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Shoulder - Glenohumeral & Scapulothoracic Rehab with Specific Consideration for Anterior
Capsulolabral Repairs & Throwing Injuries
Table of Contents
1. Glenohumeral/Scapulothoracic Rehab
Pages 105 - 117
2. Anterior Joint Repair Rehab
Pages 155 – 168
3. Shoulder Injuries in the Overhead Athlete
Pages 38 - 54
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CLINICAL COMMENTARY
]
MICHAEL M. REINOLD, PT, DPT, ATC, CSCS¹šH7<7;B;I97C?BB7"PT, PhD, CSCS, FACSM²šA;L?D;$M?BA" PT, DPT³
Current Concepts in the Scientific
and Clinical Rationale Behind
Exercises for Glenohumeral and
Scapulothoracic Musculature
T
he biomechanical analysis of rehabilitation exercises has
gained recent attention. As our knowledge of specific muscle
biomechanics and function has increased, we have seen
a gradual progression towards more scientifically based
rehabilitation exercises. Several investigators have sought to describe
common rehabilitation exercises using kinematics, kinetics, and
electromyographic (EMG) data in an attempt to better understand the
implications of each exercise on the soft tissues of the glenohumeral
and scapulothoracic joints. Advances in the understanding of
the biomechanical factors of rehabilitation have led to the enhancement of
rehabilitation programs that seek
to facilitate recovery, while placing minimal strain on specific
healing structures.
Though the fields of orthopedics and sports medicine have evolved
TIODEFI?I0 The biomechanical analysis of rehabilitation exercises has led to more scientifically
based rehabilitation programs. Several investigators have sought to quantify the biomechanics and
electromyographic data of common rehabilitation
exercises in an attempt to fully understand their
clinical indications and usefulness. Furthermore,
the effect of pathology on normal shoulder biomechanics has been documented. It is important
to consider the anatomical, biomechanical, and
clinical implications when designing exercise
to emphasize the necessity of evidencebased practice, few studies have been
conducted to determine the efficacy
of specific shoulder rehabilitation
exercises. Thus, knowledge of
anatomy, biomechanics, and function of specific musculature is critical in an attempt to develop the most
programs. The purpose of this paper is to provide
the clinician with a thorough overview of the available literature relevant to develop safe, effective,
and appropriate exercise programs for injury
rehabilitation and prevention of the glenohumeral
and scapulothoracic joints.
TB;L;BE<;L?:;D9;0 Level 5. J Orthop Sports
Phys Ther 2009; 39(2):105-117. doi:10.2519/
jospt.2009.2835
TA;OMEH:I0 electromyography, infraspinatus,
serratus anterior, supraspinatus, trapezius
advantageous rehabilitation programs.
The purpose of this paper is to provide
an overview of the biomechanical and
clinical implications associated with the
rehabilitation of the glenohumeral and
scapulothoracic joints. We will review
the function and biomechanics of each
muscle, with specific emphasis on many
commonly performed rehabilitation exercises. The goal of this is to provide the
clinician with a thorough overview of the
available information to develop safe,
potentially effective, and appropriate exercise programs for injury rehabilitation
and prevention.
HEJ7JEH9K<<CKI9B;I
T
he rotator cuff has been shown
to be a substantial dynamic stabilizer of the glenohumeral joint in multiple shoulder positions.49,88 Appropriate
rehabilitation progression and strengthening of the rotator cuff muscles are
important to provide appropriate force
to help elevate and move the arm, compress and center the humeral head within
the glenoid fossa during shoulder movements (providing dynamic stability), and
provide a counterforce to humeral head
superior translation resulting from del-
1
Coordinator of Rehabilitation Research and Education, Department of Orthopedic Surgery, Division of Sports Medicine, Massachusetts General Hospital, Boston, MA; Rehabilitation
Coordinator/Assistant Athletic Trainer, Boston Red Sox Baseball Club, Boston, MA. 2 Professor, Department of Physical Therapy, California State University, Sacramento, Sacramento,
CA. 3 Clinical Director, Champion Sports Medicine, Director of Rehabilitative Research, American Sports Medicine Institute, Birmingham, AL. Address correspondence to Dr Michael
M. Reinold, Rehabilitation Coordinator/Assistant Athletic Trainer, Boston Red Sox Baseball Club, Fenway Park, 4 Yawkey Way, Boston, MA 02215. Email: [email protected]
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 105
[
CLINICAL COMMENTARY
toid activity (minimizing subacromial
impingement).6,8,9,21,34,50,60,65,74 In addition, rotator cuff muscles are frequently
treated either conservatively or surgically
secondary to injuries.
Exercise designed to strengthen the
muscles of the rotator cuff are often prescribed to patients with pathologies such
as subacromial impingement. During
scapular plane abduction in healthy subjects, the humeral head translates 1 to 3
mm in the superior direction from 0° to
30° of abduction, slightly inferiorly from
30° to 60° of abduction, and in the superior or inferior direction during 60° to
90° of abduction.26,50,67 Other data demonstrate that, during passive scapular
plane abduction, the humeral head translates superiorly 0.6 to 1.8 mm between
0° to 150°.25,26 But during active scapular
plane abduction the humeral head remains nearly centered in the glenoid fossa throughout the range of movement.26
These data illustrate the importance of
rotator cuff strength and muscle balance
to resist humeral head superior translation and help center the humeral head
within the glenoid fossa during shoulder
elevation.74 With rotator cuff pathology,
altered kinematics and muscle activity are present,31 and superior humeral
head translation increases and subacromial space decreases.24 Moreover, during
scapular plane shoulder abduction from
30° to 90°, infraspinatus and subscapularis activity was found to be significantly
less in individuals with subacromial impingement compared to those without
impingement.68
Subjects with shoulder laxity and instability have also been shown to have
altered kinematics and firing patterns of
the rotator cuff.7,35,45,46,55,64,72 Compared to
healthy subjects, patients with generalized joint laxity demonstrated increased
subscapularis activity during internal
rotation (IR) exercise and decreased supraspinatus and subscapularis activity
during external rotation (ER) exercise.7,43
Compared to healthy subjects, those with
anterior instability exhibited less supraspinatus activity between 30° to 60°
of shoulder elevation during abduction
and scaption exercises.59
These EMG data clearly illustrate
aberrant muscle-firing patterns in individuals with shoulder pathology. It is
often the goal of rehabilitation specialists to prescribe exercises to normalize or
prevent these abnormal firing patterns.
Proper selection of exercises to activate
muscle function for each muscle of the
rotator cuff should be considered during
rehabilitation.
IkfhWif_dWjki
The supraspinatus compresses, abducts,
and generates a small ER torque to the
glenohumeral joint. Supraspinatus activity increases as resistance increases during
abduction/scaption movements, peaking
at 30° to 60° of elevation for any given
resistance. At lower elevation angles, supraspinatus activity increases, providing
additional humeral head compression
within the glenoid fossa to counter the
humeral head superior translation occurring with contraction of the deltoid.1 Due
to a decreasing moment arm with abduction, the supraspinatus is a more effective
abductor in the scapular plane at smaller
abduction angles.34,50,65
Relatively high supraspinatus activity
has been measured in several common
rotator cuff exercises3,5,17,33,54,63,70,75,79,87
and in several exercises that are not
commonly thought of as rotator cuff exercises, such as standing forward scapular punch, rowing exercises, push-up
exercises, and 2-hand overhead medicine ball throws.13,17,32,81 These results
suggest the importance of the rotator
cuff in providing dynamic glenohumeral
stability by centering the humeral head
within the glenoid fossa during all upper extremity functional movements.
This is an important concept for the
clinician to understand. The muscle’s
ability to generate abduction torque in
the scapular plane appears to be greatest with the shoulder in neutral rotation
or in slight IR or ER.50,65 This biomechanical advantage has led to the development of exercises in the plane of the
]
scapula to specifically strengthen the
supraspinatus. 38
Jobe38 was the first to recommend elevation in the scapular plane (30° anterior
to the frontal plane) with glenohumeral IR, or the “empty can” exercise, to
strengthen the supraspinatus muscle.
Other authors37,40,66,69,70,77 have suggested
the “full can” position, or elevation in the
scapular plane with glenohumeral ER,
to best strengthen and test the supraspinatus muscle. Furthermore, compared
to the empty can exercise, Blackburn5
reported significantly greater supraspinatus activity during prone horizontal
abduction at 100° with full ER, or prone
full can, position. The results of studies
comparing these exercises provide inconsistent results due to methodological
limitations, including lack of statistical
analysis,38,79 lack of data for all 3 exercises,40,54,79,87 and absence of data on deltoid
muscle activity.87
Recently, Reinold et al69 comprehensively evaluated the EMG signal of the
supraspinatus and deltoid musculature
during the full can, empty can, and
prone full can exercises in an attempt
to clarify the muscular activation during
these exercises. The results showed that
all 3 exercises provide a similar amount
of supraspinatus activity ranging from
62% to 67% of maximal voluntary isometric contraction (MVIC). However,
the full can exercise demonstrated a
significantly lower amount of middle
and posterior deltoid activity compared
to the 2 other exercises. This is clinically
significant when trying to strengthen
the supraspinatus while simultaneously
minimizing potentially disadvantageous superior sheer force due to deltoid activity.
In patients with shoulder pain,
weakness of the rotator cuff, or inefficient dynamic stabilization, it is the
authors’ opinion that activities that
produce higher levels of deltoid activity in relation to supraspinatus activity,
such as the empty can and prone full
can exercise, may be detrimental. This
is due to the increased amount of supe-
106 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy
<?=KH;'$Direction of the magnitude of the resultant force vector for different glenohumeral joint positions as a
function of different muscle activity, (A) deltoid activity, (B) rotator cuff activity, (C) combined deltoid and rotator
cuff activity. Reprinted with permission from Morrey et al.61
<?=KH;($The position of the resultant force vector of the rotator cuff and deltoid for different positions of arm
elevation with (N) neutral rotation, (I) internal rotation, and (X) external rotation. Reprinted with permission from
Poppen and Walker.66
rior humeral head migration that may
be observed when the rotator cuff does
not adequately compress the humerus
within the glenoid fossa to counteract,
or oppose, the superior pull of the deltoid (<?=KH; ').61 Poppen and Walker66
have shown that the empty can exercise
results in a greater superior-orientated
force vector than the full can exercise
(<?=KH; (). This superior humeral head
migration may result in subacromial
impingement, subdeltoid bursa trauma,
bursal thickening, and may result in
tendon degeneration and eventual failure.21 Clinically, superior humeral head
migration may be disadvantageous to
patients with rotator cuff pathology or
a deficiency in glenohumeral dynamic
stabilization that are symptomatic. This
may partially explain why the empty can
position often elicits a certain amount
of pain and discomfort in patients.
In addition to the altered ratio of supraspinatus to deltoid muscle activity,
there are several reasons why the full
can exercise may be preferred over the
empty can exercise during rehabilitation
and supraspinatus testing. Anatomically,
the IR of the humerus during the empty
can exercise does not allow the greater
tuberosity to clear from under the acromion during arm elevation, which may
increase subacromial impingement risk
because of decreased subacromial space
width.15,23,71
Biomechanically, shoulder abduction
performed in extreme IR progressively
decreases the abduction moment arm of
the supraspinatus from 0° to 90° of abduction.50 A diminished mechanical advantage may result in the supraspinatus
needing to generate more force, thus increasing the tensile stresses in the injured
or healing tendon. This may also make
the exercise more challenging for patients
with weakness, facilitating compensatory
movements such as a shoulder “shrug.”
Scapular kinematics are also different
between these exercises, with scapular
IR, or “winging” (which occurs in the
transverse plane with the scapular medial border moving posterior away from
the trunk) and anterior tilt (which occurs
in the sagittal plane with the scapular inferior angle moving posterior away from
the trunk) being greater with the empty
can compared to the full can exercise.78
This occurs in part because IR of the
humerus in the empty can position tensions both the posteroinferior capsule of
the glenohumeral joint and the rotator
cuff (primarily the infraspinatus). Tension in these structures contributes to
anterior tilt and IR of the scapula, which
contribute to scapular protraction. This
is clinically important because scapular
protraction has been shown to decrease
the width of the subacromial space, increasing the risk of subacromial impingement.76 In contrast, scapular retraction
has been shown to both increase subacromial space width76 and increase supraspinatus strength potential (enhanced
mechanical advantage), when compared
to a more protracted position.41 These
data also emphasize the importance of
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 107
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CLINICAL COMMENTARY
strengthening the scapular retractors and
maintaining a scapular retracted posture
during shoulder exercises. The authors
routinely instruct patients to emphasize
an upright posture and a retracted position of the scapula during all shoulder
and scapula strengthening exercises.
Thus, the full can exercise appears to
be the most advantageous exercise while
the empty can exercise is not commonly
recommended. The prone full can exercise warrants further consideration because the exercise results in greater EMG
signal of the posterior deltoid than the
middle deltoid, which may result in less
superior sheer force. The prone full can
exercise may also be beneficial because of
scapular muscle recruitment.
?d\hWif_dWjkiWdZJ[h[iC_deh
The infraspinatus and teres minor comprise the posterior cuff, which provides
glenohumeral compression and resists
superior and anterior humeral head
translation by exerting an inferoposterior force on the humeral head.74 The posterior cuff muscles provide glenohumeral
ER, which functionally helps clear the
greater tuberosity from under the coracoacromial arch during overhead movements, thus minimizing subacromial
impingement.
Based on 3-D biomechanical shoulder
models, the maximum predicted isometric infraspinatus force was 723 N for ER
at 90° of abduction and 909 N for ER at
0° of abduction.34 The maximum predicted teres minor force was much less than
for the infraspinatus during maximum
ER at both 90° (111 N) and 0° abduction
(159 N).34 The effectiveness of the muscles
of the posterior rotator cuff to externally
rotate the arm depends on glenohumeral
position. The superior, middle, and inferior heads of the infraspinatus have their
largest ER moment arm (approximately 2.2 cm) and generate their greatest
torque at 0° abduction.65 As the abduction angle increases, the moment arms of
the inferior and middle heads stay relatively constant, while the moment arm of
the superior head progressively decreases
until it is about 1.3 cm at 60° abduction.65
These data imply that the infraspinatus is
a more effective external rotator at lower
shoulder abduction angles. The teres minor has a relatively constant ER moment
arm (approximately 2.1 cm) and the ability to generate torque throughout shoulder abduction movement, which implies
that shoulder abduction angle does not
affect the effectiveness of the teres minor
to generate ER torque.65
Several studies have been designed to
test the results of the model; but, as in
studies on the supraspinatus, variations
in experimental methodology have resulted in conflicting results and controversy
in exercise selection.3,5,17,19,27,33,44,54,63,70,77,79,81
Several exercises have been recommended based on EMG data, including shoulder ER in the side-lying,3,70,79 standing,27,70
or prone3,70 positions performed at 0°,3,70
45°,27,70 and 90°3,70 of abduction. Another
exercise that has been shown to generate
a high EMG signal of the infraspinatus
and teres minor is prone horizontal abduction with ER.5,79
Reinold et al70 analyzed several different exercises commonly used to
strengthen the shoulder external rotators to determine the most effective
exercise and position to recruit muscle
activity of the posterior rotator cuff. The
authors report that the exercise that elicited the most combined EMG signal for
the infraspinatus and teres minor was
shoulder ER in side-lying (infraspinatus, 62% maximal voluntary isometric
contraction [MVIC]; teres minor, 67%
MVIC), followed closely by standing ER
in the scapular plane at 45° of abduction
(infraspinatus, 53% MVIC; teres minor,
55% MVIC), and finally prone ER in the
90° abducted position (infraspinatus,
50% MVIC; teres minor, 48% MVIC).
Exercises in the 90° abducted position are often incorporated to simulate
the position and strain on the shoulder
during overhead activities such as throwing. This position produced moderate
activity of the external rotators but also
increased activity of the deltoid and supraspinatus. It appears that the amount
]
of infraspinatus and teres minor activity
progressively decreases as the shoulder
moves into an abducted position, while
activity of the supraspinatus and deltoid
increases. This suggests that as the arm
moves into a position of increased vulnerability away from the body, the supraspinatus and deltoid are active to assist in
the ER movement, while providing some
degree of glenohumeral stability through
muscular contraction.
While standing ER exercises performed at 90° of shoulder abduction may
have a functional advantage over exercises performed at 0° of shoulder abduction
or performed in the scapular plane, due
to the close replication in sporting activities, the combination of shoulder abduction and ER places strain on the shoulder
capsule, particularly the anterior band of
the inferior glenohumeral ligament.30,85,86
The clinician must carefully consider this
when designing programs for patients
with capsulolabral pathology.
Side-lying ER may be the optimal exercise to strengthen the external rotators
based on the previously mentioned studies. The inclusion of this exercise should
be considered in all exercise programs
attempting to increase ER strength or
decrease capsular strain.
Theoretically, ER performed at 0° of
shoulder abduction with a towel roll between the rib cage and the arm provides
both the low capsular strain and also a
good balance between the muscles that
externally rotate the arm and the muscles
that adduct the arm to hold the towel.
Our clinical experience has shown that
adding a towel roll to the ER exercise
provides assistance to the patient by ensuring that proper technique is observed
without muscle substitution. Reinold et
al70 report that adding a towel roll to the
exercise consistently exhibited a tendency
towards higher activity of the posterior
rotator cuff muscles as well. An increase
of 20% to 25% in EMG signal of the infraspinatus and teres minor was noted
when using the towel roll compared to
no towel roll.
What is not readily apparent is the
108 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy
significant role of the infraspinatus as
a shoulder abductor in the scapular
plane. 34,50,65 From 3-D biomechanical
shoulder models, predicted infraspinatus force during maximum isometric
effort scapular plane abduction (90°
position) was 205 N, nearly twice the
predicted force from the supraspinatus
in this position.34 Liu et al50 reported
that in scapular plane abduction with
neutral rotation the infraspinatus has an
abductor moment arm that was small at
0° abduction, but increased to 1 cm at
15° abduction, and remained fairly constant throughout increasing abduction
angles. Moreover, infraspinatus activity
increases as resistance increases, peaking
at 30° to 60° for any given resistance.1 As
resistance increases, infraspinatus activity increases to help generate a higher
shoulder scapular abduction torque, and,
at lower elevation angles, infraspinatus
activity increases to resist superior humeral head translation due to the action
of the deltoid.74
In contrast to the infraspinatus, the
teres minor generates a weak shoulder
adductor torque due to its relatively
lower attachments to the scapula and humerus.34,50,65 A 3-D biomechanical model of the shoulder reveals that the teres
minor does not generate scapular plane
abduction torque when it contracts, but,
rather, generates an adduction torque
and 94 N of force during maximum effort
scapular plane adduction. 34 In addition,
Otis et al65 reported that the adductor
moment arm of the teres minor was approximately 0.2 cm at 45° of IR and approximately 0.1 cm at 45° of ER. These
data imply that the teres minor is a weak
adductor of the humerus, regardless of
the rotational position of the humerus.
In addition, because of its posterior position at the shoulder, it also helps generate a weak horizontal abduction torque.
Therefore, although its activity is similar to the infraspinatus during ER, it is
hypothesized that the teres minor would
not be as active as the infraspinatus during scapular abduction, abduction, and
flexion movements, but would show ac-
tivity similar to that of the infraspinatus during horizontal abduction. This
hypothesis is supported by EMG and
magnetic resonance imaging data, which
show that teres minor activity during
flexion, abduction, and scapular abduction is drastically less than infraspinatus
activity.1,3,5,54,77,79 Even though the teres
minor generates an adduction torque, it
is active during these different elevationtype movements, as it likely acts to enhance joint stability by resisting superior
humeral head translation and providing
humeral head compression within the
glenoid fossa.74 This is especially likely
the case at lower shoulder abduction
angles and when abduction and scapular abduction movements are performed
against greater resistance.1 In contrast to
the movements of shoulder abduction,
scapular abduction, and flexion, teres minor activity is much higher during prone
horizontal abduction at 100° abduction
with ER, exhibiting similar activity as the
infraspinatus.5,54,70,77,79
IkXiYWfkbWh_i
The subscapularis provides glenohumeral compression, IR, and anterior stability
of the shoulder. From 3-D biomechanical
shoulder models, predicted subscapularis force during maximum effort IR
was 1725 N at 90° abduction and 1297
N at 0° abduction.34 Its superior, middle,
and inferior heads all have their largest IR moment arm (approximately 2.5
cm) and torque generation at 0° abduction.65 As the abduction angle increases,
the moment arms of the inferior and
middle heads stay relatively constant,
while the moment arm of the superior
head progressively decreases until it is
about 1.3 cm at 60° abduction.65 These
data imply that the upper portion of the
subscapularis muscle (innervated by the
upper subscapularis nerve) may be a
more effective internal rotator at lower
abduction angles compared to higher abduction angles. However, there is no significant difference in upper subscapularis
activity among IR exercises performed at
0°, 45°, or 90° abduction.17,39 Abduction
angle does not appear to affect the ability
of the lower subscapularis (innervated by
the lower subscapularis nerve) to generate IR torque.65 However, lower subscapularis muscle activity is affected by
abduction angle, where some EMG data
show significantly greater activity with
IR at 0° abduction compared to IR at 90°
abduction,17 while EMG data of another
study show greater activity with IR exercise performed at 90° compared to 0°
abduction.39 Performing IR at 0° abduction produces similar amounts of upper
and lower subscapularis activity.17,28,39
Although biomechanical data remain
inconclusive as to which position to perform IR exercises (0° versus 90° abduction), during IR at 0° abduction the action
of the subscapularis is assisted by several
large muscles, such as the pectoralis major, latissimus dorsi, and teres major.17
Clinically, this may allow for compensation of larger muscles during the exercise
in the presence of subscapularis weakness. Decker et al17 demonstrated that IR
at 90° abduction produced less pectoralis
major activity compared to 0° abduction.
The authors’ findings revealed that pectoralis major and latissimus dorsi activity
increased when performing IR exercises
in an adducted position or while moving into an adducted position during the
exercise. Thus, IR at 90° abduction may
be performed if attempting to strengthen
the subscapularis while minimizing larger muscle group activity.
The subscapularis is active in numerous shoulder exercises other than specific
IR of the shoulder. Decker et al17 reported
high subscapularis activity during the
push-up with plus and dynamic-hug exercises. These authors also described another exercise that consistently produced
high levels of subscapularis activity, which
they called the “diagonal exercise” (<?=KH;
3). Relatively high subscapularis activity has been measured while performing
side-lying shoulder abduction, standing
shoulder extension from 90° to 0°, military press, D2 diagonal proprioceptive
neuromuscular facilitation (PNF) pattern
flexion and extension, and PNF scapular
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 109
[
CLINICAL COMMENTARY
<?=KH;)$Diagnonal exercise for the subscapularis begins in shoulder external rotation at 90° abduction in the
coronal plane (A) and internal rotation and horizontal adduction are performed simultaneously (B), similar to a
tennis swing.
clock, depression, elevation, protraction,
and retraction movements.17,33,44,63,75,79
The subscapularis also generates
an abduction torque during arm elevation.50,65 From 3-D biomechanical shoulder models, predicted subscapularis force
during maximum effort scapular plane
abduction at 90° was 283 N, approximately 2.5 times the predicted force for
the supraspinatus in this position.34 This
was similar to that of the infraspinatus,
highlighting the theoretical force couple
that the 2 muscles provide to center the
humeral head within the glenoid fossa
during abduction. Liu et al50 reported
that in scapular plane abduction with
neutral rotation the subscapularis had a
peak abductor moment arm of 1 cm at 0°
abduction, which slowly decreased to 0
cm at 60° abduction. Moreover, the abductor moment arm of the subscapularis
generally decreased as abduction was performed with greater shoulder IR,50 such
as performing the empty can exercise. In
contrast, the abductor moment arm of
the subscapularis generally increased as
abduction was performed with greater
shoulder ER, similar to performing the
full can exercise.
Otis et al65 reported that the superior,
middle, and inferior heads of the sub-
scapularis all have an abductor moment
arm (greatest for the superior head and
least for the inferior head) that varies as a
function of humeral rotation. The lengths
of the moment arm for the 3 muscle heads
are approximately 0.4 to 2.2 cm at 45° of
ER, 0.4 to 1.4 cm in neutral rotation, and
0.4 to 0.5 cm at 45° of IR. These data suggest that the subscapularis is most effective as a scapular plane abductor with the
shoulder in ER and least effective with
the shoulder in IR. Therefore, the simultaneous activation of the subscapularis
and infraspinatus during arm elevation
generates both an abductor moment and
an inferiorly directed force to the humeral head to resist superior humeral head
translation.74 In addition, a simultaneous activation neutralizes the IR and ER
torques these muscles generate, further
enhancing joint stability.
DELTOID
T
he deltoid plays an important
role in shoulder biomechanics and
during glenohumeral and scapulothoracic exercises. Extensive research
has been conducted on deltoid activity
during upper extremity weight-lifting
exercises, such as bench press, dumb-
]
bell flys, military press, and pushups.4,13,16,19,44,57,63,79,81,83
The abductor moment arm is approximately 0 cm for the anterior deltoid and 1.4 cm for the middle deltoid
when the shoulder is in 0° abduction
and neutral rotation in the scapular
plane.50,65 The magnitude of these moment arms progressively increases with
shoulder abduction, such that, by 60°
of abduction, they are approximately
1.5 to 2 cm for the anterior deltoid and
2.7 to 3.2 cm for the middle deltoid.
From 0° to 40°of abduction the moment
arms for the anterior and middle deltoids are less than the moment arms for
the supraspinatus, subscapularis, and
infraspinatus.50,65 These data suggest
that the anterior and middle deltoid
are not effective shoulder abductors at
low abduction angles and the shoulder
in neutral rotation, especially the anterior deltoid. This is in contrast to the
supraspinatus and to a lesser extent the
infraspinatus and subscapularis, which
are more effective shoulder abductors
at low abduction angles. These biomechanical data are consistent with EMG
data, in which anterior and middle deltoid activity generally peaks between
60° to 90° of abduction in the scapular
plane, while supraspinatus, infraspinatus, and subscapularis activity generally
peaks between 30° and 60° of shoulder
abduction in the scapular plane.1
The abductor moment arm for the
anterior deltoid changes considerably
with humeral rotation, increasing with
ER and decreasing with IR.50 At 60° ER
and 0° abduction, a position similar to
the beginning of the full can exercise, the
anterior deltoid moment arm is 1.5 cm
(compared to 0 cm in neutral rotation),
which makes the anterior deltoid an effective abductor even at small abduction
angles.50 By 60° abduction with ER, its
moment arm increased to approximately
2.5 cm (compared to approximately 1.5
to 2 cm in neutral rotation).50 In contrast, at 60° IR at 0° abduction, a position similar to the beginning of the
empty can exercise, its moment arm was
110 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy
0 cm (the same as with neutral rotation),
which suggests that in this position
the anterior deltoid is not an effective
abductor.50
It has been reported that, given a peak
isometric abduction torque of 25 N·m at
0° abduction and neutral rotation, up to
35% to 65% of this torque may be generated by the middle deltoid, 30% by the
subscapularis, 25% by the supraspinatus,
10% by the infraspinatus, 2% by the anterior deltoid, and 0% by the posterior
deltoid.50 Interestingly, the rotator cuff
provides a significant contribution to the
abduction torque. The ineffectiveness
of the anterior and posterior deltoids to
generate abduction torque with neutral
rotation may appear surprising.50,65 However, it is important to understand that
the low abduction torque for the anterior
deltoid does not mean that this muscle is
only minimally active. In fact, because the
anterior deltoid has an abductor moment
arm near 0 cm, the muscle could be very
active and generate very high force but
very little torque (in 0° abduction this
force attempts to translate the humeral
head superiorly).
The aforementioned torque data are
complemented and supported by muscle
force data from Hughes and An.34 These
authors reported predicted forces from
the deltoid and rotator cuff during maximum effort abduction with the arm 90°
abducted and in neutral rotation. Posterior deltoid and teres minor forces were
only 2 N and 0 N, respectively, which
further demonstrates the ineffectiveness
of these muscles as shoulder abductors.
In contrast, middle deltoid force was the
highest at 434 N, which suggests a high
contribution of this muscle during abduction. The anterior deltoid generated the
second highest force of 323 N. This may
appear surprising given the low abductor
torque for this muscle reported above,
but it should be re-emphasized that force
and torque are not the same, and that the
shoulder was positioned at 90° abduction
in the study by Hughes and An,34 in contrast to 0° abduction in the study by Liu
et al.50 As previously mentioned, the mo-
ment arm of the anterior deltoid progressively increases as abduction increases,
and it becomes a more effective abductor. It is also important to remember
that muscle force is generated not only to
generate joint torque, but also to provide
stabilization, such as joint compression.
Also of interest is the 608-N force that,
collectively, the subscapularis (283 N),
infraspinatus (205 N), and supraspinatus
(117 N) generate. These larges forces are
generated not only to abduct the shoulder but also to compress and stabilize
the joint, and neutralize the superiorly
directed force generated by the deltoid at
lower abduction angles.
It should also be noted that deltoid
muscle force in different shoulder positions may also affect shoulder stability.
All 3 heads of the deltoid generate a force
that increases shoulder stability at 60°
abduction in the scapular plane (helps to
stabilize the humeral head in the glenoid
fossa) but decreases shoulder stability at
60° abduction in the frontal plane (tends
to translate the humeral head anterior).48
These data provide evidence for the use
of scapular abduction exercises instead of
abduction exercises for individuals with
anterior instability.
Thus, it appears that the 3 heads of
the deltoid have different roles during
upper extremity movements and, therefore, different implications for exercise
selection. The middle deltoid may have
the most significant impact on superior
humeral head migration, and exercises
with high levels of middle deltoid activity
(as well as anterior deltoid activity), such
as the empty can exercise, should likely
be minimized for most patients. Conversely, high levels of posterior deltoid
activity may not be as disadvantageous
as high levels of middle or anterior deltoid activity. It does not appear that the
posterior deltoid has a significant role in
providing abduction or superior humeral
head migration. Thus, exercises such as
the prone full can, which generates high
levels of rotator cuff and posterior deltoid
activity, may be both safe and effective for
rotator cuff strengthening.
I97FKBEJ>EH79?9CKI9B;I
T
he primary muscles that control scapular movements include the
trapezius, serratus anterior, levator
scapulae, rhomboids, and pectoralis minor. Appropriate scapular muscle strength
and balance are important because the
scapula and humerus move together in
coordination during arm movement,
referred to as scapulohumeral rhythm.
During humeral elevation, the scapula
upwardly rotates in the frontal plane,
rotating approximately 1° for every 2°
of humeral elevation until 120° humeral
elevation, and thereafter rotates approximately 1° for every 1° humeral elevation
until maximal arm elevation, achieving
at least 45° to 55° of upward rotation.52,58
During humeral elevation, in addition to
scapular upward rotation, the scapula also
normally tilts posteriorly approximately
20° to 40° in the sagittal plane and externally rotates approximately 15° to 35° in
the transverse plane.52,58
When the normal 3-D scapular movements are disrupted by abnormal scapular
muscle-firing patterns, fatigue, or injury,
it has been hypothesized that the shoulder
complex functions less efficiently, leading
to injuries to the shoulder, including the
glenohumeral joint.10,11,12,18,58,76,80,82 During
arm elevation in the scapular plane, individuals with subacromial impingement
exhibit decreased scapular upward rotation, increased scapular IR (winging) and
anterior tilt, and decreased subacromial
space width, compared to those without
subacromial impingement.24,51 Altered
scapular muscle activity is commonly associated with impingement syndrome.
For example, upper and lower trapezius
activity increased and serratus anterior
activity decreased in individuals with impingement as compared to those without
impingement.51 Therefore, it is important
to include the scapulothoracic musculature in the rehabilitation of patients with
shoulder pathology.42
I[hhWjki7dj[h_eh
The serratus anterior works with the
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 111
[
CLINICAL COMMENTARY
]
<?=KH;+$Bilateral serratus anterior punch to 120° abduction begins with hands by the side (A) before extending
elbows and elevating shoulders up to 120° of elevation and full protraction (B).
<?=KH;*$Dynamic hug exercise for the serratus
anterior begins with the elbows in approximately 45°
of flexion, the shoulder abducted 60° and internally
rotated 45° (A). The humerus is then horizontally
adducted by following an arc movement similar to
a hugging action, until full shoulder protraction is
reached (B).
pectoralis minor to protract the scapula
and with the upper and lower trapezius
to upwardly rotate the scapula. The serratus anterior is an important muscle because it contributes to all components of
normal 3-D scapular movements during
arm elevation, which includes upward
rotation, posterior tilt, and external rotation.52,58 The serratus anterior is also
important in athletics, such as during
overhead throwing, to accelerate the
scapula during the acceleration phase of
throwing. The serratus anterior also helps
stabilize the medial border and inferior
angle of the scapula, preventing scapular
IR (winging) and anterior tilt.
Several exercises elicit high serratus
anterior activity, such as D1 and D2 diagonal PNF pattern flexion, D2 diagonal
PNF pattern extension, supine scapular
protraction, supine upward scapular
punch, military press, push-up plus, glenohumeral IR and ER at 90° abduction,
and shoulder flexion, abduction, and
scaption with ER above 120°.16,20,32,62,63
Serratus anterior activity tends to increase
in a somewhat linear fashion with arm elevation.2,20,29,52,62 However, increasing arm
elevation increases subacromial impingement risk,15,71 and arm elevation at lower
abduction angles also generates relatively
high serratus anterior activity.20
It is interesting that performing
shoulder IR and ER at 90° of abduction
generates relatively high serratus anterior activity, because these exercises are
usually thought to primarily work rotator
cuff muscles.20,63 However, during IR and
ER at 90° abduction the serratus anterior helps stabilize the scapula. It should
be noted that the rotator cuff muscles
also act to move the scapula (where they
originate) in addition to the humerus.
For example, the force exerted by the supraspinatus at the supraspinous fossa has
the ability to downwardly rotate the scapula if this force is not counterbalanced by
the scapulothoracic musculature.
Not surprising is high serratus anterior activity generated during a push-up
exercise. When performing the standard push-up, push-up on knees, and
wall push-up, serratus anterior activity
is greater when full scapular protrac-
tion occurs after the elbows fully extend
(push-up plus).53 Moreover, serratus
anterior activity was lowest in the wall
push-up plus, exhibited moderate activity during the push-up plus on knees, and
relatively high activity during the standard push-up plus.16,53 Compared to the
standard push-up, performing a pushup plus with the feet elevated produced
significantly greater serratus anterior
activity.47 These findings demonstrate
that serratus anterior activity increases
as the positional (gravitational) challenge increases.
Decker et al16 compared several common exercises designed to recruit the serratus anterior. The authors identified that
the 3 exercises that produced the greatest serratus anterior EMG signal were the
push-up with a plus, dynamic hug (<?=KH;
4), and punch exercises (similar to a jabbing protraction motion).
Ekstrom20 also looked at the activity
of the serratus anterior during common
exercises. His data indicated that the
serratus anterior is more active when
performing a movement that simultaneously creates scapular upward rotation
and protraction, as with the serratus anterior punch performed at 120° of abduc-
112 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy
tion and during a diagonal exercise that
incorporated protraction with shoulder
flexion, horizontal adduction, and external rotation. It appears that the punch exercise can be enhanced by starting at 0°
abduction and extending the elbow, while
elevating and protracting the shoulder
(<?=KH;+).
Hardwick et al29 compared the wall
push-up plus, full can, and a wall slide
exercise. The wall slide begins by slightly
leaning against the wall with the ulnar
border of the forearms in contact with
the wall, elbows flexed 90°, and shoulders abducted 90° in the scapular plane.
From this position the arms slide up the
wall in the scapular plane, while leaning
into the wall. Interestingly, the wall slide
produce similar serratus anterior activity
compared to scapular abduction above
120° abduction with no resistance. One
advantage of the wall slide compared to
scapular abduction is that, anecdotally,
patients report that the wall slide is less
painful to perform.29 This may be because during the wall slide the upper extremities are supported against the wall,
making it easier to perform while also assisting with compression of the humeral
head within the glenoid. Thus, this may
be an effective exercise to perform during the earlier protective phases of some
rehabilitation programs.
JhWf[p_ki
General functions of the trapezius include
scapular upward rotation and elevation
for the upper trapezius, retraction for the
middle trapezius, and upward rotation
and depression for the lower trapezius.
In addition, the inferomedial-directed
fibers of the lower trapezius may also
contribute to posterior tilt and external
rotation of the scapula during arm elevation,52 which decreases subacromial impingement risk24,51 and makes the lower
trapezius an important area of focus in
rehabilitation. Relatively high upper
trapezius activity occurs in the shoulder
shrug, prone rowing, prone horizontal
abduction at 90° and 135° of abduction
with ER and IR, D1 diagonal PNF pat-
<?=KH;,$The proper alignment of the upper
extremity during the prone horizontal abduction
exercise with external rotation. Note how the upper
extremity is aligned with the muscle fiber orientation
of the lower trapezius.
tern flexion, standing scapular dynamic
hug, PNF scapular clock, military press,
2-hand overhead medicine ball throw,
and scapular abduction and abduction
below 80°, at 90°, and above 120° with
ER.13,16,20,62,75 During scapular abduction,
upper trapezius activity progressively increases from 0° to 60°, remains relatively
constant from 60° to 120°, and continues to progressively increase from 120°
to 180°.2
Relatively high middle trapezius activity occurs with shoulder shrug, prone
rowing, and prone horizontal abduction
at 90° and 135° abduction with ER and
IR.20,62 Some authors have reported relatively high middle trapezius activity during scapular abduction at 90° and above
120°,2,16,20 while authors of another study
showed low EMG signal amplitude of the
middle trapezius during this exercise.62
Relatively high lower trapezius activity
occurs in the prone rowing, prone horizontal abduction at 90° and 135° abduction with ER and IR, prone and standing
ER at 90° abduction, D2 diagonal PNF
pattern flexion and extension, PNF scapular clock, standing high scapular rows,
and scapular abduction, flexion, and abduction below 80° and above 120° with
ER.20,62,63,75 Lower trapezius activity tends
to be relatively low at angles less than 90°
of scapular abduction, abduction, and
flexion, and then increases exponentially
from 90° to 180°.2,20,29,62,75,84 Significantly
greater lower trapezius activity has been
reported during the prone ER at 90° abduction exercise compared to the empty
can exercise.3 As previously mentioned,
the lower trapezius is an extremely important muscle in shoulder function due
to its role in scapular upward rotation,
external rotation, and posterior tilt.
Ekstrom et al20 reported that the greatest EMG signal amplitude of the lower
trapezius occurred during the prone full
can, prone ER at 90°, and prone horizontal abduction at 90° with ER exercises.
Based on these results, it appears that
the prone full can exercise should not be
performed at a set degree of abduction,
but should be individualized based on the
alignment of the lower trapezius fibers
(<?=KH;,). In the authors’ experience, this
is typically around 120° of abduction but
may fluctuate, depending on the specific
patient and body type.
It is often clinically beneficial to enhance the ratio of lower trapezius-to-upper trapezius strength.11 In the opinion of
the authors, poor posture and muscle imbalance often seen in patients with a variety of shoulder pathologies is often the
result of poor muscle balance between
the upper and lower trapezius, with the
upper trapezius being more dominant.
McCabe et al56 report that bilateral ER
at 0° abduction resulted in the greatest
lower trapezius-upper trapezius ratio
compared to several other similar trapezius exercises (<?=KH;-). Cools et al11 also
identified side-lying ER and prone horizontal abduction at 90° abduction and
ER as 2 beneficial exercises to enhance
the ratio of lower trapezius to upper trapezius activity.
H^ecXe_ZiWdZB[lWjehIYWfkbW[
Both the rhomboids and levator scapulae function as scapular retractors,
downward rotators, and elevators. Exercises used to strengthen rotator cuff
and scapulothoracic musculature are
also effective in eliciting activity of the
rhomboids and levator scapulae. Relatively high rhomboid activity has been
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 113
[
CLINICAL COMMENTARY
H;9ECC;D:7J?EDI
T
<?=KH;-$Bilateral external rotation for infraspinatus
and lower trapezius strengthening involves grasping
exercise tubing with both hands and externally
rotating. Emphasis should be placed on providing
scapular retraction and posterior tilting.
reported during D2 diagonal PNF pattern flexion and extension, standing
shoulder ER at 0° and 90° abduction,
standing shoulder IR at 90° abduction,
standing shoulder extension from 90°
to 0°, prone shoulder horizontal abduction at 90° abduction with IR, scapular
abduction, abduction, and shoulder flexion above 120° with ER, prone rowing,
and standing high, mid, and low scapular rows.62,63 Relatively high rhomboids
and levator scapulae activity has been
reported with scapular abduction above
120° with ER, prone horizontal abduction at 90° abduction with ER and IR,
prone rowing, and prone extension at
90° flexion.62 Therefore, the prone extension exercise may be performed in
addition to many of the previously mentioned exercises for other scapulothoracic muscles. Other specific exercises
to activate the rhomboids and levator
scapulae muscles are not often necessary to perform.
he preceding review can be used
to identify appropriate rehabilitation
exercises for specific muscles. Based
on the reported studies and the collective
experience of the authors, we recommend
that exercises should be selected based on
the appropriate anatomical, biomechanical, and clinical implications. We have
identified a set of exercises that the current authors use clinically for rehabilitation and injury prevention (TABLE). These
exercises have been selected based on the
results of the numerous studies previously cited and take into consideration these
implications for each exercise described.
Furthermore, the authors encourage the
clinician to carefully consider emphasizing posture and scapular retraction during the performance of glenohumeral and
scapulothoracic exercises.
A common recommendation in rehabilitation is to limit the amount of weight
used during glenohumeral and scapulothoracic exercises to assure that the appropriate muscles are being utilized and
not larger compensatory muscles. Two
recent studies have analyzed this theory
and appear to prove the recommendation inaccurate and not necessary. Alpert
et al7 studied the rotator cuff and deltoid
muscles during scapular plane elevation
and noted that EMG signal amplitude
of the smaller rotator cuff muscles and
larger deltoid muscles increased linearly
in relation to the amount of weight used.
This finding is consistent with that of
Dark et al,14 who showed similar results
for the rotator cuff, deltoid, pectoralis,
and latissimus dorsi during ER and IR
at 0° abduction. Thus, it appears that
larger muscle groups do not overpower
smaller groups, such as the rotator cuff.
Weight selection should be based on the
individual goals and performance of each
patient. It does not appear necessary to
limit the amount of weight performed
during these rotator cuff exercises.
As our understanding of the anatomical and biomechanical implications associated with exercise selection continues
]
to grow, we are seeing advances in exercise selection and the integration of the
whole-body kinetic-chain approach to
strengthening and rehabilitating injuries.
This may involve strengthening multiple
joints simultaneously and during movement patterns that mimic athletic and
functional daily activities of living. The
authors often employ these techniques
when our patients improve in strength
yet continue to have symptoms during
activities. In addition, we often attempt
to further challenge our patients by performing many of the recommended exercise on various unstable surfaces (such as
foam or physioballs), with altered bases
of support (such as sitting, standing, or
single-leg balancing), in an attempt to
recruit whole-body muscle patterns that
interact together to perform active range
of motion while stabilizing other areas of
the body. We believe that these concepts
are important to consider in addition to
straight-plane, isolated movements of
specific muscle groups, and that strength,
posture, balance, and neuromuscular
control are all vital components to any
injury prevention of rehabilitation program. Future research on the validity of
these techniques is needed to justify their
use. We believe that this is the next step
in the evolution of research on the clinical and biomechanical implications of
exercise selection for the glenohumeral
and scapulothoracic musculature.
9ED9BKI?ED
A
thorough understanding of
the biomechanical factors associated with normal shoulder
movement, as well as during commonly
performed exercises, is necessary to
safely and effectively design appropriate
programs. We have reviewed the normal
biomechanics of the glenohumeral and
scapulothoracic muscles during functional activities, common exercises, and
in the presence of pathology. These findings can be used by the clinician to design
appropriate rehabilitation and injury
prevention programs. T
114 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy
Recommended Exercises for Glenohumeral and Scapulothoracic Muscles
Based on Anatomical, Biomechanical, and Clinical Implications
TABLE
CkiYb[
;n[hY_i[
7dWjec_YWb?cfb_YWj_edi
8_ec[Y^Wd_YWb?cfb_YWj_edi
9b_d_YWb?cfb_YWj_edi
Supraspinatus
1. Full can
1. Enhances scapular position and
subacromial space
1. Decreased deltoid involvement
compared to empty can
1. Minimizes chance of superior humeral head migration by
deltoid overpowering supraspinatus
2. Prone full can
2. Enhances scapular position and
subacromial space
2. High posterior deltoid activity
2. High supraspinatus activity and also good exercise for
with similar supraspinatus activity
lower trapezius
1. Side-lying ER
1. Position of shoulder stability,
minimal capsular strain
1. Increased moment arm of
muscle at 0° abduction.
Greatest EMG activity
1. Most effective exercise in recruiting infraspinatus activity.
Good when cautious with static stability
2. Prone ER at 90°
abduction
2. Challenging position for stability,
higher capsular strain
2. High EMG activity
2. Strengthens in a challenging position for shoulder stability.
Also good exercise for lower trapezius
3. ER with towel roll
3. Allows for proper form without
compensation
3. Increased EMG activity with
addition of towel, also incorporates adductors
3. Enhances muscle recruitment and synergy with adductors
1. IR at 0° abduction
1. Position of shoulder stability
1. Similar subscapularis activity
between 0° and 90° abduction
1. Effective exercise, good when cautious with static stability
2. IR at 90° abduction
2. Position of shoulder instability
2. Enhances scapular position and 2. Strengthens in a challenging position for shoulder stability
subacromial space. Less
pectoralis activity
3. IR diagonal exercise
3. Replicates more functional activity 3. High EMG activity
3. Effective strengthening in a functional movement pattern
1. Easy position to produce
resistance against protraction
1. High EMG activity
1. Effective exercise to provide resistance against protraction,
also good exercise for subscapularis
2. Performed below 90° abduction
2. High EMG activity
2. Easily perform in patients with difficulty elevating arms or
performing push-up. Also good exercise for subscapularis
3. Serratus punch 120° 3. Combines protraction with
upward rotation
3. High EMG activity
3. Good dynamic activity to combine upward rotation and
protraction function
1. Prone full can
1. Can properly align exercise with
muscle fibers
1. High EMG activity
1. Effective exercise, also good exercise for supraspinatus
2. Prone ER at 90°
abduction
2. Prone exercise below 90°
abduction
2. High EMG activity
2. Effective exercise, also good exercise for infraspinatus and
teres minor
3. Prone horizontal
abduction at 90°
abduction with ER
3. Prone exercise below 90°
abduction
3. Good ratio of lower to upper
trapezius activity
3. Effective exercise, also good exercise for middle trapezius
4. Bilateral ER
4. Scapular control without arm
elevation
4. Good ratio of lower to upper
trapezius activity
4. Effective exercise, also good for infraspinatus and teres minor
1. Prone exercise below 90°
abduction
1. High EMG activity
1. Effective exercise, good ratios of upper, middle, and lower
trapezius activity
2. Prone horizontal
abduction at 90°
abduction with ER
2. Prone exercise below 90°
abduction
2. High EMG activity
2. Effective exercise, also good exercise for lower trapezius
1. Shrug
1. Scapular control without arm
elevation
1. High EMG activity
1. Effective exercise
2. Prone row
2. Prone exercise below 90°
abduction
2. High EMG activity
2. Good ratios of upper, middle, and lower trapezius activity
3. Prone horizontal
abduction at 90°
abduction with ER
3. Prone exercise below 90°
abduction
3. High EMG activity
3. Effective exercise, also good exercise for lower trapezius
1. Prone exercise below 90°
abduction
1. High EMG activity
1. Effective exercise, good ratios of upper, middle, and lower
trapezius activity
2. Prone exercise below 90°
abduction
2. High EMG activity
2. Effective exercise, also good for lower and middle trapezius
Infraspinatus
and teres
minor
Subscapularis
Serratus anterior 1. Push-up with plus
2. Dynamic hug
Lower trapezius
Middle trapezius 1. Prone row
Upper trapezius
Rhomboids and 1. Prone row
levator scapulae
2. Prone horizontal
abduction at 90°
abduction with ER
3. Prone extension with ER 3. Prone exercise below 90° abduction 3. High EMG activity
3. Effective exercise, unique movement to enhance scapular control
Abbreviations: EMG, electromyography; ER, external rotation; IR, internal rotation.
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 115
[
H;<;H;D9;I
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WWW.JOSPT.ORG
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 117
[
clinical commentary
]
Bryce W. Gaunt, PT, SCS1 • Michael A. Shaffer, MSPT, OCS, ATC2 • Eric L. Sauers, PhD, ATC3
Lori A. Michener, PT, PhD, ATC, SCS4 • George M. McCluskey III, MD5 • Chuck A. Thigpen, PT, PhD, ATC6,7
The American Society of Shoulder and
Elbow Therapists’ Consensus Rehabilitation
Guideline for Arthroscopic Anterior
Capsulolabral Repair of the Shoulder
T
he maintenance of shoulder stability is the result of a complex
interplay of static and dynamic factors. Shoulder instability
may require surgical stabilization to resolve the anatomical
deficits causing the instability and to restore shoulder function.
A variety of surgical techniques exist. The chronicity, magnitude
(dislocations or subluxations), and direction (anterior, posterior, or
multidirectional) of instability are the key factors considered during
preoperative planning. In addition, patient factors, such as a need
for mobility in the case of an overhead athlete, must be considered.
As the majority of patients with anterior instability have injuries to their
capsulolabral complex, the arthroscopic
t SYNOPSIS: This manuscript describes the
consensus rehabilitation guideline developed
by the American Society of Shoulder and Elbow
Therapists. The purpose of this guideline is to
facilitate clinical decision making during the rehabilitation of patients following arthroscopic anterior
capsulolabral repair of the shoulder. This guideline
is centered on the principle of the gradual application of stress to the healing capsulolabral repair
through appropriate integration of range of motion,
strengthening, and shoulder girdle stabilization
exercises during rehabilitation and daily activities.
Components of this guideline include a 0- to
4-week period of absolute immobilization, a staged
recovery of full range of motion over a 3-month
anterior capsulolabral repair is a commonly utilized procedure. Arthroscopic
anterior capsulolabral repair seeks to reperiod, a strengthening progression beginning at
postoperative week 6, and a functional progression
for return to athletic or demanding work activities
between postoperative months 4 and 6. This document represents the first consensus rehabilitation guideline developed by a multidisciplinary
society of international rehabilitation professionals
specifically for the postoperative care of patients
following arthroscopic anterior capsulolabral
repair of the shoulder. J Orthop Sports Phys Ther
2010;40(3):155-168. doi:10.2519/jospt.2010.3186
t KEY WORDS: Bankart repair, capsular plica-
tion, postoperative rehabilitation, shoulder instability, therapeutic exercise
store shoulder stability by suturing back
to the glenoid the detached or unstable
anterior inferior labrum, known as a Bankart lesion (FIGURE 1). In addition to a Bankart repair, capsular plication is added as
necessary to address permanent plastic
deformation of the glenohumeral joint
capsule that often accompanies recurrent
anterior inferior dislocations.6,31 Rehabilitation following the surgery must balance
the restoration of motion and function
with the desired result of an appropriately
taut capsulolabral complex.23,34
Blackburn and Guido7 published a rehabilitation guideline in 2000 for patients
following open anterior shoulder stabilization, which at the time was the most commonly performed stabilization procedure.
However, due to the less invasive nature of
arthroscopic procedures, patients undergoing arthroscopic repair today generally
regain range of motion (ROM) more easily
and with less risk of permanent restriction
than patients following comparable open
surgeries.23,34 In 2002, Wilk et al95 published a rehabilitation protocol following thermal-assisted capsulorraphy. Due
to concerns about the long-term health
of capsular tissue treated with laser- or
Director of Physical Therapy, HPRC at St Francis Rehabilitation Center, Columbus, GA. 2 Coordinator of Sports Rehabilitation University of Iowa Sports Medicine, Clinical
Specialist Department of Rehabilitation Therapies University of Iowa Hospitals and Clinics, Iowa City, IA. 3 Associate Professor and Chair, Department of Interdisciplinary Health
Sciences, A. T. Still University, Mesa, AZ. 4 Associate Professor Department of Physical Therapy, Virginia Commonwealth University-MCV Campus, Richmond, VA. 5 Director, St
Francis Shoulder Center, St Francis Orthopaedic Institute, Columbus, GA. 6 Clinical Research Scientist, Proaxis Therapy, Greenville, SC. 7 Assistant Consulting Professor, Doctor
of Physical Therapy Division, Department of Community and Family Medicine, Duke University School of Medicine, Durham, NC. Address correspondence to Bryce Gaunt, HPRC
at St Francis Rehabilitation Center, PO Box 8068, Columbus, GA 31908-8068. E-mail: [email protected]
1 journal of orthopaedic & sports physical therapy | volume 40 | number 3 | march 2010 |
40-03 Gaunt.indd 155
155
2/17/10 2:53:08 PM
[
clinical commentary
FIGURE 1. A Bankart lesion.
radiofrequency-assisted shrinkage, and
the concern about the rapid restoration of
ROM at the expense of long-term stability,
this procedure is no longer performed regularly. Although these previous guidelines
exist for patients following capsulolabral
repair, the rehabilitation for open stabilization and thermal capsulorraphy are
very different, based upon the surgical exposure and fixation method. Furthermore,
a consensus rehabilitation guideline is not
available for what is now the most commonly performed surgical procedure for
anterior inferior instability, arthroscopic
anterior capsulolabral repair.
AIM OF THE GUIDELINE
T
his consensus rehabilitation
guideline of the American Society
of Shoulder and Elbow Therapists
(ASSET) was designed for use with patients who have undergone arthroscopic
anterior capsulolabral repair in which the
detached labrum was suture anchored
back to the glenoid rim and/or capsular
tension is restored through suture tightening of the plicated capsule. This rehabilitation guideline is not intended for use
with other surgical procedures to address
glenohumeral instability because of the
variation in surgical approaches, initial
fixation strength, and varying potential
for lost ROM following the procedures.
Additionally, the repair of associated lesions, such as a rotator cuff tear or superior labrum anterior-to-posterior (SLAP)
tear, would also require a different rehabilitation program.
This consensus rehabilitation guideline, created by the members of ASSET,
is not intended to serve as the standard
of medical care. Instead, this document
should serve as a guideline and, as such,
should be used in conjunction with a thorough history and physical examination of
the individual patient. The rehabilitation
processes described herein are designed
to provide the clinician with a guideline for rehabilitation and description
of the expected outcome; however, outcome may differ for individual patients.
Individual patient values, expectations,
preferences, and goals should be used
in conjunction with this guideline. Our
guideline should evolve with advances in
knowledge and technology. ASSET takes
no responsibility and assumes no liability
for improper use of this guideline. As the
balance between mobility and shoulder
stability is delicate and involves a host of
anatomic, neuromuscular, and patientcentric factors, strict adherence to this
guideline does not guarantee a successful
outcome. In our opinion, the best chance
for success is when an informed, educated
patient works together with a competent,
knowledgeable surgeon and rehabilitation specialist, who are themselves working in concert to provide the patient with
information and techniques which are
current and grounded in science.
METHODS OF DEVELOPMENT
T
his guideline evolved after
representatives from the American
Shoulder and Elbow Surgeons Society (ASES) approached ASSET about the
need for clinical guidelines for postoperative rehabilitation. In response, ASSET
identified a panel of members with extensive experience treating patients following arthroscopic capsulolabral repairs to
review the literature and begin developing a rehabilitation guideline. This panel
included members with clinical specialty
certifications and terminal research degrees and whose members were also se-
]
lected to represent different geographic
regions of the United States.
In the development of this guideline,
our goal was to cite the best available
evidence, relying on randomized controlled trials when available. The panel
searched for clinical trials and basic science evidence from multiple databases
up to August, 2009 (Cochrane, PubMed,
CINAHL, SportDiscus), using only English language articles for this guideline.
Because of the paucity of randomized
controlled trials comparing rehabilitation protocols or no treatment postoperatively, we used basic science and
mechanistic studies, along with ASSET
member expertise and clinical opinion,
to develop this rehabilitation guideline.
After initial development by the subpanel
of the major principles and time frames
guiding rehabilitation, the guideline was
sent to all members of ASSET to review
and provide feedback from which to develop consensus. In addition, the specifics
of the guideline (ie, immobilization time
frames, when to initiate active ROM, time
to restore normal ROM, etc) were openly
debated until consensus was reached at
2 subsequent annual meetings of ASSET.
Finally, an ASES member with experience performing arthroscopic anterior
capsulolabral repairs was recruited to add
a surgeon’s perspective. The final guideline (APPENDIX) represents an international consensus rehabilitation guideline
developed by a multidisciplinary society
of rehabilitation professionals (athletic
trainers, occupational therapists, and
physical therapists who are American or
foreign members of ASSET). This is the
first clinical guideline developed for the
rehabilitation of patients following arthroscopic anterior capsulolabral repair.
REHABILITATION
GUIDELINE PRINCIPLES
A
successful outcome following shoulder instability surgery
is defined as a pain-free and stable shoulder that has enough mobility,
strength, and muscle control for a pa-
156 | march 2010 | volume 40 | number 3 | journal of orthopaedic & sports physical therapy
40-03 Gaunt.indd 156
2/17/10 2:53:09 PM
TABLE 1
Guiding Principles for the
Rehabilitation Specialist
1. A thorough understanding of the surgical procedure
2.A thorough understanding of the anatomic structures that must be protected, how they are stressed, and the rate at
which they heal
3. Appropriate selection and skilled application techniques to impart varying levels of stress to the healing tissues
4. Appropriate management of the initial immobilization period and the rate of range-of-motion progression
FIGURE 2. Suture anchors are demonstrated in the
5-, 4-, and 3-o’clock positions during an arthroscopic
capsular shift.
tient’s desired level of activity and participation. Four principles are of critical
importance for the rehabilitation professional to successfully apply controlled
stress to the shoulder and optimize patient outcome: (1) an understanding of the
surgical procedure, (2) an understanding
of the anatomic structures which must be
protected, how they are stressed, and the
rate at which they heal, (3) the identification and skilled application of techniques
to impart varying levels of stress to the
healing tissues, and (4) managing the initial immobilization period and the rate of
ROM progression (TABLE 1).
Guiding Principle 1
Understanding the surgical procedure is
important for the rehabilitation specialist.
An arthroscopic anterior capsulolabral repair begins with a thorough arthroscopic
examination of the glenohumeral joint,
which is performed to assess the extent
of pathology (ie, labral detachment and
capsular attenuation) and to develop a
plan for restoring stability.67 During the
FIGURE 3. The capsule has been shifted 5 to 10
mm superiorly with each suture limb during an
arthroscopic capsular shift.
classic anterior-inferior traumatic glenohumeral dislocation, the humeral head
is driven anterior-inferior and usually
lodges inferior to the coracoid process in
what is referred to as a subcoracoid dislocation.80 As the head is forced out of the
glenoid socket, it detaches the anteriorinferior labrum from approximately the
3-to 6-o’clock position (ie, Bankart lesion)
(FIGURE 1).90 Capsular attenuation is also
frequently present as the forces that drive
the humeral head out of the glenoid are
sufficient to cause plastic, unrecoverable
deformation of the capsuloligamentous
restraints.6,31 Therefore, some surgeons
perform capsular plication in all patients undergoing arthroscopic instability repairs.83 In patients with congenital
or atraumatic instability and an intact
labrum, capsular attenuation is the primary pathology addressed by the surgery.
Associated injuries, such as a Hill Sachs
lesion, rotator cuff tears, or osteochondral
injuries, may also be present.90 It is essential for the rehabilitation specialist to
communicate with the surgeon to deter-
mine the extent of any associated injuries
and if anything was done at the time of
surgery to address them that may impact
the rehabilitation progression.
In patients with anterior instability
but without a significant labral injury,
the surgeon tightens the capsule and
the glenohumeral ligaments with an arthroscopic capsular plication or capsular
shift procedure.83 Either biodegradable
suture anchors are placed along the
anterior-inferior labral articular surface
without disturbing the intact labrum or
the capsule is sutured directly to the intact labrum without the use of suture anchors. In either case, special instruments
are used to shuttle the suture through the
capsule and labrum, and a rasp or synovial resector is used to lightly abrade the
capsular tissue that is to be retensioned.
The amount of capsular tightening or retensioning is based on the preoperative
examination and history, the amount of
laxity demonstrated during the examination under anesthesia, and the pathologic
findings from the diagnostic arthroscopic
examination.83 In a typical capsular shift
without a Bankart repair, 3 suture anchors with a single suture in each anchor
are utilized (FIGURE 2), and the capsule is
shifted approximately 5 to 10 mm with
each suture limb from an inferior to a
superior direction (FIGURE 3), thus eliminating the capsular redundancy in the
anteroinferior joint compartment.31,83
The presence of a Bankart lesion, bony
Bankart lesion, or other labral injury requires mobilization of the capsulolabral
complex from the anterior glenoid neck or
rim.88,89 An arthroscopic elevator is utilized,
first followed by a synovial resector or small
burr to abrade the glenoid rim at the articular margin, so as to promote healing of the
labrum to bone after repair. It is generally
not necessary to shift or tighten the capsule
in a Bankart repair. The labral-capsular
complex is repaired anatomically.
Guiding Principle 2
Understanding the anatomic structures
that must be protected, how they are
stressed, and the rate at which they heal
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[
clinical commentary
is also important before rehabilitation
begins. Arthroscopic anterior capsulolabral repair involves a direct repair of
damaged capsular and labral structures.
Repair is achieved via suture and/or suture anchor reattachment, which requires
protection from excessive stresses to facilitate appropriate tissue healing.62,75 It
is well documented that specific portions
of the capsule and labrum are selectively
tensioned with specific glenohumeral
motions.68,81,86 A standard anterior capsulolabral repair, addressing attenuation
of the anterior inferior capsule, is most
directly stressed by external rotation,
particularly above 90° of abduction.68,86
In a cadaveric model, Itoi et al37 demonstrated that with the arm by the side,
external rotation to 30° could safely be
applied to the shoulder without separating a simulated Bankart lesion.
Forward flexion stresses the inferior
part of the glenohumeral joint capsule.
Therefore, based on the stress to the inferior capsule, we recommend limiting
flexion to less than 90° until 3 weeks
postsurgery, then gradually increasing
flexion to 135° through postoperative
week 6.
During the classic open Bankart repair, the subscapularis is either detached
or split to access the capsule and is then
subsequently reattached or closed with
sutures, necessitating protection from
active internal rotation during the early
postoperative period.39,50 However, during the standard arthroscopic anterior
capsulolabral repair, the subscapularis
is not detached or split, therefore it does
not need specific protection from excessive stress during the rehabilitation
program.15
It is imperative that activities be limited to those which produce less stress
to the healing tissues than the failure
strength of the repair.93 The challenge
for guiding rehabilitation based upon
the tissue healing is the limited ability
for clinicians to measure tissue healing. Moreover, the amount of stress imparted by many rehabilitation activities
remains unknown.
The rehabilitation process is divided
into 3 phases of 6 to 12 weeks in duration,
because we believe these time frames coincide with the healing and clinical milestones. The first 6 weeks postoperative
include the inflammatory and the proliferative (fibroplasia and wound contraction) phases and the beginning of the scar
maturation phase of tissue healing.19 Scar
maturation and remodeling of the tissue
likely continues throughout the rehabilitation process and may not be complete
until 40 to 50 weeks after surgery.53,96
Other factors, such as the patient’s
age and the presence of comorbidities,
may affect tissue healing and should be
considered when deciding how quickly to
progress an individual patient. Diabetes
mellitus, peripheral vascular disease, and
connective tissue disorders may impair
healing; therefore patients with these
diseases may have or require a slower rehabilitation progression. No studies have
examined the influence of comorbidities
on shoulder function following capsulolabral repair. Comorbidities do negatively
influence outcome following rotator cuff
repair and shoulder athroplasty,11,35 therefore it is possible that comorbidities may
negatively impact rehabilitation and outcomes after capsulolabral repair.
Guiding Principle 3
Correct selection and use of techniques to
apply varying levels of stress to the surgical repair is important for a successful
outcome. Following surgical repair, the
healing capsulolabral structures require
appropriate stress to stimulate optimal
healing, while protecting the repair from
excessive tension. The gradual application of stress is a stimulus for further
proliferation and differentiation of fibroblasts.19,35 A gradual increase in applied
stress, in a process analogous to Wollf ’s
law of bone healing,96 results in enhanced
structural integrity of the capsulolabral
complex as additional collagen fibers
are laid down in response to controlled
stresses. However, it is equally important
to understand that with excessive stress
to the capsulolabral complex, either in
]
terms of magnitude or timing, the tissues
will be unable to adequately adapt,32,92
and damage will result to either the healing tissues or the suture anchors. During
rehabilitation, there are 3 mechanisms
by which rehabilitation providers apply
stress to the surgical repair to positively
affect patient outcome: (1) absolute ROM,
(2) controlled submaximal tissue loading,
and (3) dynamic stabilization.
Immediately following surgery, the repair is completely reliant on the mechanical strength of the sutures and/or suture
anchors. Therefore, the absolute ROM
limit that is initially deemed safe is based
upon the surgical fixation and structural
integrity of the repair. As time passes, the
repaired tissues begin to heal through fibrous scar formation and gradually increase in tensile strength. In the case of
a Bankart lesion, the labrum develops
immature connective tissue links to the
glenoid rim, and in the case of a capsular plication, the plicated layers of the
capsule initiate formation of immature
connective tissue links to one another.
Excessive stretching during ROM activities may overload the structural integrity
of these immature cross-links in the healing tissues.30,68,81,86
Much in the same way micromotion
prevents bony union during fracture
healing, submaximal tissue loading also
has the potential to disrupt the tenuous
tissue healing bonds between the labrum
and bone and between the plicated layers
of the capsule.32,92 Repeated submaximal
stress of a ligament plication in an animal model has been shown to negatively
affect mechanical resistance properties,
even as late as postoperative week 12.32
While direct extrapolation cannot be
made to a pathologic human condition,
these findings are similar to the effects of
submaximal loading in human cadavers.
Repetitive submaximal loading has been
shown to increase the length and decrease
the subsequent load to failure of the anterior inferior glenohumeral ligament.71
The exact effect of submaximal loading
during various rehabilitation interventions is currently unknown. Thus, clini-
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cians should keep in mind that repeated
and excessive submaximal tensioning of
the repair during the remodeling phases
of tissue healing may theoretically cause
the capsule to heal at a longer length.
Therefore, even though they are below
the failure strength of the capsulolabral
tissues, repetitive submaximal stresses
should be carefully controlled as they
pose a potential threat to capsuloligamentous integrity.
While excessive submaximal loading
may be detrimental, dynamic stabilization or active stabilization of a joint by the
muscles directly surrounding it provides
protection to the surgical repair9,13,49,51 by
supporting the joint capsule,14 increasing joint compression forces,42,49 and
resisting joint displacement.55 It is vital
to understand that these 3 mechanisms
(absolute ROM, submaximal tissue loading, and dynamic stabilization) do not
occur in isolation but are interrelated in
all rehabilitation activities and should be
the primary considerations when selecting interventions during rehabilitation.
Guiding Principle 4
Appropriate management of the initial
immobilization period and ROM progression are also important for the rehabilitation specialist because the tensile
strength of the arthroscopic anterior
capsulolabral repair is reduced through
the first 12 postoperative weeks.32 Therefore, it is important to protect the surgical repair from undue stress during the
first 2 phases of this rehabilitation guideline (12 weeks total) by controlling the
rate at which ROM is regained. Gaining
ROM too quickly can limit the normal
tissue-healing process and lead to capsuloligamentous attenuation. 93 Therefore, an initial period of immobilization
is common after arthroscopic anterior
capsulolabral repair to facilitate healing
of the surgically repaired tissues,40,45,52,65,76
theoretically allowing the surgically reattached labrum a chance to bind to the
glenoid and the plicated layers of capsule
to heal to each other.
Absolute immobilization (no gle-
nohumeral ROM exercises and constant
sling use) in the first 6 weeks following
arthroscopic capsulolabral repair of the
shoulder was advocated during the infancy of these procedures,40,65 when surgical techniques were rapidly evolving and
failure rates were high.27 However, studies advocating absolute immobilization
as a means to decrease long-term failure
rates utilized surgical procedures such as
transglenoid sutures27,84 or staple repair40
that are no longer common. Current surgical methods typically employ sutures
and suture anchors to repair the labrum
and retension the glenohumeral ligaments,3,10,45,52 producing outcomes similar
to open instability repair.3,23,44 Therefore,
the need for absolute immobilization after arthroscopic Bankart repair has been
reexamined in recent years.
Studies have shown short periods of
absolute immobilization result in no
greater recurrence rate of shoulder instability and have demonstrated improved
ROM over the course of recovery.3,46 In a
randomized controlled trial comparing 3
weeks of absolute immobilization to immediate staged ROM in a select group
of patients undergoing Bankart repair,
Kim et al46 found that immediate ROM
yielded no greater recurrence rate in dislocation, or difference in pain or function
scores. These results apply to patients
with recurrent (nonacute) instability
brought on by a traumatic event, and a
Bankart lesion only without the presence of a bony fragment (bony Bankart).
These results do not apply to those patients actively participating in sports, or
to those patients with multidirectional or
posterior instability, other labral lesions,
a rotator cuff tear, or a larger bony Bankart lesion involving greater than 30%
of the glenoid. Additionally, considering
that the capsulolabral complex appears
to be within the safe boundaries of stress
with the arm in adduction and up to 30°
of external rotation,37 immediate postoperative ROM in this range is safe.46
Based on this evidence and our significant clinical experience rehabilitating patients following this surgery, we
recommend a variable period between
0 up to 4 weeks of absolute immobilization following an arthroscopic anterior
capsulolabral repair, in which sutures
or suture anchors are utilized. Relative
immobilization (out of sling only for
ROM exercises or short periods of sitting or standing) is recommended for 6
weeks, followed by sling use for comfort.
We offer ranges of immobilization as a
general guideline because we recognize
that surgeon preference plays a major
role in the postoperative immobilization
time frames for patients undergoing this
procedure and want to provide a wide
range that is safe, both in terms of early
motion and protecting the repair, and
restricted motion in terms of preventing
contractures and adhesions. Immobilization periods should be determined by the
surgeon and rehabilitation provider for
each individual patient, considering the
extent of the pathology, the integrity or
the repair, as well as the patient’s goals,
age, and comorbidities.
Regardless of the period of absolute
and relative immobilization, controlling
the rate of ROM progression is vitally
important. The integrity of the surgical repair is thought to be negatively
affected by the patient regaining ROM
too quickly during the first 8 to 12 weeks
postoperatively.32,62,75 Staged ROM goals
are an effective tool to guide the rate of
ROM progression.46,52 We have proposed
a general guideline for staged ROM goals
that we were able to achieve consensus on
from our multidisciplinary team of shoulder rehabilitation specialists (TABLE 2). As
with the specific period of immobilization, ROM goals may be modified by the
surgeon or rehabilitation provider, based
on the individual patient. The ROM goals
have the patient comfortably progressing
their ROM to the specified angle. If the
patient’s ROM is less than the targeted
range, gentle stretching should be implemented to facilitate ROM gains to the
targeted range and to prevent the development of contractures and adhesions.
On the other hand, if the targeted ROM
is easily obtained, then stretching in the
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TABLE 2
clinical commentary
Staged Range-of-Motion Goals Following
Arthroscopic Anterior Capsulolabral Repair
PFEPER at 20° AbdPER at 90° AbdAFE
POW 3
90°
10°-30°
Contraindicated
NA
POW 6
135°
35°-50°
45°
115°
POW 9
155°
50°-65°
75°
145°
POW 12
WNL
WNL
WNL
WNL
Abbreviations: Abd, abduction; AFE, active forward elevation in the scapular plane; NA, not
applicable; PER, passive external rotation; PFE, passive forward elevation; POW, postoperative week;
WNL, within normal limits.
directions in which the target motions
have already been met should be avoided to prevent overstressing the healing
tissues.19
REHABILITATION GUIDELINE
T
he APPENDIX contains ASSET’s
Consensus Rehabilitation Guideline for Arthroscopic Anterior
Capsulolabral Repair. The guideline is
divided into 3 phases, based on general
time frames of capsulolabral healing.
In addition to time, short-term goals
or milestones at each phase are used to
determine progression from one phase
to the next of the treatment program.
Clinician-rated impairments and patientrated outcome tools are used to judge
these milestones. Goals for each phase
include surgical healing, staged attainment of passive and/or active ROM, pain,
adherence to immobilization and home
exercise program, scapular posture and
dynamic control during ROM and exercise, and restoration of shoulder function. Clinician-rated impairments and
patient-rated outcomes are used to assess
the achievement of these goals. Healing
of the surgical repair is assessed by time
frames, and adherence to the precautions, immobilization, and ROM guidelines. Active and passive ROM should be
measured with an inclinometer or goniometer. Pain should be assessed with a
patient-rated numeric pain rating scale
(NPRS). Scapular posture should be assessed visually for winging or other abnormal motion during active elevation of
the arm or as the patient completes the
supervised portion of their exercise program. Completion of strengthening program should be assessed by comparing
the exercise program performed to the
protocol. Finally, measurement of shoulder functional loss or disability is best
evaluated with a patient-rated outcome
measure.
Both the clinical milestones and time
frames should be met prior to progression to the next phase. Clinician-rated
impairments should be performed every 1
to 2 weeks, to closely monitor response to
treatment and achievement of milestones.
It is critical to use patient-rated measures
of function and disability to comprehensively assess patient response to treatment. There are numerous patient-rated
measures with established measurement
properties available to assess shoulder
function and disability. Recent studies of
patient-rated measures of shoulder functional loss and disability in patients with
instability or undergoing shoulder surgery indicate that one measure is likely
not superior to another.69,70 The scales
recommended for use are patient-rated
measures specifically for instability, such
as the Western Ontario Instability Index
(WOSI) or a general shoulder measure
such as the ASES Form patient-rated
section.47,48,63
Phase 1: Postoperative Weeks 0 to 6
The focus of phase 1 rehabilitation, which
constitutes the first 6 postoperative weeks,
is to maximally protect the surgical repair and achieve, but not to exceed, the
staged ROM goals (TABLE 2), while being
especially mindful to not exceed external
]
rotation limits. Because of the minimally
invasive nature of the surgical procedure,
some patients experience little pain and
may be able to use their arm more than
is advisable during this phase. Therefore,
patient education is critical to convey the
importance of staying within the prescribed ROM limits and not overloading
the shoulder, so as to protect the healing
tissues from excessive stress and possible
anchor or tissue failure. Potentially injurious forces can be avoided by slowly
progressing through staged ROM goals,
controlling submaximal loading forces
by limiting repetitive activity of the arm,
and avoiding forces that may overstress
the structural integrity of the capsulolabral repair by not lifting heavy objects.
Wetzler et al92 estimated that a shoulder
would typically experience 1000 to 2000
loading cycles during the first 6 weeks of
rehabilitation following capsulolabral repair. Based upon their analysis, the maximum load any particular suture anchor
could accommodate is 60 to 100 N, based
upon the location of the suture anchors,
with lower forces to failure on the more
inferior portions of the glenoid. Additionally, the pull-out strength decreased precipitously within the first 100 cycles until
the suture anchor “settled.” Therefore, despite the fact that the suture anchor-bone
construct is strongest initially, the loads
during the first few weeks of rehabilitation should be minimized until the suture
anchor has “settled” into its final position.
Direct application of these data clinically
is limited, as cadaveric specimens were
used with an average age older than the
typical patient undergoing arthroscopic
capsulolabral repair. Still, we believe
these findings provide some support for
minimizing the number and amount of
repetitive loads, particularly during the
first phase of rehabilitation.92
Because the rotator cuff muscles are
not detached during arthroscopic stabilization, both passive and/or active assistive ROM exercises are appropriate in
the early stages of postoperative rehabilitation. Therefore, unlike rehabilitation of
the patient following rotator cuff repair,
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active assistive exercises can be performed
immediately for the patient following arthroscopic capsulolabral repair.
Forward elevation and external rotation in slight abduction within the prescribed ROM limits are the glenohumeral
motions performed during phase 1,
as they allow for glenohumeral ROM
without adversely stressing the surgical repair. Exercises to regain forward
elevation may include rope-and-pulleyassisted elevation, self-assisted elevation
in the supine position, or wand-assisted
elevation in the supine position. A table
step-back exercise (FIGURE 4), where the
patient’s hands remain stationary on a
surface, while the patient slowly walks his
or her body back, bending at the waist to
achieve forward elevation, may be helpful for patients who have difficulty relaxing. To regain external rotation ROM, the
clinician or family member may perform
passive external rotation with the arm at
the side, or the patient could perform active assisted external rotation with a cane
or bar to assure that ROM limits are not
exceeded and the shoulder is not positioned in extension during any external
rotation ROM exercise.
To protect the surgical repair, ROM
should never be forceful during phase 1.
During phase 1, it is recommended that
stretching exercises stop at the point
when the patient experiences a sensation
of a light stretch, as long as the ROM
is less than the staged ROM goals. If
ROM exceeds the staged goals without
any sensation of stretch, then the patient no longer has a ROM deficit. If this
circumstance occurs, ROM exercises in
this plane are discontinued until ROM
is consistent with the staged goals. During phase 1, ROM exercises should not be
used that stretch into end range external
rotation, particularly at 90° of abduction,
have the patient positioned in shoulder
extension, or stretch into straight-plane
abduction, with or without humeral external rotation, because they directly
stress the anterior or anterior inferior
glenohumeral capsule.86
Scapular exercises and active motion
FIGURE 4. (A) Starting position and (B) 90° of shoulder elevation for the table step back exercise.
of the uninvolved joints of the upper extremity, such as the elbow or wrist, are
recommended during phase 1 but are
considered supplementary activities.
Exercises to achieve scapular control are
encouraged; however, positions and exercises that stress the capsulolabral structures should be avoided, such as scapular
protraction with concomitant horizontal
abduction of the shoulder. Postures or
exercises that include scapular retraction
should be encouraged, as scapular retraction minimizes the amount of shoulder
extension needed for functional tasks and
therefore limits stress on the anteriorinferior capsule and labrum.91 However,
even though scapular elevation and retraction are relatively safe, these activities
should only be completed with very light
or no resistance.
Although the rotator cuff does not
specifically require protection following
arthroscopic stabilization, glenohumeral
active ROM and rotator cuff strengthening are purposefully de-emphasized during the early postoperative period because
of the potentially detrimental effect to the
healing tissues.32,92 Light strengthening
and active ROM within the staged ROM
goals would not likely result in excessive
loading; however, in our opinion, it sends
an inconsistent message to the patient
during this early postoperative period
that some strengthening is approved yet
significant restrictions of activities of
daily living and immobilization are necessary. We believe this inconsistency can
lead to excessive arm use, in terms of
both loading and ROM, resulting in too
much stress to the surgical repair. Healing is the first priority in phase 1. During
phase 1, the only form of strengthening
recommended is submaximal isometric
strengthening of the shoulder and elbow,
with the arm adducted to the side in neutral rotation.
Phase 2: Postoperative Weeks 6 to 12
Phase 2 begins at postoperative week 6
and after the clinical milestones identified
in phase 1 (APPENDIX) have been achieved.
The focus of this phase is continued patient education regarding postoperative
activity limitations, staged ROM goals
(TABLE 2), and the initiation of rotator
cuff and scapular neuromuscular control
activities within the allowed ROM. This
is achieved by gradual increase in ROM,
submaximal tissue loading, and dynamic
stabilization.
The goal is to achieve full ROM in all
planes at 12 weeks postoperative, with the
exception of end range external rotation at
90° of abduction. The motions of forward
elevation and external rotation in slight
abduction remain the focus of this phase,
and it is also important to measure and,
if limited, begin interventions to increase
glenohumeral joint horizontal adduction
and internal rotation. Posterior shoulder
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[
clinical commentary
mobility is important to maintaining normal arthrokinematics of the glenohumeral
joint, as a tightness of the posterior shoulder has been shown to increase superior
humeral head migration, which may lead
to impingement.28 Cross-body stretching
has been shown to yield superior gains in
internal rotation ROM when compared to
a “sleeper” stretch.60
If forward elevation or external rotation ROM lag behind staged ROM goals,
joint mobilizations or stretching can be
performed. Based upon data regarding
fatigue properties of suture anchors,92
rehabilitation professionals should be
cautious during the use of joint mobilizations. We recommend their use only
when active assisted and passive ROM
has not allowed the patient to achieve
staged ROM goals.
In addition, there is an often theorized link between anterior glenohumeral laxity and excessive external rotation
ROM, particularly in overhead athletes.
Increased laxity5,77 and greater external
rotation ROM77 have been found in the
dominant shoulders of professional baseball pitchers. However, this finding is far
from universal, as several authors have
demonstrated no asymmetry in laxity
between the dominant and nondominant
shoulders of professional pitchers.12,16 The
most direct evidence linking capsular
loading, laxity, and ROM may have been
provided by Mihata et al,64 who demonstrated a linear increase in length of the
inferior glenohumeral ligament and the
amount of glenohumeral anterior translation as a result of a prolonged, excessive
stretch into external rotation. Therefore,
it is important to remember not to perform passive stretching to gain end range
external rotation or external rotation at
90° of abduction unless significant tightness is present, as these are the motions
that impart the greatest stress to the healing capsulolabral repair.68,86
As ROM targets are met, the focus of
rehabilitation can shift to neuromuscular retraining. A program which focuses
on scapular stability and maintaining
the humeral head in a centralized posi-
tion within the glenoid fossa has been
shown to minimize strain on the capsule and thereby offers a protective effect for the surgical repair.9,13,49,51 The
neuromuscular retraining must be carried out within the staged ROM goals,
and must provide a stepwise increase in
muscular demand. If muscular demand
is increased too quickly, abnormal movement patterns are likely to occur at the
scapulothoracic and glenohumeral joints.
We recommend exercises for which the
magnitude of specific muscle activation
has been documented through electromyographic studies, to provide the clinician with the ability to objectively apply
gradually increasing loads to specific
muscles.4,8,17,18,20,22,33,36,38,43,54,57,58,66,72,73,85,87
A strengthening program that integrates
the ROM progression, progressively increasing muscular activity levels, and repetitive submaximal loading is detailed
in the phase 2 strength and endurance
section of the appendix.
Progression to active and resistive elevation activities should be performed
in phase 2. We advocate elevation in
the scapular plane because, compared
to frontal or sagittal plane elevation,
scapular plane elevation provides minimal capsular stress,21 better subacromial
clearance,41 and a more optimal lengthtension relationship for the scapula and
rotator cuff muscles.56 We advocate using the thumb-up (“full can”) position for
active and resisted elevation activities
because it provides better subacromial
clearance,25 better scapula mechanics,82
and equal rotator cuff activation8 compared to the thumb-down (“empty can”)
position.
Exercises with weight bearing applied
through the upper extremities can be helpful to achieve correct static and dynamic
scapular mechanics; however, the stresses
that these exercises place on the surgical
repair can be high. Appropriate weightbearing scapular exercises during phase 2
include maintaining scapular alignment
in the quadruped position progressing to
3-point and finally 2-point stabilization.87
While it is tempting to extrapolate this
]
information to a true push-up exercise,
in our opinion, traditional push-ups are
not appropriate during phase 2 because
they produce relatively high loads on the
shoulder and stress the anterior capsule
when the arm is brought in horizontal
abduction (“down position”). Push-ups
performed in standing with hands placed
on the wall (ie, wall push-ups, would be
appropriate at this time frame). But to
the best of our knowledge, the benefits of
this exercise have not been quantified in
published research.
Patient education regarding appropriate positions and loading is crucial during
phase 2 so the patient understands that,
even though his or her shoulder may be
starting to feel much better, there should
be no uncontrolled end range stretching,
heavy lifting, or quick motions performed
with the surgical arm. Loading of the
surgical repair must be controlled during rehabilitation and during activities
of daily living as well. The impact of this
cannot be overstated, as the patient will
spend more time performing activities
of daily living than directly performing
rehabilitation exercises. Patient education should stress that tissue healing is
incomplete through 12 weeks32 and may
not be complete until 40 to 50 weeks
postoperatively.30,96
Phase 3: Postoperative Weeks 12 to 24
Phase 3 rehabilitation begins at approximately postoperative week 12, once the
criteria to progress to phase 3 (APPENDIX)
are met. The primary focus of this final
phase of rehabilitation is normalizing
neuromuscular function with strengthening, endurance, power, and dynamic
stability exercises. This must be continued in a way that assures gradual advancement of stress to the capsulolabral
structures through graded progressions
of ROM, repetitive submaximal loading,
and dynamic stabilization. Any remaining limitations in ROM should be directly addressed early in phase 3 through
low-load, prolonged stretching and joint
mobilizations.
Time frame for the initiation of high-
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loading exercises and activities following
capsular plication or labral repair have
not been established.10,44,46 A 12-week period is often cited as the minimum postoperative time frame to begin vigorous
activities,7,23,45,61,94 and this time frame is
consistent with our review of the literature for healing rates of the capsulolabral
complex.19,96 No clinical trial evidence
supports this recommendation, only consensus from a multidisciplinary group of
rehabilitation specialists. Prior to initiating any high-load activities, the patient
should demonstrate excellent shoulder
girdle strength, endurance, and neuromuscular control.
The ultimate goal of rehabilitation is
to maximize the patient’s ability to return
to full activities of daily living, work, and
recreational activities. Setting appropriate goals should occur early in the rehabilitation process and result from a team
effort between the patient, physician,
and rehabilitation specialist. Because
each patient’s goals are different, phase 3
interventions should be tailored to each
patient. For example, an athlete who desires a return to competitive baseball will
require a greater amount of external rotation ROM in the 90° abducted position,
an ability to control the shoulder girdle
at high speeds, and endurance and power
of the entire upper extremity, torso, and
lower body. In contrast, a patient who
desires a return to work on an assembly
line may require the ability to lift heavy
loads at waist level and moderate loads
repeatedly to shoulder level. A patient
who desires only to return to normal daily activities would not require extreme
ROM and would not require high levels
of strength, endurance, and neuromuscular control needed for overhead sport or
repetitive work demands.
Although these patients have the same
entry point into this last phase of rehabilitation, every patient is unique and will require goal-specific phase 3 programs. The
final rehabilitation step for the sedentary
person may be establishing a home exercise routine consisting of selected phase 2
exercises. Rehabilitation of the assembly
FIGURE 5. (A) Starting position and (B) ending position for a high-speed elastic resistance exercise replicating the
throwing motion.
line worker would emphasize endurance
through general weight lifting, as well a
progressive routine of functional lifting.
Rehabilitation of the throwing athlete
would emphasize activities with progressively higher speed and multiplanar
sport-specific movements. Examples include exercises performed rapidly against
elastic resistance (FIGURE 5) and progressive plyometrics.24,26,29,59
Due to the extremely high sport-specific stresses placed on the upper quarter
with overhead activities, it is necessary to
progress to sport-specific programs.1,2,74
These programs should incorporate a
gradual build-up in volume and intensity, and include adequate rest.1,2,74 Return
to sporting activities should be made in
consultation with the surgeon and patient and should not occur until specific
milestones are achieved. Athletes must
be symptom free and should not return
to sport until they have demonstrated
appropriate ROM, strength, control, endurance, and power necessary for their
particular sport or activity.
CONCLUSION
A
SSET developed this consensus rehabilitation guideline based
upon 4 critical principles (TABLE 1),
to guide the rehabilitation process and
optimize patient outcome. Each fundamental principle has been reviewed and
incorporated into the development of the
consensus guideline for which the staged
ROM goals (TABLE 2) and time frames of
this consensus guideline are based. The
graded application of stress to the healing capsulolabral tissues guides rehabilitation; this stress can be modulated
through absolute ROM limits, repetitive submaximal loading, and dynamic
stabilization.
This document represents a consensus
guideline for the typical patient; modifications to the specific application of the
guideline may be required, based on the
individual patient’s pathology, goals, age,
or comorbidities. Because of the wide variety of patients who undergo arthroscopic
capsulolabral repair, we feel that final re-
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[
clinical commentary
habilitation status should be determined
by the patient’s ability to complete his
or her desired functional tasks without
pain, limitation, or residual sensations of
instability. Typically, patients are able to
return to low-demand activities at 8 to16
weeks postoperative and return to very
high-demand activities at 24 to 32 weeks.
Periodic updates to this guideline will be
necessary, as arthroscopic surgical techniques improve and our understanding of
the implementation and effects of specific
therapeutic interventions evolves. t
10.
11.
12.
13.
ACKNOWLEDGEMENTS: The authors would like
to acknowledge the members of The American Society of Shoulder and Elbow Therapists (www.asset-usa.org) for their expertise
in the development this international consensus guideline. The authors would also like to
acknowledge Carol Capers, MSMI, CMI, for
creating the figures.
14.
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appendix
The American Society of Shoulder and Elbow Therapists’ Consensus Rehabilitation
Guideline for Arthroscopic Anterior Capsulolabral Repair of the Shoulder
Phase 1: POW 0 to POW 6
Goals
• Maximally protect the surgical repair (capsule, ligaments, labrum, sutures)
• Achieve staged ROM goals. Do not significantly exceed
them:
- PFE: POW 3, 90°; POW 6, 135°
- PER at 20° abd: POW 3, 10°-30°; POW 6, 35°-50°
- PER at 90° abd: POW 3, contraindicated; POW 6, 45°
- AFE: POW 3, NA; POW 6, 115°
• Patient education in postoperative restrictions
• Minimize shoulder pain and inflammatory response
• Ensure adequate scapular function
Interventions to Avoid
• Do not allow or perform ROM/stretching significantly
beyond staged ROM goals, especially external rotation
both by the side and in abduction
• Do not allow the patient to use arm for heavy lifting or
any use of the arm that requires ROM greater than the
staged ROM goals
Specific Interventions
Activities of primary importance:
• Patient education regarding limiting use of the arm
despite lack of pain or other symptoms
• Protection of repair
• Achieve staged ROM goals through gentle ROM
activities
• Minimize inflammation
Supplementary activities:
• Normalize scapular position, mobility, and dynamic
stability
• ROM of uninvolved joints
• Begin restoration of shoulder strength through isometric exercises
Immobilization:
• Via standard sling
• Absolute immobilization (no glenohumeral ROM
exercises and constant sling use) for variable time of
0 up to 4 weeks, based on patient-specific factors and
surgeon recommendation
• Relative immobilization (out of sling for ROM exercises,
sitting with the arm supported, and standing for short
periods), starting after the period of absolute immobilization and continuing for the remainder of phase 1,
followed by sling use for comfort
Patient education:
• Explain nature of the surgery
• Discuss precautions specific to the nature of the surgical repair
- Importance of not significantly exceeding staged
ROM goals
- Importance of tissue healing
- Proper sling use (assure sling provides upward support to the glenohumeral joint)
- Limiting use of arm for ADLs
ROM:
• Following the absolute immobilization period begin:
- Pendulum exercises (unweighted)
- Passive/active assisted forward elevation to achieve
staged ROM goals listed earlier. ROM should not be
forceful
- Passive/active assisted external rotation with the
shoulder in slight abduction to achieve staged ROM
goals listed earlier. ROM should not be forceful
- Scapular clock exercises or alternately elevation,
depression, protraction, retraction. Progress to
scapular strengthening as patient tolerates78,79
• Active ROM of uninvolved joints
Miscellaneous:
• Submaximal rotator cuff isometrics as tolerated
• Postural awareness/education
Pain management:
• Activity restriction
• Proper fitting of sling to support arm
• Electrophysical agents
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appendix (continued)
• Physician prescribed or over-the-counter medications
Milestones (Testing Criteria) to Progress to Phase 2
• Appropriate healing of the surgical repair by adhering
to the precautions and immobilization guidelines.
• Staged ROM goals achieved but not significantly
exceeded
• Minimal to no pain (NPRS, 0-2/10) with ROM
Phase 2: POW 6 to POW 12
Goals
• Achieve staged ROM goals to normalize passive ROM
and active ROM. Do not significantly exceed:
- PFE: POW 9, 155°; POW 12, WNL
- PER at 20° abd: POW 9, 50°-65°; POW 12, WNL
- PER at 90° abd: POW 9, 75°; POW 12, WNL
- AFE: POW 9, 145°; POW 12, WNL
• Minimize shoulder pain
• Begin to increase strength and endurance
• Increase functional activities
Interventions to Avoid
• Do not perform stretching significantly beyond staged
ROM goals
• Do not perform any stretch to gain end range external
rotation or external rotation at 90º of abduction unless
significant tightness is present
• Do not allow the patient to use arm for heavy lifting
or any activities that require ROM beyond the staged
ROM goals
• Do not perform any strengthening exercises that place
a large load on the shoulder in the position of horizontal
abduction or the combined position of abduction
with external rotation (eg, no push-ups, bench press,
pectoralis flys)
• Do not perform scapular plane abduction with internal
rotation (empty can) at any stage of rehabilitation due
to the likelihood of impingement
Specific Interventions
Activities of primary importance
• Continued patient education
• Passive/active assisted ROM as needed to achieve but
not significantly exceed staged ROM goals
• Establish basic rotator cuff and scapular neuromuscular control within the allowed ROM
Supplementary activities:
• Introduction of functional patterns of movement
• Progressive endurance exercises
Patient education:
• Counsel about using the upper extremity for appropriate ADLs in the pain-free ROM (starting with waist-level
activities and progressing to shoulder-level and finally
to overhead activities over time)
• Continue education regarding avoidance of heavy lifting
or quick, sudden motions
• Education to avoid positions that place stress on the
anterior inferior capsule during ADLs
ROM:
• Passive/active assisted ROM as needed to achieve
staged ROM goals in all planes. Many times only light
stretching or no stretching is needed
• If ROM is significantly less than staged ROM goals,
gentle joint mobilizations may be performed. However,
they should be done only into the limited directions and
only until staged ROM goals are achieved
• Address scapulothoracic and trunk mobility limitations.
Ensure normal cervical spine ROM and thoracic spine
extension to facilitate full upper extremity ROM
Neuromuscular re-education:
• Address abnormal scapular alignment and mobility
PRN
- Strengthen scapular retractors and upward rotators
- Increase pectoralis minor flexibility if limited
- Biofeedback by auditory, visual, or tactile cues
- Weight-bearing exercises with a fixed distal
segment. Examples: quadruped position while
working to maintain proper position of the scapula,
quadruped with scapula protraction, progressing
from quadruped to tripod position, no push-ups87
• Address core stability deficits PRN
• Activities to improve neuromuscular control of the
rotator cuff and shoulder girdle such as use of unstable
surfaces, Bodyblade, manual resistance exercises
Strength/endurance:
• Scapula and core strengthening
• Balanced rotator cuff strengthening to maintain the
humeral head centered within the glenoid fossa during
progressively more challenging activities
- Should be initially performed in a position of comfort with low stress to the glenohumeral joint, such
as less than 45° elevation in the plane of the scapula
(eg, elastic band or dumbbell external rotation,
internal rotation, forward flexion)
- Exercises should be progressive in terms of shoulder
elevation (eg, start with exercises performed at
waist level progressing to shoulder level and finally
overhead activities)
- Exercises should be progressive in terms of muscle
demand. It is suggested to use activities that have
muscle activity levels documented with EMG4,8,17,18,20,
22,33,36,38,43,54,57,58,66,72,73,85,87
- Elevation activities may progress from assistive
exercises (eg, rope and pulley, wall walks) to active,
to resistive upright exercises, then, finally, to prone
exercises
- Nearly full active elevation in the plane of the
scapula should be achieved before progressing to
elevation in other planes
- Exercises should be progressive in terms of adding
stress to the anterior capsule, gradually working
towards a position of elevated external rotation in
the coronal plane, the “90-90” position PRN
- Rehabilitation activities should be pain free and performed without substitutions or altered movement
patterns
- Rehabilitation may include both weight-bearing and
non–weight-bearing activities
- Rehabilitation may include both isolated and
complex movement patterns
- Depending upon the goals of the exercise
(control versus strengthening), rehabilitation
activities may also be progressive in terms of
speed once the patient demonstrates proficiency
at slower speeds
- The rotator cuff and scapula stabilizer strengthening program should emphasize high repetitions
(typically 30-50 reps) and relatively low resistance
(typically 1-2 kg)
- No heavy lifting or plyometrics should be performed
during this stage
- Elbow flexion/extension strengthening with elbow by
the side can begin in this phase
Pain management:
• Ensure appropriate use of arm during ADLs
• Ensure appropriate level of therapeutic interventions
• Electrophysical agents as needed
Milestones to Progress to Phase 3
• Staged active ROM goals achieved with minimal to no
pain (NPRS, 0-2/10) and without substitution patterns
• Appropriate scapular posture at rest and dynamic
scapular control during ROM and strengthening
exercises
• Strengthening activities completed with minimal to no
pain (NPRS 0-2/10)
Phase 3: POW 12 to POW 24
Goals
• Normalize strength, endurance, neuromuscular control,
and power
• Gradual and planned build-up of stress to anterior
capsulolabral tissues
• Gradual return to full ADLs, work, and recreational
activities
Interventions to Avoid
• Do not increase stress to the shoulder in a short period
or in an uncontrolled manner
• Do not perform advanced rehabilitation exercises (such
as plyometrics or exercises requiring end range ROM)
if the patient does not perform these activities during
ADLs, work, or recreation
• Do not progress into activity-specific training until
patient has nearly full ROM and strength
• Do not perform weightlifting activities that place excessive stress on the anterior capsule. For instance,
latissimus pull-downs, and military press performed
with the hands behind the head stress the anterior
journal of orthopaedic & sports physical therapy | volume 40 | number 3 | march 2010 |
40-03 Gaunt.indd 167
167
2/17/10 2:53:20 PM
[
clinical commentary
]
appendix (continued)
capsule with no additional benefit in terms of muscle
activity. Similarly, activities which encourage end
range shoulder extension, such as dips, should also
be avoided
Specific Interventions
Activities of primary importance:
• Progressive strengthening and endurance exercises
• Progressive neuromuscular control exercises
• Activity-specific progression: sport, work, hobbies
Supplementary activities:
• Normalize core and scapular stability
Patient education:
• Counsel in importance of gradually increasing stress to
the shoulder while returning to normal ADLs, work, and
recreational activities, including heavy lifting, repetitive
activities, and overhead sports
ROM:
• Passive ROM, stretching, and joint mobilizations as
needed to address any remaining deficits
Neuromuscular re-education:
• Address any remaining deficits of the rotator cuff,
scapula musculature, or trunk musculature
Strength/endurance/power:
• Continue shoulder-strengthening program as initiated
in phase 2, with increasing emphasis on high-speed
multiplanar activities that incorporate the entire
kinetic chain
• Gradually progress rehabilitation activities to replicate
demanding ADL/work activities
• Progressive return to weight-lifting program emphasizing the larger, primary mover upper extremity muscles
(deltoid, latissimus dorsi, pectoralis major)
- Start with relatively lightweight and high repetitions
(sets of 15-25 repetitions), and gradually decrease
repetitions and increase weight after several months
- Suggested upper extremity exercises for early phase 3
• Biceps curls, shoulder adducted (added in
phase 2)
• Triceps press-downs or kick-backs, shoulder
adducted (added in phase 2)
• Shoulder shrugs
• Rows (scapular retraction), shoulder adducted
• Latissimus bar pull-downs, with hands in front of the head
• Dumbbell overhead shoulder press with hands starting in front of the shoulders (not in the abducted/externally rotated position)
• Push-ups as long as the elbows do not flex
past 90º
- Suggested upper extremity exercises to be added in
intermediate phase 3
• Isotonic pressing activities (eg, flat or incline
presses using machines, barbells, or dumbbells)
• Dumbbell shoulder raises to 90º
• Rows (scapular retraction), shoulders elevated
• Machine or barbell shoulder presses that do not
require end range abduction/external rotation
- Suggested upper extremity exercises to be added in
late phase 3
• Overhead presses with shoulders in abduction
with external rotation (military press)
• Pectoralis major flys
• Dead lift
• Power cleans
- Upper extremity exercises that are not advisable for
this patient population
• Dips
• Latissimus pull-downs or military press with the
bar behind head
Plyometric program (as necessary):
• Criteria to initiate plyometric program
- Goals of returning to overhead athletics or
other work or recreational activities requiring large
amounts of upper extremity power
- Adequate strength (4+/5) of entire shoulder girdle
musculature
- Pain free with basic ADLs and current strengthening
program
- At least 3 weeks of tolerance to high-speed multiplanar activities that progressively mimic functional
demands
• Parameters
- Due to the explosive nature of this type of exercise,
emphasis of plyometrics exercises should be on
quality not quantity
- Perform a few times a week and utilize moderate
repetitions (eg, 3-5 sets of 15-20 repetitions)
- Begin with unweighted balls and progress to lightly
weighted balls (plyoballs)
Interval sport programs for activities such as throwing,
swimming, and golf, once approved by physician (usually
POW 16 or longer)
Milestones to Return to Work, Hobbies, Sport
• Clearance from physician
• No complaints of pain at rest and minimal to no pain
(NPRS 0-2/10) with activities
• No or minimal sensation of instability with activities
• Restoration of sufficient ROM to perform desired activities
• Adequate strength and endurance of rotator cuff and
scapular muscles to perform activities with minimal to
no pain (NPRS 0-2/10) or difficulty
• If the patient struggles with confidence or shoulder
stability, a stabilizing brace may be considered for
return to activity, but is most commonly used only for
collision sports
Abbreviations: Abd, abduction; ADL, activities of daily living; AFE, active forward elevation; EMG, electromyography; NPRS, numeric pain rating scale; PER, passive external rotation; PFE,
passive forward elevation; POW, postoperative week; ROM, range of motion; WNL, within normal limits.
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168 | march 2010 | volume 40 | number 3 | journal of orthopaedic & sports physical therapy
40-03 Gaunt.indd 168
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[
CLINICAL COMMENTARY
]
KEVIN E. WILK, PT, DPT¹šF7:H7?9E8C7" MD²š9>7HB;I:$I?CFIED??"DPT³
;$BOB;97?D"MD4š@;<<H;O:K=7I"MD4š@7C;IH$7D:H;MI"MD5
Shoulder Injuries in the Overhead Athlete
he overhead throwing motion is a highly skilled movement
performed at extremely high velocity, which requires
flexibility, muscular strength, coordination, synchronicity,
and neuromuscular control. The throwing motion generates
extraordinary demands on the shoulder joint. It is because of these
high forces, which are repetitively applied, that the shoulder is the
most commonly injured joint in professional baseball pitchers.27
T
During the throwing movement, tre- body weight (BW) during the late cockmendous forces are placed on the shoul- ing phase, and there is a distraction force
equal to BW during the deceleration
der joint at extremely high angular
phase.43 Consequently, throwing
velocities. The acceleration phase
of the pitch is the fastest moverequires a high level of muscle
ment recorded and reaches a peak
activation, as indicated by the
SUPPLEMENTAL
VIDEO ONLINE
angular velocity of 7250°/s.41,43 It
electromyographic signal of the
shoulder musculature, which can
has been estimated that the anexceed 80% to 100% of the signal
terior translation forces generated
when pitching are equal to one-half measured during a maximum voluntary
TIODEFI?I0 The overhead throwing motion is an
extremely skillful and intricate movement. When
pitching, the overhead throwing athlete places
extraordinary demands on the shoulder complex
subsequent to the tremendous forces that are generated. The thrower’s shoulder must be lax enough
to allow excessive external rotation but stable
enough to prevent symptomatic humeral head
subluxations, thus requiring a delicate balance
between mobility and functional stability. We refer
to this as the “thrower’s paradox.” This balance is
frequently compromised and believed to lead to
various types of injuries to the surrounding tissues.
Frequently, injuries can be successfully treated
with a well-structured and carefully implemented
nonoperative rehabilitation program. The key to
successful nonoperative treatment is a thorough
clinical examination and accurate diagnosis.
Rehabilitation follows a structured, multiphase
approach, with emphasis on controlling inflammation, restoring muscles’ balance, improving soft
tissue flexibility, enhancing proprioception and
neuromuscular control, and efficiently returning
the athlete to competitive throwing. Athletes often
exhibit numerous adaptive changes that develop
from the repetitive microtraumatic stresses occurring during overhead throwing. Treatment should
include the restoration of these adaptations.
TB;L;BE<;L?:;D9;0 Level 5. J Orthop
Sports Phys Ther 2009;39(2):38-54. doi:10.2519/
jospt.2009.2929
TA;OMEH:I0 baseball, glenohumeral joint,
labral lesions, pitching, rotator cuff
isometric contraction (MVIC).34 Lastly,
the thrower’s shoulder often exhibits
excessive motion and laxity. Wilk et al112
stated that the thrower’s shoulder must
be “loose enough to throw but stable
enough to prevent symptoms.” Whether
the typical injury sustained to the thrower’s shoulder is due to hyperlaxity or
capsular tightness is currently a controversial topic of discussion. Shoulder pathology can manifest as pain, diminished
performance (velocity and accuracy), or a
decrease in strength or range of motion.
The challenge for medical practitioners
is to determine the accurate differential
diagnosis, the cause of the injury, and the
most effective treatment plan based on
the identified pathology.
In this manuscript, we will discuss the
physical characteristic of the overhead
athlete, common pathologies seen, and
the nonoperative, surgical, and postoperative treatment.
F>OI?97B9>7H79J;H?IJ?9I
I
t is important for the clinician
to realize and appreciate the “typical”
physical characteristics of the overhead thrower.
HWd][e\Cej_ed
Most throwers exhibit an obvious motion
disparity, whereby shoulder external rotation (ER) is excessive and internal rotation (IR) is limited when measured at 90°
1
Vice President of Education, Physiotherapy Associates, Exton, PA; Associate Clinical Director, Champion Sports Medicine, A Physiotherapy Associates Clinic, Birmingham,
AL; Director of Rehabilitation Research, American Sports Medicine Institute, Birmingham, AL; Rehabilitation Consultant, Tampa Bay Rays Baseball Organization, Tampa Bay,
FL. ² Orthopaedic Sports Medicine Fellow, Andrews Sports Medicine, Birmingham, AL. ³ Physical Therapy Fellow, Champion Sports Medicine, Birmingham, AL. 4 Orthopaedic
Surgeon, Andrews Sports Medicine Center, Birmingham, AL. 5 Orthopaedic Surgeon, Andrews Sports Medicine Center, Birmingham, AL; Medical Director, Tampa Bay Rays
Baseball Organization, Tampa Bay, FL. Address correspondence to Dr Kevin E. Wilk, Champion Sports Medicine, 805 St Vincent’s Drive, Suite C100, Birmingham, AL 35205.
E-mail: [email protected]
38 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy
of abduction.11,18,20,54,112 This loss of IR of
the throwing shoulder has been referred
to as glenohumeral internal rotation deficit (GIRD). Several investigators have
documented that pitchers exhibit greater
ER of the shoulder than do position players.11,54,111 Brown et al18 reported that professional pitchers exhibited a mean SD
of 141° 15° of shoulder ER measured at
90° abduction. This was approximately 9°
more than for their nonthrowing shoulder and approximately 9° more than the
throwing shoulder of position players.
Recently, Bigliani et al11 reported that
dominant shoulder ER measured at 90°
shoulder abduction averaged 118° (range,
95°-145°) in pitchers, whereas it averaged
108° (range, 80°-105°) for the dominant
shoulder of positional players.
Wilk et al105 reported on the glenohumeral joint range of motion (ROM)
measured in 879 professional baseball
pitchers from 2003 to 2008. Pitchers exhibited an average SD of 136.9° 14.7°
of ER and 40.1° 9.6° of IR when passively assessed at 90° abduction. In pitchers, the ER is approximately 9° greater in
the throwing shoulder when compared to
the nonthrowing shoulder, while IR was
8.5° greater in the nonthrowing shoulder.
In addition, the total motion (ER and IR
added together) in the throwing shoulder
was similar (within 7°) when compared
to total motion of the nonthrowing shoulder, with the total rotational arc of motion being 176.3° 16.0° on the throwing
shoulder and nonthrowing shoulder.114
We refer to this as the “total motion
concept” (<?=KH;'). Several authors have
previously reported that total motion is
equal comparing the throwing and nonthrowing shoulder.4,6,40,77,114
BWn_jo
Most throwers exhibit significant laxity
of the glenohumeral joint, which permits
excessive ROM. The hypermobility of the
thrower’s shoulder has been referred to
as “thrower’s laxity.”112 The laxity of the
anterior and inferior glenohumeral joint
capsule may be appreciated by the clinician during the stability assessment of the
<?=KH;($Glenohumeral laxity testing done on Telos
device to objectively assess the amount of joint laxity.
<?=KH;'$The total-rotational-motion concept.
External rotation (ER) + internal rotation (IR) = total
motion. Total rotational motion is equal bilaterally.
joint. Andrews et al7 have reported that the
excessive laxity exhibited by the thrower is
the result of repetitive throwing, referring
to this as “acquired laxity”; but others have
documented that the overhead thrower
exhibits congenital laxity.11
Borsa et al14,15 reported no difference
in the throwing shoulder compared to
the nonthrowing shoulder when objective glenohumeral joint laxity testing
was performed on the Telos device (<?=KH;(). Furthermore, they noted greater
posterior laxity compared to anterior
laxity and no association between measurements of joint laxity and ROM. In
some cases, pitchers exhibited extremely
diminished glenohumeral joint IR motion, while exhibiting significant posterior capsule laxity on Telos testing.
Thus, the changes in glenohumeral joint
motion seen in pitching may be due to
factors other than glenohumeral joint
capsular laxity.
Eii[eki7ZWfjWj_edi
Several investigators23,29,85,88,89 have reported an osseous adaptation of the hu-
meral head in the thrower’s shoulder.
Crockett et al29 reported on 25 professional baseball pitchers who underwent
computerized tomography (CT) scan to
determine humeral head and glenoid fossa retroversion. The investigators noted
that the humeral head on the throwing
side exhibited a 17° increase in retroversion when compared to the nonthrowing
shoulder. Furthermore, when comparing
the pitchers to a group of nonthrowers,
the nonoverhead athlete group exhibited
no difference in their bilateral retroversion values. This could partially provide
an explanation for the side-to-side differences noted in the throwers glenohumeral joint rotational ROM. An increase in
humeral head retroversion would result
in an increase in ER ROM and a decrease
in IR. Lastly, Meister et al77 documented
in adolescent baseball players that the
greatest change in glenohumeral joint
ROM occurs between the ages of 12 and
13, when the growth plates are open.
CkiYb[Ijh[d]j^
Several investigators have examined
muscle strength parameters in the overhead throwing athlete with varying
results and conclusions.1,9,18,28,30,48,107,108
Wilk et al107,108 performed isokinetic testing on 83 professional baseball players
as part of their physical examinations
during spring training. The investigators
demonstrated that the ER strength of
the pitcher’s throwing shoulder was significantly weaker (P.05) than the nonthrowing shoulder by 6%. Conversely, IR
of the throwing shoulder was significantly
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 39
[
CLINICAL COMMENTARY
Glenohumeral Muscular Strength
Values in Professional Baseball
Players (n = 83) 103,104
J78B;'
'.&–%i
)&&–%i
*+&–%i
Bilateral comparisons (%)*
External rotation
95-109
85-95
80-90
Internal rotation
105-120
100-115
100-110
Abduction
100-110
100-110
Adduction
120-135
115-130
External/internal rotation
63-70
65-72
Abduction/adduction
82-87
92-97
External rotation/abduction
64-69
66-71
†
Unilateral peak torque ratios (%)
62-70
Peak torque-body weight ratios‡
External rotation
18-23
15-20
Internal rotation
27-33
25-30
Abduction
26-32
20-26
Adduction
32-36
28-33
* Strength ratio of the dominant to the nondominant side for each muscle group.
†
Data for the dominant (pitching) arm only.
‡
Peak torque measured in ft-lb and body weight in lb.
stronger (P.05) than the nonthrowing
shoulder by 3%. Additionally, adduction strength of the throwing shoulder
was significantly stronger (P.05) than
that of the nonthrowing shoulder by approximately 9% to 10%. We believe that
an important isokinetic value is the unilateral muscle ratio, which describes the
antagonist-agonist muscle strength ratio
of 1 shoulder. A proper balance between
agonist and antagonist muscle groups is
thought to provide dynamic stabilization
to the shoulder joint. To provide proper
muscle balance, the glenohumeral joint
external rotator muscles should be at
least 65% of the strength of the internal
rotator muscles.113 Optimally, the external-internal rotator muscles strength
ratio should be 66% to 75%.108 112,113 J78B;
1 illustrates the optimal muscle strength
values of professional baseball players.
Furthermore, Magnusson et al,72 using
a handheld dynamometer, reported that
professional pitchers exhibited significant
weakness of the supraspinatus muscle on
the throwing side compared to the nonthrowing side.
The scapulothoracic musculature
plays a vital role during the overhead
throwing motion. 34 Proper scapular
movement and stability are imperative
for asymptomatic shoulder function.56,57
These muscles work in a synchronized
fashion and act as force couples about
the scapula, providing both movement
and stabilization. Wilk et al117 documented the isometric scapular muscle
strength values of 112 professional baseball players. The results indicated that
pitchers and catchers exhibited significantly higher strength of the protractor
and elevator muscles of the scapula when
compared to position players. All players (except infielders) exhibited significantly stronger depressor muscles of the
scapula on the throwing side compared
with the nonthrowing side. In addition,
we believe that the agonist-antagonist
muscle ratios are important values when
considering how the scapula provides
stability, mobility, and symptom-free
function. J78B;I ( 7D: ) illustrate the
scapular muscle strength values in the
overhead-throwing athlete.
Feijkh[WdZIYWfkbWhFei_j_ed
As previously mentioned, the ability of
the scapula to function as a cohesive unit
]
with the upper body is essential for the
overhead athlete. To be able to function
properly, the scapula needs to be in the
proper position to assist in the movement
of the humerus. Kibler et al57 defined alterations in motion of the scapula during
coupled scapulohumeral movements as
“scapular dyskinesis.” Numerous authors
have noted the role of scapular dyskinesis
and the positive correlation to shoulder
pathology.56,57
Oftentimes, the overhead athlete
has changes in posture that result in a
change of resting position of the scapula. Burkhart et al19 has described these
postural changes as the “SICK” scapula,
which stands for scapular malpositions
that include inferior medial border
prominence, coracoid pain and malposition, and dyskinesis of scapular movement. This syndrome often presents
clinically as an asymmetric “dropped”
scapula. Bastan et al10 reported the position of the scapula in the overhead athlete in 3 planes (rotation, tilt, elevation)
for 4 different shoulder positions (rest,
90° abduction, 90° abduction with maximal ER, and 90° abduction with maximal IR). Their results indicated that the
scapula of the dominant side, with the
shoulder at rest, was significantly more
protracted (P = .006) and tilted anteriorly (P = .007); with the shoulder at 90°
of abduction, it was more rotated in the
upward direction (P = .039); with both
maximal ER and IR at 90° of abduction,
it was more tilted anteriorly (P.001).10
Macrina et al70 reported that once the
scapular musculature gets fatigued,
scapular position worsened, resulting
in greater scapular protraction and anterior tilting. This anterior tilt position
correlates with a loss of glenohumeral
joint IR.13,66 As previously mentioned,
there have been numerous studies on
the association between scapular positional change, scapular dyskinesis, and
increased shoulder pathology. These
studies further the belief that there is
an increased rate of scapular position
change that may lead to increased shoulder pathology in the overhead athlete.
40 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy
J78B;(
Strength of the Scapulothoracic
Musculature*
:ec_dWdj7hc
DedZec_dWdj7hc
33.6 5.9
Pitchers
Protraction
32.2 4.5
Retraction
28.1 3.6
27.2 3.2
Elevation
37.6 6.4
38.1 6.8
Depression
10.0 2.7
8.2 2.3
Catchers
Protraction
30.8 4.5
33.1 4.5
Retraction
28.6 2.3
26.8 3.2
Elevation
39.9 6.8
38.6 3.6
9.5 1.8
7.3 2.3
Depression
Position players
Protraction
26.3 4.5
26.3 5.0
Retraction
25.9 2.7
25.4 2.7
Elevation
29.5 5.4
29.9 5.0
8.6 2.3
8.2 2.3
Depression
* Values are mean SD kg.
J78B;)
Strength Ratios of the
Scapulothoracic Musculature
:ec_dWdj7hc
DedZec_dWdj7hc
Pitchers
Protraction/retraction
87%
81%
Elevation/depression
27%
21%
Protraction/retraction
93%
81%
Elevation/depression
24%
19%
Protraction/retraction
98%
94%
Elevation/depression
29%
27%
Catchers
Position players
9B?D?97B;N7C?D7J?ED
>_ijeho
7
lthough acute injuries to the
shoulder do occur in the overheadthrowing athlete, it is much more
common for injuries to be secondary to
overuse and fatigue. General information about the patient, as well as specific
information about symptoms and throwing history, is required to make a correct
diagnosis (7FF;D:?N 7).45 Important information, such as onset of symptoms,
changes in mechanics, development of
a new pitch, training regimen, single-
game and season pitch counts, as well as
previous treatments, needs to be determined. It is equally important to see any
imaging studies the patient had prior to
evaluation. The imaging studies must be
correlated to the physical examination to
establish an accurate and differential diagnosis. Numerous imaging studies may
be beneficial in establishing the diagnosis, such as plain radiographs, magnetic
resonance arthrograms (MRA), or computerized tomography scans.
F^oi_YWb;nWc
After a thorough medical history has
been obtained, the physical examination will focus the differential diagnosis
down to a manageable list of possibilities.
Each medical practitioner should have a
consistent progression to follow for every physical exam (7FF;D:?N 8). There
are multiple tests or exam techniques to
arrive at a diagnosis, and it is important
that each medical practitioner use exam
techniques that they are familiar with
and are capable of duplicating with each
patient.
Visual observation of the shoulder
should be performed first, with special
attention focused on any skin lesions or
muscle atrophy. Next, the shoulder is palpated, feeling all bony prominences, with
special attention on the bicipital groove,
greater tuberosity, and acromioclavicular
(AC) joint. Pain in these areas can indicate
biceps tendon involvement, rotator cuff
involvement, and AC joint arthrosis, respectively. ROM, both active (AROM) and
passive (PROM), is observed, focusing on
glenohumeral as well as scapulothoracic
motion. Glenohumeral joint PROM is
assessed for ER and IR at 90° abduction
and for ER at 45° abduction in the scapular plane. When assessing IR, care is taken
to palpate and stabilize the scapula. When
assessing PROM, the clinician should assess both the quantity of motion and the
end feel. Forward flexion, abduction, IR,
and ER are important to assess, especially
for any deficits that may be evident. Palpation of the shoulder during ROM can uncover crepitus, which may indicate certain
pathologic lesions, such as bursa thickening, rotator cuff tears, and arthritis.
Muscle strength is the next component
of the examination. To test the supraspinatus, the patient is asked to flex the
shoulder to 90°, with the arm horizontally
abducted to around 45° and the thumb
pointing upward (full can). Resistance is
applied in this position.55,91 Weakness or
pain may indicate a lesion of the supraspinatus muscle. With the arm at the side
and the elbow flexed to 90°, the patient
is asked to externally rotate against resistance (infraspinatus and teres minor) and
internally rotate against resistance (sub-
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 41
[
CLINICAL COMMENTARY
<?=KH;)$Biceps load test performed to assess
for possible SLAP lesion. The patient abducts the
shoulder to 90°, fully externally rotates the shoulder,
flexes the elbow to 90°, and fully supinates the
forearm. The patient is asked to actively flex the
elbow against resistance. Pain is positive indication
for a SLAP lesion.
scapularis). Again, weakness or pain may
indicate a lesion. Resisted ER and IR are
subsequently performed at 90° of abduction and neutral rotation, which is a more
functional position to assess the overhead
athlete. It may be beneficial to assess ER
and IR strength at 90° of abduction, with
the patients moving through an arc of
motion concentrically and eccentrically
against resistance.
At this point, the examiner can perform certain provocative maneuvers
to assess other possible pathology (7FF;D:?N 8). A few selected common tests
performed in the clinic will be discussed
below in more detail.
To assess subacromial impingement,
the Hawkins-Kennedy test is often utilized. This subacromial impingement
test has been reported to have 66% to
100% sensitivity and 25% to 66% specificity for the diagnosis of impingement,
rotator cuff tears, and bursitis.21,69,87 The
patient’s shoulder joint is forward flexed
to 90° and the shoulder is forcibly internally rotated. This maneuver drives
the greater tuberosity farther under the
coracoacromial ligament, producing impingement. Pain with this maneuver may
indicate subacromial impingement.98 The
test is performed at 90° of abduction in
the scapular plane, sagittal plane, and
with horizontal adduction beyond the
sagittal plane, with the more horizon-
<?=KH;*$Pronated biceps load test to assess for
possible SLAP lesion. The patient assumes the same
position as the biceps load test but fully pronates
the forearm. The patient is again asked to actively
flex the elbow against resistance. Pain located in the
superior glenohumeral joint (deep) is indicative of a
SLAP lesion.
tally adducted positions causing greater
impingement and, therefore, being possibly more provocative for pain.
There are a variety of tests described
to assess for a possible superior labrum
anterior posterior (SLAP) tear.33 O’Brien’s
active compression test is frequently
used.83 The examiner asks the patient to
forward flex the affected arm 90°, with
the elbow in full extension. The patient
then adducts the arm 10° to 15° medially.
The arm is internally rotated so that the
thumb is pointing downward. The examiner then applies a uniform downward
force to the arm. The exact same technique is performed again, this time with
the patient placing the palm up toward
the ceiling. The test is considered positive
if pain (located within the subacromial or
superior glenohumeral joint) is elicited
with the first maneuver and is reduced
or eliminated with the second maneuver.99 O’Brien et al83 have reported 100%
sensitivity and 97% to 99% specificity for
this test in detecting glenoid labral or AC
joint abnormality. The tests we perform
to test the integrity of the glenoid labrum
are the biceps load test, pronated biceps
load test,116 and resisted ER with supination test.80 These tests, illustrated in <?=KH;I)J>HEK=>+ (EDB?D;L?:;E), have been
shown to be highly sensitive for SLAP
tears/lesions in the overhead athlete.80
There exist numerous joint stability
tests. For a complete and thorough de-
]
<?=KH;+$Resisted external rotation with supination
performed to assess integrity of the superior labrum.
The patient is asked to abduct the arm to 90°,
and flex the elbow to 90°, keeping the shoulder in
neutral rotation. The examiner resists the patient,
while active external rotation of the arm and forearm
supination is performed. Pain is considered a positive
sign for a SLAP lesion.
scription of these tests the reader is encouraged to review Wilk et al.113,116 Those
we routinely perform are the anterior
drawer, fulcrum, relocation, and internal
impingement signs and tests. The most
important aspects of these tests are to
determine the extent of laxity present,
end point, and, in particular, the tissue
elasticity at end range. To assess end
point elasticity, the fulcrum test is performed at 90° of abduction. The posterior impingement sign is performed in the
plane of the scapula at 90° of abduction,
with the examiner passively rotating the
arm into maximum ER (EDB?D;L?:;E). A
positive test is indicated by complaints
of pain in the deep posterior shoulder.
Meister et al76 have reported 76% sensitivity and 85% specificity when performing this test for posterior rotator cuff
and/or labrum tears.
?cW]_d]
Imaging is the next important step in determining a diagnosis. Plain radiographs
with multiple views of the involved glenohumeral joint are mandatory. Routine
radiographic evaluation includes anterior-posterior (AP), Stryker notch, West
Point, axillary, and acromial outlet views.
These views allow visualization of the glenohumeral articulation as well as acromial morphology and the inferior glenoid.
42 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy
The imaging modality of choice to assess soft tissue pathology of the shoulder
is magnetic resonance imaging (MRI)
with intra-articular contrast (MRA). This
allows the best view of the rotator cuff
tendons and muscles, glenoid labrum,
biceps tendon, and other associated pathology, such as spinoglenoid cysts. Intraarticular contrast is especially useful to
determine if there is a full-thickness versus partial-thickness tear of the rotator
cuff. Furthermore, the MRA technique
allows the physician to evaluate the glenoid labrum to determine if a detached
labrum or frayed labrum exists. In the
throwing athlete the most common lesions are partial-thickness rotator cuff
tears and glenoid labrum pathology.
9B7II?<?97J?EDE<B;I?EDI
T
here are numerous lesions that
may occur in the overhead athlete
(7FF;D:?N9).
healthy thrower. Differential diagnosis
of tendonitis versus tendonosis is based
on MRI and duration and frequency of
symptoms. On MRI, the patient with
tendonitis will exhibit inflammation of
the tendon sheath (the paratenon); conversely, when tendonosis is present, there
exists intrasubstance wear (signal) of the
tendon.
Tendonitis/tendonosis is most frequently an overuse injury in the overhead
athlete and does not usually represent an
acute injury process. The symptoms frequently occur early in the season, when
the athlete’s arm is not conditioned properly.114 These injuries may also occur at the
end of the season, as the athlete begins to
fatigue. If the athlete does not participate
in an in-season strengthening program to
continue proper muscular conditioning,
tendonitis/tendonosis may also develop.
Specific muscles (external rotator muscles and scapular muscles) may become
weak and painful due to the stresses of
throwing.114
HejWjeh9k÷J[dZed_j_i%
J[dZedei_i%8khi_j_i
HejWjeh9k÷J[Whi
Tendonitis, tendonosis, and bursitis are
3 separate clinical entities for which the
names are often incorrectly used interchangeably. Tendonitis is inflammation
of the tendon. In many cases, it is actually
the tendon sheath that is inflamed and
not the tendon itself. Bursitis is inflammation of the subacromial bursa. Tendonosis implies intratendonous disease,
such as intrasubstance degeneration or
tearing.
The patient clinical presentation of
tendonitis or tendonosis of the rotator
cuff are pain with overhead activity and
weakness secondary to pain. The symptoms in the thrower are pain during the
late cocking phase of throwing, when the
arm is in maximal ER, or pain after ball
release, as the muscles of the rotator cuff
slow the arm during the deceleration
phase.37 Weakness of the supraspinatus
and infraspinatus are common findings
in throwers with shoulder pathology;
but asymmetric muscle weakness in the
dominant shoulder is often seen in the
Muscles of the rotator cuff are active
during various phases of the throwing
motion.35,42,50 During the late cocking
and early acceleration phases, the arm is
maximally externally rotated, potentially
placing the rotator cuff in position to
impinge between the humeral head and
the posterior-superior glenoid. Known
as “internal impingement” or “posterior
impingement,” this may place the rotator cuff at risk for undersurface tearing
(articular sided). Conversely, in the deceleration phase of throwing, the rotator
cuff experiences extreme tensile loads
during its eccentric action, which may
lead to injury.36 Rotator cuff tears in the
overhead athlete may be of partial or full
thickness. The history of shoulder pain
either at the top of the wind-up (acceleration) or during the deceleration phase
of throwing should alert the examiner
to a rotator cuff source of pain or loss of
function. Any history of trauma, changes
in mechanics, loss of playing time, previous treatments, voluntary time off from
throwing, and history of previous injury
should be noted.
Rotator cuff tears may be caused by
primary tensile cuff disease (PTCD), primary compressive cuff disease (PCCD),
or internal impingement. PTCD results
from the large, repetitive loads placed on
the rotator cuff as it acts to decelerate the
shoulder during the deceleration phase of
throwing in the stable shoulder. The injury is seen as a partial undersurface tear
of the supraspinatus or infraspinatus.2,7
PCCD is found on the bursal surface of
the rotator cuff in throwers with stable
shoulders. This process occurs secondary
to the inability of the rotator cuff to produce sufficient adduction torque and inferior force during the deceleration phase
of throwing. Processes that decrease the
subacromial space increase the risk for
this type of pathology.2 Partial-thickness
rotator cuff tears can also occur from internal impingement.
?dj[hdWb?cf_d][c[dj
Internal impingement was first described
in 1992 by Walch and associates in tennis
players.104 They presented arthroscopic
clinical evidence that partial, articularsided rotator cuff tears were a direct consequence of what they termed “internal
impingement.” Internal impingement is
characterized by contact of the articular
surface of the rotator cuff and the greater
tuberosity with the posterior and superior glenoid rim and labrum in extremes of
combined shoulder abduction and ER.49
In overhead throwing athletes, it appears that excessive anterior translation
of the humeral head, coupled with excessive glenohumeral joint ER, predisposes
the rotator cuff to impingement against
the glenoid labrum.63 Repeated internal
impingement may be a cause of undersurface rotator cuff tearing and posterior
labral tears. It is important that the underlying laxity of the glenohumeral joint
be addressed at the time of treatment for
an internal impingement lesion to prevent recurrence of the lesion.7 Burkhart
et al20 have proposed that restricted
posterior capsular mobility may result
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 43
[
CLINICAL COMMENTARY
in IR deficits and may cause pathologic
increases in internal rotator cuff contact
and injury. The authors of this manuscript believe that the loss of IR is most
often due to osseous adaptation29,89 and
muscular tightness, as opposed to capsular tightness.
Patients with internal impingement
usually describe an insidious onset of pain
in the shoulder.5 Pain tends to increase
as the season progresses. Symptoms may
have been present over the past couple of
seasons, worsening in intensity with each
successive year. Pain is usually dull and
aching, and is located over the posterior
aspect of the shoulder. Late cocking phase
seems to be most painful. Loss of control
and velocity is often present secondary to
the inability to fully externally rotate the
arm without pain.
On physical examination, pain may
be elicited over the infraspinatus muscle
and tendon with palpation. Pain to palpation is more often posterior, in contrast
to rotator cuff tendonitis, which usually
elicits pain to palpation over the greater
tuberosity.5 With internal impingement,
patients usually have full ROM. In both
the normal and pathologic thrower’s
shoulder the dominant arm tends to have
10° to 15° more ER and 10° to 15° less IR
with the arm abducted to 90°, compared
with the nondominant arm.29 The most
common presentation is for the overhead
athlete to have 1+ to 2+ anterior laxity and
2+ posterior laxity. Inferior laxity is often
present. Most provocative tests are negative. The most frequent provocative exam
to elicit pain is the internal impingement
sign,76 described earlier.
IB7FB[i_edi
SLAP lesions are a complex of injuries to
the superior labrum and biceps anchor at
the glenoid attachment. Andrews and associates4 were the first to describe this lesion in 1985. They reported arthroscopic
findings in a group of throwing athletes
with shoulder dysfunction. Snyder and
associates94 later classified this injury
complex as superior labrum anterior
and posterior lesions, and coined the
term SLAP lesion. The arthroscopic appearances of the lesions were originally
classified into 4 distinct lesion types,
with 3 variations later being added.71 The
pathophysiology of SLAP lesions is debated frequently, but the essentials of the
lesion are agreed upon.
Patients who have SLAP lesions fall
into 2 basic categories. The first consists
of overhead athletes, most commonly
baseball players, with a history of repetitive overhead activity and no history of
trauma. The second category involves patients with a history of trauma.49
Burkhart et al20 have described the
peel-back lesion of the superior labrum,
which frequently occurs in the overhead
athlete (<?=KH; ,). Peel-back lesions are
considered a type II SLAP lesion. The
athlete often presents to the practitioner with complaints of vague onset of
shoulder pain and possibly problems
with velocity, control, or other throwing
complaints. The patient may complain
of mechanical symptoms or pain in the
late cocking phase, often poorly localized.
The diagnosis of SLAP lesions can be very
difficult, as symptoms can mimic rotator
cuff pathology and glenohumeral joint
instability. Definitive diagnosis can only
be made by arthroscopy.49
Feij[h_eh=b[de_Z;neijei_i
8[dd[jjÊiB[i_ed
Thrower’s exostosis is an extracapsular
ossification of the posteroinferior glenoid rarely seen except in older longtime
throwers.75 This condition is a result of
secondary ossification involving the posterior capsule, probably due to repetitive trauma.6 The osteophyte is thought
to originate in the glenoid attachment
of the posterior band of the inferior glenohumeral ligament, possibly from traction during deceleration. Patients often
have a tight posterior capsule, with capsular contracture and asymmetric shoulder motion with an IR deficit.
This lesion can often mimic internal
impingement. Pain is often found in
the posterior part of the shoulder and is
worse in late cocking. Patients often de-
]
<?=KH;,$Arthroscopic view of peel-back lesion of
the superior labrum.
scribe a pinching sensation during throwing. Pain usually is relieved by rest. Plain
radiographs will assist in differentiating
this lesion from internal impingement.
IKH=?97B?DJ;HL;DJ?EDI
HejWjeh9k÷J[dZedei_i%
J[dZed_j_i%8khi_j_i
I
ubacromial impingement pathologies can frequently be treated
nonoperatively with or without a
subacromial (extra-articular) injection,
often consisting of a mixture of local anesthetic and a corticosteroid. The anesthetic and steroid are used to relieve pain
and inflammation, allowing the patient to
more effectively perform a therapy program. After the injection is performed,
a period of rest and rehabilitation is
used. It is common for the patient to
be re-evaluated after 2 to 3 weeks. If no
improvement is seen, a second injection
may be indicated. If the patient fails this
nonoperative course, shoulder arthroscopy with rotator cuff debridement may
be indicated. At the time of surgery, the
shoulder can be assessed for other lesions
and any identified pathology addressed.
Often, instability and hyperlaxity are underlying causes for rotator cuff lesions.
HejWjeh9k÷J[Wh
Surgical intervention is only considered
with a full-thickness rotator cuff tear or
with partial-thickness tears, after the
patient has failed at least 1, but usually
2, courses of rehabilitation, followed by
an interval throwing program. Prior to
physical therapy for partial-thickness ro-
44 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy
tator cuff tears, either a subacromial corticosteroid injection or a glenohumeral
injection is frequently performed. If the
patient fails this course of treatment, arthroscopy is indicated.
The first step in the operative intervention is an examination under anesthesia.
After the examination under anesthesia
has been performed, diagnostic arthroscopy of the shoulder begins by establishing a posterior viewing portal to visualize
the glenohumeral joint. Care is taken to
look at the labrum, with special attention
to the superior labrum, biceps anchor,
and articular surface of the rotator cuff.
The glenoid and humeral articular surfaces are also visualized for lesions. Other
structures visualized include the biceps
tendon, superior border of the subscapularis tendon, the middle glenohumeral
ligament, rotator interval, and axillary
pouch. An anterior working portal is
then created through the rotator interval.
A probe is brought into the joint to assess integrity of the superior labrum and
biceps anchor, the rotator cuff, and any
other structures in question. The arthroscope is then placed in the anterior portal
to visualize the posterior structures.
Once any intra-articular pathology
has been identified, a full-radius shaver
is brought in through the anterior portal.
Any fraying of the labrum or undersurface
of the rotator cuff can be debrided back
to a stable base. Undersurface rotator cuff
tears are evaluated for the percent thickness of the tendon that is torn. The normal rotator cuff attaches to the articular
margin of the humerus, and the footprint
spans approximately 14 mm from medial
to lateral. Partial articular-sided tears can
be measured from the articular margin to
assess the percentage of injury (7 mm exposed surface from the articular margin,
50% tear). Tears of less than 50% thickness are debrided, while tears of greater
than 50% thickness may also be debrided
or repaired to the footprint.37 Significant
partial-thickness tears or full-thickness
tears may be repaired arthroscopically or
through a standard mini-open technique.
Arthroscopic repair involves placing the
arthroscope into the subacromial space
(in most cases), performing a subacromial decompression, and repairing the
involved rotator cuff tendon or tendons
with side-to-side repair or suture anchors. More recently, double-row rotator cuff repairs have become increasingly
popular. The postoperative outcomes of
rotator cuff repairs in the overhead athlete have been reported to be less than
optimal, with approximately less than
15% of athletes returning to play.73
?dj[hdWb?cf_d][c[dj
As mentioned earlier, internal impingement is a common pathology seen in the
overhead athlete. The best treatment for
this lesion is a thorough and well-developed nonoperative treatment program.
If nonoperative measures fail, surgery
is indicated. As with other shoulder injuries, an examination under anesthesia,
followed by diagnostic arthroscopy, is
performed. Simple arthroscopic debridement of rotator cuff tears and labral
fraying was originally described to treat
internal impingement. 3 Results were
mixed with simple debridement, and
it became evident that some sort of anterior stabilization was also required to
help stabilize the shoulder. Therefore, in
conjunction with debridement of the rotator cuff or labral lesions, capsulolabral
reconstruction51 or thermal capsuloraphy63 has been recommended. Generally, subacromial decompression does not
have a role in the treatment of internal
impingement.
IB7FB[i_edi
Once the diagnosis has been established,
treatment options are considered. The
nonsurgical treatment of SLAP lesions
depends upon the type of lesion. Most lesions in the overhead athlete are type II
and may not respond well to nonsurgical
management.
When pain and dysfunction persist
after a period of rest and rehabilitation,
surgical intervention is indicated. As with
other shoulder injuries, a physical examination under anesthesia is done, followed
by diagnostic arthroscopy. All of the intra-articular structures are visualized and
evaluated. Close attention to the superior
labrum and biceps anchor is warranted.
If a true superior labral detachment
is noted, arthroscopic repair is the procedure of choice. SLAP lesions occurring
in the overhead athlete are almost always
type II.49 These tears must be repaired.
Initially, the lesion must be identified and
the surgeon determines if there is a primarily posterior or anterior component.
The location of the predominant pathology dictates arthroscopic portal placement
and repair techniques. Prior to repair of
the lesion, a shaver must be used to debride the glenoid neck and prepare a bony
bed to which the labrum is reattached.
Lesions with anterior extension may or
may not need an additional accessory
lateral portal. Suture anchors are placed
along the glenoid rim, and the labrum
and biceps complex are secured back to
the glenoid with arthroscopic knots. If the
lesion is predominantly located posterior
to the biceps anchor, an accessory posterior portal will likely need to be created.
Subacromial decompression is generally
not indicated after SLAP repair.
Feij[h_eh=b[de_Z;neijei_i
8[dd[jjÊiB[i_ed
Treatment of athletes with this lesion is
controversial. The senior author (J.R.A.)
believes that the presence of posterior
glenoid exostosis is highly predictive of
an undersurface rotator cuff tear caused
by internal impingement and injury to
the posterior labrum.6 Initially, these
patients are treated with a period of active rest and supervised rehabilitation.
Throwers with posterior glenoid exostosis can be conservatively managed for
some time; however, long-term success
is limited and surgical intervention may
become necessary.114
As with other shoulder lesions, when
nonsurgical measures fail to relieve
symptoms, operative intervention is undertaken. Initially, examination under
anesthesia is performed, followed by diagnostic arthroscopy. Any concurrent in-
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 45
[
CLINICAL COMMENTARY
tra-articular pathology is addressed at the
time of arthroscopy. A 70° arthroscope is
placed in the anterior portal to improve
visualization over the posterior glenoid
rim. The posterior glenoid exostosis is
uncovered through a small capsulotomy
at the medial edge of the posteroinferior
capsule by penetrating the capsule with
a shaver just off the posterior labral attachment. A small round burr is then
employed to debride the exostosis back to
the normal contour of the posterior glenoid rim.7 Underlying glenohumeral joint
instability is also addressed during the
surgical procedure. The posterior capsule
is generally not repaired, resulting in an
effective posterior capsular release.
]
<?=KH;.$Horizontal adduction with internal rotation
stretch. The patient flexes the arm to 90°. The
rehabilitation specialist applies a stabilizing force
to the lateral border of the scapula while the arm is
horizontally adducted and then applies a gentle force
into internal rotation.
L?:;E) and supine horizontal adduction
DEDEF;H7J?L;
H;>78?B?J7J?EDFHE=H7C
C
ost shoulder injuries in the
overhead thrower can be successfully treated nonoperatively. The
rehabilitation program involves a multiphased approach that is progressive and
sequential, and is based on the physical
examination, the specifically involved
structures, and the primary cause. The
key to successful rehabilitation is the
identification of the underlying factors
and structures causing the lesion. The
specific goals of each of the 4 phases of
the program are outlined in 7FF;D:?N :.
Each phase represents a progression, the
exercises becoming more aggressive and
demanding, and the stresses applied to
the shoulder joint gradually greater.
F^Wi['07Ykj[F^Wi[
One of the goals, to diminish the athlete’s
pain and inflammation, is accomplished
through the use of local therapeutic
modalities such as ice, iontophoresis,
nonsteroidal anti-inflammatory drugs
(NSAIDs), and/or injections. We prefer
the use of iontophoresis for soft tissue
inflammation about the shoulder. In addition, the athlete’s activities (such as
throwing and exercises) must be modified to a pain-free level. The thrower is
often instructed to abstain from throwing
<?=KH;-$Sleeper stretch performed to increase
internal rotation. The patient is asked to lay on the
involved side with arm flexed to 90°. The patient
grabs the wrist/forearm of the involved extremity and
pushes the extremity into internal rotation. Care is
given to assume the proper position to lock down the
scapula. (B) Sleeper stretch with lift. The examiner
lifts the patient’s scapula and repositions it laterally,
stabilization of the scapula may be necessary.
until advised by the physician or rehabilitation specialist. Additionally, stretching
exercises have been shown to assist in reducing the athlete’s pain.81
Another essential goal during the first
phase of rehabilitation is to normalize
shoulder motion, particularly shoulder IR
and horizontal adduction. It is common
for the overhead thrower to exhibit loss of
IR of 20° or more, referred to as “GIRD.”
This loss of IR has been suggested to be a
cause of specific shoulder injuries.19
We believe that the loss of IR is most
often due to osseous adaptations of the
humerus and posterior muscle tightness.15 We do not believe that the loss of
IR is routinely due to posterior capsular
tightness. It appears that most throwers
exhibit significant posterior laxity when
evaluated.15 Thus, to improve IR motion
and flexibility, we prefer the stretches illustrated in <?=KH;I-7D:.. These stretches include the sleeper’s stretch (EDB?D;
with IR. These stretches are performed
to improve the flexibility of the posterior musculature, which may become
tight because of the muscle contraction
during the deceleration phase of throwing. We do not recommend performing
stretches for the posterior capsule unless
the capsule has been shown on clinical
examination to be excessively hypomobile. If the posterior glenohumeral joint
capsule is hypomobile, then a posteriorlateral joint mobilization glide technique
is performed to effectively mobilize the
posterior capsule.
The rehabilitation specialist, in addition to helping restore glenohumeral
motion, should assess the resting position
and mobility of the scapula. Frequently,
we see overhead throwers who exhibit a
posture of rounded shoulders and a forward head. This posture appears associated with muscle weakness of the scapular
retractor muscles due to prolonged elongation or sustained stretches. In addition,
the scapula may often appear protracted
and anteriorly tilted. An anteriorly tilted
scapula has been shown to contribute to
a loss of glenohumeral joint IR.13,70 In
overhead throwers, it is our experience
that this scapular position abnormality
is associated with pectoralis minor muscle tightness and lower trapezius muscle
weakness, and a forward head posture.
Tightness of the pectoralis minor muscle
46 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy
can lead to axillary artery occlusion and
neurovascular symptoms, such as arm
fatigue, pain, tenderness, and cyanosis.8,82,93,95 The lower trapezius muscle is
an important muscle in arm deceleration
in that it controls scapular elevation and
protraction.34 Weakness of the lower trapezius muscle may result in improper mechanics or shoulder symptoms. Thus, the
rehabilitation specialist should carefully
assess the position, mobility, and strength
of the overhead thrower’s scapula. We
routinely have throwers stretch their
pectoralis minor muscle and strengthen
the lower trapezius muscle in addition to
the scapular retractors. Furthermore, a
scapular brace may be utilized to assist
in postural correction.
Additional primary goals of this first
phase are to restore muscle strength,
re-establish baseline dynamic stability,
and restore proprioception. In the early
phase of rehabilitation, the goal is to reestablish muscle balance.112,113 Therefore,
the focus is on improving the strength of
the weak muscles such as the external rotator muscles, the scapular muscles, and
those of the lumbopelvic region and lower extremities.112,113 If the injured athlete
is extremely sore or in pain, submaximal
isometric exercises should be employed;
conversely, if the athlete exhibits minimal
soreness, then lightweight isotonic exercises may be safely initiated. Additionally,
during this phase, we use rehabilitation
exercise drills designed to restore the
neurosensory properties of the shoulder
capsule that has experienced microtrauma and to enhance the sensitivity of the
afferent mechanoreceptors.60,62
Specific drills that restore neuromuscular control during this initial phase
are rhythmic stabilization exercises for
the internal/external rotator muscles of
the shoulders. Additionally, proprioceptive neuromuscular facilitation patterns
are used with rhythmic stabilization
and slow reversal hold to re-establish
proprioception and dynamic stabilization.58,60,62,96,111,112 The purpose of these exercises is to facilitate agonist/antagonist
muscle coactivation. Efficient coactiva-
tion assists in restoring the balance in the
force couples of the shoulder joint, thus
enhancing joint congruency and compression.46 Padua et al84 used proprioceptive neuromuscular facilitation patterns
for 5 weeks and significantly improved
their subjects’ shoulder function and enhanced functional throwing performance
test scores. Uhl et al101 reported improved
proprioception after specific neuromuscular training that challenged the glenohumeral musculature.
Other exercises commonly used during this first rehabilitation phase include joint repositioning tasks60-62 and
axial loading exercises (upper extremity
weight-bearing exercises). Active joint
compression stimulates the articular receptors.26,59 Thus, axial loading exercises,
such as weight shifts, weight shifting on
a ball, wall push-ups, and quadruped positioning drills, are beneficial in restoring
proprioception.106,112,109
F^Wi[(0?dj[hc[Z_Wj[F^Wi[
In phase 2 of the rehabilitation program, the primary goals are to progress
the strengthening program, continue to
improve flexibility, and facilitate neuromuscular control. During this phase,
the rehabilitation program is progressed
to more aggressive isotonic strengthening activities, with emphasis on restoration of muscle balance. Selective muscle
activation is also used to restore muscle
balance and symmetry. In the overhead
thrower, the shoulder external rotator
muscles and scapular retractor, protractor and depressor muscles are frequently
isolated because of weakness. We have established a fundamental exercise program
for the overhead thrower that specifically
addresses the vital muscles involved in
the throwing motion.106,118 This exercise
program was developed based on the
collective12,31,47,53,64,74,78,86,91,100 information
derived from electromyographic research
of numerous investigators and is referred
to as the “Thrower’s Ten” program.115 Frequently, the patient exhibits ER muscular
weakness. The specific exercises we prefer
are side-lying ER (EDB?D;L?:;E) and prone
<?=KH;/$Scapular neuromuscular control drills. The
athlete lies on his side with the hand placed on the
table and the clinician applies manual resistance to
resist scapular movements (such as protraction and
retraction). The athlete is instructed to perform slow
and controlled movements.
rowing into ER. Both have been shown to
elicit the highest amount of muscular activity of the posterior cuff muscles.91
The scapula provides proximal stability to the shoulder joint, enabling distal
segment mobility. Scapular stability is
vital for normal asymptomatic arm function. Several authors have emphasized the
importance of scapular muscle strength
and neuromuscular control in contributing to normal shoulder function.31,56,57,85
Isotonic exercises are used to strengthen
the scapular muscles. Furthermore, Wilk
et al111 developed specific exercise drills
to enhance neuromuscular control of the
scapulothoracic joint. These exercise drills
are designed to maximally challenge the
scapulothoracic muscle force couples and
to stimulate the proprioceptive and kinesthetic awareness of the scapula. These
scapular neuromuscular control drills are
illustrated in <?=KH;/(EDB?D;L?:;E).
Another popular exercise used by athletes is the “empty can” exercise. With this
exercise movement, the arm is placed in
the scapular plane with the hand placed
in full IR (thumb down). Originally Jobe
and Moynes52 reported high levels of
activation of the supraspinatus muscles
during this exercise. Recently, Reinold
et al90,91 reported that the best exercise
for supraspinatus muscle was instead
the “full can” exercise. Blackburn et al12
noted that the position with the patient
lying prone and with the arm abducted
to 100° and full ER produced the highest
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 47
[
CLINICAL COMMENTARY
<?=KH;'&$Ball throw into wall. The patient throws
a 2-pound (0.9 kg) Plyoball (Functional Integrated
Technologies, Watsonville, CA) against the wall at end
range of external rotation (late cocking).
<?=KH;''$Neuromuscular dynamic stabilization
exercise: exercise tubing resisting shoulder external
rotation with manual resistance at end range.
EMG signal in the supraspinatus muscles
compared to the empty can position.
Also during this second rehabilitation
phase, the overhead throwing athlete
is instructed to perform strengthening
exercises for the lumbopelvic region,
including the abdomen and lower back
musculature. Plus, the athlete should
perform lower extremity strengthening
and participate in a running program,
including jogging and sprinting. Upper
extremity stretching exercises are continued as needed to maintain soft tissue
flexibility.
F^Wi[)07ZlWdY[ZIjh[d]j^[d_d]F^Wi[
In phase 3, the advanced strengthening
phase, the goals are to initiate aggressive
strengthening drills, enhance power and
endurance, perform functional drills,
and gradually initiate throwing activities.
During this phase, the athlete performs
the Thrower’s Ten exercise program,
continues manual resistance stabiliza-
tion drills, and initiates plyometric drills.
Dynamic stabilization drills are also
performed to enhance proprioception
and neuromuscular control. These drills
include specific stabilization techniques
that employ the concept of perturbations
and range stability. These drills include
rhythmic stabilization exercise drills by
throwing a ball against the wall (<?=KH;
10), push-ups onto a ball, and tubing ER
with end range manual resistance (<?=KH;
''"EDB?D;L?:;E). Many of the stabilization
exercises may be performed on a physioball. The authors believe that performing
these exercises improves dynamic stabilization and increases muscular demands
(<?=KH;I '( 7D: ')). Plyometric training
may be used to enhance dynamic stability, enhance proprioception, and gradually
increase the functional stresses placed on
the shoulder joint.
Plyometric exercises employ 3 phases, all intended to use the elastic reactive properties of muscle to generate
maximal force production.16,22,25 The first
phase is the eccentric phase, where a
rapid prestretch is applied to the musculotendinous unit, stimulating the muscle
spindle. The second phase is the amortization phase, representing the time between eccentric and concentric phases.
This time should be as short as possible
so that the beneficial neurologic effects of
prestretch are not lost. The final phase is
the resultant concentric action. Wilk et
al111-112,114 established a plyometric exercise program for the overhead thrower.
The initial plyometric program consists
of 2-handed exercise drills such as chest
passes, overhead soccer throws, side-toside throws, and side-throws. The goal of
the plyometric drills is to transfer energy
from the lower extremities and trunk to
the upper extremity. Once these 2-handed
exercise drills are mastered, the athlete is
progressed to 1-handed drills. These drills
include standing 1-handed throws in a
functional throwing position, wall dribbling, and plyometric step-and-throws.
Swanik et al97 reported that a 6-week
plyometric training program resulted in
enhanced joint position sense, enhanced
]
<?=KH;'($Seated external rotation on a physioball
with single-leg support. Resisted external rotation
is performed with exercise tubing. To enhance the
demands on the shoulder stabilizers, a rhythmic
stabilization technique may be performed.
<?=KH;')$Scapular horizontal abduction performed
on a physioball. This exercise is performed to
enhance scapular muscle activity and core stability.
kinesthesia, and decreased time to peak
torque generation during isokinetic testing. Fortun et al44 noted improved shoulder IR power and throwing distances
after 8 weeks of plyometric training in
comparison with conventional isotonic
training.
Additionally, muscular endurance
exercises should be emphasized for the
overhead thrower. Lyman et al68 documented that the overhead athlete is at
greater risk for shoulder or elbow injuries
when pitching when fatigued. Recently,
Murray et al79 documented the effects of
fatigue on the entire body during pitching using kinematic and kinetic motion
analysis. Once the thrower was fatigued,
shoulder ER decreased and ball velocity
diminished, as did lead lower extremity knee flexion and shoulder adduction
torque. Voight et al103 documented a relationship between muscle fatigue and
diminished proprioception. Chen et al24
demonstrated that once the rotator cuff
48 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy
muscles are fatigued, the humeral head
migrates superiorly when arm elevation
is initiated. Furthermore, Lyman et al67
reported that the predisposing factor
that correlated to the highest percentage of shoulder injuries in Little League
pitchers was complaints of muscle fatigue
while pitching. Thus the endurance drills
described here appear critical for the
overhead thrower.
Specific endurance exercise drills we
use include wall dribbling with a Plyoball
(Functional Integrated Technologies, Watsonville, CA), wall arm circles, upper body
cycle, or isotonic exercises using lower
weights with higher repetitions. Other
techniques that may be beneficial to enhance endurance include throwing an underweighted or overweighted ball (that is, a
ball that is either less than or more than the
weight of an official baseball).17,25,32,39,65,102
These techniques are designed to enhance
training, coordination, and the transfer of
kinetic energy. Fortun et al44 noted an increase in shoulder IR strength and power
after an 8-week plyometric training program using a weighted ball. Most commonly, the underweighted ball is used to
improve the transfer of energy and angular
momentum.32,39,102 Conversely, the overweighted ball is generally used to enhance
shoulder strength and power.32,39,102
During this third rehabilitation phase,
an interval throwing program may be initiated. Before initiating such a program,
we occasionally suggest that the athlete
perform “shadow” or mirror throwing,
which is the action of mimicking throwing mechanics into a mirror, but not actively throwing. This is designed to allow
the athlete to work on proper throwing
mechanics before throwing a baseball.
The interval throwing program92 is initiated once the athlete can fulfill these
specific criteria: (1) satisfactory clinical
examination, (2) nonpainful ROM, (3)
satisfactory isokinetic test results, and (4)
appropriate rehabilitation progress. The
interval throwing program is designed to
gradually increase the quantity, distance,
intensity, and type of throws needed to facilitate the gradual restoration of normal
biomechanics.
Interval throwing is organized into 2
phases: phase 1 is a long-toss program
(45-180 ft [15-60 m]) and phase 2 is
an off-the-mound program for pitchers.
During this third rehabilitation phase,
we usually initiate phase 1 of the interval throwing program at 45 ft (15 m) and
progress to throwing from 60 ft (20 m).
The athlete is instructed to use a crowhop type of throwing mechanism and lob
the ball with an arc for the prescribed distance. Flat-ground, long-toss throwing is
used before throwing off the mound to allow the athlete to gradually increase the
applied loads to the shoulder while using
proper throwing mechanics. In addition,
during this phase of rehabilitation, we
routinely allow the position player to initiate a progressive batting program that
progresses the athlete from swinging a
light bat, to hitting a ball off a tee, to softtoss hitting, to batting practice.
F^Wi[*0H[jkhd#je#J^hem_d]F^Wi[
Phase 4 of the rehabilitation program,
the return-to-throwing phase, usually
involves the progression of the interval
throwing program. For pitchers, we progress the long-toss program to 120 ft (40
m), whereas position players would progress to throwing from 180 ft (60 m). Once
the pitcher has successfully completed
throwing from 120 ft, the athlete is instructed to throw 60 ft from the windup
on level ground. Once this step is successfully completed, phase II (throwing
from the mound) is performed.92 Position
players continue to progress the long-toss
program to 180 ft, then perform fielding
drills from their specific position. While
the athlete is performing the interval
throwing program, the clinician should
carefully monitor the thrower’s mechanics and throwing intensity. In a study
conducted at our biomechanics laboratory, we objectively measured the throwing intensity of healthy pitchers. When
pitchers were asked to throw at 50%
effort, radar gun analysis indicated that
actual effort was approximately 83% of
their maximum speed. When asked to
throw at 75% effort, they threw at 90% of
their maximum effort. This indicates that
these athletes threw at greater intensities
than were suggested, which may imply
difficulty of controlling velocity at lower
throwing intensities.
In addition, during this fourth phase,
the thrower is instructed to continue all
the exercises previously described to improve upper extremity strength, power,
and endurance. The athlete is also instructed to continue the Thrower’s Ten
program, stretching program, core stabilization exercise training, and lower extremity strengthening activities. Lastly,
the athlete is counseled on a year-round
conditioning program based on the principles of periodization.38 Thus, the athlete
is instructed when to begin such things as
strength training and throwing.112 To prevent the effects of overtraining or throwing when poorly conditioned, it is critical
to instruct the athlete specifically on what
to do through specific exercises throughout the year. This is especially critical in
preparing the athlete for the following
season. Wooden et al119 demonstrated
that performing a dynamic variable resistance exercise program significantly
increased throwing velocity.
IKCC7HO
E
verhead-throwing athletes
typically present with a unique
musculoskeletal profile. The overhead thrower exhibits ROM, postural,
and strength changes, which appear
to be from adaptations from imposed
demands. This unique client exhibits
unique lesions, and the recognition and
treatment of these lesions may present
a significant challenge to the clinician.
Based on the accurate recognition of
the lesion and underlying cause of the
pathology, a successful nonoperative or
in some cases operative treatment plan
can be implemented. In this manuscript,
we have attempted to provide the reader
with information regarding the evaluation and treatment of the overhead
throwing athlete. T
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 49
[
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General information
Age
Gender
Dominant-handedness
Position
Years throwing
Level of competition
Injury pattern
Onset of symptoms: acute, chronic
History of trauma or sudden injury
Symptom characteristics
Location of symptoms: anterior, lateral, posterior
Quality of symptoms: sharp, dull, burning
Presence of mechanical symptoms
Presence of weakness or instability
Severity of symptoms
Duration of symptoms
Activities that worsen symptoms
Activities that relieve symptoms
Presence of neurosensory changes
Phases of throwing that produce symptoms
Innings pitched per season/year
Frequency of starts/relief appearances
Changes in velocity of pitches
Loss of control/location of pitches
Treatment/rehabilitation
Amount of rest from throwing
Type and duration of rehabilitation
Type, location, and frequency of injections
Related symptoms
Cervical spine
Radicular symptoms
Brachial plexus injury
Peripheral nerve entrapment
Medical information
Past medical/surgical history
Medications
Allergies
Family/social history
Review of test, symptoms, and systems
52 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy
APPENDIX B
PHYSICAL EXAMINATION OF THE THROWING SHOULDER
Subjective History
Observation/Inspection
Palpation
1. Sternoclavicular joint
2. Acromioclavicular joint
3. Clavicle, acromion, coracoid
4. Bicipital groove
5. Scapula
6. Musculature
Range of Motion
1. Crepitus
2. Glenohumeral motion
a. Active
b. Passive
3. Scapulothoracic motion
Motor Strength
1. Glenohumeral
2. Scapular
3. Arm/forearm
Impingement Signs
1. Neer/Hawkins signs
2. Cross-chest adduction test
3. Internal impingement sign
Stability Tests
1. Sulcus sign
2. Anterior drawer
3. Anterior fulcrum
4. Relocation test
5. Posterior drawer
6. Posterior fulcrum
7. Push-pull test
Special Tests, Biceps
1. Speed’s test
2. Yergason’s test
Special Tests, SLAP
1. Clunk test
2. O’Brien’s active compression
3. Biceps load
4. Lemak test
5. Pronated biceps load
6. Resisted supinated external rotation test
Neurologic Examination
Cervical Spine Examination
Performance Testing
1. Isokinetic testing
2. Motion analysis testing
APPENDIX C
CLASSIFICATION OF MOST COMMON SHOULDER LESIONS IN OVERHEAD ATHLETES
Rotator Cuff Lesions
Tendonitis
Tendonosis
Strains
Bursitis
Rotator Cuff Tears
Partial thickness
Full thickness
Internal impingement
Glenohumeral Joint Capsular Lesions
Laxity
Instability
Capsulitis
Superior Labral Tear (SLAP)
Frayed (type I)
Tear (type III, IV)
Detached (type II)
Peel-back
Osseous Lesions
Glenoid osteochondritis dissecans
Bennett’s lesion
Biceps Tendon Lesions
Tendinitis
Tendonosis
Subluxation
Neurovascular Lesions
Axillary neuropathy, quadrilateral space
Long thoracic neuropathy
Thoracic outlet syndrome
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 53
[
CLINICAL COMMENTARY
]
APPENDIX D
NONOPERATIVE REHABILITATION OF THE OVERHEAD ATHLETE: PHASES AND GOALS
Phase 1: Acute phase
Goals:
Diminish pain and inflammation
Normalize motion
Delay muscular atrophy
Reestablish dynamic stability (muscular balance)
Control functional stress/strain
Exercises and modalities:
Cryotherapy, iontophoresis, ultrasound, electrical
stimulation
Flexibility and stretching for posterior shoulder muscles
to improve shoulder internal rotation and horizontal
adduction
Rotator cuff strengthening (especially external rotator
muscles)
Scapular muscles strengthening (especially retractor
and depressor muscles)
Dynamic stabilization exercises (rhythmic stabilization)
Weight-bearing exercises
Proprioception training
Abstain from throwing
Phase 2: Intermediate phase
Goals:
Progress strengthening exercises
Restore muscular balance
Enhance dynamic stability
Control flexibility and stretches
Exercises and modalities:
Continue stretching and flexibility (especially shoulder
internal rotation and horizontal adduction)
Progress isotonic strengthening
š 9ecfb[j[i^ekbZ[hfhe]hWc
š J^hem[hÊiJ[dfhe]hWc
Rhythmic stabilization drills
Initiate core lumbopelvic region strengthening program
Initiate lower extremity program
Phase 3: Advanced strengthening phase
Goals:
Aggressive strengthening
Progress neuromuscular control
Improve strength, power, and endurance
Exercises and modalities:
Flexibility and stretching
Rhythmic stabilization drills
J^hem[hÊiJ[dfhe]hWc
Initiate plyometric program
Initiate endurance drills
Initiate short-distance throwing program
Phase 4: Return-to-activity phase
Goals:
Progress to throwing program
Return to competitive throwing
Continue strengthening and flexibility drills
Exercises:
Stretching and flexibility drills
J^hem[hÊiJ[dfhe]hWci[[M_ba[jWb115 for full
program)
Plyometric program
Progress interval throwing program to competitive throwing (see Reinold et al92 for full program)
VIEW Videos on JOSPT’s Website
Videos posted with select articles on the Journal’s website (www.jospt.org)
show how conditions are diagnosed and interventions performed. For a
list of available videos, click on “COLLECTIONS” in the navigation bar in the
left-hand column of the home page, select “Media”, check “Video”, and
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54 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy