This is the exercise programme used for large rotator cuff tears, including the ones surgeons describe as irreparable. It looks strange at first, because it does not try to strengthen the torn muscles at all. It trains the deltoid instead, and it starts with you lying flat on your back. That design is deliberate, it is backed by published outcomes, and it works for a substantial share of people who have been told their cuff cannot be fixed.
Where a repair is on the table, costs and recovery are set out in PhysioHub's guide to private shoulder surgery.
The rotator cuff is a group of muscles around the shoulder, running from the shoulder blade to their attachment at the top of the arm bone (the humerus). They can tear through repetition and prolonged use, or through the wear and tear of normal ageing. A torn cuff often makes lifting the arm above shoulder height difficult. Large tears are frequently beyond repair, and they can still be managed very well with an exercise programme.
The deltoid sits over the upper part of your arm, and it can be strengthened to take on the work of supporting the shoulder. Building it up may bring your pain down and may improve how far the arm will move, for instance when you reach up into a cupboard.
Building deltoid strength takes at least 12 to 24 weeks, and the exercises have to be done every day.
The two numbers in bold are the ones to hold on to: every day, for three to six months. This is a rebuild rather than a course of treatment.
The programme is strictly sequential. Each stage runs until the muscles tire or pain arrives, and you move on only once the current stage is easy. Gravity is the load: lying flat is the easiest position, semi-reclined is harder, and standing is hardest, which is why the progression moves you upright rather than adding weight first.
Exercise one
Lie on your back on a mat or a firm mattress with a pillow under your head. Bend the elbow, then take the arm up to 90 degrees so the elbow points straight at the ceiling, in line with your shoulder. With the arm at 90 degrees, straighten the elbow. Pain or weakness may mean supporting that elbow with your stronger arm. Bend the elbow again and come back to the start.
Keep repeating until the muscles tire or pain arrives. Move on to exercise two only once exercise one is easy, which may take two to three weeks.
Exercise two
Lie on your back on a mat or a firm mattress with a pillow under your head. Take the arm to 90 degrees so the elbow points at the ceiling, then move the whole arm slowly in small circles, clockwise and anticlockwise. Supporting the elbow with your strong arm may be needed. Moving the arm forwards and backwards, or from side to side, are equally good variations.
Fifteen to 30 seconds may be all you manage at first. Build the repetitions up over two to three weeks. Where it proves too painful or too hard, drop back to exercise one for a week or two.
Exercise three (with or without weight)
Add a weight to progress this stage: a tin of beans, or a half to 1kg dumbbell. Lie on your back on a mat or a firm mattress with a pillow under your head, holding the weight in the weak hand. Take the arm up to 90 degrees so the elbow points at the ceiling, then lower it back to your side.
Repeat until the muscles tire or pain arrives. Where it proves too painful or too hard, try it without a weight, or with a lighter one, or drop back to exercise two for a week or two.
Exercise four
Move from lying flat to sitting up at roughly 30 degrees, the long sitting or semi-reclined position, propped on pillows or in a reclining chair. Repeat exercise three without a weight: take the arm up to 90 degrees so the elbow points at the ceiling, then lower it to your side. Supporting the elbow with your strong arm may be needed.
Exercise five
Stay sitting up at roughly 30 degrees, the long sitting or semi-reclined position. Repeat exercise four holding a weight of half to 1kg, or a tin of beans: take the arm to 90 degrees so the elbow points at the ceiling, then lower it to your side. Supporting the elbow with your strong arm may be needed.
Exercise six
Take exercise five into standing. Standing against a wall to support your upper back and shoulder blades helps. Start without a weight, and once the muscles feel stronger or the pain begins to settle, add half to 1kg, or a tin of beans.
Build the repetitions up over two to three weeks. Once it all feels easy, the weight can usually go up to two kilograms.
Exercise seven
Stand and place your forearm flat against a wall. Press the hand into the wall, and while keeping that pressure on, slide the hand up the wall.
The rotator cuff's main mechanical job is to hold the head of the humerus down and centred in the socket while the big muscles move the arm. Without it, the deltoid's pull tends to drag the humeral head upwards instead of rotating it, which is why a large tear leaves people unable to lift the arm despite having plenty of muscle available.
Anterior deltoid retraining is built on the observation that the deltoid can be taught to do both jobs, generating elevation without the upward migration, if it is trained through a range where gravity is not fighting it. Hence starting supine and working upright by degrees.
The published outcomes are better than most people expect. Ainsworth's 2006 study of physiotherapy rehabilitation in patients with massive, irreparable rotator cuff tears reported significant improvements in shoulder function over a 12-week programme of anterior deltoid strengthening. Work on the same approach by Levy and colleagues on anterior deltoid reeducation reported Constant scores rising from a mean of 26 before treatment to 60 afterwards, with forward elevation improving from a mean of 40 degrees to 160 degrees.
Those are averages from selected groups rather than a promise, and the trials are small. What they establish is that a torn cuff and a functional shoulder are not mutually exclusive, and that the work needed to get there is unglamorous and long.
The most common way this programme fails is moving through it too quickly.
Working until the muscles tire, rather than to a set number of repetitions, is a genuine instruction rather than a hedge. Fatigue is the target, and stopping at a fixed number of reps because it seemed like a round figure undertrains the muscle. Equally, going back a stage when a session goes badly is built into the programme in several places and is not a setback.
Two practical additions worth knowing. Supporting the elbow with the good arm is allowed at every stage and is how most people get through the first fortnight. And exercise seven, sliding the forearm up the wall while pushing into it, is doing something different from the others: pushing into the wall recruits the shoulder blade muscles that stabilise the base of the joint, and it is worth keeping on permanently after the rest of the programme is done.
If the shoulder pain came on without a torn cuff being confirmed, the broader picture is covered in our article on physiotherapy for rotator cuff injury.
What has changed in clinic over the past few years is the number of people arriving with a scan report that says "massive" or "irreparable" and the belief that this means nothing can be done. Cuff tears are increasingly picked up on imaging in people over sixty, partly because scans are easier to get, and the wording on a radiology report reads far more final than the clinical situation usually is.
The clinical point is that repairability and function are two different questions. A tear that a surgeon would not attempt to stitch can still belong to a shoulder that lifts overhead, sleeps through the night and carries shopping, and the deltoid programme above is how a good share of those shoulders get there. Tears are also extremely common in shoulders that have never hurt at all, which is why the report is read alongside what the shoulder can actually do rather than instead of it. In the Uckfield clinic, the most useful thing early on is usually testing what the shoulder manages with the elbow supported, because that is what predicts whether this programme is worth committing three to six months to.
If you have a scan report and no clear plan attached to it, booking an assessment is the step that turns it into one.
Can a rotator cuff tear heal without surgery?
A full-thickness tear does not knit back together. The shoulder around it can be trained to work well, which is what this programme is for.
How long do these exercises take to work?
At least 12 to 24 weeks of daily work. Meaningful change before 12 weeks is unusual.
Why do the exercises start lying down?
Lying flat removes gravity from the movement, so the deltoid can be trained before it is strong enough to lift the arm upright.
Should I do these before or after surgery?
This programme is for tears being managed without repair. After a repair, follow the protocol from your surgical team, which restricts movement for several weeks. Our guide to post-surgery rehabilitation covers that route.
What weight should I use?
The sheet specifies half to 1kg, or a tin of beans, progressing to 2kg when the exercises feel easy. Adding load faster than that is the usual reason people flare.
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