My Top 5 LEAST Favorite Exercises

This post originally appeared in early December 2008 as my top 5 LEAST favorite rehabilitation exercises and has proven to be one of the most popular posts I have written so far.  I guess controversy sells!  I have enhanced and reposted to also include recommendations on how to achieve similar (if not better) results using other exercises.    So, to begin, I want to clarify:

  • This purely just my opinion
  • I may be wrong
  • You may get great results with these exercises
  • Or you may get great results despite these exercises!

 

The Empty Can Exercise

I have been trying real hard the last several years to provide enough evidence that we shouldn’t be using the empty can exercise.  Still, it comes up and I suspect is still a fairly common exercise.   The legendary Dr. Frank Jobe was the first to recommend this exercise for the supraspinatus.  Since then it was widely popular as an exercise to isolate the supraspinatus.  To clarify, it is a good exercise for the supraspinatus, but not the best.  Jobe did discuss the empty can exercise in his classic 1983 article on shoulder exercises but he never mentioned that it “isolated” the supraspinatus.  As we all know, we can’t isolate the supraspinatus like this.

empty-can

So why do I dislike this exercise?  Have you tried it?  It hurts.  Why does it hurt?  It is simple actually.  My EMG paper a few years ago discussed that EMG of the supraspinatus was the same between the empty can and full can exercise, but that the middle deltoid was significantly more active during the empty can.  This articles is free to read from the Journal of Athletic Training.

Simply said, if the deltoid overpowers the supraspinatus, the rotator cuff can not keep the humeral head centered within the glenoid fossa and superior migration occurs.  Superior humeral head migration = impingement.  Not good, and that is why it hurts.  There are numerous other anatomical and biomechanical reasons to not use the empty can exercise, but if the full can has the same EMG activity I don’t see the controversy.

Solution: The Full Can Exercise

This is a simple solution.  The empty can should be a thing of the past at this time.  I am not sure if there is any place for it as an exercise, though I still use it as a provocative test.  As described above, the full can exercise produces the same amount of EMG of the supraspinatus but has the least amount of surrounding muscle activity.  In patients with shoulder pain, weakness of the rotator cuff, or inefficient dynamic stabilization, activities that produce higher levels of deltoid activity in relation to supraspinatus activity, such as the empty can exercise, may be detrimental. This is due to the increased amount of superior humeral head migration that may be observed when the rotator cuff does not adequately compress the humerus within the glenoid fossa to counteract, or oppose, the superior pull of the deltoid.

In addition to the altered ratio of supraspinatus to deltoid muscle activity, there are several reasons why the full can exercise may be preferred over the empty can exercise during rehabilitation and supraspinatus testing. Anatomically, the IR of the humerus during the “empty can” exercise does not allow the greater tuberosity to clear from under the acromion during arm elevation, which may increase subacromial impingement risk because of decreased subacromial space width.

Biomechanically, shoulder abduction performed in extreme IR progressively decreases the abduction moment arm of the supraspinatus from 0-90° of abduction. A diminished mechanical advantage may result in the supraspinatus needing to generate more force, thus increasing the tensile stresses in the injured or healing tendon. This may also make the exercise more challenging for patients with weakness, facilitating compensatory movements such as a shoulder “shrug.”

Scapular kinematics are also different between these exercises, with scapular IR (winging, which occurs in the transverse plane with the scapular medial border moving posterior away from the trunk) and anterior tilt (which occurs in the sagittal plane with the scapular inferior angle moving posterior away from the trunk) being greater with the “empty can” compared to the “full can” exercise. This occurs in part because IR of the humerus in the “empty can” position tensions both the posteroinferior capsule of the glenohumeral joint and the rotator cuff (primarily the infraspinartus). Tension in these structures contribute to produce anterior tilt and IR of the scapula, which contribute to scapular protraction. This is clinically important because scapular protraction has been shown to decrease the width of the subacromial space, increasing the risk of subacromial impingement.

 

Prone Hangs for Knee Extension

What do you do when your patient has some tightness and can’t achieve full knee extension?  That is a common dilemma as a knee flexion contracture is not good for our patients.  One option is prone hangs over the edge of the table.

prone-hang

Why do I dislike this exercise?  When someone can’t achieve full knee extension, there knee typically hurts and is uncomfortable stretching, especially when performing a low-load, long-duration stretch for 10+ minutes.  It is difficult for the patient to relax, avoid compensation, and sit still in this position.  What happens is the patient ends up rotating and flexing his hip to decrease knee extension, and thus minimize any potential benefit from the stretch.  Interestingly, I couldn’t even find a picture of this without a clinician in the photo holding their hip down, which isn’t very realistic for a stretch.

Solution: Supine Knee Extension

By placing the patient supine, they can relax their lower extremity and assume a more normal and comfortable position.  To get the most out of this exercise, I place a rolled up ankle weight under the heel of the patient.  This alone will provide a gentle load into extension from gravity.

Next, another ankle weight is draped over the distal thigh, just above the knee.  Why not right on the knee?  You don’t want to compress the patellofemoral joint.  I use anywhere from 5 to 15 pounds depending on the situation.  To help the patient relax, you can place another weight on the outside of the leg to let the patient relax their groin and allow the hip to not sag into external rotation.  If you still find that the patient is compensating proximally, you can use a strap along the ASISs and under the table, though I very rarely have to do this.

supine-knee-extension

JAS-kneeAlso, don’t underestimate the use of a Joint Active Systems brace for the knee, these things work like a charm and are great for stretching at home.  Rather than use a dynamic brace, the JAS brace allows you to just dial in a stretch and maintain for a long duration of time.  In my opinion we use these tools too infrequently.

 

Working Through a Shoulder Shrug

shrugMany times after shoulder surgery, we want to try to work on both passive and active range of motion.  When a patient is either tight (usually tight inferior capsule) or does not have adequate rotator cuff function (see empty can description above), a shrug may occur.  This can occur during many active and active-assisted ROM exercises such as rope and pulley, L-bar exercises, or simply just during arm elevation.

Why do I dislike this exercise?  It comes down to what is actually happening with the shrug.  If the inferior capsule is tight or the cuff can’t center the humeral head, again, superior humeral head migration occurs.  And what does that cause?  That’s right, impingement.   Over the years I have seen patients try to work through a shrug by working through the exercise or even by watching themselves in a mirror.  Unfortunately, this isn’t a neuromuscular pattern that needs to be relearned.  You need to solve the cause of the shrug first and foremost.

Solution: Train the Cuff to Dynamically Stabilize

I will disregard the solution to the tight inferior capsule, obviously you work on restoring mobility of the inferior capsule.  When a patient can not elevate their arm without shrugging you need to work the cuff below 90 degrees and restore adequate posterior rotator cuff (ER) strength.  I work on rhythmic stabilizations and ER strength predominately and eventually the shrug goes away.  You can also eliminate gravity and perform elevation in the sidelying position.

Unfortunately, there isn’t a quick fix, but if you start to elevate before strength returns, the shrug will likely cause even worse problems.  I have discussed this previously and have a video demonstrating some of these techniques on my post on rehabilitation following rotator cuff repair.  Be sure to follow the link and watch that video.

 

Stool Scooting for Hamstrings

Many patients need to work on hamstring strength.  One rehab exercise I see is stool scooting, where the patient sits and digs their heels into the ground, scooting around your clinic.

stool

Why do I dislike this exercise?  This one isn’t too low down the list for me, I don’t think it is that bad.  But, I really don’t think it is good either.  You really are not getting a lot of hamstring strengthening, you are basically just work on endurance.  But, I tend to not use this because it really irritates patients.  I have seen hamstring tendonitis, pes irritation, and other annoyances that could be avoided.  Sorry, I don’t use this exercise so I didn’t even have a picture of it, nice stool, though!

Solution: Work the Hamstrings Functionally

Realistically, how many times a day do you stand there and flex your knee with your legs together?  Traditional hamstring strengthening exercises are fine when baseline strength is needed, but they should be progressed to train the hamstring more functionally once a fair amount of strength is restored.  Two exercises perfect for this are single leg deadlifts and physioball hamstring curls

I know deadlifts sounds intimidating for a rehabilitation patient, but I am not talking Olympic lifting here, I am talking about hamstring strength and eccentric control of hip flexion.  Really a great exercise.  Here is an excellent video from Michael Boyle:

For physioball curls, there are several variations that work on core stability, hip extension, and trunk control.  The below video is a decent example, there are better example on Youtube, but I this video is well produced and clear:

Behind the Back Internal Rotation Stretching

ir-behind-back

The winner of my least favorite rehabilitation exercise is hand down the behind the back stretch for shoulder internal rotation.  This is performed by the patient actively, with the assist of a towel, or even manually by a clinician.

Why is this my least favorite common rehabilitation exercise?  It places the rotator cuff at an extremely disadvantageous position, placing considerable torque on the rotator cuff insertion.  This can lead to even more irritation or worse for the cuff.  This really isn’t a pure IR stretch, either, it is a combined motion of shoulder extension, adduction, and IR.  My thought is that if the patient is limited in that motion, there must be a reason.  Rather than just jam my hand behind my back and try to push harder or use a towel to torque even more, I would rather try to address cause, not the effect.

Solution: IR and Cross Body Horizontal Adduction Stretching

I am a firm believer that if you have a loss of IR, you can restore this motion easily with simple horizontal adduction stretching and IR stretching at 90 degrees abduction.  For many patients, this will not be enough and you will have to stretch out the inferior capsule.  Notice I didn’t say the posterior capsule.  Limitations in IR at 90 degrees of abduction are from the inferior capsule, and the posterior-band of the inferior capsule.  Perform standard inferior and posteroinferior mobilizations and you should see improvement.

horizontal-adduction-stretch

 

Sorry for the controversy!  I want to hear your thoughts, do you agree or disagree?  What else would you add to this list?  How would you solve these 5 exercises?  To view the original discussion from this original post, follow this link to my Top 5 LEAST Favorite Rehabilitation Exercises.

34 replies
  1. Elizabeth
    Elizabeth says:

    I love this post. I agree that the empty can rings out the supraspinatus, which already has a poor blood supply. I use the IR rope stretch far more than I should. So many of my female patients want to be able to fasten their bra and this exercise is the closest thing to the actual function. What do you suggest I do other than focus on inferior capsule tightness and IR with horizontal adduction?

  2. Robin
    Robin says:

    One clarification on the physioball curls video – to increase stability, move arms into abduction to increase base of support. To decrease base of support, place hands on abdomen.

  3. Katherine
    Katherine says:

    These are fantastic posts. I look forward to this information every week. Thank you for making this accessible to trainers.

  4. john smith
    john smith says:

    When the subscapularis is shut off, IR without pecs need to be implements for isolation. The pecs need to be compromised and stretched out so the subscapularis can be contracted. The best way to accomplish this is by placing the hand behind the back stretching out the pecs and aligning the subscapularis for better contraction advantage. Then lift slowly. This isolates the subscapularis.

  5. Tim Buresh
    Tim Buresh says:

    Hi Mike,

    Unfortunately there is not publication comparing prone hangs to supine heel props. What I can say is that any clinician can easily do this particular clinical trial on a knee patient with passive knee extension deficiency.
    Today March 12, 2012 I was again able to compare the effectiveness of the two positions on two different patients (60 year old with a TKA and an 18 year old with a recent ACL tear).
    The patient with the TKA had a 9 degree extension deficiency with the supine heel props, but reached 0 degrees with the prone hangs. The ACL patient had 0 degrees in supine and 5 degrees hyperextension in prone. In both cases careful goniometric measurement were taken, especially by making sure the goniometer hits the center of the greater trochanter (this is done by first palpation the posterior and anterior borders of the greater trochanter to prevent error).
    Both patients also commented that the prone hangs were more comfortable.
    Over the course of my 16 years as a PT I have found that it is not uncommon to see prone hangs extension measurements be 10 degrees better than what is measured with supine heel props. With both supine and prone exercises pressure is applied per patients tolerance.

  6. Tim Buresh
    Tim Buresh says:

    Mike,

    In regards to your commentary on prone hangs.
    I have done alot of clinical trials comparing the improvement in knee extension using prone hangs with knee on table, prone hangs with knee off table, and heel props. My consistent findings have been that prone hangs with knee on table (edge of table 2 inches below knee) is alot better at improving extension than the other 2 methods.
    Obviously I don’t use prone hangs when there is an incision issue in the anterior knee. If there are other anterior knee issue or discomfort I will position a pillow under the knees.
    You don’t get the teeter totter effect causing the hip to elevate like when your knee is hanging off of the table.
    Every 30-45 sec I have them do 10 reps of gentle prone hamstring curls and then return to the stretch.
    Give this method a try and let me know how it goes. I have had countless successes with this method.

    • Mike Reinold
      Mike Reinold says:

      That sounds great Tim, can you share your research? Did you publish it? Would be interested in sharing your results with everyone, sounds like a great study! Thanks for sharing.

  7. Jim Schueller, CSCS
    Jim Schueller, CSCS says:

    Mike, thanks for the post. In the video of the physioball hamstring curls, do you promote the hip flexion that the young lady allows to happen? When I utilize this exercise with my training clients, I cue them to keep their hips extended throughout the movement. Please clarify if you get a moment. Thanks.

  8. Kasey
    Kasey says:

    Hi Mike,

    Thanks for sharing all of these. I’d be interested to hear your thoughts regarding the behing the back IR stretch being a part of the FMS? When it is just for testing purposes and NOT as an active stretch is your opinion changed or would you change the method of screening shoulder mobility?

    Thanks for all the information you provide,
    Kasey

  9. paresh
    paresh says:

    The morning started off with Super Joints. We spent a few hours going over a ton of different joint mobility exercises, warm-up drills, dynamic and static stretching, contract and relax stretching and various breathing techniques. We spent a lot of time on the hips and were shown various ways to open up and find space in your hip joints so you can get better depth in your squat and deadlift. This part of the workshop was really beneficial for me because I've always had tight hips, tight hamstrings and lower back problems.
    ============================
    Stretching Exercises

  10. mike L
    mike L says:

    Mike L PT/ATC Emg studies have been referred to as " Are the muscles screaming or singing" since muscles are never asked to function solo in the real world why would we ask them to fly solo in an abnormal position that just so happens to make it scream. Thanks for all the thought provoking posts.

  11. Rachel
    Rachel says:

    During PT my trainer has been having me use a Total Gym. At first I thought this was odd, but soon found out it is pretty common. I really like the routine. Any advice if I should purchase once PT is over?

  12. Julie, PT
    Julie, PT says:

    Mike, couldn't agree with you more re: empty can…OUCH! I have never used it.
    I have been using the physioball curls for years for the hams, glutes, as well as for lumbar stabilization.
    I occasionally recommend prone hangs to increase knee extension if the supine position is too uncomfortable; usually utilizing a bed to ease patellofemoral discomort. The most effective method is 15-25lbs of traction distally while a downward force is applied from below the extremity using a pulley system. There is a nylon sleeve spreading the force over the femur and tibia and a cutout for the patella. Patients affectionately call it "The Rack."
    I utilize similar manual techniques to increase internal rotation; but patients want that behind the back movement so I stress that they perform the horizontal adduction stretch first.

  13. Anonymous
    Anonymous says:

    Thank you for this info. I had ACL reconstructive surgery on Nov. 6, 2009. For the last 3 weeks I have been doing the stool scooches. Every time I would be doing these, Iwould say to myself, These cannot be good for me." Finally, this week I told them I did not want to do these. Iwas also getting pain on the outside of my knee. Wondering if the pain came from this exercise, I found your blog. Thanks for your information, my gut feeling was right.

  14. Christopher Johnson
    Christopher Johnson says:

    Mike,

    Keep up the great work and just wanted to add my two cents. Dont forget about lower extremity oscillations to facilitate knee extension rather than prone hangs as your solution is most likely cueing knee flexion. Think about this way…if you were at the edge of a cliff and someone was trying to push you off, the natural response would be to bear down and lean in to them. This is very similar to putting a weight on top of the thigh as the patient's response is going to be to counter it by wanting to flex the knee. Why is it that no one is talking about forward shoulder asymmetry? This is clearly a problem, especially in the overhead athlete. This is a critical impairment or adaptation that we will find out in time is missing from the model of the throwing shoulder. Simply put, when you look at shoulder position in supine, the shoulder that lies more anterior is associated with a greater loss of internal rotation as well as a more restricted tyler test (Johnson et al CSM 2008) and tends to affect the dominant arm to a greater extent especially in the face of pathology. We need to be paying more attention to this impairment!

  15. Christopher Adams, PT, MPT
    Christopher Adams, PT, MPT says:

    Mike,

    One thing I like to add to the supine stability ball curl is a “super bridge”. Everything is the same, but there’s a 3rd component added. (1)Bridge on the ball, (2)perform curl, (3)bridge higher, (4)Lower to 2nd position, (5)Straighten LEs, (6) Lower bridge. I incorporate this into my lumbar/core program as an intermediate to advanced exercise. Patients must be able to maintain neutral spine during exercise.

  16. Christie Downing, PT, DPT, cert.MDT
    Christie Downing, PT, DPT, cert.MDT says:

    …awww, thanks Mike…glad to know I’m appreciated.

    …I’m trying to cut my internet addition. My new i-phone is not helping. But I check your blog about every other day…

    Keep it up.

  17. Mike Reinold
    Mike Reinold says:

    Christie, i have missed you and your great comments!

    Chad, yeah the bridge is the key, have you tried these yourself? They are killer. I can do a HS curl mnachine all day but fatigue out at 10 reps with the ball.

    Harrison, great points, pain is typically bad I would say. Means you are doing something wrong. With the IR stretch specifically, pain tends to be over the anterior aspect near the greater tuberosity, which is the cuff attachment site. Now image stretching the quad and feeling pain on your tib tub, not good right? Now you see my point…

  18. Chad Ballard
    Chad Ballard says:

    Liked the addition of alternative exercises this time around. Never been a fan of supine physioball curls, but I have to admit that I like the addition of maintaining a bridge for additional recruitment and core involvement. I will add that one to my list. Thanks!

  19. Harrison Vaughan, PT, DPT
    Harrison Vaughan, PT, DPT says:

    Good stuff Mike. I especially agree with your empty-can exercise. I deal alot with pain as a whole and I tend to get that some physical therapists do keep the whole "physical torturer" aspect of care. I don't feel exercise should be "painful" (fatigue, yes) or it is completely contradicting. Painful exercises keep people from wanting to exercise, in turn performing HEP; but exercise should be the aspect of their care that they can take home to give them relief of their symptoms. Many are only seen 2x/wk now and pts are more than likely in pain the other 5x/wk, especially initially. I know performing scaption is not in the 'pain-phase' aspect of care but more into 'functional & strengthening phase'; but this is my opinion as a whole. Keep it up!

    Harrison

  20. Christopher Adams, PT, MPT
    Christopher Adams, PT, MPT says:

    Mike,

    Great post and thanks for the tips! I agree with each of your dislikes for the exercises mentioned, especially the IR stretch and the empty can exercise. I’m sure most of us were taught these maneuvers in PT school or clinical rotations. Even then, I thought to myself “This empty can thing hurts…this can’t be good for patients”.

    Keep the posts coming!

  21. Christie Downing, PT, DPT, cert. MDT
    Christie Downing, PT, DPT, cert. MDT says:

    I'm not sure if you remember my post on the hand behind back maneuver. Basically, I had said it's very useful in shoulder derangment syndrome as classified aka McKenzie style if the maneuver leads to an immediate reduction in pain, pain during movements or immediately restores motion/funciton. This is particularly true in people with painful and limited flexion and painful and limited IR>than ext.

    HOWEVER, I will say that in those who worsen with this maneuver, or for those who maintain full extension, the horrizontal ADD is FREQUENTLY the maneuver of choice.

    I've had both patients who did better with hand behind back and not so good with horizontal ADD, and vice versa.

    In the end, in terms of reduction of "shoulder derangement," it's what ever maneuver immediately reduces pain and/or immediately improves function.

    This is a hard concept for people who rely on pathoanatomic diagnosis…sometimes it's just irrelevant!

    …no more comments about ripping off the rotator cuff, please Mike! ;)

    …I definetely like the idea of the hamstring exercises

  22. Mike
    Mike says:

    Nice Post.

    I would have to say that the ball leg curl is much better when the hips are maintained in extension there by training both functions of the hamtring group and involving more glute max.

    Michael Reid

Trackbacks & Pingbacks

  1. […] softball players, primarily because it excessively internally rotates the humerus into the classic “empty can” position traditionally used in rehab settings but becoming a popular contraindicated exercise because of the […]

  2. […] prefer performing LLLD stretching for knee extension in the supine position rather than prone knee hangs (follow the link to learn why).  This has always been a more comfortable and thus more beneficial […]

  3. […] My Top 5 Least Favorite Exercises SOLVED!- Mike Reinold […]

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