 4: late strengthening Early: week 20 Active flexion/abduction

phase Delayed: week 20 Prone horizontal abduction at 90° and 100°
EMG activation: ≥50% MVIC Strengthening: rotation
Standing ER (in 90° of abduction) to prone (ER) in 90° of abduction
Push-up/push-up plus, dynamic hugs
Abbreviations: EMG, electromyography; ER, external rotation; IR, internal rotation; MVIC, maximal voluntary isometric contraction; ROM, range of motion.

vation patterns may differ due to pain, for differentiating between passive and method to base the progression of ther-
altered shoulder biomechanics, pathol- active, rather than traditional, MVICs. apeutic exercises on likely stress on the
Journal of Orthopaedic & Sports Physical Therapy®

ogy, ROM restrictions, and/or muscular
disuse in pathological patients or patients
following surgery. Previous literature has
suggested that patients with painful,
symptomatic shoulders activate muscles
differently and are unable to remain as
passive as healthy control subjects.8,40
Therefore, caution should be applied in
extrapolating data collected from healthy
subjects and applying results strictly in a
clinical setting to postoperative patients.
Ellsworth et al8 compared muscle activa-
tion patterns between pathological and
healthy participants during the pendu-
lum exercise, and reported that patients
with shoulder pathology had greater dif-
ficulty relaxing their supraspinatus and
upper trapezius than healthy partici-
pants. Murphy et al40 examined patients
postsurgery and reported muscle activa-
tion levels during exercises by normaliz-
ing EMG as a percentage of the activity
observed during rest at baseline, which
was also used as the criterion threshold
The authors reported that for the supra-
spinatus, exercises such as therapist- and
self-assisted external rotation, therapist-
assisted elevation, pendulums, and iso-
metric internal rotation and adduction
can be considered passive, while for the
infraspinatus, no exercises were shown to
be considered passive, given that all exer-
cises exceeded the baseline activity level.
Electromyography studies alone can-
not provide definitive guidelines on the
relative safety of exercises without know-
ing the specific force levels that cause
damage to a repair. Muscle activity level,
along with the plane of motion, cyclic
loading, and the weight and length of an
individual’s upper limb, are also likely to
affect the tension on the repair.51 While
only moderate correlations have been
made between muscle tension and EMG
activity,10 in the clinical setting, where
stress and tension imparted by reha-
bilitation exercises cannot be measured,
EMG evidence does offer a pragmatic
repaired rotator cuff.51 Percent MVIC is
the most common method of normalizing
the EMG signal as a reference value for a
given muscle and is usually performed by
using a manual muscle test to produce a
maximum contraction for the muscle of
interest. Given the nature of EMG, subtle
differences in the methodology between
included studies may account for varying
results, even when performing the same
exercise. Factors such as variance in par-
ticipant characteristics, disparities in the
procedure for normalizing and segment-
ing maximal muscle activity data, differ-
ences in EMG technical procedures such
as calculating MVIC, and differences in
exercise procedures may all affect report-
ed amplitudes.
Large variations in reported am-
plitudes may also be due to the type of
electrode chosen for evaluation, as well
as its chosen location. This review ex-
cluded studies in which the supraspi-
natus was recorded using surface EMG,

journal of orthopaedic & sports physical therapy | volume 47 | number 12 | december 2017 | 941

 [ research report
as inaccurate readings of muscle activ-
ity can occur due to cross-talk between
muscles at different depths.14 However,
given that the infraspinatus is superficial
and easily accessible and produces simi-
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lar assessments using both surface and
intramuscular electrode types,29 this re-
view included studies that measured the
infraspinatus by surface EMG. The pres-
ent review pooled the normalized mean
peak EMG amplitudes from each study,
irrespective of electrode use, which may
account for the wide range of reported
values for the infraspinatus. Previous
studies have also found that the upper
and lower portions of the subscapularis
muscle have separate functions4 and may
require separate rehabilitation exercises,
particularly if repaired. In our review,
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
only Decker et al4 differentiated and in-
vestigated both upper and lower portions
of the muscle, hence their results were
reported separately. Studies using ma-
chine-based equipment during exercises,
aside from dumbbells and resistance
bands, which have demonstrated no dif-
ferences during rehabilitation exercises,2,5
were excluded from the present review.
Journal of Orthopaedic & Sports Physical Therapy®
The procedures for the performance of
exercises were generally the same be-
tween studies, and the exercises were
generally dynamic, with the exception
of those in Wattanaprakornkul et al,56
which employed isometric flexion and
extension. The loads applied during ex-
ercises also varied between studies, with
some tailored to suit the individual and
others more generalized. Finally, anoth-
er limitation was presented by the need
to estimate data values from studies in
which the results were only represented
graphically and the authors could not be
contacted.
This review highlights the large va-
riety of studies that have investigated
strengthening exercises in the shoulder
and the limited number of good-quality
studies that have evaluated passive and
active-assisted exercises that may be safe
to implement in the early postoperative
stages. Many of the studies included in
this review evaluated primarily the su-
942 | december 2017 | volume 47 | number 12 | journal of orthopaedic & sports physical therapy
praspinatus and infraspinatus, and very
few evaluated the subscapularis and the
teres minor muscles. Therefore, caution
must be taken when applying the guide-
lines in this review to patients present-
ing with repairs of the subscapularis
and teres minor. There is also a need for
future research to focus on the evalua-
tion of similar rotator cuff exercises in
individuals with pathology, such as rota-
tor cuff disorders, and on exercises that
include more parameters than simply
peak muscle activation. Future research
should continue to focus on bridging the
gap between conservative rehabilitation
protocols and rehabilitation protocols
that are too aggressive.
CONCLUSION
D
espite the emergence of re-
search detailing patient outcomes
after rotator cuff repair, little is
known about the appropriate postopera-
tive loading and exercise protocols. Un-
til now, no guidance to clinicians in the
management of these patients has been
available. This review provides the treat-
ing therapist with a continuum of specif-
ic shoulder rehabilitation exercises that
can be prescribed to safely and progres-
sively improve upper-limb movement,
strength, and function following rotator
cuff repair. t
KEY POINTS
FINDINGS: This review identified 20
studies that assessed muscular activity
demand (percent maximal voluntary
isometric contraction) in the perfor-
mance of 43 exercises, spanning passive
range of motion, active-assisted range
of motion, and strengthening exercises.
Out of 13 active-assisted exercises, 9
were identified as suitable to load the
supraspinatus and 10 as suitable to load
the infraspinatus early in the postopera-
tive rehabilitation setting.
IMPLICATIONS: This review provides evi-
dence-based recommendations for ex-
ercises that may be used in a graduated
rehabilitation program for the rotator
]
cuff, including passive and active-assist-
ed exercises that are unlikely to result
in structural, failure from early to later
stages following surgery.
CAUTION: It is critical to consider in-
dividual patient characteristics and
risk factors that may negatively influ-
ence tendon healing and subsequently
increase the risk for retear before
prescribing postoperative exercise.
Furthermore, no direct relationship
has been established between dynamic
electromyography activity and tension
in the respective musculotendinous
structures, and, therefore, the results
from this review should be only used
as a pragmatic guide for the appropri-
ate selection of exercises to prescribe to
patients throughout the postoperative
timeline after cuff repair.
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