Intrinsic Factors

• •
  

  The following intrinsic factors may play a role in the development of primary adhesive capsulitis:

  
  
  
  
  • •
    

    Angiogenesis and synovitis consistent with inflammation

  
  
  
  
• •
  

  Secondary adhesive capsulitis and restriction of glenohumeral range of motion may result from:

  
  
  
  
  • •
    

    Rotator cuff tendonitis

    
    
  • •
    

    Rotator cuff tears

    
    
  • •
    

    Calcific tendonitis

    
    
  • •
    

    Contracture of the rotator cuff interval

    
    
  • •
    

    Subacromial scarring

    
    
  • •
    

    Inflammation of the long head of the biceps tendon and its synovial sheath

  
  

Extrinsic Factors

• •
  

  Trauma is the only known extrinsic factor implicated in the development of adhesive capsulitis.

  
  
• •
  

  Patients with diabetes mellitus are at greater risk of developing adhesive capsulitis, with a prevalence between 10% and 20%

  
  
• •
  

  Although more rare, both thyroid dysfunction and Parkinson disease are also associated with the development of adhesive capsulitis

Classic Pathological Findings

• •
  

  General pathological findings are synovial hyperplasia and capsular fibrosis further characterized by:

  
  
  
  
  • •
    

    Elevated cytokine expression in shoulder capsule including transforming growth factor-β (TGF-β), platelet-derived growth factor, and hepatocyte growth factor

    
    
  • •
    

    Excess accumulation and propagation of fibroblasts (Type I and II collagen)

  
  
  
  
• •
  

  Specific pathological findings vary dependent upon the current stage of the patient. These are further described in Table 8-1 .

  
  
  
  

  Table 8-1

  
  

  Stages of Adhesive Capsulitis

  
  

  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  

  	Arthroscopic Appearance	Biopsy
  Stage 1 (Preadhesive)	Fibrinous synovial inflammatory reaction No adhesions or capsular contracture	Rare inflammatory cell infiltrate Hypervascular, hypertrophic synovitis Normal capsular tissue
  Stage 2 (Freezing)	Christmas tree synovitis Some loss of axillary fold	Hypertrophic, hypervascular synovitis Perivascular, subsynovial capsular scar
  Stage 3 (Frozen)	Complete loss of axillary fold Minimal synovitis	Hypercellular, collagenous tissue with a thin synovial layer Similar features to other fibrosing conditions
  Stage 4 (Thawing)	Fully mature adhesions Identification of intraarticular structures difficult	Not reported

   
  
  

History

• •
  

  Insidious onset without a definitive action or event causing symptoms

  
  
• •
  

  Progressive increase in pain with development of sleep-disturbing night pain

  
  
• •
  

  Deep achy pain at rest with acute intense pain associated with quick motion or rapid stretch

  
  
• •
  

  ROM is initially limited by pain, not capsular contracture. It then progresses to global stiffness shoulder.

  
  
• •
  

  Initial loss of external and internal rotation

  
  
• •
  

  Passive and active motions are more restricted owing to pain at or before end range secondary to muscle guarding.

Physical Examination

Imaging

• •
  

  Plain radiographs (X-rays) are routinely performed to rule out calcific tendinitis or glenohumeral arthritis.

  
  
• •
  

  Osteopenia is a common radiographic finding.

  
  
• •
  

  Magnetic resonance imaging (MRI) is not essential for diagnosis but can rule out confounding pathology.

  
  
• •
  

  Hallmark of adhesive capsulitis on MRI is thickening and loss of volume of the axillary pouch.

  
  
• •
  

  MRI in stages 1 and 2 demonstrates increased signal in capsule and synovium consistent with hyperemia and synovitis.

  
  
• •
  

  MRI in stages 3 and 4 demonstrates low signal capsule with increased capsular thickness in anterior capsule, posterior capsule, and axillary pouch.

  
  
• •
  

  One-third of stage 2 adhesive capsulitis patients show some form of supraspinatus pathology on magnetic resonance arthrography. The clinical significance is unknown but should be correlated with physical examination.

  
  
• •
  

  Axillary recess thickening up to 1.3 cm or more compared with normal measurement of less than 4 mm

  
  
• •
  

  Rotator interval thickening

  
  
• •
  

  Glenohumeral ligament thickening

Nonoperative Management

• •
  

  Physical therapy including patient education, manual therapy, therapeutic ROM exercises and periscapular strengthening, neuromuscular re-education and modalities for pain, relaxation, and tissue extensibility (moist heat, cryotherapy, TENS, low power laser)

  
  
• •
  

  Oral nonsteroidal antiinflammatory medications (NSAIDs)

  
  
• •
  

  Oral corticosteroid

  
  
• •
  

  Intraarticular corticosteroid injection

  
  
• •
  

  Distension arthrography or hydrodilation

  
  
• •
  

  Closed manipulation

Surgical Indications

• •
  

  When physical and pharmacological therapies have failed, surgical options should be considered and discussed with the patient.

  
  
• •
  

  Failed therapy should be considered when a patient has reached a plateau or progress in increased ROM is extremely slow.

  
  
• •
  

  Surgery may be indicated for a painful shoulder that has failed to respond to intraarticular corticosteroids.

  
  
• •
  

  Surgery is indicated when the patient is failing to improve with a minimum of 6 months of conservative treatment .

Management of Pain and Swelling

• •
  

  NSAIDs

  
  
• •
  

  Intraarticular injection

  
  
• •
  

  Patient education

  
  
• •
  

  Activity modification

  
  
• •
  

  Positioning ( Figure 8-1 )

  
  

  
  

  
  

  

  
  

  
  

  Positioning of the UE in the plane of the scapula with the elbow higher than shoulder. Also support limitations in IR ROM.

  
  
  
  
• •
  

  Cryotherapy

  
  
• •
  

  TENS

  
  
• •
  

  Hydrotherapy

  
  
• •
  

  Manual therapy

  
  
• •
  

  Moist heat

  
  
• •
  

  Low power laser therapy

Techniques for Progressive Increase in Range of Motion

Other Therapeutic Exercises

• •
  

  TLS to tolerance. Monitor and avoid exercises that involve loading the shoulder and upper extremity.

  
  
• •
  

  Core stability emphasizing the lower abdominals can be performed using the legs to challenge the core. At this time, avoid exercises that load the shoulder with weight through the elbows.

  
  
• •
  

  TAS: can perform scapular retraction, scapular elevation to tolerance, biceps curls, triceps extension with arm in neutral position. Avoid heavy weights that will cause compensatory anterior translation of the humeral head.

Activation of Primary Muscles Involved

• •
  

  Strengthening of the scapular muscles can be initiated to tolerance such as retraction, elevation, protraction. Side lying position with the involved arm on top and supported by pillows can be used to decrease gravity for increased tolerance to exercise. Tactile cues can be helpful to ensure proper movement. Manual resistance can be given by the physical therapist. With increased strength, the patient can perform scapular retraction in sitting, scapular protraction in supine. Resistance can be added with elastic bands or hand weights. Perform 10 reps, 3 sets; however, the emphasis is on quality of movement.

  
  
• •
  

  Hydrotherapy, because the buoyancy provides an environment for active-assistive exercise. The patient is instructed to perform modified breast stroke movements (horizontal abduction and adduction), flexion in the plane of the scapula, and gentle internal and external rotation. The water temperature is warm to create an environment that promotes relaxation.

Sensorimotor Exercises

• •
  

  Hydrotherapy can be used for its hydrostatic properties, which create a “glove-like” effect stimulating the proprioceptors of the skin.

Open and Closed Kinetic Chain Exercises

• •
  

  Pain-free, closed kinetic chain (CKC) exercises below shoulder height, such as physioball scapular stabilization exercises can be initiated with adequate ROM/ soft tissue length. A physioball is placed on a stable surface (chair, resting on a toss back) so that the UEs are positioned below shoulder height and slightly wider than her body. With the elbows straight, the patient then compresses the ball and performs small movements as instructed by the therapist.

Techniques to Increase Muscle Strength, Power, and Endurance

• •
  

  Strengthening of the scapular muscles can be initiated as described previously.

Neuromuscular Dynamic Stability Exercises

• •
  

  Rhythmic stabilization exercise for IR/ER in the PoS in modified neutral to tolerance. With the patient lying in supine, the patient’s upper extremity is positioned in the plane of the scapula and the elbow is supported on a towel roll with the elbow flexed to 90°. The therapist applies gentle pressure at the wrist in the direction of internal and external rotation in alternating fashion to work on humeral head control. The patient is instructed to hold the arm stable, thus working on coordination. This can be performed for 10 seconds initially for three to four sets.

Milestones for Progression to the Next Phase

• •
  

  Control of pain/inflammation

  
  
• •
  

  Resolution of resting pain, and decreased irritability of the shoulder allows for progression of ROM exercises

  
  
• •
  

  Patient compliance with home exercise program

  
  
• •
  

  Minimize ROM loss

  
  
• •
  

  Retard/halt the progression from synovitis to capsular fibroplasias, which is determined by end feel and pain. An empty end feel is more indicative of synovitis, whereas a capsular, firm end feel is more indicative of fibroplasia.

  
  
• •
  

  Maximize function. During each phase the therapist wants to maximize the patient’s functional strength within the available pain-free ROM. This allows the patient to then use the extremity during ADLs in the available ROM without compensatory movements. If the functional strength is not sufficient, and the patient continues to use the arm during ADLs, impingement symptoms will occur. This in turn will slow the return of ROM because the shoulder will be painful and inflamed. Use of the arm in pain-free arcs of motion will help the patient gain ROM.

  
  
• •
  

  Avoid symptoms of impingement. The patient is not encouraged to use the arm outside available ROM/AROM.

Management of Pain and Swelling

• •
  

  Oral NSAIDs

  
  
• •
  

  Intraarticular injection

  
  
• •
  

  Patient education

  
  
• •
  

  Activity modification

  
  
• •
  

  Positioning

  
  
• •
  

  Modalities: cryotherapy, TENS

  
  
• •
  

  Hydrotherapy

  
  
• •
  

  Manual therapy

  
  
• •
  

  Moist heat will promote relaxation and tissue extensibility and can assist with controlling pain.

Techniques for Progressive Increase in Range of Motion

Other Therapeutic Exercises

• •
  

  Strengthening exercises are performed two to three times per week.

  
  
• •
  

  TBS

  
  
  
  
  • •
    

    Stationary bicycle, elliptical. As the patient is comfortable using the UE for balance, the stationary bike and elliptical can be used. The bicycle will be introduced first followed by the elliptical without UE movement. Use of the UEs can be started progressively on an interval basis (30 seconds work, 1 minute rest). The individual will move the shoulder in a pain-free ROM, below shoulder height. Pain and progression of ROM will guide tolerance to these exercises.

    
    
  • •
    

    Use of the arms below shoulder height with cardiovascular equipment (elliptical, bicycle) can be introduced for a short duration, as tolerated.

  
  
  
  
• •
  

  Core strengthening

  
  
  
  
  • •
    

    Lower abdominal strengthening using Sahrmann progression, bridging bilateral to marching in place, to single leg bridge. Avoid loading the elbow as in a plank position.

  
  
  
  
• •
  

  TAS

  
  
  
  
  • •
    

    Avoid overhead exercise.

    
    
  • •
    

    Perform pain-free exercise within the available ROM such as biceps curls, triceps extensions, scapular retraction, and scapular protraction. While performing biceps curls and triceps extensions, it is important that the patient avoid forcing the humeral head anterior. This is achieved by making sure that the weight is not too heavy causing the patient to not go through the full ROM at the elbow. Upper body ergometry can be incorporated as a warmup.

  
  
  
  
• •
  

  TLS

  
  
  
  
  • •
    

    Squats, knee extension, knee flexion, side lying hip abduction

    
    
  • •
    

    Machines for hip abduction/adduction

  
  

Activation of Primary Muscles Involved

• •
  

  Emphasis is on periscapular muscles—rhomboids, serratus, latissimus, trapezius—to provide a proximal stable base for distal mobility and to reestablish force couples necessary for shoulder elevation: scapular retraction, protraction, extension to neutral. Scapular retraction can be performed in sitting—resistance with elastic bands can be added; scapular protraction in supine—resistance with hand weights can be added; lower trapezius isometrics in an upright position, which will also be postural cues, shoulder extension to neutral with elastic bands progressing from ≈45° flexion to 0° (side of body). These exercises will be performed three times per week. Three times 10 reps progressing to two times 15 reps before increasing resistance

  
  
• •
  

  Progress from submaximal RC isometrics in modified neutral: 5-second hold, 5-second rest for 10 reps, two times per day to isotonics in S/L position to neutral. Five reps, three sets, two-three times per week.

  
  
• •
  

  Active exercise is performed in the plane of the scapula.

Sensorimotor Exercises

• •
  

  Hydrotherapy for its hydrostatic properties

Open and Closed Kinetic Chain Exercises

• •
  

  CKC physioball stabilization exercises can be performed below shoulder height with double arm support. CKC exercise causes contraction of the force couples, allows the rotator cuff to work as a compressor, and creates an axial load (weightbearing). A physioball is positioned on a secured surface (chair, resting on a toss back) so that the UE is positioned below shoulder height. The size of the ball allows the patient to position her arms slightly wider than her body. With the elbows straight, the patient then compresses the ball and performs small movements in the coronal plane (side to side), the sagittal plane (up and down) with the shoulder girdle positioned, as instructed by the therapist, in retraction, protraction, or neutral. Three sets of 10 repetitions can be performed in each direction, as tolerated.

  
  
• •
  

  OKC exercises such as pain-free forward flexion—full can position—in the plane of the scapula can be initiated with good scapulohumeral rhythm; dumbbell row with hand weights, shoulder extension in prone with hand weights, single arm cable column pulldown in plane of scapula.

Techniques to Increase Muscle Strength, Power, and Endurance

• •
  

  These exercises should be pain-free and performed two to three times per week. Exercising into pain or with pain will further irritate the shoulder and cause loss of motion, and thus function. There is a balance of enough resistance to stimulate the muscle without aggravating the joint.

  
  
• •
  

  Upper body ergometry can be incorporated: Airdyne (arms only) with elevated seat height for 5 minutes, as tolerated; upper extremity bicycle also with high seat height.

  
  
• •
  

  Use of arms below shoulder height with cardiovascular equipment (elliptical, bicycle) can be introduced for a short duration.

  
  
• •
  

  Strengthening of the periscapular muscles for retraction in sitting or standing with elastic bands or manual resistance, protraction in supine with weight of arm, then progressing to hand weights, and extension in standing with elastic bands or prone with weight of arm against gravity progressing to hand weights to neutral is important to reestablish force couples for synchronous arm elevation.

Neuromuscular Dynamic Stability Exercises

• 
  
  
  
  
  
  • •
    

    Proprioceptive neuromuscular facilitation (PNF) exercise such as rhythmic stabilization in supine is performed for IR/ER (PoS) in modified neutral and at shoulder height with the elbow as tolerated. This can be performed for 10 seconds initially for three to four sets.

  
  

Functional Exercises

• •
  

  Begin pain-free scapula plane elevation—full can position—to shoulder height when good scapulohumeral rhythm is evident.

  
  
• •
  

  Hydrotherapy may be used initially to provide environment for active-assistive exercise.

Sport-Specific Exercises

• •
  

  N/A with the exception of progressive ROM exercises.

  
  
• •
  

  Incorporating exercises for core, TBS, TAS, and TLS is encouraged, keeping in mind the limitations and precautions associated with the involved shoulder.

Milestones for Progression to the Next Phase

• •
  

  Control pain/inflammation

  
  
• •
  

  Resolution of rest and night pain

  
  
• •
  

  Compliance with home exercise program

  
  
• •
  

  Avoid subacromial impingement

  
  
• •
  

  Avoid rotator cuff inhibition, which is determined by increased pain with therapeutic exercise, pain at rest, and increased compensatory movements.

  
  
• •
  

  Minimize loss of ROM

  
  
• •
  

  Minimize capsular contracture. This can be determined by assessing joint play, end feel with humeral head glides, as well as by postural habitus and ROM deficits.

  
  
• •
  

  Normalize scapulohumeral rhythm to shoulder height in the plane of the scapula, pain-free

Management of Pain and Swelling

• •
  

  Patient education

  
  
• •
  

  Oral NSAIDs

  
  
• •
  

  Intrarticular injection

  
  
• •
  

  Avoid pain with strengthening

  
  
• •
  

  ROM exercises to the shoulder’s tolerance

  
  
• •
  

  Cryotherapy

  
  
• •
  

  Moist heat

  
  
• •
  

  Activity modification.

Techniques for Progressive Increase in Range of Motion

Other Therapeutic Exercises

• •
  

  Strengthening exercises are performed two to three times per week.

  
  
• •
  

  TBS

  
  
  
  
  • •
    

    Stationary bicycle

    
    
  • •
    

    Elliptical

    
    
  • •
    

    Use of the UE during cardiovascular exercise can be initiated to tolerance such as bike with arms, elliptical with arms.

    
    
  • •
    

    The patient can perform a modified breast stroke.

  
  
  
  
• •
  

  Core strengthening

  
  
  
  
  • •
    

    Lower abdominal strengthening

    
    
  • •
    

    Bridging

    
    
  • •
    

    Introduce trunk rotation strengthening.

  
  
  
  
• •
  

  TAS

  
  
  
  
  • •
    

    Avoid overhead exercise.

    
    
  • •
    

    Perform pain-free exercise within the available ROM such as biceps curls, triceps curls, scapular retraction, and scapular protraction.

    
    
  • •
    

    Upper body ergometry, use of arms in c-v equipment progresses to tolerance.

  
  
  
  
• •
  

  TLS

  
  
  
  
  • •
    

    Squats, RDLs, knee extension, knee flexion, side-lying hip abduction

    
    
  • •
    

    Machines for hip abduction/adduction, gluteals

    
    
  • •
    

    Lunges, lunges with rotation

  
  

Activation of Primary Muscles Involved

• •
  

  Perform two to three times per week.

  
  
  
  
  • •
    

    With adequate ROM and no pain with muscle activation, rotator cuff exercises in the PoS are progressed from side-lying position to the upright position with elastic resistance in modified neutral.

    
    
  • •
    

    With adequate ROM, advanced, progressive scapular strengthening can be performed. These exercises can include: single arm pull down with cable column from overhead, chest press, latissimus pulldown, and prone horizontal abduction for middle trapezius with adequate length of pectorals.

  
  

Sensorimotor Exercises

• •
  

  Hydrotherapy for its hydrostatic properties: The water temperature is warm to create an environment that promotes relaxation. Supine abduction with buoyancy-assisted device at surface of water, ER ROM with paddle, and pass behind the back with buoyancy device for functional IR. If the patient is willing, the patient can go under water to increase arc of buoyancy. Walking forwards with arms abducted will help stretch the anterior chest. Gentle strengthening of proximal scapular musculature can be achieved with scapular retraction/protraction with dumbbells or paddle board; shoulder extension with gloves or paddles, scaption to surface of water with appropriate resistance as tolerated, as well as IR/ER with appropriate resistance of paddle. Walking backward in water will facilitate scapular retractors,

  
  
• •
  

  Hydrotherapy exercises will replace one day of strengthening on land.

Open and Closed Kinetic Chain Exercises

• •
  

  Quadruped can be initiated to tolerance for scapular stabilization.

  
  
• •
  

  Physioball exercises below shoulder height can be progressed from double arm support to single support, as tolerated.

Techniques to Increase Muscle Strength, Power, and Endurance

• •
  

  Upper body ergometry for 5 minutes

  
  
• •
  

  Strengthening of the biceps and triceps with comfortable resistance.

  
  
• •
  

  Reestablish force couples for arm elevation above shoulder height.

  
  
• •
  

  Bench/chest press can be performed in water with a paddle, on land with dumbbells, and wall pushups.

Neuromuscular Dynamic Stability Exercises

• •
  

  PNF such as PoS rhythmic stabilization for IR/ ER in modified neutral, and shoulder height elevation will be progressed to more challenging positions.

  
  
• •
  

  Initiate PNF D2 flexion in supine for 10 reps, one set, three times per week.

Functional Exercises

• •
  

  Scapular plane elevation (full can position) to shoulder height with good scapula-humeral rhythm

  
  
• •
  

  Hydrotherapy

  
  
• •
  

  Wall slides ( Figure 8-4 ) are performed in the PoS.

  
  

  
  

  
  

  

  
  

  
  

  Wall slides to assist with AROM.

  
  

Milestones for Progression to the Next Phase

• •
  

  Resolution of night pain, pain with ADLs, therapeutic exercise

  
  
• •
  

  AROM = PROM

  
  
• •
  

  Maximize function. This is measured using an outcomes scale (DASH), and by observation of movement patterns such as raising the arm, reaching behind the back, reaching out to the side, as well as patient willingness to use the arm. This is also achieved when AROM = PROM.

  
  
• •
  

  Normalize scapulohumeral rhythm above shoulder height—measured by observation as the patient raises the arm. In the middle of the arc of motion, scapular motion should be greater than humeral motion so that the glenoid is positioned to receive the humeral head.

  
  
• •
  

  Reestablish force couples for arm elevation. Manual muscle testing allows the physical therapist to assess muscle strength; however, timing is assessed with observation.

  
  
• •
  

  Avoid impingement.

  
  
• •
  

  Compliance with home exercise program

Management of Pain and Swelling

• •
  

  Cryotherapy

  
  
• •
  

  Functional progression

  
  
• •
  

  Avoid pain with exercise.

  
  
• •
  

  Patient education: activity modification; avoid too much, too soon; avoid subacromial impingement

  
  
• •
  

  Emphasize quality of movement.

Techniques for Progressive Increase in Range of Motion

Other Therapeutic Exercises

• •
  

  As described previously

Activation of Primary Muscles Involved

• •
  

  These exercises are performed two to three times per week, emphasizing quality of movement:

  
  
  
  
  • •
    

    Advanced periscapular strengthening such as prone exercises for lower trapezius, middle trapezius, and latissimus. These exercises are performed with scapular setting before upper extremity movement.

    
    
  • •
    

    Pain-free RC PREs IR/ ER with elastic resistance. Place a towel roll under the arm and rotate only to neutral position.

  
  

Sensorimotor Exercises

• •
  

  PNF diagonal pattern D2 flexion progressions from supine to standing

Open and Closed Kinetic Chain Exercises

• •
  

  Wall pushup progression to pushups beginning with an upright position and gradually progressing to floor, single arm ball stabilization

Techniques to Increase Muscle Strength, Power, and Endurance

• •
  

  Upper body ergometry

  
  
• •
  

  Cardiovascular equipment with UEs

  
  
• •
  

  Upper body weight training: row, lat pulldown, chest press

Neuromuscular Dynamic Stability Exercises

• •
  

  PNF diagonal patterns D2 flexion progressing from supine to standing progression

  
  
• •
  

  Bodyblade can be introduced in modified neutral position with IR/ER oscillations for 30 seconds.

Plyometrics

• •
  

  Latter part of phase: Ball toss such as chest pass, overhead toss, and side to side toss can be introduced.

Functional Exercises

• •
  

  PNF diagonal patterns D2 flexion initiated in supine for 10 reps

  
  
• •
  

  Scapular plane elevation—full can position—with good scapula-humeral rhythm, pain-free (emphasize quality of movement). Emphasize posture and stabilization through core. Do not perform more than 10 reps in a set. May perform three sets.

Sport-Specific Exercises

• •
  

  These are introduced based on the demands of the sport that the athlete is returning to.

Milestones for Progression to Advanced Sport-Specific Training and Conditioning

• •
  

  Resolution of pain with ADLs, therapeutic exercise

  
  
• •
  

  AROM/ flexibility to meet demands of sport

  
  
• •
  

  Strength to meet the demands of sport; 85% of uninvolved shoulder with isokinetic dynamometer or manual muscle tester

  
  
• •
  

  Pain-free progression of exercises

  
  
• •
  

  Normalized S-H Rhythm throughout the ROM via observation. In the early part of the ROM (0° to 60°), humeral motion is greater than scapular motion. Between 60° and 120°, scapula motion is greater than humeral motion, and in the final phases of elevation (120° to180°), humeral motion is greater than scapular motion.

Management of Pain and Swelling

• •
  

  Cryotherapy

  
  
• •
  

  Patient education: Avoid too much, too soon; emphasize quality of movement, functional progression. As described above, as patient demonstrates decreased irritability, improved ROM, and strength, exercise progressions will build on previous reached milestones.

Techniques for Progressive Increase in Range of Motion

Other Therapeutic Exercises

• •
  

  As described previously

Activation of Primary Muscles Involved

• •
  

  Advanced periscapular strengthening such as prone exercises for lower trapezius, middle trapezius, latissimus

  
  
• •
  

  RC PREs: IR/ ER at 90° abduction as tolerated

Sensorimotor Exercises

• •
  

  These are initially performed for 10 repetitions and then progresses to three sets:

  
  
  
  
  • •
    

    PNF diagonal pattern progressions from supine to standing; from no resistance to manual resistance and resistance with elastic bands.

  
  

Open and Closed Kinetic Chain Exercises

• •
  

  Wall pushup progression to pushups

  
  
• •
  

  Single arm ball stabilization

  
  
• •
  

  Quadruped activities continue

Techniques to Increase Muscle Strength, Power, and Endurance

• •
  

  Upper body ergometry: can be incorporated using a row­ing ergometer, upper body bicycle, or Airdyne beginning with 5 minutes and progressing to patient tolerance.

  
  
• •
  

  Cardiovascular equipment with UEs: such as elliptical, rowing ergometer, Nordic track

  
  
• •
  

  RC and periscapular strengthening: prone exercises such as prone horizontal abduction, prone lower traps

  
  
• •
  

  Isokinetic training for IR/ER

  
  
• •
  

  Upper body weight training: row, lat pulldown, chest press

Neuromuscular Dynamic Stability Exercises

• •
  

  Beginning with 10 reps.

  
  
• •
  

  PNF diagonal patterns progressing from supine to standing progression ( Figure 8-6 )

  
  

  
  

  
  

  

  
  

  
  

  Proprioceptive neuromuscular facilitation performed manually in supine.

  
  
  
  
• •
  

  Bodyblade with longer lever arm, in diagonal patterns

  
  
• •
  

  Stabilization exercises

  
  
• •
  

  RC strengthening at 90/90 position with rhythmic stabilization at end range for five reps

  
  
• •
  

  Quadruped on unstable surfaces for 15 to 30 seconds, three reps

Plyometrics

• •
  

  Ball tosses are performed for 10 reps each, two sets.

  
  
• •
  

  Initiate ball toss—two-hand chest pass

  
  
• •
  

  Activity-specific plyos

  
  
• •
  

  Ball tosses: chest pass, overhead pass progressing from two-handed to single-handed, side passes

Functional Exercises

• •
  

  PNF diagonal patterns progressing from supine to standing progression

  
  
• •
  

  Deceleration exercises with cable column, ball toss

Sport-Specific Exercises

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  These are introduced based on the demands of the sport and position that the athlete is returning to and will be introduced on an individual basis.

  
  
  
  
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    If the athlete is returning to throwing, an interval throwing program should be used to gradually introduce stresses.

  
  
  
  
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  The program will be adjusted according to sport and position, and will begin with a day of rest in between throwing sessions. Soreness is expected, sharp pain should not be worked through.

  
  
  
  
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    Throwing

    
    
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    Catching/receiving

    
    
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    Tackling

    
    
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    Swimming

    
    
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    Swinging

    
    
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    Batting

    
    
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    Rowing

    
    
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    Lifting