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Sport Injuries and Rehabilitation
Principals for Shoulder Rehabilitation – Part 2
ABSTRACT
These courses are based on the physiology and
biomechanics of the shoulder.
They provide very effective rehabilitation protocols in
terms of return to play.
They will assist you to diagnose not only local
anatomical lesions, such as rotator cuff tear or
Bankart lesion, but also the biomechanical deficits
that exist in the shoulder girdle and spine
But that’s not all. Distant disorders such as inflexibilities of hip rotation, short hamstrings,
or the stiff back also often contribute to shoulder abnormalities.
The course will enable you to make a complete diagnosis and to look beyond the injured
tissues to tissues that may be overloaded. You will also learn to detect functional
biomechanical deficits as well as the subclinical adaptations that sports people use to try
to maintain performance
dependent patterns that are present in skilled
1.
PLYOMETRIC EXERCISES
1.1
PRINCIPLE
sports-people.
Most athletic activities involve development of
8.2 PRACTICE
power. Power is the rate of doing work and,
Plyometrics
therefore, has a time component. For most
segments involved in the activity, and not just
sports, this time component is relatively rapid.
the shoulder. Hip rotation, knee flexion and
Plyometric activities develop the sportsperson's
extension, and trunk rotation are all power
ability
activities
to
generate
power
by
producing
a
should
that
be
require
done
for
plyometric
all
body
activation.
stretch-shortening cycle in which the muscle is
Plyometric activities for the lower extremity can
eccentrically stretched and slowly loaded. This
be done in the early phases of rehabilitation, but
pre-tensioning phase is followed by a rapid
plyometric exercises for the upper extremity
concentric
large
should be instituted in later phases. Many
amount of momentum and force. Because these
different activities and devices can be utilised in
exercises develop a large amount of strain in
plyometric exercises.
contraction
to
develop
a
the eccentric phase of the activity, and force in
Rubber tubing is a very effective plyometric
the concentric phase of the activity, they should
device (Fig 8). The arm or leg can be positioned
be done when compete anatomical healing has
exactly in the position of the athletic activity and
occurred. Similarly, because large ranges of
then the motion can be replicated by use of the
motion are required, full range of motion should
rubber
be obtained before the plyometric activities are
started.
These
sequences
are
stretch-shortening
part
of
the
Balls
are
also
excellent
plyometric devices. The weight of the ball
activation
normal
tubing.
creates a pre-stretch as the ball is caught and
force1
Sport Injuries and Rehabilitation
Principals for Shoulder Rehabilitation – Part 2
creates resistance for contraction forces (Fig 9).
Light weights can also be used for plyometric
activities, but caution must be used in using
heavier weights in a plyometric fashion due to
the forces applied on the joint. Plyometric
activities with larger weights can be done more
easily in the lower extremity than the upper
extremity.
By
reproducing
these
stretch-
shortening cycles at positions of physiological
function,
these
plyometric
activities
also
stimulate proprioceptive feedback to fine-tune
the
muscle
activity
patterns.
Figure 9: Throwing and catching a basketball
against a mini-trampoline.
Plyometric
exercises are the most appropriate open chain
exercises for functional shoulder rehabilitation.
2.
ROTATOR CUFF EXERCISES
2.1
PRINCIPLE
The rotator cuff muscles act as a unit in
functional shoulder activities. Because many
pathological conditions contribute to rotator cuff
overload,
exercises
selective
are
isolated
frequently
not
rotator
successful
cuff
in
relieving the clinical symptoms.
2.2
PRACTICE
Rotator cuff muscles should be rehabilitated as
an integrated unit, rather than as individual
muscles. They do not work in isolation in
shoulder function, and the anatomical positions
and motions that are used for testing are not
seen in shoulder function. Because they require
Figure
8:
Rubber
tubing
plyometric
exercises. The tubing creates an eccentric
stretch and offers resistance to concentric
contraction
a stabilised scapula to provide a stable base of
muscle origin, and because individual rotator
cuff
activity
creates
shear
across
the
glenohumeral joint, early rotator cuff exercises
should be done in a closed chain fashion.
2
Sport Injuries and Rehabilitation
Principals for Shoulder Rehabilitation – Part 2
Closed
chain
rotator
cuff
strengthening
physiotherapist
on
the
techniques
of
exercises redevelop the composite rotator cuff
rehabilitation. Most of the physiotherapy can be
effectively
cuff
done by home programs once the exercises
exercises are not commonly needed in later
have been taught appropriately. Physiotherapy
stages of rehabilitation. An effective progression
office
of rotator cuff activation exercises includes
achievement of the individual goals for the
progression from close chain to open chain
rehabilitation
methods,
to
exercises to be done in the next phase, and
vertical to diagonal, and exercise speed from
specific guidance as to goals to achieve for the
low to high.3
next rehabilitation phase. Modalities such as ice,
and
arm
that
isolated
position
from
rotator
horizontal
visits
are
used
sequence,
for
assessment
instruction
in
of
the
electrotherapeutic modalities, ultrasound, and
If rotator cuff deficits are till observed in the
heat are very rarely indicated after the initial
later phases of rehabilitation, isolated rotator
stages of pain reduction.
cuff exercises can be prescribed. If prescribed,
individual
rotator
cuff
exercises
should
be
This protocol assumes, if surgery has been
incorporated into an integrated conditioning
performed, stable repair of the labrum, capsule
program.
or rotator cuff, and ability to achieve 90º of
abduction without impingement or excessive
A useful clinical sign for deficiencies in rotator
capsular stretch at the time of the operation.
cuff rehabilitation is exacerbation of clinical
The time frame depends on the severity of the
symptoms
injury or extent of the surgical procedure(s).
when
rotator
cuff
exercises
are
started. This can most likely be traced to
The
rehabilitation
goal
abnormalities in other parts of the kinetic chain,
postoperative
most commonly the scapular stabilizers.
reconstructions, and acromioplasties to 90º of
labral
is
to
repairs,
progress
shoulder
passive or active assisted abduction by three
3.
PUTTING IT ALL TOGETHER – SPECIFIC
weeks, and rotator cuff repairs to 90º of passive
REHABILITATION PROTOCOLS.
or active-assisted abduction by four to six
weeks.
Many different therapeutic exercises can be
used to fulfil each of the above principles. The
3.1
protocol should address the functional deficits
ACUTE PHASE
The goals of the acute phase are:
identified and should follow a general sequence
as described above, although exact details will
be based on the patient's clinical presentation
and the therapist's skill and imagination.

Tissue healing

Reduction of pain and inflammation

Re-establishment of non-painful range of
motion below 90º of abduction
Adherence to this program requires patient
education and guidance from the physician and
3

Retardation of muscle atrophy

Scapular control
Sport Injuries and Rehabilitation
Principals for Shoulder Rehabilitation – Part 2

Maintenance of fitness in other components
patients with labral or capsular repair, but not in
of the kinetic chain.
those with rotator cuff repairs.
3.1.1 TISSUE HEALING
4.
SCAPULAR CONTROL
Tissue healing is a combination of:
The
exercises

Rest
include:

Short-term immobilisation


Modalities

Surgery
Isometric
to
maintain
scapular
scapular
pinches
and
control
scapular
elevation

Low row - see Part 1

Closed chain weight shifts, with hands on
3.1.2 REDUCTION OF PAIN AND INFLAMMATION
table and the shoulders flexed less than 60º
Aggressive treatment is used to control pain, to
and abducted less than 45º

decrease muscle atrophy and scapular instability
Tilt board or circular board weight shifts with
the same limitation (Fig 10)
due to serratus and/or trapezius inhibition. This
is done through:

Analgesic
medications
(with
due
consideration to the negative effects of
NSAIDs on tendon healing)

Electrotherapeutic modalities

Ice or cold compression devices

Posture positioning
3.1.3 RE-ESTABLISHMENT OF RANGE OF MOTION
The range of motion should be started in painfree arcs, kept below 90º of abduction, and may
Figure 10: Closed chain weight shift using tilt
board.
be passive or active-assisted. The degree of
movement is guided by the stability of the
operative repair. Range of motion should be re-
5.
established by:

Pendulum exercises

Manual capsular stretching and cross-fiber
KINETIC CHAIN
Exercise to maintain fitness in the rest of the
kinetic chain include:
massage

MAINTENANCE OF FITNESS IN REST OF

T-bar or ropes and pulleys.
Aerobic
exercises
such
as
running,
bicycling, or stepping
3.1.4 RETARDATION OF MUSCLE ATROPHY
Isometric exercises, with the arm below 90º of

Anaerobic agility drills

Lower
extremity
strengthening
by
machines, squat exercises, or open chain
abudction and 90º of flexion, should be done in
leg lifts.
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Sport Injuries and Rehabilitation
Principals for Shoulder Rehabilitation – Part 2

7.
Elbow and wrist strengthening by isometric
RECOVERY PHASE
exercises or rubber tubing

Flexibility exercises for areas of tightness
The goals of the recovery phase are:

Integration of the kinetic chain by leg and

glenohumeral range of motion
trunk stabilisation on a ball, employing
rotational
and
oblique
patterns
Normal active and passive shoulder and
of
contraction (Fig 11).

Improved scapular control

Normal
upper
extremity
strength
and
balance

Normal shoulder arthrokinetics in single
and then multiple planes of motion

Normal kinetic chain and force generation
patterns.
7.1 NORMAL RANGE OF MOTION
Normal
active
and
passive
shoulder
and
glenohumeral range of motion is achieved by:

Active-assisted
motion
above
90º
of
abduction with wand

Active-assisted,
then
active,
motion
in
internal and external rotation, with scapula
Figure 11: Plyoball hip and trunk rotation
exercise
stabilised so that glenohumeral rotation is
normalised without substitution movements
6.
CRITERIA FOR MOVEMENT OUT OF THE
from the scapula.
ACUTE PHASE
The criteria for movement out of the acute
7.2 Scapular control
phase include:
Scapular control is improved by


Progression of tissue healing (healed or
Scapular
proprioceptive
neuromuscular
facilitation patterns
sufficiently stabilised for active motion and

tissue loading)
Closed chain exercises at 90º of flexion,
Passive range of motion at 66-75% of
90º
opposite side
retraction/protraction

Minimal pain
elevation/depression (See Part 1 - Fig 5a

Manual muscle strength in non-pathological
and 5b on page 6)


areas of 4+/5


of
abduction,
and
scapular
scapular
Modified push-ups (See Part 1 - Fig 6a and
6b on page 7)
Achievement of scapular asymmetry of less
than 1.5cm (0.6in)

Regular push-ups
Kinetic chain function and integration.

Ball catch and push exercises (Fig 9 on
page 9)
5
Sport Injuries and Rehabilitation
Principals for Shoulder Rehabilitation – Part 2

Dips (See Part 1 - Fig 3 pages 3 and 4)
-
clock
-
low row
-
lawn mower.
normal
neurological
patterns
for
joint
including
mild
stabilisation.

Open
chain
exercises,
plyometric exercises, which may be built
upon
the
base
of
the
closed
chain
7.3 UPPER EXTREMITY STRENGTH AND BALANCE
stabilisation to allow normal control of joint
Normal upper extremity strength and balance
mobility.
are achieved by:

Glenohumeral proprioceptive
7.5 NORMAL
neuromuscular facilitation patterns

Closed chain exercises at 90º of flexion
then
90º
of
abduction,
using
Normal
the

internal/external rotators
Forearm curls

Isolated rotator cuff exercises

Machines
weights
for

bench
kinetic
chain
and
force
generation
Normalisation of all inflexibilities throughout
Normal agonist-antagonist force couples in
jumps, lunges and hip extensions.

The resistance should initially be light, then
mechanics,
Trunk rotation exercises with medicine ball
or tubing.
progress as strength improves. Emphasis is
proper
FORCE
the legs using squats, plyometric depth
light
presses, military presses and pull-downs.
on
AND
the kinetic chain

placed
CHAIN
patterns are achieved by:
glenohumeral depressors and glenohumeral
or
KINETIC
GENERATION

proper
Integrated exercises with legs and trunk
stabilisation, rotations, diagonal patterns
technique, and joint stabilisation.
from hip to shoulder, and medicine ball
throws.
7.4 NORMAL SHOULDER ARTHROKINETICS
Normal shoulder arthrokinetics is achieved by:

Range of motion exercises with arm at 90º
Rotator cuff strength of 4+/5 or higher.

Normal kinetic chain function.
of abduction - this is the position where
9. FUNCTIONAL PHASE
most throwing and serving activities occur;
The goals of the functional phase are:
the

periarticular
completely
loose
soft
tissues
must
and
balanced
at
be
this
To increase power and endurance in the
upper extremity
position.



To
increase
normal
Muscle activity at 90º of abduction - normal
neuromuscular
muscle
and in the entire kinetic chain
firing
regionally,
re-
both
in

Instruction in rehabilitation activities
organisation of force generation and force

Sport-specific activity
at
this
must
control-locally,
be
established
patterns
multiple-plane
position,
regulation patterns, and in proprioceptive
sensory feedback; closed chain patterns are
an excellent method to re-establish the
6
Sport Injuries and Rehabilitation
Principals for Shoulder Rehabilitation – Part 2
10. REHABILITATION
9.1 POWER AND ENDURANCE IN UPPER EXTREMITY
Power is the rate of doing work. Work may be
The sportsperson who is injured while playing a
done to move the joint and the extremity, or it
sport will most often return to the sport with the
may be done to absorb a load and stabilise the
same sports demands. The body should be
joint or extremity. Power has a time component
healed from the symptomatic standpoint and
and, for shoulder activity, quick movements and
should be prepared for resuming the stresses
quick reactions are the dominant ways of doing
inherent in playing the sport. The aim of
work. These exercises should, therefore, be
rehabilitation is to restore:
done with relatively rapid movements in planes

that approximate normal shoulder function (i.e.
an emphasis on sport-specific problems
90º of abduction in shoulder, trunk rotation, and
(shoulder
diagonal arm motions, rapid external/internal
Diagonal
and
multiplanar
motions
small
medicine
balls,

6a
on
page
7)
corner
medicine
balls
are
should
be
adaptations,
as
amounts
and
generation,
strength
trunk
balance
rotation
for
the

Power - rapid movements in appropriate
planes with light weights
motor
re-established.
such
appropriate
shoulder)
effective

9.2 MULTIPLE-PLANE NEUROMUSCULAR CONTROL
force-dependent
-
force
strength,
plyometric devices.
The
Strength
for
push-ups,
very
back, hip
activities (quadriceps/hamstring strength
weighted ball throws, and tubing. Tubing
and
the arm, low
elbow
trunk rotation strength for sport-specific
Plyometrics - wall push-ups (See Part 1 Fig
and
locations of strength for force generation,
and
isokinetic machines.

rotation
rotation, and hamstrings in the legs)
with
rubber tubing (Fig 8 on page 9), light
weights,
internal
extension in
rotation). The exercises include:

Flexibility - general body flexibility, with
firing
No
"opening
due to short duration, explosive, and
patterns
ballistic
subclinical
up"
Endurance - mainly anaerobic exercises
activities
seen
throwing
and
serving. These exercises should be based
(trunk
on
rotation too far in front of shoulder rotation),
the
periodization
principle
of
conditioning.
three-quarter arm positioning on throwing, or
excessive wrist snap should be allowed. Help in
10.1 SPORT-SPECIFIC ACTIVITY
this area can be obtained by watching pre-injury
Functional progressions of throwing or serving
videos or by using a knowledgeable coach in the
must be completed before the sportsperson can
particular sport. Special care must be take to
return to competition. These progressions will
integrate all of the components of the kinetic
gradually test all of the mechanical parts of the
chain completely, to generate and funnel the
throwing or serving motion. Very few deviations
proper forces to and through the shoulder.
from normal parameters of arm motion, arm
7
Sport Injuries and Rehabilitation
Principals for Shoulder Rehabilitation – Part 2
ABOUT THE AUTHORS
position, force generation, smoothness of all of
the kinetic chain, and pre-injury form should be
allowed, as most of these adaptations will be
biomechanically inefficient.
The
W Ben Kibler MD, FACSM
sportsperson
Medical Director, Lexington Clinic Sports
may move through the progressions as rapidly
Medicine Center, The Shoulder Center of
as possible.
Kentucky, Section of Orthopaedic Surgery,
11. CRITERIA FOR RETURN TO PLAY
Lexington Clinic, Lexington, KY, USA
The criteria for return to play include:

Normal clinical examination

Normal shoulder arthrokinetics

Normal kinetic chain integration

Completed progressions.
REFERENCES
PLEASE
SEE
George A C Murrell MBBS, DPhil
Professor and Director, Department of
Orthopaedic Surgery, St George Hospital
Campus, the University of New South Wales,
Sydney, Australia
SEPARATE
ATTACHMENT
Babette Pluim MD, PhD, MPH, FFSEM (UK, Ire)
Sports Medicine Physician, Royal Netherlands
Lawn
Tennis
Association,
Amersfoort,
the
Netherlands; Deputy Editor, British Journal of
Sports Medicine
8