Disorders of the Shoulder: Diagnosis and Management
2nd Edition

40
Disease-Specific Methods of Rehabilitation
Brian G. Leggin
Martin J. Kelley
Rehabilitation of the shoulder is a critical component to the recovery of function following surgical procedures. However, the quantity of rehabilitation does not always equate to quality. Each patient requires a different level of intervention. Supervised therapy three times per week is not necessary for all patients. Many patients need only instruction in a home program and periodic evaluation and progression of the rehabilitation program. Therefore, it is incumbent upon therapists, surgeons, and the patient to administer the appropriate amount of rehabilitation following shoulder surgery.
We believe in a team approach to shoulder rehabilitation. The team consists of the surgeon, the therapist, and most importantly, the patient. Frequent and effective communication among team members is essential. The surgeon must provide the patient and therapist with surgical findings, precautions, and contraindications. The therapist must instruct the patient on an appropriate program and
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guide its progression. The patient needs to receive the information, follow through with adherence to precautions and exercise program, and communicate to the therapist and surgeon about progress. When complications develop or progress is not as expected, the therapist must make necessary modifications to the rehabilitation program. If these modifications fail to yield expected results, the therapist should inform the surgeon and make appropriate recommendations. When all members of the team perform their roles effectively, the result is a successful outcome.
A previous chapter discussed the specific exercises and modalities employed in shoulder rehabilitation (Chapter 39). This chapter will discuss the rehabilitation principles and guidelines for common shoulder disorders utilizing those exercises and modalities. The approach to rehabilitation when complications following shoulder surgery occur will also be discussed.
Examination
The postoperative rehabilitation program will depend largely on the pathology, type of surgery performed, and tissue healing. The patient’s impairments and functional limitations must also be considered. There are a few pieces of information that should be gleaned from the history. It is important to note the patient’s age, occupation, and recreational activities, as well as the patient’s goals following surgery and rehabilitation. Whether the patient received any presurgery therapy will help the clinician understand the patient’s conception of rehabilitation. It is also extremely important to communicate with the surgeon who performed the procedure and, if possible, to obtain a copy of the operative note. Gaining this information helps the clinician understand the quality of the soft tissue that was repaired, as well as any nuances of the surgery that may affect the rehabilitation process. Frequently, patients ask the therapist about what was done during surgery. Having a copy of the operative report or communicating directly with the surgeon will allow the therapist to answer that question and further gain the confidence of the patient.
The postoperative physical examination will not include special tests such as impingement signs or instability testing. The examination will be predicated and modified based on the stage of rehabilitation. For example, active range-of-motion (ROM) testing is almost always contraindicated in the first 6 weeks after surgery.
Pain is a parameter that should always be measured, especially during the first 3 months after surgery. The intensity of shoulder pain may vary depending upon the position or activity the patient is engaging in at any one time. Some patients experience very little pain after surgery, especially when their arm is immobilized. However, when they are able to start moving and using their upper extremity, pain may increase. Therefore, a complete assessment of pain should include pain experienced at rest as well as with activities of daily living and more strenuous activities.
Shoulder ROM is an important outcome of shoulder surgery. However, because of the multiplanar motion of the shoulder, it can be difficult to reproduce and compare with results reported by other clinicians.1 In response to the need to standardize measurements, the American Shoulder and Elbow Surgeons (ASES) recommend that four functionally important ranges of motion be documented: forward elevation, external rotation with the arm at the side, external rotation in the 90-degree abducted position, and internal rotation with the hand up the back.2,3 Forward elevation is defined as the maximum angle the arm makes with the trunk when the patient is asked to raise his or her arm above the head with the elbow held straight. It should be noted that this plane of motion is not considered to be true flexion or abduction. Experience tells us that most patients will raise their arm somewhere between true flexion and the plane of the scapula. The angle that the arm makes with the thorax is measured in the upright position for active motion, whereas passive measurement is made in the supine position. We will discuss when it is appropriate to measure each of these motions following specific surgical procedures.
Muscle force assessment is another commonly reported impairment used to document effectiveness of surgical or therapeutic intervention. As with ROM testing, it is important to have standardized testing protocols for reproducibility in a clinical setting. A variety of methods for quantifying muscle performance are available, including manual muscle testing (MMT), handheld isometric dynamometry, and isokinetic dynamometry. MMT is the most widely used method of clinical evaluation of muscle strength.4 This technique, however, has been criticized for its subjectivity and lack of reliability within the good and normal ranges.5,6 Isokinetic devices have fallen out of favor for use in the clinic because they are nonportable, are relatively expensive, and require elaborate setup and stabilization procedures.
Handheld dynamometry has been demonstrated to be reliable in both patient and nonpatient populations.7,8,9,10,11 This method of muscle force measurement is portable, is relatively inexpensive, and does not require elaborate setup. Handheld dynamometry can also detect subtle differences in strength that MMT cannot. To accurately compare results of muscle force measurements, standardization of test position, stabilization, and protocol must be established. Measuring shoulder muscle performance of internal and external rotation with the arm at the side in neutral rotation and forward elevation at 45 degrees in the plane of the scapula has been demonstrated to be reliable and is the authors’ preferred method of shoulder muscle force measurement.11
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Impairment measures alone are not adequate measures of outcome.12 It is also important to document any functional difficulties the patient may have. Several tools have been developed and used to document outcomes of patients with shoulder pathologies, including generic health status measures and condition-specific tools.3,13,14,15,16,17,18,19,20,21,22 Condition-specific tools have been demonstrated to be more responsive than general health status measures in patients with shoulder disorders.14 In the authors’ practice, we use the Penn Shoulder Score (PSS) and the ASES Shoulder Score Index.3,22 Outcome measurement is discussed in more detail in a later chapter (Chapter 41).
Rehabilitation Principles
The principles of rehabilitation after shoulder surgery remain constant regardless of the type of surgery performed. First, pain is always respected and rarely encouraged. Constant reevaluation after the introduction of a new exercise or technique is necessary to help prevent increased symptoms. Any increase in pain should be addressed through patient education on precautions, positioning, and proper exercise technique. Second, treatment is prioritized based on the impairments identified during the examination. Tissue healing is always taken into consideration prior to initiating any rehabilitation program. Third, exercise and techniques are advanced in motion, resistance, and movement planes based on symptoms and the functional demands of the patient. To assess their effect, modalities are introduced to the program one at a time. Range of motion should be restored in a protected, pain-free manner. Once the appropriate time frame for tissue healing has passed and pain and passive range of motion have improved, active range of motion and muscle performance can be assessed and addressed.
Emphasis is placed on the performance of a home exercise program. As such, no more than two or three new exercises are introduced at any one time. This helps the patient digest the information given and hopefully improves compliance and proper performance of the exercises. It also helps the therapist assess the effect a new set of exercises has on the patient. Improvements in these impairments lead to the introduction of activities to replicate the patient’s functional demands.
Patient Education
The importance of patient education cannot be emphasized enough. The patient must understand and adhere to the precautions and instructions outlined by the surgeon and therapist, especially during the first 6 weeks after surgery (Table 40-1). The patient needs to be educated about the healing process and the importance of protecting the surgical repair. The patient should also be instructed in proper positioning of the arm for comfort and to promote healing. Many patients report that while at rest or sleeping, the most comfortable position is with the arm supported in the plane of the scapula. From a biomechanical standpoint, this also appears to be a more advantageous position.
TABLE 40-1 POSTOPERATIVE PRECAUTIONS AND INSTRUCTIONS
Able to use arm for waist-level activities and basic activities of daily living (in appropriate patient)
No leaning on elbows
No sleeping on the involved side (emphasize arm supported in the plane of the scapula)
No sudden movements
No lifting and carrying with involved arm
No pushing or pulling
Importance of home exercise emphasized
Use of ice emphasized
Modalities
In addition to avoiding aggravating activities and positions, modalities have been advocated for pain reduction and relief of inflammation. Much of the evidence for their use is anecdotal or a product of questionable experimental design. A variety of modalities can be used during the rehabilitation process. The four main objectives for using modalities are to (a) reduce pain, (b) reduce inflammation, (c) improve range of motion, and (d) muscle reeducation. Most modalities achieve their physiologic effect by the transfer of thermal energy. These modalities include hot packs, cold packs, ultrasonography, diathermy, and infrared. Another mode of achieving a physiologic effect is through the use of electric stimulation. Electric stimulation modalities include transcutaneous electric nerve stimulation (TENS), as well as low-voltage, high-voltage, interferential, and direct current stimulation.
Range of Motion
Range-of-motion and stretching exercises are designed to prevent adhesions and/or fibrosis, reduce pain, allow collagen healing, and increase tissue length. Postoperative ROM exercises are performed within the direction and protected range allowed with respect to tissue healing and type of surgery performed. Stretching into provocative positions or aggressive stretching should not be performed to avoid putting the surgical repair at risk.
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When restoring normal ROM of the shoulder, one should consider which structure might limit the motion. Studies have shown that external rotation with the arm at the side is most limited by the subscapularis and the coracohumeral ligament.23,24,25 External rotation with the arm at 45 degrees appears to be limited by the subscapularis and middle fibers of the anterior glenohumeral ligament.24 The inferior glenohumeral ligament limits external rotation when the arm is abducted to 90 degrees.24 Gerber and colleagues simulated capsular contractures in cadavers and measured changes in elevation and rotation ROM. They found that restriction of the anterior capsule restricted external rotation ROM and posterior contractures restricted internal rotation ROM.23 Contracture of the superior capsular structures limited rotation motions with the arm adducted.23 Contracture of the inferior structures yielded restriction in abduction and rotation in the more elevated positions.23
We have divided our ROM exercises into phase I and phase II. They have been discussed in more detail in a previous chapter (Chapter 39). Phase I exercises may be initiated within the first 6 weeks postoperatively and include pendulums, passive or active assisted elevation, and external rotation with the arm positioned at 45 degrees in the plane of the scapula (Chapter 39, Fig. 39-7). Phase II ROM exercises are considered more provocative to surgically repaired tissue and may not be initiated until at least 6 weeks after surgery. These exercises include extension, internal rotation, and cross-body adduction (Chapter 39, Fig. 39-9). The patient is asked to take the extremity to a position of tolerable stretch and hold the position for 10 to 20 seconds. Each exercise is repeated 10 times, three to six times per day at home.
Strengthening
Muscular strength refers to the capacity for active tension development by a muscle.26 Multiple factors influence muscle strength.27 Strength gains occur by two types of neuromuscular changes: increased motor unit recruitment and hypertrophy.28 Appropriately loading a muscle will result in hypertrophy or increased muscle mass and, subsequently, increased muscle force production. However, significant strength gains have been shown to occur in the absence of hypertrophy due to improved motor unit recruitment and synchronization.27 Enhancing synchronization of the rotator cuff, deltoid, and scapular muscles, also referred to as neuromuscular training, is generally the rationale for improving shoulder function.
There are several methods therapists can use for improving strength and neuromuscular control. These include manual resistance, elastic resistance, free weights, and machines. Regardless of the method, the underlying principle guiding the therapist is that exercises should begin in nonprovocative or supported positions with a gradual progression toward potentially provocative or functional positions.
Our strengthening exercise program is also categorized by phases and has been discussed in more detail in a previous chapter (Chapter 39). Phase I exercises include external and internal rotation with the arm at the side, and extension with elastic resistance (Chapter 39, Fig. 39-21). Patients are typically asked to perform 10 repetitions with the lightest resistance. They are able to add a second set of 10 when the first set is performed without difficulty. A third set is added when there is no difficulty with the first two. When all three sets become easy, the patient may progress to the next level of resistance. Phase II of the strengthening exercise program is added when the patient can perform all three of the phase I exercises with the third level of resistance. These exercises include abduction to 45 degrees, forward elevation below shoulder level, and external rotation with the arm supported at 45 degrees (Chapter 39, Fig. 39-24).
The scapular strengthening program has also been divided into phases. Phase I is meant to address all portions of the trapezius muscle. Scapular retraction can be performed at three different positions: waist level, above the head, and ground level. Retraction with the resistance above the head should only be performed if this is a pain-free position for the patient. Phase II of the scapular strengthening program includes combination movements such as horizontal abduction with scapular retraction, horizontal adduction with scapular protraction, and scapular retraction with glenohumeral external rotation.
Some patients may go on to more strenuous exercises, which we term phase III. These include activities in more provocative and functional positions. Exercises with a Bodyblade (Hymanson Inc., Playa Del Ray, CA) or plyometrics with a weighted ball can be employed to enhance strength, dynamic control, proprioception, and endurance (Chapter 39, Figs. 39-27, 39-28 and 39-29). Instruction in proper performance and use of variable resistance machines or free weights can also be introduced at this time.
General Rehabilitation Guidelines
As a general guideline, the authors recommend that the patient perform most of the rehabilitation exercises at home during the initial 6 to 12 weeks after surgery. Physical therapy visits are coordinated with the patient’s postoperative physician visits at specified time intervals. Individual patient need may dictate more frequent physical therapy visits. The patient typically returns to the physician 7 to 10 days after surgery. In most cases, the patient is instructed in phase I ROM exercises and asked to perform the exercises three to six times per day until their next physician visit at 6 weeks postsurgery. We recommend supervised therapy for patients who fit one or more of the following criteria: unable to demonstrate exercises properly,
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passive forward elevation ROM less than or equal to 100 degrees, or less than 10-degree improvement in passive forward elevation during the first visit. When the patient exceeds these criteria, he or she may be allowed to continue with the home program. At the 6-week postoperative visit, patients may be instructed in phase II ROM exercises and phase I strengthening. Phase I of the scapular strengthening exercises may also be introduced at this time. Patients may be progressed to phase II strengthening exercises at the 12-week postoperative visit.
Rotator Cuff Dysfunction
Subacromial Decompression with Intact Rotator Cuff
Patients with a prominent anterior acromion who have failed nonoperative management including rest, modalities, nonsteroidal antiinflammatory drugs, exercise, and a subacromial injection of cortisone will be considered for acromioplasty. Open acromioplasty has been an effective procedure with long-term satisfactory results ranging from 80% to 90% in most studies.29,30,31,32 Arthroscopic acromioplasty has demonstrated similar results to open acromioplasty and is now the preferred method of treatment.33 The major advantage of arthroscopic over open decompression is that deltoid detachment is avoided.34 Use of the arthroscope allows inspection of the glenohumeral joint, as well as the undersurface of the rotator cuff, and any pathology encountered can then be addressed.35 Finally, an arthroscopic decompression is less invasive and can be performed more easily on an outpatient basis.35
Following the procedure, the patient is sent home with the arm immobilized in a sling. The patient is allowed to remove the sling on the second postoperative day as long as there is no discomfort. The postoperative instruction packet includes instructions for the patient to perform pendulum exercises, elbow active range of motion (AROM), and hand squeezes four to six times per day. Most patients will be seen by a physical therapist for two to three visits after this type of surgery. Andersen and colleagues demonstrated that a self-training exercise program yielded similar results to physical therapist–supervised (six visits) program following subacromial decompression.36
The patient will return to the surgeon 7 to 10 days postoperatively for suture removal and further instructions. At this time, the patient will be instructed by a physical therapist in phase I ROM exercises including supine passive forward elevation and external rotation (Table 40-2). A majority of patients will be discharged from therapy with this home exercise program to be performed four to six times per day. The next postoperative visit occurs 4 to 6 weeks after surgery. At this point, the patient is instructed in phase II ROM exercises (extension, internal rotation, cross-body adduction), phase I rotator cuff strengthening (external rotation, internal rotation, extension), and scapular retraction with resistance. At the 8- to 12-week postoperative visit the patient will be progressed to phase II strengthening exercises and, possibly, phase II scapular strengthening exercises. Patients with lower demands (nonathletes or laborers) will continue to progress their home exercise program and possibly add a variable resistance program.
Beyond 12 to 16 weeks postoperatively, the patient who must return to work may be gradually progressed to work-simulated activities. Patients are instructed in proper lifting techniques, tool use, and modification of activities. The overhead athlete will be progressed to activities simulating his or her sport demands. Rotator cuff strengthening at 90 degrees abduction, plyometric exercise with weighted balls, and use of the Bodyblade may all be included in this phase of rehabilitation.
Rotator Cuff Repair
Among the many presentations of rotator cuff tears are degenerative or partial-thickness tears, an acute extension of degenerative or partial-thickness tears, chronic full-thickness tears, massive tears involving more than one tendon, associated biceps tendonitis or ruptures, and associated traumatic arthritis of the glenohumeral joint secondary to cuff deficiencies.37 The presence of a rotator cuff tear is not necessarily an indication for surgery.35 The indications for surgical repair of rotator cuff tears are, therefore, the presence of pain or functional deficits that interfere with activities and have not responded to conservative measures.35 Most surgeons continue nonoperative treatment for at least 3 to 4 months before considering repair; when weakness is prominent or progressive, more timely repair may be considered.35
Although the best method for repair of full-thickness rotator cuff tears has been controversial, complete arthroscopic repair techniques have been evolving as an alternative to traditional open and mini-open repairs.38,39,40,41 Neer reported the results of anterior acromioplasty in combination with rotator cuff mobilization and repair in 1972.31 The surgical fundamentals emphasized in that report substantially improved the reliability of the outcomes of repairs of rotator cuff tears.38 The fundamentals include (a) preservation or meticulous repair of the deltoid origin, (b) adequate decompression of the subacromial space by resection of any anteroinferior osteophytes, (c) surgical releases as necessary to obtain freely mobile muscle–tendon units, (d) secure fixation of the tendon to the greater tuberosity, and (e) closely supervised rehabilitation including early passive range of motion within a protected range.38
The current options for rotator cuff repair include the following: (a) arthroscopically assisted open repair, which consists of arthroscopic subacromial decompression followed
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by open repair of the rotator cuff through a lateral deltoid-splitting approach; (b) mini-open arthroscopically assisted repair, which includes arthroscopic subacromial decompression, release of adhesions, placement of tagging sutures, and débridement of the tendon edges followed by a mini-open deltoid splitting approach to obtain suture management and bone–tendon fixation; and (c) complete arthroscopic repair, in which subacromial decompression, release of adhesions, and bone–tendon fixation are all carried out in an arthroscopic fashion.38 Early reported experience with complete arthroscopic rotator cuff repairs has been promising, and the technique has become increasingly popular among experienced shoulder surgeons as a preferred means to obtain repair of the rotator cuff.38 In experienced hands, the technique appears to offer less pain and morbidity as well as quicker recovery than do alternative techniques such as open or mini-open repair.
TABLE 40-2 PENN PRESBYTERIAN MEDICAL CENTER SHOULDER AND ELBOW SERVICE ACROMIOPLASTY GUIDELINES—INTACT ROTATOR CUFF
Phase I: 0–4 Weeks Postoperative
Goals:
  1. Patient education
  2. Permit healing
  3. Control pain and inflammation
  4. Initiate ROM exercises
Treatment:
Immediately postoperative or postoperative day 1:
  1. Immobilized in sling
    Use sling for comfort and public only
  2. Pendulums
  3. Hand squeezes
  4. Elbow AROM
    Supine PROM forward elevation (in appropriate patient)
Postoperative days 7–10:
  1. Pendulums
  2. Supine PROM forward elevation and external rotation
  3. Heat and ice
    Active scapular exercises (shoulder shrugs, scapular retraction)
Phase II: 4–6 Weeks Postoperative
Goals:
  1. Improve to full ROM
  2. Improve neuromuscular control and strength
Treatment:
  1. Continue all stretches
  2. Add phase II stretches (extension, IR, and cross-body adduction)
  3. Progress to phase II strengthening exercises when at green for all phase I strengthening (abduction, forward elevation, and external rotation at 45 degrees in POS with arm supported)
  4. Advanced scapular strengthening
  5. Manual resistance for rotator cuff, deltoid, and PNF
Phase III: 6–12 Weeks Postoperative
Goals:
  1. Full pain-free ROM
  2. Optimize neuromuscular control
  3. Improve endurance
  4. Initiate return to functional activities
Treatment:
  1. Continue all stretches and strengthening; progress rotator cuff exercises into POS abduction
  2. Appropriate variable resistance and/or free-weight resistance
  3. Strengthening above 90 degrees
  4. Plyometrics*/Bodyblade
  5. Work-/sport-specific exercise*
Phase IV: 12–16 Weeks Postoperative
Goals:
  1. Return to sport,* occupation,* or desired activities
  2. Promote concept of prevention
Treatment:
  1. Work hardening*
  2. Sport-specific training*
*Applies to athlete or laborer.
AROM, active range of motion; IR, internal rotation; PNF, proprioceptive neuromuscular facilitation; POS, plane of the scapula; PROM, passive range of motion; ROM, range of motion.
Reprinted with permission from Penn Presbyterian Medical Center, Shoulder and Elbow Service.
Rehabilitation following rotator cuff repair may vary based on surgical technique, cuff tear size, tissue quality, amount of tension at the repair site, patient age, patient goals, functional demands of the patient, and systemic disease processes. The prognosis following repair has been correlated to the rotator cuff tear size, presurgery atrophy, and presurgery ROM restrictions.42,43,44,45,46,47 The amount of postoperative interaction the patient has with the surgeon and therapist is dictated by individual patient need. Typically, the therapist sees the patient at the time of postoperative visits with the surgeon. These visits usually occur 7 to 10 days, 6 weeks, 3 months, and 6 months postoperatively. Approximately 70% of patients in our service are managed in this way. More frequent visits to a therapist may be called for if the patient is not progressing as expected. An assessment of the amount of therapy needed in the first 6 weeks after surgery is made at the first postoperative visit. Patients are
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expected to achieve the following at that visit: at least 100 degrees of passive forward elevation, at least 30 degrees of passive external rotation, and no difficulty performing the home exercises. Patients who do not meet those criteria will be seen in physical therapy on at least a weekly basis until the range of motion improves sufficiently.
Two studies have demonstrated that patients achieve a good outcome after rotator cuff repair regardless of the amount of contact with a physical therapist.48,49 Roddey et al. demonstrated that with a therapist available for questions, patients who utilized a videotape method for their home exercise program instruction had self-reported outcomes equal to patients instructed in their home program personally by a physical therapist.48 However, one must question whether there was really much difference in the treatment technique between the two groups. In addition, 30% of the patients who entered the study dropped out. It is unclear whether they may have entered supervised physical therapy. Hayes and colleagues randomized patients following rotator cuff repair into an individualized physical therapy treatment group and a standardized unsupervised home exercise regime.49 By 24 weeks postoperative, most patients demonstrated favorable outcomes regardless of rehabilitation mode. However, 6% of the patients in the home exercise group sought individualized physical therapy by 6 weeks postoperative, 19% sought physical therapy by 12 weeks postoperative, and 28% sought physical therapy by 24 weeks postoperative.
The rehabilitation program we are presenting consists of a core set of stretching and strengthening exercises. The timing of when these exercises are introduced to the patient depends on the type of procedure performed and size of the rotator cuff tear (Tables 40-3 and 40-4). We will discuss the rehabilitation process after rotator cuff repair through four phases.
Phase I
When beginning rehabilitation after rotator cuff repair, a therapist must know the size of the tear and tendon involvement, quality of the tissue and ease of tendon mobilization, surgical technique, presurgery treatment, and the patient’s goals. Patients who have had repair of a small or medium cuff tear will most likely be immobilized in a sling, with or without a small abduction pillow, to be used for comfort and when they are in public places. The sling is used when dressing or bathing for the first 7 to 10 days. It is then used predominantly when the patient is in a public place.
Patients who have a large or massive rotator cuff repair are oftentimes immobilized in an abduction pillow or brace for the first 3 to 6 weeks postoperatively. The rationale for bracing in this position stems from work to examine the passive tension generated in the supraspinatus musculotendinous unit at the time of repair in patients undergoing repair of long-standing rotator cuff rupture.50 This study found that shoulder adduction increases the amount of passive tension of the muscle. Therefore, positioning the arm at 30 to 45 degrees of elevation in the plane of the scapula would seem to allow healing while reducing the risk of damage to the rotator cuff repair site. Patients immobilized in this way are only allowed to remove the brace for exercising, bathing, and dressing, but must keep the arm passively supported at 45 degrees in the plane of the scapula during those activities. If possible, it is helpful to instruct a family member in the techniques of donning and doffing the brace and supporting the arm during bathing and dressing. We also recommend that a patient utilize a slightly deflated beach ball for support during bathing.
Patients begin with pendulum exercises, elbow AROM, and hand squeezes within the first week after surgery. At the first postoperative visit, patients are instructed in phase I stretching exercises, which are supine passive forward elevation and external rotation with a cane or stick. Emphasis is placed on the patient achieving a tolerable, submaximal stretch several times per day rather than aggressive short bouts of stretching. The patient is asked to perform 10 to 20 repetitions with at least a 10-second hold, four to six times per day at home. The therapist also must assess whether the patient requires more supervised physical therapy during these initial 6 weeks after surgery. We have found that patients who achieve greater than 100 degrees of passive forward elevation or a 10-degree improvement in forward elevation during the first visit do well continuing with the home program on their own. In addition, patients must be able to demonstrate independence with the performance of these exercises. Patients who do not fit these criteria will be recommended for more supervised therapy. The surgeon may hold off beginning these ROM exercises until 3 to 6 weeks postoperatively for some patients with large or massive cuff tears.
Phase II
This stage typically begins 6 weeks after surgery. Patients are asked to continue performing the phase I ROM exercises. The supine forward elevation exercise may now be performed with a cane or stick to achieve end-range forward elevation passive range of motion (PROM). Patients are instructed in phase II ROM exercises and phase I strengthening exercises at this time. Caution must be employed with patients who have had large or massive rotator cuff tears. Restrictions in internal rotation ROM are to be expected due to the nature of the repair. Therefore, this exercise must be performed submaximally. Pain or weakness with the strengthening exercises may necessitate shorter arcs of motion. In some cases of a complex repair or where the integrity of the repair may be in question, rotator cuff strengthening may not be initiated until 8 to 12 weeks postsurgery.
TABLE 40-3 PENN PRESBYTERIAN MEDICAL CENTER SHOULDER AND ELBOW SERVICE REHABILITATION GUIDELINES FOR SMALL/MEDIUM ROTATOR CUFF TEARS FOLLOWING SURGICAL REPAIR
Phase I: 0–6 Weeks Postoperative
Goals:
  1. Patient education
  2. Permit healing
  3. Control pain and inflammation
  4. Initiate ROM exercises
Treatment:
Immediately postoperative or postoperative day 1:
  1. Immobilized in sling
    Use sling for comfort and public only
  2. Pendulum
  3. Hand squeezes
  4. Elbow AROM
Postoperative days 7–10:
  1. Pendulums
  2. Supine PROM forward elevation and ER (at 45 degrees in POS)
  3. Heat and ice
  4. Active scapular exercises (shoulder shrugs and scapular retraction)
Phase II: 6–8 Weeks Postoperative
Goals:
  1. Improve to full ROM
  2. Improve neuromuscular control and strength
  3. Emphasize normal scapulohumeral rhythm
Treatment:
  1. Continue all ROM exercises
  2. Add phase II ROM exercises (extension, IR, and cross-body adduction)
  3. Phase I strengthening (ER, IR, extension)
  4. Submaximal manual resistance (ER/IR) with arm supported
  5. Resisted scapular strengthening (with arms below shoulder height)
Phase III: 8–12 Weeks Postoperative
Goals:
  1. Full pain-free PROM
  2. Optimize neuromuscular control
  3. Improve endurance
  4. Initiate return to functional activities
Treatment:
  1. Resisted scapular strengthening
  2. Manual resistance for rotator cuff and deltoid
  3. Progress to phase II strengthening (abduction, forward elevation, and ER at 45 degrees in POS with arm supported when at green for all phase I exercises)
  4. Appropriate variable resistance and/or free-weight resistance
  5. Strengthening in 45- to 90-degree position (keep pain free and in POS)
Phase IV: 16 Weeks–6 Months Postoperative
Goals:
  1. Return to sport, occupation, or desired activities*
  2. Promote concept of prevention
Treatment:
  1. Work- or sport-specific exercises*
  2. Work hardening*
  3. Gradual return to sport or desired activities*
*Applies to athlete or laborer.
AROM, active range of motion; ER, external rotation; IR, internal rotation; POS, plane of the scapula; PROM, passive range of motion; ROM, range of motion.
Reprinted with permission from Penn Presbyterian Medical Center, Shoulder and Elbow Service.
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Patients who are not progressing as expected may be referred to supervised therapy. To help advance PROM, glenohumeral mobilizations and gentle, relatively pain-free manual stretching can be performed. To augment strengthening, manual resistance can be applied with alternating isometrics beginning with the arm supported at 45 degrees in the plane of the scapula (POS) and neutral rotation. Scapular strengthening exercises can also begin at this time period. Exercises should be performed with the arms below shoulder height to avoid increasing pain.
Phase III
This phase begins 12 weeks after surgery. The patient should have nearly full PROM for forward elevation (FE) and external rotation. It should be expected that internal rotation ROM will be only slightly better than at the beginning of phase II. It is important to assess AROM at this point. Many patients, especially those with large or massive rotator cuff repairs, may not be able to achieve greater than 90 degrees of active forward elevation. The therapist must evaluate whether this deficiency is due to weakness, stiffness, or lack of neuromuscular control. If near full PROM is present and there is good rotator cuff strength with the arm at the side, lack of neuromuscular control is the suspected culprit. It may have been 6 to 12 months since the rotator cuff worked in functional positions, and it is reasonable to suspect that it needs to be “retrained” to work in the elevated or end-range positions. In addition, the deltoid has not been used in this manner and most likely lacks the necessary strength to elevate the arm against gravity.
Patients who are unable to actively elevate the arm against gravity should also perform strengthening exercises
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in the supine position (Fig. 40-1). In this position, gravity is virtually eliminated and patients can “practice” raising their arm past 90 degrees while strengthening the deltoid. When the patient can comfortably perform 30 repetitions of this exercise, the head is slightly elevated to add the weight of gravity to the exercise. This sequence continues until the patient is able to raise the arm while standing upright. This exercise can be enhanced with the use of weighted balls or elastic resistance tied to the foot (Fig. 40-2).
TABLE 40-4 PENN PRESBYTERIAN MEDICAL CENTER SHOULDER AND ELBOW SERVICE REHABILITATION GUIDELINES FOR LARGE/MASSIVE ROTATOR CUFF TEARS FOLLOWING SURGICAL REPAIR
Phase I: 0–6 Weeks Postoperative
Goals:
  1. Patient education
  2. Permit healing
  3. Control pain and inflammation
  4. Initiate ROM exercises
Immediately postoperative or postoperative day 1:
  1. Patients may be immobilized in sling or abduction brace
    If sling, use for comfort and public
    If abduction brace, immobilized for 3–6 weeks
  2. Pendulums
  3. Hand squeezes
  4. Elbow AROM
Postoperative days 7–10:
  1. Pendulums
  2. Supine PROM forward elevation and ER in appropriate patient
  3. Heat and ice
Phase II: 6–12 Weeks Postoperative
Goals:
  1. Improve to full ROM
  2. Improve neuromuscular control and strength
Treatment:
  1. Continue all ROM exercises (add phase I ROM exercises if not performing)
  2. Add gentle phase II ROM (IR, cross-body adduction, and extension)
  3. Submaximal manual resistance (ER/IR) with arm supported
  4. Phase I strengthening (ER, IR, extension)
  5. Resisted scapular strengthening (with arms below shoulder height)
Phase III: 12–16 Weeks Postoperative
Goals:
  1. Full pain-free ROM
  2. Optimize neuromuscular control
  3. Improve endurance
  4. Initiate return to functional activities
Treatment:
  1. Continue all ROM and strengthening
  2. Progress to phase II strengthening when at green for all phase I exercises (abduction, forward elevation, ER at 45 degrees in POS with arm supported)
  3. Manual resistance for rotator cuff and deltoid
Phase IV: 16 Weeks–6 Months Postoperative
Goals:
  1. Return to work, sport, or desired activities*
  2. Promote concept of prevention
Treatment:
  1. Work hardening
  2. Gradual return to work or desired activity
  3. Progress Bodyblade into elevated positions
  4. Work-/sport-specific exercises
*Applies to athlete or laborer.
AROM, active range of motion; ER, external rotation; IR, internal rotation; POS, plane of the scapula; ROM, range of motion.
Reprinted with permission from Penn Presbyterian Medical Center, Shoulder and Elbow Service
Patients who are able to raise their arm against gravity and are able to perform the phase I strengthening exercises with green Thera-Band will be instructed in phase II strengthening exercises. These exercises are designed to begin training the rotator cuff and deltoid for functional demands. However, as always, pain is respected and the intensity of the exercises must be monitored.
Phase IV
This phase typically begins at 16 weeks and continues for up to 6 months postoperatively. At this time, lower-demand patients continue to gradually progress their home exercise program. Patients are encouraged to approach overhead activities with caution and whenever possible to use ladders or stools to raise their hand closer to the task so that the elbow can remain below shoulder level. They are again instructed in the biomechanics of lifting in an effort to reduce the risk of rotator cuff overload.
For the athlete, sport-specific training can begin utilizing plyometrics to enhance neuromuscular control, strength, and proprioception. Recommendations and instruction for proper use of gym equipment should also be done at this time. Patients should be encouraged to avoid exercises with the arm behind the plane of the body. Latissimus
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pull-downs should be performed to the chest, not behind the head. Caution should be employed when performing any type of “pushing” exercise such as chest press or shoulder press. It is safer to perform these exercises with a machine to allow for greater safety.
Figure 40-1 Supine forward elevation progression. (A) Patient begins by performing exercise with elbow bent to 90 degrees. (B) Exercise is progressed to a longer lever arm with elbow fully extended. (C) Exercise against gravity is gradually introduced by increasing the angle of the table. (Reprinted with permission from
Leggin B, Kelley M, Williams G. Postoperative management of the shoulder. Orthopaedic Section Independent Study Course 15.2.6, APTA. La Crosse, WI, 2005:17.
)
The patient who must return to work is gradually progressed to work-simulated activities. Emphasis is placed on simulating work activities in a safe, effective manner. The patient is educated on proper lifting mechanics and ergonomic modifications.
Latissimus Dorsi Tendon Transfer
Irreparable rotator cuff tears are characterized by the inability to achieve a direct repair of the native tendon to the proximal humerus despite mobilization of the remaining
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tissue with conventional techniques of soft tissue release.51 Surgical options that restore tendon continuity in recurrent, irreparable defects are limited by the duration of time since injury and inferior tissue quality.51 Gerber et al.52 described the technique of latissimus dorsi tendon transfer as a reconstructive option for irreparable posterosuperior rotator cuff defects. By replacing damaged and atrophied rotator cuff tissue with a healthy extrinsic tendon, latissimus dorsi tendon transfer is thought to restore an external rotation moment at the glenohumeral joint through both active contraction of the transferred muscle and the passive effect of tenodesis.51,52,53
Figure 40-2 Supine forward elevation progression with weighted ball (A) and elastic resistance (B). (Reprinted with permission from
Leggin B, Kelley M, Williams G. Postoperative management of the shoulder. Orthopaedic Section Independent Study Course 15.2.6, APTA. La Crosse, WI, 2005:17.
)
Gerber reported that more than 80% of the 16 patients in his original study achieved good to excellent results.53 The mean gain in active forward flexion was 52 degrees.53 The mean adjusted Constant score was 73% overall and 82% when patients with a subscapularis lesion were excluded.53 Aoki et al.54 reported on 12 shoulders in 10 patients with irreparable rotator cuff tears treated with transfer of the latissimus dorsi. They reported excellent results in four shoulders, good in four, fair in one, and poor in three. Active forward elevation improved from a preoperative average of 99 degrees to a postoperative average of 135 degrees. Electromyography (EMG) revealed that nine of the 12 transferred muscles showed activity that was synergistic with the supraspinatus on external rotation with abduction.
Warner and Parsons51 compared outcomes for 16 patients who underwent latissimus dorsi transfer as a salvage reconstruction for a failed rotator cuff repair with outcomes for six patients who underwent a primary reconstruction for irreparable cuff defect. There was a statistically significant difference in Constant score between groups, which measured 55% for the salvage group compared with 70% for the primary group.51 Late rupture of the tendon transfer occurred in 44% of patients in the salvage group compared with 17% in the primary group.51 Rupture had a statistically significant effect on the Constant score, with a mean decline of 14%. Therefore, these authors concluded that salvage reconstruction of failed prior rotator cuff repairs yields more limited gains in satisfaction and function than primary latissimus dorsi transfer.51 Factors associated with more limited outcomes among patients in this study included poor tendon quality, severe fatty degeneration, and deltoid detachment.51
Rehabilitation following latissimus dorsi tendon transfer is very similar to the rehabilitation following massive rotator cuff tears, with a few caveats. For the first 6 weeks after surgery, patients may be immobilized in an abduction pillow or brace. Patients will perform pendulum exercises, hand squeezes, elbow AROM, supine passive forward elevation, and external rotation. After 6 weeks, gentle phase II ROM exercises (extension, cross-body adduction, internal rotation) will be added.
Six to 8 weeks after surgery, phase I strengthening exercises (internal rotation, external rotation, extension) with elastic resistance can be added. We have noticed that patients who do well following this procedure have greater internal rotation strength on the involved side than the
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uninvolved side. Although the insertion of the latissimus dorsi has been relocated to the position of an external rotator, the muscle still contracts upon resisted adduction of the arm. Therefore, the latissimus needs to be retrained to act as an external rotator during elevation of the arm.
We begin to retrain the latissimus dorsi by positioning the patient’s arm on a table at 45 degrees elevation in the POS and neutral rotation. The patient is asked to perform an isometric adduction contraction. At the same time the therapist positions the arm in slight external rotation. The patient is asked to hold the arm in this position. This “place-and-hold” technique is performed for all ranges of external rotation until the patient is able to perform a continuous arc of external rotation. The exercise is gradually progressed to greater degrees of elevation up to 90 degrees.
Another training technique we utilize is to position the patient supine with the elbow bent to 90 degrees. The therapist places his or her hands on the medial wrist and medial elbow of the patient. The patient is asked to simultaneously adduct and internally rotate into the therapist’s hands while also raising the arm overhead. This simulates active elevation with a contraction of the latissimus to assist with centralization of the humeral head. This exercise is progressed by gradually raising the angle of the table and subsequently adding gravity until the patient can raise the arm against gravity. The latissimus never contracts without volitional control of the patient. Some patients are able to actively contract the latissimus while elevating the arm. These patients seem to achieve greater overhead function and power than those who are unable to learn this maneuver.
Beyond 12 weeks after surgery, emphasis is placed on improving the strength of the deltoid with both the supine elevation progression and elastic resistance in standing. Scapular strengthening exercises may also be added anytime after the 6-week postoperative period. Many patients are able to begin using the arm at shoulder level at this point. The patient will continue performing a home exercise program aimed at maximizing shoulder function for up to 6 to 12 months after surgery.
Glenohumeral Instability
Glenohumeral instability is defined as abnormal symptomatic translation of the humeral head relative to the glenoid. The incidence of anterior instability (80%) far exceeds that of posterior instability; however, some believe the true incidence of posterior instability (greater than 79%) is not appreciated due to spontaneous relocation and poor diagnostics.55,56,57 The incidence of instability differs for those above and below 40 years of age, with a recurrence rate of more than 79% in those under 30 and 15% in those over 40.56,58,59 The difference in recurrence rate is mostly related to activity level but also to connective tissue differences and associated pathology. One should recognize that the incidence of a rotator cuff tear in the older patient (over 40 years) who experiences an anterior dislocation can be as high as 85%.60,61 Subluxation occurs when partial dissociation of the humerus and glenoid occurs, whereas dislocation occurs when the humerus and glenoid fully separate.
Instability can be classified several ways, the simplest of which are traumatic and atraumatic. Atraumatic instability can be further classified as voluntary and involuntary. Traumatic instability can result from a high-velocity uncontrolled end-range force causing a breach in the capsulolabral–bone interface or Bankart lesion. The acronym TUBS (traumatic, unilateral, Bankart lesion, surgery indicated) is used to describe the characteristics of the traumatic group. Commonly these individuals require surgery to repair the Bankart lesion and to remain active and without recurrence of instability. A second acronym, AMBRI (atraumatic, multidirectional, bilateral, rehabilitation effective, inferior capsular shift if surgery), is used to describe those who suffer from atraumatic instability. These individuals have a patulous capsule due to increased connective tissue elasticity, capsular stretching, or a combination of these two factors with dynamic stabilizer weakness. Commonly these individuals have symptomatic translation in multiple directions and are therefore described as having multidirectional instability. A strengthening program for the glenohumeral and scapulothoracic muscles may be beneficial to this group, but if they do not respond, a capsular shift may be required.62
A Bankart repair is performed to correct unidirectional shoulder instability by reattaching the detached labrum and associated glenohumeral ligaments with little disruption to the length or attachment of other structures around the shoulder. An open Bankart repair may involve detachment and later reattachment of the humeral insertion of the subscapularis and a reattachment of the labrum to the anterior glenoid with sutures through bone or with suture anchors.63 It may also be necessary to reduce any capsular redundancy by tightening the anterior capsule with sutures. The disruption of the subscapularis has implications for postoperative rehabilitation. The surgeon will typically assess the amount of external range of motion available at the time of repair of the subscapularis. It is imperative the patient does not or is not stretched beyond this point during the first 6 to 8 weeks postoperatively. Greis et al. reported on several cases of subscapularis rupture within the first 4 weeks following surgery.64 It should also be noted that open anterior stabilization can be associated with a 12-degree loss of shoulder external rotation.65
Recently, arthroscopic techniques to repair anterior unidirectional glenohumeral instability have been advocated. The advantages of arthroscopic repair include less invasive surgery, no damage to the subscapularis, and, therefore, less loss of external rotation than open procedures. Although there is no damage to the subscapularis during the arthroscopic repair, external rotation range of motion should still be restricted to 30 to 45 degrees during the first
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6 to 8 weeks after surgery. Patients who have undergone arthroscopic stabilization may be held from performing PROM exercises for the first 6 weeks after surgery if the surgeon feels that they have adequate PROM during the first 7 to 10 days after surgery. These patients typically return 6 weeks after surgery with near full PROM.
A recent study compared two rehabilitation programs following arthroscopic Bankart repair.66 One group was immobilized for 3 weeks after surgery prior to initiating ROM exercises. The second group began ROM and submaximal isometric exercises on the third postoperative day. There was no difference in recurrence rate, shoulder scores, return to activity, pain score, and ROM between the two groups at the final follow-up evaluation. However, the group who began rehabilitation sooner demonstrated a faster return to functional ROM and activity, as well as more satisfaction with the rehabilitation program.
TABLE 40-5 PENN PRESBYTERIAN MEDICAL CENTER SHOULDER AND ELBOW SERVICE REHABILITATION GUIDELINES FOLLOWING BANKART PROCEDURE
Phase I: 0–4 Weeks (Exercise 4–6 Times per Day)
Goals:
  1. Patient education
  2. Permit capsuloligamentous labral healing
  3. Control pain and inflammation
  4. Initiate ROM exercises
Treatment:
Postoperative day 1:
  1. Educate patient on precautions
  2. Pendulum exercises
  3. Elbow AROM, hand-squeeze exercises
  4. Ice (instruct patient on use of ice at home)
Postoperative days 7–10:
  1. Continue with pendulum exercises
  2. Phase I stretching
    Forward elevation
    ER at 45 degrees in POS (limit range to 30 degrees)
Phase II: 4–6 Weeks
Goals:
  1. Decreased pain and inflammation
  2. Normal arthrokinematics of glenohumeral and scapulothoracic joint
  3. Improve strength
Treatment:
  1. Continue with above treatment
  2. Phase II stretching (extension, IR, cross-body adduction)
  3. Manual resistance for glenohumeral and scapulothoracic stabilization
  4. Phase I strengthening (at 6 weeks; ER, IR, extension)
  5. Add shoulder shrugs and scapular retraction
Phase III: 6–12 Weeks
Goals:
  1. Increase strength of rotator cuff and deltoid
  2. Increase strength of scapular muscles
  3. Increase total arm strength (biceps, triceps, forearms, etc.)
  4. Initiate strengthening in provocative positions
Treatment:
  1. Continue with above (decrease frequency of stretching exercises)
  2. Add phase II strengthening when at green for phase I strengthening (abduction, forward elevation, ER at 45 degrees in POS); progress strengthening to more provocative positions
  3. Variable resistance and/or free-weight resistance
  4. Bodyblade progression
  5. Plyoball progression (begin with chest pass)
Phase IV: 12–16 Weeks
Goals:
  1. Initiate return to sport or occupational activity*
Treatment:
  1. Bodyblade in overhead positions
  2. Plyoball throwing
  3. Work-/sport-specific activities*
*Applies to athlete or laborer.
AROM, active range of motion; ER, external rotation; IR, internal rotation; POS, plane of the scapula; ROM, range of motion.
Reprinted with permission from Penn Presbyterian Medical Center, Shoulder and Elbow Service.
Rehabilitation Following Bankart Repair
Phase I
Patient education is important in the early phases following surgery. Patients are instructed to use their arm for waist level activities when tolerated. They are cautioned about lifting anything, particularly by pushing the hands together (internal rotation), sleeping on the surgical side, leaning on the elbow, and making sudden movements. They are encouraged to use ice frequently throughout the day. When sitting, the patient is encouraged to position the arm on a pillow or armrest in slight abduction and the arm in neutral rotation. This helps to prevent prolonged internal rotation contractures.
The patient will be shown pendulum exercises the day of surgery and is to perform them four to six times per day (Table 40-5). Hand and wrist exercises are also encouraged.
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The patient will typically be asked to use the sling for comfort or when out in public. At 1 to 2 weeks postoperative, the patient is examined at the surgeon’s office. If the surgeon feels that there is inadequate shoulder range of motion, the patient will begin phase I PROM exercises of forward elevation utilizing the opposite hand, and external rotation with the arm at 45 degrees in the POS utilizing a cane or stick. External rotation should not exceed 30 to 45 degrees or the amount of motion achieved in the operating room for an open procedure. Assessment of generalized hyperelasticity and hypoelasticity should be performed and will guide the progression of ROM exercise. If a hyperelastic patient presents with 150 degrees of elevation and 45 degrees of external rotation within the first 6 weeks following surgery, ROM exercises will be discouraged. However, if a hypoelastic patient presents with significant restriction within the first 6 weeks postsurgery, ROM and stretching will be encouraged.
Phase II
Depending on the status of the patient and quality of repair, the patient will be progressed to phase II ROM and phase I strengthening exercises at 4 to 6 weeks. Either an elastic band or free weights (0.5 to 2 lb) can be used. Stretching is continued in all directions. If the patient is being followed in a supervised manner, manual resistance starting at 45 degrees in the POS can be initiated using alternating isometrics. Scapular muscle integration and appropriate scapulohumeral rhythm is encouraged in all strengthening exercises. The patient can be progressed to phase II strengthening if he or she is able to perform phase I exercises with the third level of elastic resistance or a 4-lb dumbbell. If excessive stiffness is demonstrated, more progressive stretching is performed and joint mobilization techniques can be utilized. Rotational strengthening exercises may be progressed to 45 degrees of elevation.
Phase III
At this time the patient can be progressed to light-weight isotonics, using free weights or variable resistance units. Many times these exercises can be initiated in the latter part of phase II. Strengthening of the biceps and triceps can be initiated. The shoulder should remain in a protected position (less than 20 degrees of elevation) and the scapula “fixed” to integrate scapular muscle function into the exercise. A rowing exercise also can be performed with the same type of resistive equipment. Elastic band or free-weight strengthening is progressed in resistance, repetition, and position of elevation. Diagonal patterns (D2 and D1) can be incorporated into the program. The patient can progress to latissimus pull-downs performed in front of the body. The upper body ergometer (UBE) may be used with motion performed in each direction. The Bodyblade may be used in nonprovocative positions with progression to functional positions and increased time intervals of up to 60 seconds (Chapter 39, Fig. 39-27). The Plyoball progression may be used, particularly if the patient is a competitive or recreational athlete or laborer (Chapter 39, Figs. 39-28 and 39-29). Stretching should continue in this phase until full elevation is achieved and external rotation stretching is progressed to 90 degrees of abduction (90/90 position). External rotation at neutral still may be lacking up to 20 degrees, but external rotation at 90 degrees of elevation should be within 10 degrees of the other side. One must remember that collagen tissue continues to remodel for up to 12 months; therefore, further gains will be achieved over time.
The Athlete
The throwing athlete will be progressed at an accelerated pace, relative to external rotation stretching in phase II since this motion is critical to performance; however, stability cannot be sacrificed. In phase III the throwing or swimming athlete will be advanced to the provocative positions for their glenohumeral dynamic stabilizer exercises. Specific manual techniques may be emphasized for the glenohumeral dynamic stabilizers and scapular muscles. Cardiovascular exercise is strongly encouraged in the group.
Phase IV
Patients will be progressed to phase IV at 12 to 16 weeks and can begin to participate in their particular activities. The swimmer is encouraged to perform slow strokes. The basketball player can begin shooting. The thrower can begin light throwing of a tennis ball; the patient then moves back into an interval program over weeks 14 to 20. Patients can progress their variable resistance for a free program. Chest pressing can be initiated after 14 weeks; however, the degree of horizontal abduction may be limited and weight will be added gradually. We also encourage patients to begin chest presses with a machine that will allow restricted and protected movement.
Rehabilitation Following Anterior Capsulorrhaphy
Anterior capsulorrhaphy is performed to reduce the volume within a redundant capsuloligamentous complex (CLC). The degree of CLC redundancy can vary significantly. Thus, one may encounter a throwing athlete with minimal redundancy and “stiff” connective tissue as opposed to an individual with a very patulous CLC and “loose” connective tissue who has undergone unsuccessful stabilization procedures or has true multidirectional instability. These two types of athletes would be progressed very differently, but with the ultimate goal of allowing CLC
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healing and optimizing neuromuscular control. In the throwing athlete, near-normal ROM would be encouraged, whereas in the individual with failed previous surgeries, ROM restrictions of 10 to 20 degrees may be encouraged. Phase I may be slightly more protracted after capsulorrhaphy as compared with phase I after an open Bankart procedure.
Phase I
Patient education is emphasized and is identical to that of the postoperative Bankart patient. The patient’s arm is placed in a sling following surgery. The initiation of pendulum exercises varies based on the patient’s connective tissue elasticity and the surgeon’s preference. Pendulum exercises typically are started within the first 4 weeks (Table 40-6). Some patients may not begin any type of ROM exercises until 6 weeks.
TABLE 40-6 PENN PRESBYTERIAN MEDICAL CENTER SHOULDER AND ELBOW SERVICE REHABILITATION GUIDELINES FOLLOWING ANTERIOR CAPSULORRAPHY
Phase I: 0–4 Weeks
Goals:
  1. Patient independent with precautions and home exercise program prior to discharge from hospital (typical inpatient hospital stay = 1 day).
  2. Permit capsular healing
  3. Control pain and inflammation
  4. ROM exercises will be initiated depending on surgeon’s preference
Postoperative day 1:
  1. Educate patient on precautions
  2. Pendulum exercises (25 times in each direction), depending on surgeon
  3. Elbow AROM, hand-squeeze exercises
  4. Ice (instruct patient on use of ice at home)
Phase II: 4–6 Weeks
Goals:
  1. Decreased pain and inflammation
  2. Normal arthrokinematics of glenohumeral and scapulothoracic joint
  3. Improved strength
Treatment:
  1. Continue with above treatment
  2. Add phase I stretching (forward elevation and ER in POS); limit ER to 45 degrees
  3. Manual resistance for glenohumeral and scapulothoracic stabilization
  4. Add phase I strengthening
  5. Add shoulder shrugs and scapular retraction
  6. Bodyblade in POS
Phase III: 6–12 Weeks
Goals:
  1. Increase strength of rotator cuff and deltoid
  2. Increase strength of scapular muscles
  3. Increase total arm strength (biceps, triceps, forearms, etc.)
  4. Initiate strengthening in provocative positions
Treatment:
  1. Continue with above (decrease frequency of stretching exercises)
  2. Add phase II stretching (extension, IR, cross-body adduction)
  3. Add phase II strengthening (abduction, forward elevation, ER at 45 degrees in POS)
  4. Variable resistance and/or free-weight resistance
  5. Bodyblade in nonprovocative positions with progression to functional positions
  6. Plyoball progression (begin with chest pass)
Phase IV: 12–16 Weeks
Goals:
  1. Initiate return to sport or occupational activity*
Treatment:
  1. Bodyblade in overhead positions
  2. Plyoball throwing
  3. Work-/sport-specific activities*
*Applies to athlete or laborer.
AROM, active range of motion; ER, external rotation; IR, internal rotation; POS, plane of the scapula; PROM, passive range of motion; ROM, range of motion.
Reprinted with permission from Penn Presbyterian Medical Center, Shoulder and Elbow Service.
Phase II
After 4 to 6 weeks the patient may begin PROM forward elevation with the opposite hand and passive external rotation with the arm placed in 45 degrees in the POS. Forward elevation may be limited to 90 degrees and external rotation may be limited to neutral until 6 to 8 weeks after surgery. At this point, the patient can begin phase II ROM exercises and phase I strengthening exercises using elastic band and/or free weights (0.5 to 2 lb). Elevation exercises are continued, moving toward full range. External rotation stretching may be limited to no more than 45 degrees in the POS. External rotation at 90 degrees in the POS is checked and should not progress beyond 70 degrees. The goal is for this patient to have some degree of tightness by the end of 12 weeks. Approximately 10 to 20 degrees of limited motion in all planes is desired at 12 weeks because continued collagen remodeling will occur over time. This may vary depending on the extent of the capsulorrhaphy
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and if the patient has hyperelastic tissue. Manual strengthening techniques using alternating isometrics in the midrange are strongly emphasized. Although the capsule has been tightened, it is critical that the glenohumeral dynamic stabilizer function be optimized. Short arc manual resistive exercises and/or the use of free weights are utilized in an effort to maximize these muscles in their stabilization function across the glenohumeral joint. Scapular muscle integration is again strongly emphasized. Use of the UBE may begin, again performed in both directions. The Bodyblade can be started toward the end of the phase at 10 to 12 weeks, starting in the nonprovocative position.
Phase III
The patient follows the same regimen as described for that following the Bankart procedure. Again, strong emphasis is placed in midrange function with strengthening being performed and progressed toward the end range. The use of the Plyoball will be based on the functional demands of the patient. If the patient is an athlete or laborer and therefore requires use of the arm in provocative positions, then plyometrics will be utilized in phase III. Various resistance exercises are also performed.
Phase IV
The patient is progressed to activities of phase IV at approximately 16 weeks. If the patient is a throwing athlete, an interval program is initiated. For a swimming athlete, progression will be slow, with initial work on stroke and technique and finally distance. The patient will not be encouraged to aggressively stretch as many swimmers tend to do because such an action may stretch out the reconstruction. A gradual return of ROM will be encouraged in the next 6 to 9 months.
Rehabilitation Following Thermal Capsulorraphy
The arthroscopic application of thermal energy to selectively shrink the glenohumeral joint capsule has been developed over the past 8 to 10 years.67,68,69,70 Several authors have reported 82% to 93% return to competition following thermal-assisted capsulorraphy procedures in overhead athletes.71,72,73,74 However, the use of thermal capsulorraphy to correct shoulder instability may be declining due to poor outcomes reported with this procedure in some patients.75
Phase I
Since the early capsular tensile strength is presumed to be weak, the early rehabilitation program is more conservative than other stabilization procedures.76 The goal in the immediate postoperative period of 4 to 6 weeks is to allow healing of the tissue. This phase consists of distal arm strengthening exercises and providing pain relief.76 Patients are encouraged to keep their arm in a sling most of the day and perform hand squeezes and elbow ROM exercises. They are able to use their arm for waist-level activities and basic activities of daily living.
Phase II
This phase begins 4 to 6 weeks after surgery. Range of motion and rotator cuff strength are assessed at this time. Many patients present with full passive forward elevation and little restriction of external rotation. Patients who may have a restriction in these two motions will be instructed in pendulum exercises and phase I ROM exercises such as forward elevation and external rotation. The patient is encouraged to apply a gentle stretch to the end range of motion to allow gradual and progressive restoration of range of motion.
Phase I strengthening exercises with elastic resistance for external rotation, internal rotation, and extension are initiated at this time as well. Scapular strengthening exercises such as scapular retraction without resistance and progressing toward elastic resistance can also be added at this time. Manual resistance for alternating isometrics to promote stability and proprioception are also useful at this stage. Scapular muscle integration and appropriate scapulohumeral rhythm is encouraged in all strengthening exercises. Patients can be progressed to phase II strengthening if they are able to perform phase I exercises with the third level of elastic resistance or a 4-lb dumbbell.
Phase III
Patients should have achieved nearly full or full range of motion and rotator cuff strength relative to the opposite extremity by 12 weeks postoperative.77 At this time the patient can be progressed to light-weight isotonics, using free weights or variable resistance units. Many times these exercises can be initiated in the latter part of phase II. Strengthening of the biceps and triceps can also be initiated. A seated row exercise with resistive equipment can be performed. Elastic band or free-weight strengthening is progressed in resistance, repetition, and position of elevation. Diagonal patterns (D2 and D1) can be incorporated into the program. The patient can progress to latissimus pull-downs performed in front of the body. It is very important to emphasize this position and discourage the performance of this exercise with the bar brought behind the head due to the potential stress on the anterior glenohumeral joint. The UBE may be used with motion performed in each direction. The Bodyblade may be used in nonprovocative positions with progression to functional positions and increased time intervals of up to 60 seconds (Chapter 39, Fig. 39-27). The plyoball progression may be
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used, particularly if the patient is a competitive or recreational athlete or laborer (Chapter 39, Figs. 39-28 and 39-29).
The Athlete
The throwing athlete will be progressed at an accelerated pace, relative to external rotation stretching in phase II since this motion is critical to performance; however, stability cannot be sacrificed. In phase III throwing or swimming athletes will be advanced to the provocative positions for their glenohumeral dynamic stabilizer exercises. Specific manual techniques may be emphasized for the glenohumeral dynamic stabilizers and scapular muscles. Cardiovascular exercise is strongly encouraged in the group.
Phase IV
Patients will be progressed to phase IV at 12 to 16 weeks and can begin to participate in their particular activities. The swimmer is encouraged to perform slow strokes. The basketball player can begin shooting. The thrower can begin light throwing of a tennis ball; the patient then moves back into an interval program over weeks 14 to 20. Patients can progress their variable resistance for a free program. Chest pressing can be initiated after 14 weeks; however, the degree of horizontal abduction may be limited and weight will be added gradually. We also encourage patients to begin chest presses with a machine that will allow restricted and protected movement.
SLAP Lesions
Superior labrum anterior-posterior (SLAP) lesions have been classified into four distinct categories based on the labral injury and the stability of the labrum–biceps complex found at arthroscopy.78 Subsequent authors have added additional classification categories and specific subtypes.79,80,81 Type I lesions denote fraying and degeneration of the superior labrum with a normal biceps tendon anchor. Type II lesions may have fraying of the superior labrum, but their hallmark is a pathologic detachment of the labrum and biceps anchor from the superior glenoid. In type III SLAP lesions, the superior labrum has a vertical tear analogous to a bucket-handle tear in the meniscus of the knee. A type IV pattern involves a vertical tear of the superior labrum, but this superior labral tear extends to a variable extent up into the biceps tendon as well. The torn biceps tendon tends to displace with the labral flap into the joint, whereas the biceps anchor itself remains firmly attached to the superior glenoid. Last, a complex of two or more SLAP lesions may occur, with the most common presentation being a type II and a type IV.82
Surgical treatment of SLAP lesions is generally performed as described by Snyder et al.78,82 Type I lesions, seen as significant fraying about the superior labrum, are débrided with a shaver placed through the anterior portal.83 Type II lesions, in which the biceps origin and superior labrum are detached from the bony base of the glenoid, are treated, depending on the instability of the lesion and the age of the patient.83 Some type II lesions are relatively stable and can be treated by débridement and bony abrasion alone.83 When the labral detachment is significant and it can easily be pulled off of the superior glenoid, either repair or tenodesis should be considered.83 Younger patients and those who engage in overhead activities are treated with repair. Tenodesis may be preferred for some patients generally over the age of 45 and who do not regularly participate in overhead activities.
Treatment of type III lesions is generally accomplished with débridement of the flapped labrum.83 Type IV lesions are treated depending on the amount of biceps tearing. Those lesions with less than 25% extension into the biceps tendon are treated with débridement alone.83 Those with more than 25% extension into the biceps tendon are treated with either repair in younger patients or tenodesis in older patients.83
The characteristics of rehabilitation following a SLAP lesion débridement or repair are very similar to those found in the rehabilitation following rotator cuff repair and Bankart lesion. Any position, which may create tension on the biceps, should be avoided during the first 6 weeks following surgery and approached with caution thereafter. These positions include shoulder extension, internal rotation behind the back, and using the arm to carry or lift objects with the elbow extended. In addition, external rotation with the arm at 90 degrees of abduction should be approached with caution. When a biceps tenodesis is performed, any resistive active motion of the elbow, either in flexion or supination, is avoided.83
Phase I
Patients are instructed in the precautions as described previously. A sling is used for comfort during the first 7 to 10 days following surgery. Phase I ROM exercises are then initiated and performed to tolerance (Table 40-7). The surgeon may request that external rotation range of motion be limited to 45 degrees in patients who have evidence of a peel-back tear. Patients are expected to achieve full passive forward elevation 6 weeks following surgery.
Phase II
This phase begins 6 weeks after surgery. Active and passive range of motion as well as rotator cuff and deltoid strength are assessed at this time. Patients are instructed in phase II ROM exercises (extension, internal rotation, cross-body adduction) and phase I of the strengthening exercises (external rotation, internal rotation, extension). Scapular retraction exercises with elastic resistance can also be performed at this time.
TABLE 40-7 PENN PRESBYTERIAN MEDICAL CENTER SHOULDER AND ELBOW SERVICE REHABILITATION GUIDELINES FOLLOWING SLAP REPAIR
Phase I: 0–6 Weeks (Exercise 3–5 Times per Day)
Goals:
  1. Patient education
  2. Permit capsuloligamentous labral healing
  3. Control pain and inflammation
  4. Initiate ROM exercises
Treatment:
Postoperative day 1—first postoperative visit:
  1. Educate patient on precautions
  2. Ice (instruct patient on use of ice at home)
Postoperative days 7–10:
  1. Educate patient on precautions
  2. Instruct in pendulum exercises
  3. Phase I stretching
    Forward elevation
    ER at 45 degrees in POS (limit range to 30 degrees)
Phase II: 6–8 Weeks
Goals:
  1. Decreased pain and inflammation
  2. Normal arthrokinematics of glenohumeral and scapulothoracic joint
  3. Improve strength
Treatment:
  1. Continue with above treatment
  2. Phase II stretching (extension, IR, cross-body adduction)
  3. Manual resistance for glenohumeral and scapulothoracic stabilization
  4. Phase I strengthening (at 6 weeks; ER, IR, extension)
  5. Add shoulder shrugs and scapular retraction
Phase III: 8–12 Weeks
Goals:
  1. Increase strength of rotator cuff and deltoid
  2. Increase strength of scapular muscles
  3. Increase total arm strength (biceps, triceps, forearms, etc.)
  4. Initiate strengthening in provocative positions
Treatment:
  1. Continue with above (decrease frequency of stretching exercises)
  2. Add phase II strengthening when at green for phase I strengthening (abduction, forward elevation, ER at 45 degrees in POS); progress strengthening to more provocative positions
  3. Variable resistance and/or free-weight resistance
  4. Bodyblade in nonprovocative positions and progress to functional positions
  5. Plyoball progression (begin with chest pass)
Phase IV: 12–16 Weeks
Goals:
  1. Initiate return to sport or occupational activity*
Treatment:
  1. Bodyblade in overhead positions
  2. Plyoball throwing
  3. Work-/sport-specific activities*
*Applies to athlete or laborer.
ER, external rotation; IR, internal rotation; POS, plane of the scapula; ROM, range of motion.
Reprinted with permission from Penn Presbyterian Medical Center, Shoulder and Elbow Service
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Phase III
This phase begins 10 to 12 weeks after surgery and continues until week 16. Patients who are able to perform the phase I strengthening exercises with the green band are instructed in phase II strengthening (abduction, forward elevation, external rotation supported at 45 degrees). Advanced scapular strengthening exercises may be employed at this time. In addition, biceps strengthening with light weights may begin.
Phase IV
This phase typically begins at 16 weeks and continues for up to 6 months postoperatively. Patients are instructed in the biomechanics of lifting in an effort to reduce the risk of overload. For the athlete, sport-specific training can begin utilizing plyometrics to enhance neuromuscular control, strength, and proprioception. Recommendations and instruction for proper use of gym equipment should also be done at this time. Patients should be encouraged to avoid exercises with the arm behind the plane of the body. Latissimus pull-downs should be performed to the chest, not behind the head. Caution should be employed when performing any type of “pushing” exercise such as chest press or shoulder press. It is safer to perform these exercises with a machine to allow for greater safety.
The patient who must return to work is gradually progressed to work-simulated activities. Emphasis is placed on simulating work activities in a safe, effective manner. The patient is educated on proper lifting mechanics, ergonomic modifications, and common sense.
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Proximal Humerus Fractures
Fractures of the proximal humerus can produce as many as four major fracture fragments.84 These include the head, the greater tuberosity, the lesser tuberosity, and the shaft of the proximal humerus. Neer introduced a four-part classification system based on the anatomic and biomechanical forces that contribute to the displacement of the fracture fragments.85,86 Displacement is defined as greater than or equal to 1 cm of translation or 45 degrees of angulation from the fragment’s normal anatomic position as seen on radiographs.86 A proximal humerus fracture in which none of the major fragments is displaced is a one-part or nondisplaced proximal humerus fracture.
Management of proximal humerus fractures varies depending on the type and amount of displacement. A majority of proximal humerus fractures are nondisplaced and do not require surgery.86,87,88,89 In these cases, the patient’s arm is placed in a sling with the arm at the side. In some two-, three-, and four-part proximal humerus fractures, surgery is indicated. The preferred methods include closed reduction, open reduction and internal fixation, and prosthetic arthroplasty.90 The type of fracture present as well as the medical and functional status of the patient determine the type of procedure to be performed.90
Communication between the therapist, surgeon, and patient is essential to successful rehabilitation following proximal humerus fracture.85 The rate of exercise advancement is coordinated with the surgeon and depends on the severity of the fracture, stability of reduction, and formation of callus.85 In most cases, the patient has never had a previous shoulder injury. Therefore, the patient should be educated on the importance of performing a home exercise program, techniques for pain relief, the length of the rehabilitation process, and expected outcome. Several factors affect outcome, including patient age and compliance with the home exercise program, complexity of the fracture, type of reduction, and soft tissue involvement.85
A detailed history should be obtained from the patient and should include mechanism of injury, presence of additional injuries, prior functional status, and patient’s goals. Proximal humerus fractures result primarily from low bone mass and falls.91,92,93,94,95 These fractures appear to be associated with fractures and fall history; medical conditions such as epilepsy, depression, and diabetes; use of seizure medication; and left-handedness.91 To help prevent another proximal humerus fracture, recommendations for those at risk for a proximal humerus fracture may include moderate levels of physical activity, use of calcium carbonate tablets as a calcium supplement, other measures to reduce loss of bone mass and prevent falls, and maintaining a high dietary calcium intake.91 If the physician has not provided a detailed description of the type and stability of the fracture, the therapist should obtain this information prior to initiating movement of the extremity. The therapist should also perform a good neurovascular examination of the distal extremity.
Phase I
The rehabilitation process may begin when the surgeon is confident that adequate stabilization of the fracture has been achieved. This can be as early as the first postoperative day in many cases. In those cases in which surgery has not been performed or less than ideal fixation has been achieved, the rehabilitation program may require modification.
The importance of performing the home exercise program four to six times per day should be emphasized to the patient. Pain is a major consideration in this population and should always be respected. Many patients with proximal humerus fractures have never had shoulder pain similar to the magnitude they now experience; therefore, it is occasionally more difficult to motivate them to perform their home exercise program. Initial exercises include pendulums, supine passive forward elevation with the opposite hand, and supine passive external rotation with a stick. Patients are slowly advanced to passive extension, internal rotation, and cross-body adduction at approximately 6 weeks postfixation. Special consideration is given to those patients with greater tuberosity fractures because these exercises provide tension to the rotator cuff and its attachment. If excessive tightness is determined, joint mobilization is implemented to facilitate the return of motion.
Phase II
Approximately 6 to 8 weeks postfixation, the patient should have achieved an improvement in passive ROM. Rotator cuff strengthening with isometrics and/or Theraband can begin at this time. In addition, scapular strengthening exercises also may be initiated. If the patient is being followed in supervised therapy, manual isometrics at 45 degrees in the POS can be introduced.
Phase III
Approximately 8 to 12 weeks postfixation, the patient should have 80% full passive ROM and good rotator cuff strength. Phase III strengthening exercises with the elastic band can begin at this time. These exercises include abduction to 45 degrees, forward elevation, and external rotation at 45 degrees. Progression of resistance for shoulder shrugs, scapular retraction, biceps curls, and triceps extension is also accomplished. For patients who are being followed in supervised therapy, manual resistance in unsupported positions can be progressed utilizing alternating isometrics and proprioceptive neuromuscular facilitation (PNF) diagonals.
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Glenohumeral Arthritis
Several diseases affect the osteoarticular surface of the glenohumeral joint and can result in the need for surgical intervention. The most common among these disorders include degenerative osteoarthritis, traumatic arthritis, osteonecrosis, arthritis of glenohumeral instability, rheumatoid arthritis, rotator cuff arthropathy, and crystal-induced arthritis.90,96,97,98 Other less common disorders include hemophilic arthropathy, Paget’s disease, psoriasis, and ochronosis.90 Arthritic conditions can cause deformity of the normal articulating surfaces, loss of the articular cartilage, and synovitis associated with generalized joint inflammation.90 As a result, the patient may experience joint pain, instability, limited active and passive ranges of motion, and decreased strength, which limits the patient’s daily, recreational, and work activities.90 The primary indication for prosthetic arthroplasty is pain that limits functional activity and is not improved with conservative management.90 Limited ROM in the absence of pain is not an indication for surgery.98
Prosthetic joint replacement can include total shoulder arthroplasty or hemiarthroplasty (proximal humeral replacement). Indications for hemiarthroplasty include conditions in which the glenoid is intact, such as acute proximal humerus fractures, avascular necrosis, and younger patients.90,98,99,100 Another indication for hemiarthroplasty is patients who have massive, irreparable deficiencies of the rotator cuff such as those with cuff tear arthropathy, crystal-induced arthritis, and rheumatoid arthritis.29,30,100 Patients with massive rotator cuff deficiency have a higher incidence of glenoid component loosening than patients with the same disease process but an intact rotator cuff.100 Therefore, hemiarthroplasty is the preferred procedure for these patients.90 Total shoulder arthroplasty in patients with an intact rotator cuff and significant glenoid degeneration will result in improved shoulder mechanics and postoperative pain level.90,97,98
Postoperative Rehabilitation
Good communication between the rehabilitation specialist and orthopedic surgeon is critical to successful outcome after shoulder arthroplasty. Rehabilitation after shoulder arthroplasty depends on the underlying diagnosis, integrity of the rotator cuff, and variations in surgical technique. The rehabilitation specialist should know the amount of external rotation and forward elevation achieved by the surgeon at the time of wound closure.90 The kind of joint stability and quality of the subscapularis repair should be determined. The patient’s goals and motivation to participate in the rehabilitation process are also significant factors affecting outcome. Neer recommended classifying patients into standard goals and limited goals categories.98 Those patients with good preoperative ROM and rotator cuff function are placed into the standard goals category (Table 40-8). Patient’s with poor postoperative ROM and/or poor or ruptured rotator cuffs are classified as having limited goals. It is essential for the rehabilitation specialist to have knowledge of as much of these factors as possible prior to initiating the rehabilitation program (Table 40-9).
Phase I
Patients are typically hospitalized for 2 days after surgery. During this time, emphasis is placed on patient education and a core of essential ROM exercises. The rehabilitation process begins the morning of the first postoperative day with patient education. The patient is told to expect swelling and discoloration of the affected extremity and occasionally of the chest wall as a result of the surgery. With the exception of special cases, patients are encouraged to refrain from using the sling unless they are in public or experiencing discomfort. They are also instructed in the use of ice for control of pain and inflammation. Patients can use their extremity for waist-level activities and bring their hand to the mouth with the elbow held at the side. Patients are also asked to not sleep on or make sudden movements with the operated side. In addition, they are asked to avoid lifting, carrying, pushing, pulling, and leaning on the affected side. Evaluation should include documentation of distal neurovascular status and passive arcs of forward elevation and external rotation. In addition, knowledge and documentation of external rotation, forward elevation, and ROM achieved by the surgeon in the operating room is important. To respect the healing of the subscapularis, the patient should be instructed to not exceed the external rotation limitation during the first 6 weeks after surgery.
It should be emphasized that all exercises are to be performed four to six times per day. To help maintain distal upper-extremity strength and decrease distal extremity swelling, the patient is instructed in hand-squeezing exercises and elbow-active ROM. The patient is also instructed in pendulum exercises, which are to be performed 25 times in each direction. Supine passive forward elevation with the opposite hand and external rotation with a stick or the opposite hand holding the forearm are instituted in the afternoon session on the first postoperative day. Patients are asked to perform these exercises in their room when they are not being seen by the therapist. Criteria for discharge from the hospital include independence with the exercise program and precautions, passive forward elevation of 120 degrees, and passive external rotation of 20 degrees.
Patients in the limited goals category often have bilateral shoulder disease or polyarticular arthritis and may require modification of the exercise program. This may include help from a family member or arrangement of home or outpatient therapy.
TABLE 40-8 PENN PRESBYTERIAN MEDICAL CENTER SHOULDER AND ELBOW SERVICE REHABILITATION GUIDELINES FOLLOWING TOTAL SHOULDER ARTHROPLASTY
Phase I: 0–3 Weeks (Exercise 4–6 Times per Day)
Goals:
  1. Patient education
  2. Allow healing of subscapularis
  3. Control pain and inflammation
  4. Initiate ROM exercises
Postoperative day 1 (a.m. session):
  1. Educate patient on precautions
  2. Pendulum exercises
  3. Elbow AROM, hand-squeeze exercises
  4. Ice (instruct patient on use of ice at home)
Postoperative day 1 (p.m. session):
  1. Review precautions
  2. Pendulums, elbow AROM, and hand squeezes
  3. Supine passive forward elevation stretching in POS
  4. Supine passive ER stretching in POS (within limits of range achieved in OR)
  5. Ice
Postoperative days 2–5:
  1. Continue with above until patient is independent with home exercises and precautions
  2. Begin light ADLs (hand to mouth, writing, etc.)
  3. Ice
Postoperative days 7–10 (first MD visit postoperative):
  1. Review home exercise program
  2. Add phase II stretching (if good tissue quality)
    PROM extension, IR, and cross-body adduction
Phase II: 3–8 Weeks
Goals:
  1. Decreased pain and inflammation
  2. Increased ADLs
  3. Continue stretching until full PROM is achieved
  4. Initiate strengthening exercises
Treatment:
  1. Review all exercises and precautions
  2. Add phase II stretching (if not already)
  3. Initiate light isometrics for rotator cuff (may omit IR depending on healing of subscapularis)
  4. Progress to phase I strengthening at 4–6 weeks (ER, IR, extension)
  5. Scapular strengthening (shoulder shrugs, scapular retraction)
Phase III: 6–12 Weeks
Goals:
  1. PROM full and pain free
  2. Increase functional activities
  3. Increase strength of scapular stabilizers
Treatment:
  1. Phase II strengthening (abduction, forward elevation, ER at 45 degrees in POS)
  2. Upper-extremity PNF diagonals
  3. Progress resistance of shoulder shrugs, scapular retraction, biceps, triceps
Phase IV: 12–16 Weeks
Goals:
  1. Full functional activities
  2. Return to work or sport*
Treatment:
  1. Work- or sport-specific training*
  2. Suggest modifications to work, sport, or functional activities*
*Applies to athlete or laborer.
ADL, activity of daily living; AROM, active range of motion; ER, external rotation; IR, internal rotation; OR, operating room; PNF, proprioceptive neuromuscular facilitation; POS, plane of the scapula; PROM, passive range of motion; ROM, range of motion.
Reprinted with permission from Penn Presbyterian Medical Center, Shoulder and Elbow Service.
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Phase II
Patients continue all stretching exercises until full passive ROM is achieved. At 3 to 6 weeks after surgery, patients in the standard goals category should be able to perform many of their waist-level activities of daily living. At 6 weeks after surgery, phase II ROM exercises (extension, internal rotation, and cross-body adduction) and phase I strengthening exercises with elastic bands can be instituted and progressed. When the patient is able to perform all phase I exercises with the green band, phase II strengthening exercises can begin. In addition, shoulder shrugs and scapular retraction exercises can begin.
Patients who are having difficulty achieving full passive ROM may be followed in supervised therapy. Glenohumeral joint mobilizations and gentle manual stretching can be initiated to help improve ROM. The patient may also be given a pulley for home use to help achieve full passive forward elevation. Manual resistance to external and internal rotation with the arm supported at 45 degrees in the POS can be initiated using alternating isometrics.
Patients in the limited goals category will begin the phase II stretching exercises at 3 to 6 weeks postoperatively. They may also initiate submaximal rotator cuff isometrics and scapular strengthening at this time.
TABLE 40-9 PENN PRESBYTERIAN MEDICAL CENTER SHOULDER AND ELBOW SERVICE REHABILITATION GUIDELINES FOLLOWING TOTAL SHOULDER ARTHROPLASTY—LIMITED GOALS
Phase I: 0–3 Weeks (Exercise 4–6 Times per Day)
Goals:
  1. Stress importance of precautions and performance of home exercise program
  2. Allow healing of subscapularis
  3. Control pain and inflammation
  4. Initiate ROM exercises (instruct family member, etc., in exercises)
Postoperative day 1 (a.m. session):
  1. Educate patient on precautions
  2. Pendulum exercises
  3. Elbow AROM, hand-squeeze exercises
  4. Ice (instruct patient on use of ice at home)
Postoperative day 1 (p.m. session):
  1. Review precautions
  2. Patient performs pendulums, elbow AROM, and hand squeezes
  3. Supine passive forward elevation stretching in POS*
  4. Supine passive ER stretching in POS (within limits of range achieved in OR)*
Postoperative days 2–5:
  1. Continue with above until patient is independent with home exercises and precautions
  2. Add standing AAROM extension with stick
  3. Begin light ADLs (hand to mouth, writing, etc.)
  4. Ice
Postoperative days 7–10:
  1. Review home exercise program
Phase II: 3–8 Weeks
Goals:
  1. Decrease pain and inflammation
  2. Increase ADLs
Treatment:
  1. Review all exercises and precautions
  2. Phase II stretching (PROM extension, IR, and cross-body adduction)
  3. Submaximal rotator cuff isometrics
Phase III: 8–12 Weeks
Goals:
  1. ROM full and pain free
  2. Increase functional activities
  3. Begin rotator cuff strengthening
Treatment:
  1. Continue with above
  2. Phase I strengthening (ER, IR, extension)
Phase IV: 12–16 Weeks:
Goals:
  1. Return to functional activities
  2. Continue to improve strength
Treatment:
  1. Continue with all stretches and strengthening
  2. Add scapular strengthening
  3. Add phase II strengthening if able
*Instruct patient or caregiver.
ADL, activity of daily living; AAROM, active assisted range of motion; AROM, active range of motion; ER, external rotation; IR, internal rotation; OR, operating room; POS, plane of the scapula; PROM, passive range of motion; ROM, range of motion.
Reprinted with permission from Penn Presbyterian Medical Center, Shoulder and Elbow Service.
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Phase III
Twelve weeks after surgery, the patient should have 80% full and pain-free passive ROM, as well as good rotator cuff strength. Phase II strengthening exercises with the elastic band can usually begin if they have not already. These exercises include abduction to 45 degrees, forward elevation, and external rotation with the arm supported at 45 degrees. Progression of resistance for shoulder shrugs, scapular retraction, biceps curls, and triceps extension is accomplished. For patients who are being followed in supervised therapy, manual resistance in unsupported positions can be progressed utilizing alternating isometrics and PNF diagonals. Patients with limited goals should have adequate soft tissue healing and stability of the glenohumeral components and can begin phase I strengthening exercises.
Evaluation of the integrity of the subscapularis may also be performed at this time. Miller and colleagues101 performed a retrospective review of 41 patients following total shoulder arthroplasty. Terminal internal rotation was evaluated by the lift-off and belly-press examinations. Abnormal results were found for 25 of 37 lift-off examinations (67.5%) and 24 of 36 belly-press examinations (66.6%). Of 25 patients with an abnormal lift-off finding, 92% reported reduced subscapularis function.
Phase IV
The patient will be progressed to this phase at approximately 16 weeks postsurgery. This phase includes work- or sport-specific training as well as suggestions for modification of work, sport, or functional activities. Patients are discouraged from participating in heavy work or recreational
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activities that result in high loads and forces to the glenohumeral joint.90 Golf, swimming, bicycling, aerobics, and running activities are acceptable activities for patients following shoulder arthroplasty. To decrease the load on the shoulder during these activities, the therapist should emphasize proper mechanics and improving overall flexibility. Patients with severe arthritis or poor soft tissues with massive rotator cuff tears typically have lower functional demands and are typically satisfied with their ability to perform normal daily activities.
Multidirectional and Voluntary Instability
Multidirectional instability is defined as dislocation or subluxation in a combination of anterior, posterior, or inferior directions. The basic pathology is congenital or acquired patulous capsuloligamentous complex that lacks the stabilizing barrier and compression effect. The degree of instability may vary from those being able to participate in athletic events to those unable to lift the arm without subluxing. Typically, the labrum is intact but fraying or tearing may occur with repetitive instability events.102 Often individuals with multidirectional instability are athletes such as swimmers and gymnasts who commonly have generalized hyperelasticity. Patients may describe diffuse achy pain with activity or at rest. Instability can be sensed with normal daily or overhead high-demand activities and weakness or paresthesias may be reported. Atraumatic posterior instability may be most notable.
An interesting patient group labeled as having multidirectional instability are those who habitually or voluntarily sublux. This includes patients who can sublux at will but are asymptomatic and do not require treatment. However, the symptomatic group may sublux/dislocate for secondary gain or psychiatric reasons but some appear to have developed an unconscious coordinated muscle firing sequence resulting in instability. EMG and biofeedback studies have identified several different abnormal firing patterns involving a combination of increased activation of the anterior deltoid and pectoralis major in conjunction with decreased activation of the posterior rotator cuff and serratus anterior.103,104,105 Significant medial scapular winging can be associated with voluntary and involuntary instability (usually posterior). Although abnormal muscle activation patterns can result in posterior instability, we also believe that immediate posterior subluxation during elevation causes serratus anterior “shutdown.”
Figure 40-3 (A) Posterior subluxation and scapular winging present during elevation. (B) Scapular external rotation stabilization maneuver reduces the joint and eliminates the winging.
Examination
Instability testing typically reveals increased translation in all directions and an excessive sulcus sign. Posture and scapular position are noted. A depressed and downwardly rotated scapula may predispose the joint to instability.106 Inadequate scapula muscle integration is identified by poor scapular stabilization during active range motion or resisted motion testing in multiple positions. Patients are stratified into those with and without scapular winging. Patients with scapular winging usually are considered to have abnormal firing patterns, symptomatic voluntary instability, or significant compromise of the CLC (i.e., patulous CLC, large SLAP lesions). If patients present with scapular winging during sagittal plane elevation, they are asked to repeat elevation with the arm maintained in external rotation. Elimination of scapular winging confirms posterior instability. This is called an external rotation stabilization maneuver (Fig. 40-3). Our belief is that many patients immediately posteriorly sublux, causing the serratus anterior
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to reduce firing. We have measured multidirectional instability patients who demonstrate significant scapular winging using three-dimensional telemetry and electromyography and found limited scapular upward rotation and posterior tilt in conjunction with dramatic reduced firing of the serratus anterior (16% maximal voluntary contraction). Our studies have shown scapular kinematics and serratus anterior activation to normalize when the patient elevates while maintaining external rotation. Some patients, usually those with voluntary instability or those with an unconscious abnormal firing pattern, require serratus anterior preactivation to reduce the joint and prevent scapular winging. The patient is asked to protract and slightly elevate the scapula with the arms at the side followed by shoulder elevation in the sagittal plane while maintaining shoulder external rotation (Fig. 40-4). The patient must reach slightly forward to suppress attempts to downwardly rotate the scapula. The ability to dramatically reduce scapular winging and improve elevation or achieve full elevation identifies the posterior instability component and abnormal muscle recruitment patterns. If winging persists, the examination algorithm presented in the Scapular Muscle Dysfunction section is followed.
Figure 40-4 Preactivating the serratus anterior by protracting and slightly elevating the scapula while keeping the arms at the side.
Intervention
All patients demonstrating multidirectional instability without scapular winging are initially treated with glenohumeral stabilizer strengthening exercises in nonprovocative positions with scapular muscle integration.107,108 Special attention is directed toward activating scapular muscles in isolation and then in combination with arm motion. Strengthening must be pain free and the patient’s shoulder is palpated to identify subluxation while exercising. Manual resistance is applied since immediate feedback is gained for position or resistance accommodation. Initially, isometrics are utilized in varying planes and degrees of elevation. If stable and pain free, the patient is progressed to short arc motions and eventually full arc motions. Elastic bands or free-weight exercises are progressed from nonprovocative to provocative elevated positions. Functional strengthening and proprioceptive training can be achieved manually with the Bodyblade (Hymanson Inc., Playa Del Ray, CA) and Plyoball as discussed in Chapter 39. Depending on the degree of instability and the patient’s demands, a limited or complete upper-extremity strengthening program is initiated. Closed-chain exercises may be utilized in certain athletic populations such as gymnasts or wrestlers. Patients who respond to a conservative approach but are felt to be high risk for future instability events are strongly discouraged from performing bench pressing, flys, overhead presses, or pushups.
Patients with scapular winging and a positive external rotation stabilization maneuver (including those requiring serratus anterior preactivation) are treated with a specific program. First poor resting scapular positioning is addressed through postural retraining and scapular retractor muscle activation. The essential component of intervention with this group is making the patient aware of repetitive subluxations. The vicious cycle of instability, pain, and muscle deactivation resulting in more instability must be broken. We show patients their abnormal movement pattern when elevating either in the mirror or by video. They are then instructed in an accentuated corrected movement pattern by preactivating the serratus anterior (protract and slightly elevate the scapula) and elevating in external rotation. The change in symptoms and range is dramatic and has a significant visual feedback effect if played back on video. The patient is instructed that during daily activities requiring forward reaching, they are to do so by using this accentuated movement pattern. This reduces the number of subluxations, breaking the vicious cycle, and it “uninstalls” the abnormal pattern and “installs” an appropriate pattern. Biofeedback may also be used for muscle retraining.104,105 Along with postural exercise, the only other initial exercise the patient may receive is to isolate the serratus anterior by protracting and slightly elevating the scapula (arms at side). They are to do this 10 to 20 times 10 times a day. When symptoms and subluxation events reduce, patients are asked to do the
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same but lift the arm to 90 degrees in the sagittal plane while maintaining external rotation. If they sublux or the scapula wings, they are not ready to progress. Typically by 1 to 2 weeks, patients have integrated appropriate muscle activation so that elevation occurs with a normal movement pattern, the glenohumeral joint remains stable, and the scapula is fixed on the thoracic wall—they have installed the new program.
Once the symptoms are controlled, subluxation events are significantly reduced, and the movement pattern looks normal, the patient is started on glenohumeral strengthening with scapular muscle integration, already discussed previously. Some patients may require further unconventional strengthening by having them hold a stick with the elbows bent at 90 degrees and in supination. They perform an isometric for the external rotators by attempting to pull the stick apart and elevate the arms in the sagittal plane while maintaining the isometric pull.
Since some patients function with asymptomatic instability, success is returning them to this status. Returning a patient back to a high level of functioning can be difficult.109 If stability is improved but cannot be fully regained for low-demand activities, surgery is considered. Patients are required to go through a conservative rehabilitation program, especially those with scapular winging. We have found the response to the movement retraining helpful in surgery selection and improved postsurgical outcomes.
Multidirectional instability is a challenge to both the therapist and surgeon. Recognition of the pathology and using a symptom-dependent exercise progression program can return patients back to symptom-free activities. Patients with scapular winging and abnormal firing patterns require special attention since most will fail if the subluxation frequency and abnormal firing patterns are not addressed.
Scapular Winging and Dyskinesia
Scapular dyskinesia is an alteration in the normal position or motion of the scapula during coupled scapulohumeral movements.110 Scapular winging may be considered a type of scapular dyskinesia characterized by significant scapular medial border displacement during shoulder motion. Quantitative scapular kinematic studies have shown abnormal scapular motion associated with certain pathologies.111,112,113 Unfortunately, the equipment used to attain these measurements is not clinically applicable. The clinician is left with visual inspection and linear measurements that have low reliability.114 Insight regarding the origin, examination, and intervention of scapular dyskinesia continues to develop.
Kuhn115,116 described a classification system for scapular winging: primary, secondary and voluntary. Primary winging is related to neurologic, osseous, and soft tissue pathology. The two most common reasons for neurologic scapular winging are long thoracic nerve, affecting the serratus anterior, and spinal accessory nerve palsy, affecting the trapezius. Kuhn discussed a rarely seen winging due to rhomboid weakness created by a dorsal scapular nerve palsy or C-5 radiculopathy. Mixed palsies due to brachial plexopathy can also occur. Osseous malformations such as osteochondromas, clavicular malunions, or scoliosis cause scapular winging. Soft tissue abnormalities such as muscle ruptures, congenital absence anomalies, or scapular bursitis can result in scapular winging. Secondary winging is related to pathology at the glenohumeral joint or related tissues and the acromioclavicular joint. Glenohumeral joint instability, typically posterior, is a common cause of scapular winging. Scapular winging or dyskinesia is often related to poor scapular motor control in an intact neural system. This is referred to as motor control dyskinesia, and although it is seen in conjunction with other shoulder pathology, it is commonly encountered among asymptomatic individuals. The third category causing scapular winging is voluntary, nonpathologic and pathologic. Patients without true pathology but who coordinate muscle activity to cause scapular winging represent the nonpathologic group, while those with true pathology (i.e., instability and symptomatic voluntarily wing) are categorized as pathologic.
Examination
Kelley described an examination algorithm for scapular muscle assessment to determine if winging was due to neurologic, secondary causes and motor control dyskinesia.117 The patient is first observed standing for resting winging and obvious atrophy. If resting winging is noted, the patient is checked for a scoliosis demonstrated by a thoracic rib hump during trunk flexion. Active range of motion of both shoulders is assessed in the standing position by elevating in the sagittal plane. Significant scapular winging that normalizes beyond 90 degrees during sagittal plane flexion elevation is related to motor control dyskinesia (typically the serratus anterior). If medial winging persists beyond 90 degrees, a long thoracic nerve palsy or posterior glenohumeral instability is suspected. Posterior instability causes scapular winging for two reasons: reflexive serratus anterior “shut down” resulting from immediate posterior subluxation or abnormal shoulder girdle muscle activation. The patient is then asked to elevate the arm in the sagittal plane while the arm is maintained in full external rotation to differentiate between instability or a long thoracic nerve palsy. This is referred to as the external rotation stabilizing maneuver (Fig. 40-3). Sometimes preactivating the serratus anterior by scapular protraction and slight elevation is required, especially in those patients who habitually sublux or have developed an unconscious abnormal firing pattern (discussed in the Multidirectional and Voluntary Instability section). Elimination of scapular winging with the external rotation stabilizing maneuver identifies
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the underlying pathology as posterior instability. Maintaining humeral external rotation during elevation tightens the capsuloligamentous complex in addition to contracting the external rotators, both of which prevent posterior subluxation and allow normal serratus anterior activation. Further instability special tests can be performed to confirm instability.
Figure 40-5 (A) Plus sign is performed by having the patient elevate to 90 degrees and then reach forward. (B) The scapula should protract along the thoracic wall but if winging increases, it is a sign of complete paralysis.
If humeral external rotation does not eliminate scapular winging, the patient is asked to perform scapular protraction and slight scapular elevation while the arm is at 90 degrees of sagittal plane flexion. This is called a “plus” sign. The lower trapezius commonly attempts to stabilize the medial border during forward flexion in the presence of a long thoracic nerve palsy. When protraction at 90 degrees is performed, the lower trapezius reflexively deactivates due to antagonistic inhibition and the serratus anterior is left to control scapular movement. If scapular winging increases during attempted protraction, the patient is considered to have absent serratus anterior activity. Inability to protract the scapula on the thoracic wall is referred to as a positive “plus” sign (Fig. 40-5). If the patient protracts and the scapula fully moves forward on the thoracic wall or the movement is incomplete, motor dyskinesia or partial serratus anterior activity due to a recovering palsy is suspected, respectively. A recovering long thoracic nerve palsy cannot be ruled out if complete scapular protraction is achieved since enough fibers may be innervated to complete the task. Next the patient is asked to place the arm at 135 degrees of sagittal plane elevation and the examiner resists, pushing into shoulder extension while palpating the scapular inferior border.118 Easy posterior displacement of the inferior border with minimal resistance is a sign of significant serratus anterior weakness and considered to be a resolving neurologic insult. Patients with very dramatic scapular dyskinesia but an intact neurologic system and void of glenohumeral subluxation will easily maintain the scapula fixed on the thoracic wall during resisted shoulder flexion at 135 degrees.
Identification of a spinal accessory nerve injury is assisted by the presence of trapezius atrophy and a depressed and protracted shoulder girdle. Coronal plane abduction is then performed and scapular movement noted. If good sagittal plane elevation is present but the patient cannot lift above 90 degrees in the true coronal plane (without pain), a spinal accessory nerve palsy is suspected. The trapezius is further examined by performing the “flip” sign.119,120 The “flip” sign is performed with the examiner standing to the patient’s side and resisting the involved shoulder’s external rotators. The examiner visually examines the scapula to determine if the scapular medial border “flips” from the thoracic wall.120 A positive “flip” sign occurs when significant displacement of the medial border occurs off the thoracic wall. The mechanism for this sign is unopposed pull of the infraspinatus and posterior deltoid by the middle and lower trapezius. Interestingly, the rhomboid muscle does not spontaneously activate to stabilize the scapula in this position. Further isolation to determine manual muscle testing strength grade of the middle and lower trapezius can be performed with the patient prone as described by Kendall and McCreary.118
Intervention
Rehabilitation will be discussed for patients with neurologic involvement, glenohumeral instability, and motor control dyskinesia.
Neurologic Involvement
Rehabilitation of the individual with either a long thoracic or spinal accessory nerve palsy begins with understanding
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pathology. There is nothing we can do to facilitate reinnervation other than creating a friendly environment for nerve regeneration. Postural education and supporting the arm are important to eliminate the dependent weight of the extremity, minimize scapular depression, avoid separation of headed neck, and reduce pain. The most important aspect of rehabilitation in this patient population is improving scapular muscle compensatory activity. Individuals with serratus anterior paralysis are encouraged to activate the rhomboid and trapezius to gain greater stabilization and upper extremity “power.” The patient is instructed in exercise to isolate and integrate the rhomboid and middle and lower trapezius by retracting and/or elevating the scapula. Phase I strengthening exercises (external rotation, internal rotation, and extension) are performed by first preactivating the trapezius and rhomboid. Resisted elbow flexion and extension exercises are performed with scapular muscle integration. Teaching scapular muscle preactivation encourages scapular stability during distal functional movement patterns. Diagonal patterns simulating a “backhand” are performed emphasizing scapular retraction. Manual therapy is performed to isolate and challenge the retractors. As the nerve recovers and serratus anterior muscle activation is noted, the serratus may first be activated supine, performing a scapular protraction with the arm positioned at 90 degrees. Exercise is progressed to standing and then with resistance. Progression to weight-bearing exercise is attempted in a graduated manner.
A patient with a spinal accessory nerve palsy is encouraged to isolate and integrate the serratus anterior and rhomboid. The same exercises previously described are performed, in addition to forward flexion with a “plus.” The progression includes diagonal patterns and gravity-minimized and antigravity positions.
Intermittent visits are encouraged when treating both long thoracic or spinal accessory nerve palsies in conjunction with a consistent home exercise program since recovery following is time dependent.
Glenohumeral Instability
Rehabilitation of patients with primary instability (usually posterior) and scapular winging is achieved by attempting to stabilize the glenohumeral joint. Commonly, these patients have a history of voluntary subluxation. Voluntary instability or patients trapped in an unconscious pattern activate/deactivate scapular, axiohumeral, and glenohumeral muscles to sublux the glenohumeral joint and create scapular winging. Patients must be made aware of their volitional involvement. Subluxation typically occurs with any attempted forward movement of the arm. The external rotation stabilizing maneuver is performed. This maneuver can prevent the subluxation, suppress abnormal muscle firing patterns, and eliminate scapular winging. The patient must understand the inflammatory nature of the vicious cycle; subluxation leads to pain and joint irritation resulting in reflexive muscle shutdown, which results in instability. The cycle must be interrupted and the frequency of subluxations reduced. Once this is achieved, typical strengthening of the glenohumeral and scapulothoracic stabilizers can be performed.
Motor Control Dyskinesia
Rehabilitation of individuals with scapular motor control dyskinesia requires a thorough examination and integration of anatomechanics and kinesiology. Some degree of motor control dyskinesia is quite common in the general population, but most remain asymptomatic. Weight lifters or those who previously performed heavy bench pressing or high-repetition pushups tend to demonstrate poor eccentric scapular muscle control. Symptomatic dyskinesia occurs in throwing athletes who demonstrate significant resting scapular depression and protraction. Burkhart et al.121 described the SICK scapula in which the abnormal scapular resting position results in altered kinematics and ultimately rotator cuff tendinopathy and glenohumeral instability. Pectoralis minor stretching helps to reestablish a normal resting position, allowing appropriate scapular posterior tilting and rotation during elevation. Isolation through manual techniques and/or active range of motion is essential to teach scapular muscle control.121,122 Unfortunately, many therapists believe dyskinesia is related to inadequate “strength”; however, we believe it is related to poor muscle “control.” Aggressive scapular muscle strengthening can increase symptoms due to provocative positioning. Once appropriate scapular muscle isolation and coordination is achieved, resistance is applied either manually, with elastic bands, or with free weights. The patient is progressed to strengthening in functional positions and return to activity/sports.
Rehabilitation of scapular winging and dyskinesia requires an algorithmic examination approach to identify the pathology and the appropriate intervention. Aggressive strengthening before motor control is established leads to symptom perpetuation and frustration. Scapular muscle isolation and eventual integration into functional movement patterns will improve outcomes.
Summary
Proper rehabilitation of the shoulder is essential to the recovery of patients treated both conservatively and postoperatively. Successful rehabilitation is dependent on effective communication and interaction between the physician, therapist, and patient. Each of these team members has a defined role in the rehabilitation process and must fulfill his or her responsibilities for the desired outcome to be achieved.
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This chapter presented principles and rationales for rehabilitation of various shoulder pathologies. In addition, guidelines for instruction and exercise progression were illustrated. Whether the patient will be followed in regular supervised therapy or seen in the office at specific intervals, extensive patient education is essential to successful rehabilitation. The patient must understand the pathology and rationale for each phase of the rehabilitation process. Constant reevaluation by the physician and therapist is important to make necessary program modifications if the patient is not achieving preset goals.
The common goals of the rehabilitation process include reduction of pain and inflammation, facilitation of collagen healing, improvement in ROM and strength, and optimization of proprioception and endurance. This is achieved by gradually increasing the program from nonprovocative to provocative positions. It is the rehabilitation specialist’s and surgeon’s responsibility to identify when to implement the appropriate modalities or exercises to improve the impairment and thereby increase the patient’s function.
Prospective studies that demonstrate rehabilitation of impairments and functional limitations associated with various shoulder pathologies are needed in the literature. Once these studies exist, a dialogue between physicians and therapists can be further developed. The end result will be more efficient and successful rehabilitation for the most important member of the team—the patient.
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