Shoulder Rehabilitation and the Kettlebell

May 24, 2019 | Russell Dunning, MPT, MS, SFGII

Our human nature involves repeating tasks daily for work or play; this can include extremes from sitting at a desk for 60+ hrs a week to throwing a ball overhead 100 times a session as hard as possible. Our human nature is to specialize in tasks to improve our performance with our physical health coming second to that end goal. Shoulder physical therapy should be about breaking out of those habits into positions that expose our weakness and lack of control. The kettlebell’s unique design can be essential.

The shoulder issues that commonly plague our human body in fitness, sport, and recreational activity include rotator cuff strains, internal impingements, external impingements, instability dysfunctions, and bicep tendonitis. The common mechanical dysfunctions that lead to these issues can involve thoracic mobility, scapular control/stability, glenohumeral mobility/control/stability, and grip & core strength. The use of a kettlebell is ideal for addressing these issues once functional mobility is established.

The design of the bell allows for two distinct hand positions. The standard position with the hand thread through the handle allows the bell’s weight to become one with your arm while demanding your grip to be fully activated. Our motor sensory cortex places a large emphasis in brain matter on the hand and how it is activated; consequently, the fastest way to improve body and arm strength is through the grip. So with the kettlebell, pretend you are in an arm wrestling match, and you are winning.

The other hand position that necessitates good grip coordination is “bottom up” position. In this position, you place your hand on the bell as if you were to do a pushup on it (on the ground of course), and lift into a bottom up position, balanced. In this position, you can squat, walk, lunge, press, in a position that is inherently unstable due to the bell’s weight position. The instability of the bell demands a grip emphasis. This emphasis allows the user to better co-contract trunk stabilizers. If you don’t believe me, try it. But like many things regarding strength the task needs to feel medium hard (if not hard) to cause adaptation.

Traditional shoulder physical therapies involve using very light weight or tubing in various planes. Once proficiency is established and a reasonable score on a manual muscle test is achieved, then often times the PT or coach will move on to functional drills such as pushing and pulling drills. These methods do not appreciate the importance of doing hard tasks for the body emphasizing core control and grip. The neuro-musculo-skeletal body is a dynamic system rather than a collection of mini systems. An attempt to only work the shoulder in isolation with planar activity undermines how important the neurological strategies our body uses which require grip strength, glenohumeral control, scapular stability, and trunk/core strength. The integration of isolation activity with functional activity is essential.

The path to improve shoulder stability is much easier with functional grip and core strength. From this foundational platform, enhanced shoulder function stems from control through near full range of motion activity. With this perspective, kettlebell halos, Arm Bars, Get Ups, and various carrying patterns are essential. These drills require movement control in both glenohumeral and scapulo-thoracic joint systems. The halo requires near full glenohumeral external rotation, horizontal abduction, flexion and scapulo-thoracic protraction, retraction, and upward rotation. The Arm Bar requires the above in conjunction with thoracic rotation/extension. The Get Up requires all the above in both closed chain and open chain positions. In addition the Get Up requires all trunk and hip stabilizers to work as a team to create fluid movement. The carry series can be used to emphasis any aspect of the above drills as finishing work. A sample shoulder strength and movement program might look like this: Soft Rolling Pattern 1×5 (not covered here), bottom up supine arm bar 12 kg 3×10 sec, standard hold prone arm bar 16kg 3×20 sec, halo 12 kg 1×5, Get Up 12 kg & 16 kg 1×5 each side, Farmer Carry 24kg and Bottom Up rack carry 16 kg 100 ft each, Lateral Raises 3 lbs and External Rotations medium tubing (Isolation) 2×10.

The path to enhanced shoulder stability is predicated on the full functional use of the arm with enough resistance to expose fatigue and weakness (but not so much to lose quality or stability). In other words, the user should feel the difficulty while the coach should see the movement quality. If the outside viewers sees instability/weakness/compensation, then the weight is too much for whichever drill it is. Train stability (Coach says “That looks good!”, user feels “This is hard”) rather than train instability (Coach says “You are losing form!”, user feels “This is impossible”).

Learn more at

Kang M, Oh J, Jang J. Differences in Muscle Activity of the Infraspinatus and Posterior Deltoid during Shoulder External Rotation in Open Kinetic Chain and Closed Kinetic Chain Exercises. J Phys Ther Sci 26:895-897, 2014.

McGill S. Kettlebell Swing, Snatch, and Bottoms-Up Carry: Back and Hip Muscle Activation, Motion, and Low Back Loads. J Stre Cond Res 26(1)/16-27, 2012.

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