Fwd: principals of shoulder rehab

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Principles of Shoulder Rehabilitation

Benjamin D. Rubin MD, MS

Key Points

• The shoulder functions in the context of a kinetic chain, a series of links and segments activated sequentially in a coordinated fashion to generate and transmit force.
• The axioscapular shoulder muscles, which attach the scapula to the thorax, include the serratus anterior, the trapezius, the rhomboids, and the levator scapulae posteriorly, and the pectoralis minor anteriorly.
• The scapulohumeral shoulder muscle group consists of supraspinatus, infraspinatus, teres minor, subscapularis, deltoid, and teres major.
• The axiohumeral muscles are the "power" muscles of the shoulder and include the pectoralis major and latissimus dorsi.
• Abnormal scapular kinematics occur as a result of alterations in anatomy, physiology, and/or biomechanics; or musculoskeletal adaptations to these aberrations.
• The goal of functional rehabilitation goes beyond resolving symptoms to regaining normal function by re-establishing normal anatomy, physiology, biomechanics, and kinematics, thus restoring the integrity of the kinetic chain.

The goal of successful shoulder rehabilitation following an injury or surgery is to establish normal function rather than to merely resolve symptoms. In order to accomplish this, restoration of the normal anatomy, physiology, and biomechanics of the shoulder, as well as correction of any associated musculoskeletal adaptations that have occurred, are necessary to re-establish the normal kinematics. To many, the concept of evaluating and treating the shoulder in the context of the musculoskeletal system, rather than in isolation, represents a paradigm shift from the more traditional approach. This chapter will address shoulder function and dysfunction, and in that light, address the concepts and specifics of core-based functional rehabilitation of the shoulder.

The Shoulder in the Kinetic Chain

The shoulder functions in the context of a kinetic chain, which is defined as a series of links and segments activated sequentially in a coordinated fashion to generate and transmit forces to accomplish a specific function (1,2,3). This can easily be understood by remembering the mechanics of the childhood game "crack the whip," when a group of children holds hands in a line to try to increase the speed of the last child. The first child forms the base and whips the second child, who whips the third, thus transmitting the force and velocity, which are sequentially passed on until the final child is maximally accelerated. Each child represents a segment of the chain, and their joined hands represent links in the chain. In activities that utilize a throwing motion, (e.g., pitching or tennis), there is an open-ended kinetic chain with proximal to distal muscle activation and coordination of body segments producing interactive moments at the terminal segment (hand or racket) (4,5). In throwing, the sequence of link activation begins with the creation of a ground reaction force as a result of the foot and leg pushing against the ground. The force is increased as it is transmitted through the knees and hips through the large muscles of the

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legs, into the lumbopelvic region and the rest of the trunk. The proximal segments, i.e., the legs and trunk, produce roughly half the energy (51%) and force (54%) that is ultimately delivered to the distal end of the kinetic chain (6,7,8). The scapula and glenohumeral joint function as both a link and a segment in the kinetic chain, increasing the kinetic energy and force generated; and as a conduit to funnel and transmit these forces to the distal segments (9).

When an individual reaches, pushes, or pulls from a sitting position, there is less energy and force contribution from the legs, and the primary generator for upper-extremity motion is the initiation of trunk stabilization. Hodges has shown that before either arm or leg movement is initiated, the transverses abdominis is consistently activated first, increasing the intra-abdominal pressure in preparation of the action (10). Coordinated muscle activation sequences result in movement patterns, which create joint motions to efficiently accomplish specific tasks. These diagonal activation patterns create a "serape" effect from the knee or lumbopelvic region to the shoulder (11), act locally on one joint or harmonize several joints, provide co-contraction force couples that control joint perturbations and provide stability, and generate and transmit force. This enables the scapular stabilizing muscles to position the scapula optimally for shoulder function and for the rotator cuff to compress and position the humeral head in the glenoid fossa.

Functional Shoulder Anatomy

The Scapula in Shoulder Function

The scapula provides both anatomic and kinematic connections between the torso and the upper extremity. The shoulder muscles can be classified anatomically by their origins and insertions into the axioscapular, scapulohumeral, and the axiohumeral groups (12). The axioscapular muscles, which attach the scapula to the thorax, include the serratus anterior, the trapezius, the rhomboids, and the levator scapulae posteriorly, and the pectoralis minor anteriorly. These scapular stabilizing muscles position the scapula optimally for the humeral head. In the case of the serratus anterior and the trapezius, the muscles are so large and the muscle fibers course in different directions; therefore, each muscle may have multiple functions that relate to activity and arm position (13).

The scapulohumeral group consists of the supraspinatus, infraspinatus, teres minor, subscapularis, deltoid, and teres major. The rotator cuff muscles provide concavity/compression at the glenohumeral joint and fine tune humeral head rotation and depression, thus keeping the humeral head centered in the glenoid throughout the arc of upper-extremity motion. The axiohumeral muscles are the "power" muscles of the shoulder and include the pectoralis major and latissimus dorsi. The biceps and triceps comprise a special category, because they extend from the scapula to the forearm.

The shoulder is an important kinematic link between the trunk and arm, providing a stable platform for arm rotation during throwing. The shoulder includes the scapulothoracic articulation and the glenohumeral, acromioclavicular, and sternoclavicular joints, which together form two individual but paired mechanisms—one an open chain and one a closed chain (14). A closed kinetic chain, such as the one formed by the thorax, scapula, and clavicle is defined by the terminal link being fixed or immovable. The open kinetic chain mechanism, i.e., the glenohumeral joint, involves movement of the terminal link, which is the hand. Normal function requires that all four articulations participate in a simultaneous, synchronous, and coordinated manner, as well as in succession, creating what is termed scapulohumeral rhythm (15).

Every movement of the scapula involves six degrees of freedom of motion, which involves three rotations and three translations along three orthogonal axes (Fig 22-1). The medial-lateral axis is parallel to the spine of the scapula; the superior-inferior (vertical) axis is perpendicular to the transverse plane; and the anterior-posterior axis is perpendicular to the coronal plane. This six degrees of freedom motion of the scapula can be quite complex and confusing from a biomechanical perspective; therefore, for clinical purposes, the most dominant kinematic parameter for each functional motion is described below. The motions include anterior/posterior tilt (rotation on the sagittal plane about a medial-lateral axis—Fig 22-2A), internal and external rotation (rotation on the transverse plane about a vertical axis—Fig 22-2B), and upward and downward rotation (rotation on the coronal plane about an anterior-posterior axis—Fig 22-2C). Scapular translations are elevation/depression (translation along the vertical axis), abduction/adduction (translation along the medial-lateral axis), and anterior-posterior movement (translation along the anterior-posterior axis). Protraction and retraction, which are terms frequently used in the clinical setting, represent combinations of motions and translations to describe scapular movements and are dependent on the rotation of an intact clavicle about the sternoclavicular joint. Protraction, a movement frequently associated with shoulder dysfunction, involves anterior movement, anterior tilt, and upward rotation. During glenohumeral elevation, the normal scapula demonstrates a pattern of upward rotation, external rotation, and posterior tilting (16). The predominant motion is upward rotation, and to a lesser degree external rotation and posterior tilt. In addition, the scapula translates into a more superior and posterior position (16). Dynamic scapulohumeral rhythm depends on scapular motions and translations, combined with arm motion.

The scapular stabilizing muscles function as force couples to control the motions of the scapula. A force couple is formed when two forces act in opposite directions to impose rotation about an axis (17). The serratus anterior controls the movements of protraction and retraction (abduction and adduction), depending on shoulder position (18). This is counteracted by the upper and lower trapezius and the rhomboids, which act as retractors (adductors). Scapular

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elevation is a function of the upper trapezius, the levator scapula, and the upper serratus anterior. This is balanced by the scapular depression resulting from the function of the lower portions of the trapezius and serratus anterior (12,13,18,19).

Fig 22-2. Scapula rotations.

The Scapula in Shoulder Dysfunction

Abnormal scapular kinematics occur as a result of alterations in anatomy, physiology, and/or biomechanics, or musculoskeletal adaptations to these aberrations, and can usually be classified

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as being proximally or distally derived (Table 22-1) (20). When the basic problem occurs proximal and posterior to the glenohumeral joint, the observed scapular dyskinesis is considered proximally derived (PDSD). When an abnormality of the glenohumeral joint, subacromial space, clavicle, acromioclavicular or sternoclavicular joints occurs, the resulting dyskinesis that is usually observed is considered distally derived (DDSD). The exception to this classification is the presence of shortening or tightness of the pectoralis minor or clavipectoral fascia, which fits best into PDSD despite its anterior position. Recently, Borstad and Ludewig (21) have documented the effect of altered pectoralis minor resting length on scapular kinematics in healthy individuals. In the context of the kinetic chain, PDSD is associated with proximal link or segment weakness or interruption, while DDSD is the result of "recoil" or "kick back" from a distal link or segment dysfunction. This has important implications in the treatment of shoulder and upper-extremity conditions. The pattern of abnormal scapular motion is usually multi-planar and frequently changes with the plane of arm elevation, concentric or eccentric function of the scapular stabilizers, and fatigue; however, if scapular dyskinesis is observed, the sensitivity of the observation is 0.74 and the positive predictive value is 0.84 (22).

TABLE 22-1 Causes of Scapular Dyskinesis

Proximally derived scapular dyskinesis (PDSD) Neurologic Long thoracic neuropathy Spinal accessory neuropathy Dorsal scapular neuropathy Axial Postural dysfunction Scoliosis Lumbopelvic instability (weakness) Proximal kinetic chain interruption Scapulothoracic Axioscapular force couple imbalance (weakness/injury) Pectoralis minor contracture or increased tension Malunited scapula fracture Muscle avulsion Scapulothoracic bursitis Osteochondroma Muscular dystrophy Fibrous contracture Distally derived scapular dyskinesis (DDSD) Glenohumeral Labral tear or detachment Instability Internal impingement Capsular laxity Biceps tendonitis/tears/pulley lesions Focal capsular restrictions (e.g., GIRD) Adhesive capsulitis Glenohumeral arthritis Fracture of glenoid or humeral head Rotator cuff Rotator cuff tears (partial or complete) Rotator cuff tendinosis/tendonitis Calcific tendonitis Primary subacromial impingement syndrome Clavicle and acromion Acromioclavicular dislocations/arthropathy/arthritis Sternoclavicular instability/arthropathy/arthritis Malunion/nonunion of clavicle Malunion/nonunion of acromion Os acromiale

PDSD is frequently associated with postural dysfunction. The classic presentation is that of the patient who sits or stands with the head and neck in a forward position, with focal cervical lordosis (usually at C5-C6), thoracic kyphosis, and protracted scapulae (23). Lumbar lordosis with poor control of the abdominal musculature is frequently associated. Proximal kinetic chain weakness can be due to abnormalities of the lower extremities, lumbopelvic, lumbar, or thoracolumbar deficits. Lumbopelvic weakness appears to be one of the most common causes of primary scapular dyskinesis in the throwing athlete (11). Injury to either the long thoracic nerve or spinal accessory nerve causes weakness and atrophy of the serratus anterior and trapezius, respectively. Long thoracic stretch mononeuropathy is actually more common in overhead athletes than previously thought, and recently has been associated with the use of heavy backpacks by children and young adults (backpack palsy). When these muscles are compromised either from neurologic interruption or fatigue, force couple imbalances ensue, and a significant adverse cascade of events occurs(Fig 22-3). Proprioception is altered, a dyssynchronous muscle firing pattern occurs, with an abnormal increase in scapular mobility (usually loss of external rotation) and subsequent increased stress on the glenohumeral joint capsule, glenoid labrum, and rotator cuff (24,25,26,27,28). Increased protraction has been shown to specifically increase the strain on the anterior band of the inferior glenohumeral ligament and decrease anterior translation of the humeral head (28). As indicated in the discussion above concerning the role of the scapula as a kinematic link between the trunk and the arm, optimum rotator cuff activation occurs only in the presence of a scapula that is optimally positioned for stability (27). As a result, increased intrinsic joint loads and decreased force are delivered to the terminal segment (4).

DDSD is very common. Almost all shoulder pathology is associated with alterations in the ability to position the scapula properly, usually quite early in the pathologic process (8,27,29,30,31,32,33,34,35,36,37,38). Related intra-articular pathology may include labral tears or detachments and capsular attenuation or tears (with resultant instability), focal capsular restrictions such as glenohumeral internal rotation deficit (GIRD), which is commonly seen in overhead athletes, biceps lesions, adhesive capsulitis, and glenohumeral arthritis. Rotator cuff tendonitis and tears, primary impingement syndrome, and calcific tendonitis have been observed to be associated with scapular malposition. In these cases, the pain and altered biomechanics associated with the pathology causes inhibition of the serratus anterior and lower trapezius, with the subsequent events outlined earlier. This results in the vicious cycle of scapular dysfunction and shoulder pathology summarized in Figure 22-3.

Fig 22-3. Cascade of kinetic chain failure.

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Subacromial impingement syndrome has been associated with increased flexion of the thoracic spine, which results in elevation and anterior tilting of the scapula at rest, decreased upward rotation and posterior tilt of the scapula with glenohumeral elevation, decreased elevation of the glenohumeral joint, and decreased force generated at 90 degrees of scapular plane abduction (39). In addition, they have shown that with cervical spine flexion of 25 degrees, there is an increase in scapular upward rotation and a decrease in posterior tilting in healthy subjects. Recently, Meskers et al. (40) have demonstrated that the supraspinatus outlet narrows during elevation in the frontal plane from 30 to 130 degrees; however, with external rotation and movement in the horizontal plane the greater tuberosity moves away from the coracoacromial ligament. Borstad and Ludewig (41) have shown an association between subacromial impingement and anterior tilting, increased internal rotation, and decreased upward rotation of the scapula. Cools et al. (42,43) has shown that patients with subacromial impingement demonstrate a decrease in peak force for isokinetic protraction, decreased protraction/retraction ratio, and decreased EMG activity in the lower trapezius, as well as abnormal muscle recruitment in overhead athletes with delayed activation of the middle and lower trapezius.

Loss of the normal strut function of the clavicle as a result of a displaced, malunited, or ununited fracture, or higher degree acromioclavicular joint dislocation is commonly associated with dyskinetic scapular motion. The pain associated with arthrosis or arthritis of the acromioclavicular or sternoclavicular joint can also cause compromise of the periscapular muscle firing patterns.

In many cases in which shoulder symptoms are chronic, especially glenohumeral instability, GIRD, and rotator cuff tendon failure, it is difficult to determine whether the scapular dyskinesis was instrumental in causing the intra-articular and/or subacromial pathology or vice versa. Over time, there is a significant overlap due to the cyclic nature of the interaction between the segments of the kinetic chain.

Although it is not always possible to determine the primary underlying cause of abnormal scapular motion, it is important to attempt to do so, because correction of the dyskinetic pattern of motion must occur to restore normal shoulder function. This differentiation is made by clinical evaluation, selective injections and response to rehabilitation. In PDSD, surgical intervention is usually not necessary, because most patients respond to correction of posture and weaknesses in the kinetic chain. If the dyskinesis is determined to be distally derived, and the patient does not respond to functional rehabilitation techniques or specific local steroid injections, then surgical intervention is usually required to correct the underlying pathoanatomy to restore the integrity of the kinetic chain.

Principles and Rationale of Core-Based Functional Rehabilitation

The goal of functional rehabilitation is not merely to resolve symptoms, but to regain normal function by re-establishing normal anatomy, physiology, biomechanics, and kinematics, thus restoring the integrity of the kinetic chain (20,44). In some cases, such as in swimmers or patients who function in a seated position, the kinetic chain is somewhat shortened. For this reason, the concept of core-based functional rehabilitation has been introduced (10,45). Based on the concepts outlined above regarding scapular function and dysfunction in the context of the kinetic chain, the rehabilitation process can be made more predictable and successful if the clinician, physical therapist, and athletic trainer adhere to certain principles and guidelines.

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• Core Stabilization. Hodges has demonstrated that before either arm or leg movement is initiated, the transverses abdominis is consistently activated first, to increase the intra-abdominal pressure and stabilize the torso for the anticipated action (10). Therefore, strengthening of the abdominal musculature and the other core muscles is done early in the rehabilitation process. We have found that the incorporation of the principles of Pilates-based exercises, including concentration, breathing, centering, control, precision, flowing motion, isolation, and routine is quite helpful in re-establishing core strength (46).
• Postural Alignment. In order for the body to function properly, it must be in proper alignment. Upper-quarter posture depends on correct positioning of the pelvis, lumbopelvic region, cervical and thoracic spine, scapula, and shoulder. Rehabilitation exercises should be carried out with a neutral spine, appropriate pelvic position, and proper activation of trunk musculature. Shoulder protraction, excessive cervical and lumbar lordosis, and thoracic kyphosis are frequent causes of scapular dysfunction. Postural abnormalities, especially thoracic hypomobility, which is commonly seen, must be corrected early in the rehabilitation process. Exercises should be performed in the erect position as much as possible in order to replicate function.
• Kinetic Chain. Proximal stability must be regained (or obtained) before distal mobility; otherwise, there can be an exacerbation of the distal problem, especially in subacromial impingement (see 4. Scapular Position below). Proper activation of trunk musculature and normal trunk and leg strength and flexibility will facilitate scapular position. Therefore, rehabilitation progresses from proximal to distal. When possible, correct proximal weaknesses first; then add the upper extremity. During this time, scapular and upper extremity exercises can be done in the seated position to separate the dysfunctional segments. The rehabilitation program should integrate functional movement patterns as soon as possible. Trunk stabilization exercises (balance work) are critical to enhance return of normal function.

  Fig 22-4. Scapula Stabilizing System (S3). (From Alignmed, Inc. Santa Ana, Ca; with permission.)

• Scapular Position. Ability to position the scapula properly by retraction and depression is critical to the success of any shoulder rehabilitation program. The scapular stabilizing muscles control protraction when functioning in an eccentric mode. Patients should be taught very early in the process (preoperatively if surgery is contemplated) how to "find" their scapula and position it properly in order to enhance humeral head compression by the rotator cuff and decrease subacromial impingement due to anterior tilting of the acromion. In some cases it is helpful to use either single- or dual-channel surface biofeedback techniques to monitor muscle activity with auditory and/or visual cues. The electrodes are placed to monitor the activity of the muscles and the patient is encouraged to either facilitate (increase) or inhibit (decrease) muscle activity. We have found inhibition of the upper trapezius or latissimus dorsi and activation of the lower trapezius to be particularly beneficial in these patients. It is frequently necessary to re-establish normal length of the periscapular muscles (see 5. Range of Motion below). It is very common for the postoperative patient to develop subacromial bursitis as a result of inability to position the scapula correctly. Various taping and bracing techniques have been developed to decrease the incidence of this occurrence. These techniques do not hold the scapula in position, but rather they provide a proprioceptive link to the brain to stimulate the scapular stabilizing muscles to externally rotate and posteriorly tilt (retract and depress) the scapula, to widen the subacromial space. Recently, Walther and Werner (47) have shown that bracing improves shoulder function. This is consistent with our observations utilizing the Scapular Stabilizing System (S3) device (Alignmed, Inc.) in patients with postural dysfunction and difficulty positioning their scapulae (Fig 22-4).
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• Range of Motion. To achieve normal scapular position, soft tissue restrictions must be addressed. Areas of particular concern in scapular dyskinesis include pectoralis minor, which causes anterior tilting; subscapularis, which causes scapular internal rotation; upper trapezius and levator scapulae, which cause elevation; infraspinatus and teres minor, which prevent normal protraction; and the posterior capsule of the glenohumeral joint. In cases where GIRD is present, the posterior inferior capsule contracture must be corrected early to restore normal glenohumeral kinematics. Postoperatively, range of motion is usually initiated in the scapular plane, but all planes must be included as the patient progresses. Specific surgical procedures must be taken into account during the period of healing.
• Pain.Apainful joint will not progress. During rehabilitation, pain is a sign that the wrong exercise is being done for that phase of the patient's recovery, the exercise is being done incorrectly, or the muscles are showing fatigue. Do not try to push the patient through the pain. Lack of pain is a major criterion for advancement.
• Functional Progression. Progression is based on acquisition of function rather than time; therefore, the phases of the program are based on obtaining normal proximal control and proceeding distally. Learning speed and neuromuscular control differ among patients as a result of different learning abilities, intelligence, age, ability to focus, complicating medical issues, etc. Monitor progress by the overall trend of improvement rather than by chronological landmarks. In general, exercise progression is from general to specific, simple to complex, easy to difficult, proximal to distal, single-plane to multiple-plane, isometric stability to isometric movement, stability to mobility, controlled mobility to skill movements, controlled environment to uncontrolled environment, horizontal movements to vertical movements, and unidirectional movements to multidirectional movements (48). In addition, the patient moves from lesser to greater volume, lesser to greater intensity, and lesser to greater frequency.
• Therapeutic Exercise. Strengthening exercises should incorporate whole-body movements whenever possible. Teach patients to isolate muscles; then train muscle groups in a coordinated, synchronous pattern to re-establish force couples, and thus functional patterns and proprioception. Muscles should be strengthened in concentric and eccentric patterns, with emphasis on control of eccentric movements.
  Closed-chain exercises replicate both the physiologic and biomechanical patterns of movement. Physiologically, there is coordinated muscle firing resulting in rotator cuff muscle coactivation, reciprocal inhibition, and proprioceptive feedback. Biomechanically, there is increased joint compression with decreased shear, translational, and distractive forces on the glenohumeral joint and rotator cuff, with resultant improved control of joint movement and re-establishment of scapulohumeral rhythm. This allows the patient to increase strength and motion while protecting healing and repaired tissue (44,49,50). Closed-chain activities for the shoulder should be primarily eccentric to slow the effects of gravity and inertia and may be used in the reverse-origin mode, for example, using the latissimus dorsi as a trunk extensor rather than as an extensor and medial rotator of the shoulder (50). Open-chain exercises, which enable movement of the terminal segments, increase the stress on the soft tissue structures; however, they are important in completing the recovery to normal function. These exercises involve concentric movement against gravity with no fixation feedback, e.g., free weight training. In general, progression is from closed-chain to open-chain exercises as healing, strength, and control are improved. Incorporation of motor patterns that include the legs and trunk should be done as soon as the patient can tolerate these activities. Sequential distal segment activation is facilitated with exercises that connect the hip and trunk with the scapula, and the scapula with the rotator cuff. Some exercises are performed in diagonal patterns to reproduce the "serape effect."
• Quality versus Quantity. Quality is more important than quantity. Focus on control rather than the number of repetitions. Strengthening exercises should never be performed past the point of fatigue, which is frequently manifested by pain or "loss of form" in doing the exercise. In the postoperative patient, watch for elevation of the scapula as a sign of fatigue of the scapular stabilizing muscles, because this will frequently lead to subacromial bursitis, which usually inhibits functional progression.
• Cardiovascular Training. Aerobic activity is encouraged early in the rehabilitation process to enhance blood flow and healing, as well as encouraging a feeling of control and well being for the patient. Postoperative patients can utilize a stationary bike, stair stepper, treadmill for walking, or elliptical trainer while still in a sling as long as they are comfortable and there is no impact or downward traction such as with running. Impact activities such as running are usually deferred until healing is more advanced, which is usually between 2 and 3 months postoperatively, depending on the procedure.

Phases of Rehabilitation—Goals and Progression Criteria

In the traditional approach, rehabilitation is divided into the acute, recovery, and functional phases. In the acute phase, the goals are to decrease pain and inflammation, promote healing, begin to restore range of motion, and establish more-normal scapulohumeral rhythm, scapular position, and postural and core strength. In the recovery phase, attention is directed to restoring normal range of motion, flexibility, strength, control, and endurance, and normalizing kinematics. Finally, in the functional phase, the goal is to restore work- and sport-specific kinematics, by re-establishing the strength, power, coordination,

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quickness, speed, and endurance required for the desired activity of the patient (20).

TABLE 22-2 Phases of Core-based Functional Rehabilitation

PROXIMAL KINETIC CHAIN    Goals Optimize postural alignment. Correct proximal kinetic chain strength and flexibility deficits. Achieve lumbo-pelvic stability and improve core strength. Improve thoracic spine mobility. Normalize upper quarter soft tissue mobility to accomplish a-d.    Progression Criteria Normal postural alignment, thoracic spine mobility, and core stability. Normal soft tissue mobility in upper one-fourth and periscapular musculature. SCAPULOTHORACIC    Goals Normalize upper quarter soft tissue mobility. Achieve independent scapular positioning to control pain, decrease subacromial impingement, and facilitate muscle education. Strengthen scapular stabilizers and re-establish force couples to position scapula for optimal shoulder function. Restore scapulothoracic kinematics.    Progression Criteria Functional scapular stability and mobility. GLENOHUMERAL    Goals Strengthen rotator cuff in context of kinetic chain; re-establish rotator cuff force couples for joint compression. Begin to restore normal glenohumeral motion and kinematics. Begin to restore normal upper quarter kinematics.    Progression Criteria Full AROM in glenohumeral and scapulothoracic joints. Ability to recruit and train rotator cuff musculature without joint pain. Joint symptoms resolved or at a tolerable level. Independent in-home exercise program. FUNCTION SPECIFIC    Goals Restore function-specific glenohumeral kinematics. Restore function-specific upper quarter kinematics.    Progression Criteria Normal activity-specific upper quarter kinematics, strength, mobility, endurance, and function.

This organization of phases, however, does not seem to relate as well to functional rehabilitation of the shoulder in the context of the kinetic chain as the model that we have recently developed. In our classification (Table 22-2), progression is divided into the proximal kinetic chain, scapulothoracic, glenohumeral, and function-specific phases based on the concepts and principles that have been addressed earlier. Although in this scheme, there may be overlap of phases depending on strength and flexibility deficits of the patient, it is felt that this approach focuses on the return of function in a more kinematic and physiologic manner.

Table 22-3 presents a rehabilitation protocol that is based on these phases and can be used for patients with proximally or distally based scapular dyskinesis, glenohumeral instability, subacromial impingement syndrome, partial-thickness or small full-thickness rotator cuff tears, GIRD, other nonoperative disorders, and preoperative preparation. When surgical intervention is anticipated, preoperative therapy is usually performed for 4 to 6 weeks to improve scapular control preoperatively and to give the patient a head start on postoperative rehabilitation. This list of exercises and treatment options is in an approximate order of progression. By design and necessity it is incomplete, to allow for individualization of the program to meet the specific needs of an individual patient and to encourage physical therapist creativity based on the previously outlined principles. Not all exercises are appropriate for all patients.

In patients who have undergone surgery to correct a problem with instability or labral injury, the phases are divided into the protective, preparatory, progressive, and

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performance phases. The goals of these phases are similar to those outlined in the classification in Table 22-2 with the protective and preparatory phases stressing proximal stability and the progressive and performance phases stressing distal mobility. In the protective phase, it is critical to the success of the program to maintain control of pain and inflammation and to educate the patient regarding postural alignment and scapular control exercises. Progression must take into account adequate time for soft tissue healing. The progression criteria following stabilization surgery are outlined in Table 22-4.

TABLE 22-3 Nenoperative Shoulder Rehabilitation Protocol

Proximal Kinetic Chain Phase Correct proximal kinetic chain weaknesses in lower extremity as necessary Ankle, knee, hip, etc. Postural correction Instruction in neutral spine position T roll or foam roll for thoracic mobility Soft tissue releases as necessary Especially pec minor, subscapularis, pec major, and lat dorsi Core strengthening Pelvic tilt Supine alternate/double leg slides Abdominal crunches Supine supported marching/progression Supine unsupported marching/progression Exercise ball progression-foot slides Sports-specific progression Posterior capsule/cuff stretch Side lying scapula fixed—done at 70 degrees, 90 degrees, 110 degrees elevation Sleeper stretch Stand against wall 90 degrees FF/elbow at 90 degrees passive horizontal add Latissimus dorsi stretch Prayer stretch Passive pectoralis minor stretch (rolled towel or polystyrene foam roll between scapulae) Passive pectoralis major stretch (doorway —> progress to corner) Full kinetic chain movements—all done with scapular retraction at end Grid lunges Grid lunges with opposite trunk rotation dips Step ups with opposite/same side hip flexion Step ups with opposite/same side hip extension Grid lunges with shoulder flexion Grid lunges with shoulder punch Step ups with shoulder flexion and opposite/same side hip flexion Step ups with shoulder flexion and opposite/same side hip extension Step down lunge punch/forward and to side Step down lunge drop punch/forward and to side SCAPULOTHORACIC PHASE Scapular squeeze Scapular clocks Scapular clocks – closed chain Scapular external rotation/depression-reverse corner push ups Lawnmower starts Isometric ball/table humeral head depression Lower trapezius isometics (low rows) Isometric ball/wall Scapular PNF (if P.T. available) Upper one-fourth pivots enables P.T. to identify specific location of weakness Wall rocking Weight shifting on table progression Single leg balance Double leg balance on bubble Single leg balance on bubble Weight shifting—knee to toe progression, then single arm lift Single arm pull down progression Single arm pull down—rotation/same side Single arm pull down—hip flexion/same side Single arm pull down—hip flexion/rotation same side Single arm pull down progression while on bubble Single arm rows progression Single arm rows—rotation/same side Single arm rows—bent knee/same side Single arm rows—bent knee/rotation/same side Single arm rows progression while on bubble Push up plus progression Closed-chain perturbations Prone middle/lower trap lifts Wall angels (isometrics at varying degrees of elevation —> full elevation movements) Scapular depressions on blocks (press up plus) Prone bilateral ER with T-band (on elbows) Exercise ball weight shifting—chest/hips/feet Exercise ball walk outs—chest/hips/feet Rowing/bilateral arms Pull downs/bilateral arms Iron cross with resistance band GLENOHUMERAL PHASE Cuff-specific exercises (done with scapular retraction and depression, correct axial alignment) Isometrics Resistance band IR/ER with good scapular position IR/ER walkouts Sidelying ER Prone ER Flexion, scaption, empty can raises PNF with resistance band-standing/exercise ball Closed-chain perturbations Full kinetic chain coordination Snatch with resistance band Wall wash-standing with squat Pail dumps Exercise ball sitting/tubing in PNF patterns Activity-specific coordinated movements without resistance Progress activity-specific full kinetic chain movements from Phase I item #10 to: e.g., throwing technique swimming technique (breast, freestyle, backstroke, butterfly) tennis strokes (forehand —> backhand —> overhead —> serve) diving hurdle FUNCTION-SPECIFIC PHASE (with Examples) Full range of motion strengthening Activity-specific strengthening progression with resistance (tubing and weights) Open-chain perturbations Activity-specific strength, agility, power, and endurance drills (work with coach and/or trainer) Resistance band mock throwing Ball bounce/wall-single/double arm Sport-specific medicine ball progression Tennis strokes with weights Exercise ball ceiling press (diving) Resistance band swimming prone on exercise ball Sport-specific medicine ball work for swimmers, throwers, divers Handstand sways and pushups for divers Progress activity-specific full kinetic chain movements from Phase I item #10—add weight, repetitions, and plyometrics Grid Lunges with shoulder flexion Grid Lunges with shoulder punch Step ups with shoulder flexion and opposite/same side hip flexion Step ups with shoulder flexion and opposite/same side hip extension Step down lunge punch/forward and to side Step down lunge drop punch/forward and to side Hurdle with jump for divers FF, forward flexion; PNF, proprioceptive neuromuscular facilitation; P.T., physical therapy; ER, external rotation; IR, internal rotation.

Table 22-4 Postoperative Progression Criteria (Anterior instability, posterior instability, multidirectional instability, SLAP, or Bankart repair)

Protective to Preparatory Minimal pain on range of motion and with isometric exercises Adequate scapular control Adequate soft tissue healing Soft tissue restrictions cleared (improving soft tissue, thoracic spine, and GH mobility) Understanding and performance of core stabilization exercises Compliance with home exercise program Preparatory to Progressive Pain-free range of motion Minimal pain with therapeutic exercise Active elevation to 150 degrees Normal soft tissue, thoracic spine, and GH mobility Improved joint kinematics and control Compliance with home exercise program Progressive to Performance Full functional range of motion and flexibility Normal kinematics Pain free with all exercises Adequate scapular control for functional demands Compliance with home exercise program Approximately 75% strength, power, and endurance Graduation Normal upper quarter kinematics, range of motion, flexibility for specific activity or sport Approximately 90% strength, power, and endurance Symptom free with activity or sport-specific drills

Rehabilitation following rotator cuff repair is controversial. Steinman (51) reported that it takes 12 weeks for the development of Sharpey fibers at the footprint of the supraspinatus following surgical repair. On this basis, many surgeons delay range of motion exercises for 4 to 6 weeks and strengthening exercises for 12 weeks. Our postoperative protocol is determined by the size of the tear, quality of repaired tissue, age and physiology of the patient, and quality of the repair. Although postoperative stiffness is a concern, passive range of motion exercises have been shown to activate the rotator cuff musculature (53) and therefore should be done only under optimal conditions. Wise et al. (52) have demonstrated that early closed chain exercises can improve shoulder function while avoiding shear on the glenohumeral joint and excessive traction on the repaired tissue. In a majority of cases, we maintain the operated extremity in a sling for 4 to 6 weeks, permitting active assistive external rotation in adduction and gentle closed-chain active assistive elevation when the patient is comfortable enough to tolerate it. Our goal is for the patient to have approximately 90 degrees of elevation by this time. Passive elevation in the scapular plane is then allowed with a goal of 150 degrees of scaption. After this motion is achieved, open-chain eccentric rotator cuff strengthening between 90 and 150 degrees is encouraged in addition to closed-chain strengthening exercises that were initiated earlier. Wise et al. (52) have shown that based on rotator cuff activation levels, progression can be from closed to open chain, horizontal to vertical to diagonal, and from slow to fast speed.

The programs that have been outlined above allow for functional progression of range of motion, strength and kinematics; however, in the postoperative patient, it is important to protect healing tissues from adverse stress while advancing the process of rehabilitation. Table 22-5 summarizes specific precautions that should be observed after surgical correction of pathology.

TABLE 22-5 Specific Postoperative Precautions by Procedure

Suprapinatus Repair Sling is worn for 3 to 6 weeks (depending on size of tear, quality of tissue, security of repair). Ultrasling is worn at night. Avoid lifting with operated arm, although it is OK to move hand to mouth. Avoid reaching across the body or out to the side. Avoid behind the back reaching for 6 weeks. Subscapularis Repair Sling is worn for 3 to 4 weeks. Ultrasling is worn at night. Avoid lifting with operated arm, although it is OK to move hand to mouth. Limit external rotation to neutral. SLAP Repair Ultrasling is worn 3 to 4 weeks. Avoid lifting with the operated arm, although it is OK to move hand to mouth. Limit ROM to 90 degrees for 3 to 4 weeks. ROM work done with active assistance with elbow bent. Avoid horizontal abduction. Avoid internal rotation in posterior slap repairs. Elevation in scapular plane or forward flexion. External rotation to 45 degrees done in scapular plane for 3 to 4 weeks. Capsular Shift and Capsulolabral Reconstructions Anterior Sling is worn 3 to 4 weeks. Ultrasling at night. No lifting with operated arm for 6 weeks, although it is OK to move hand to mouth. No external rotation in adduction past neutral for 2 to 3 weeks, then OK to externally rotate to 45 degrees in scaption. Elevation in the scapular plane or forward flexion. Avoid combined abduction and external rotation; allow full ROM at 6 weeks post operatively. Posterior Ultrasling worn in gunslinger position for 6 weeks. Avoid forward flexion for 3 weeks. No internal rotation movements past neutral for 3 weeks. Limit active motions to scapular plane, with bias toward external rotation. Avoid horizontal adduction for 6 weeks. Begin gentle active internal rotation in scaption at 4 weeks and reaching behind back for at least 6 weeks post operatively.

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Summary

Successful rehabilitation of the injured or surgically repaired shoulder should be carried out in the context of the kinetic chain in which upper-extremity function occurs. Core-based functional rehabilitation encompasses the concepts of proximal stability and core strengthening before distal mobility; exercising with proper postural alignment; correcting soft tissue restrictions early; teaching the patient to isolate muscles, then training muscle groups in a coordinated, synchronous pattern to re-establish functional patterns and proprioception; and ultimately restoring dynamic stability and normal kinematics. Following the principles that have been discussed in this chapter should allow physicians and therapists to improve the outcomes of treatment in patients with shoulder disorders.

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