CHAPTER 17

Rehabilitation of Shoulder Injuries

Elizabeth Hibberd, PhD, ATC
Joseph B. Myers, PhD, ATC
Brett Pexa, PhD, ATC
Terri Jo Rucinski, MA, PT, ATC
William E. Prentice, PhD, PT, ATC, FNATA
Rob Schneider, PT, MS, LAT, ATC

Figure 17-1. Skeletal anatomy of the shoulder complex.

FUNCTIONAL ANATOMY AND BIOMECHANICS

The anatomy of the shoulder joint complex allows for tremendous range of motion (ROM). This wide ROM of the shoulder complex proximal permits precise positioning of the hand distally, to allow both gross and skilled movements. However, the high degree of mobility requires some compromise in stability, which, in turn, increases the vulnerability of the shoulder joint to injury, particularly in dynamic overhead athletic activities.5

The shoulder girdle complex is composed of 3 bones—the scapula, the clavicle, and the humerus—that are connected either to one another or to the axial skeleton or trunk via the glenohumeral joint, the acromioclavicular joint, the sternoclavicular joint, or the scapulothoracic joint (Figure 17-1). Dynamic movement and stabilization of the shoulder complex require integrated function of all 4 articulations if normal motion is to occur.¹⁷⁸

Sternoclavicular Joint

The clavicle articulates with the manubrium of the sternum to form the sternoclavicular joint, the only direct skeletal connection between the upper extremity and the trunk. The sternal articulating surface is larger than the sternum, causing the clavicle to rise much higher than the sternum. A fibrocartilaginous disc is interposed between the 2 articulating surfaces. It functions as a shock absorber against the medial forces and also helps to prevent any displacement upward. The articular disc is placed so that the clavicle moves on the disc, and the disc, in turn, moves separately on the sternum. The clavicle is permitted to move up and down, forward and backward, in combination, and in rotation.

The sternoclavicular joint is extremely weak because of its bony arrangement, but it is held securely by strong ligaments that tend to pull the sternal end of the clavicle downward and toward the sternum, in effect anchoring it. The main ligaments are the anterior sternoclavicular, which prevents upward displacement of the clavicle; the posterior sternoclavicular, which also prevents upward displacement of the clavicle; the interclavicular, which prevents lateral displacement of the clavicle; and the costoclavicular, which prevents lateral and upward displacement of the clavicle.²⁹

It should also be noted that for the scapula to abduct and upward rotate throughout 180 degrees of humeral abduction, clavicular movement must occur at both the sternoclavicular and acromioclavicular joints.⁵⁰

Acromioclavicular Joint

The acromioclavicular joint is a gliding articulation of the lateral end of the clavicle with the acromion process. This is a rather weak joint. A fibrocartilaginous disc separates the 2 articulating surfaces. A thin, fibrous capsule surrounds the joint.

The acromioclavicular ligament consists of anterior, posterior, superior, and inferior portions. In addition to the acromioclavicular ligament, the coracoclavicular ligament joins the coracoid process and the clavicle and helps to maintain the position of the clavicle relative to the acromion. The coracoclavicular ligament is further divided into the trapezoid ligament, which prevents overriding of the clavicle on the acromion, and the conoid ligament, which limits upward movement of the clavicle on the acromion. As the arm moves into an elevated position, there is a posterior rotation of the clavicle on its long axis that permits the scapula to continue rotating, thus allowing full elevation. The clavicle must rotate about 50 degrees for full elevation to occur, otherwise elevation would be limited to about 110 degrees.29

Coracoacromial Arch

The coracoacromial ligament connects the coracoid to the acromion. This ligament, along with the acromion and the coracoid, forms the coracoacromial arch over the glenohumeral joint. In the subacromial space between the coracoacromial arch superiorly and the humeral head inferiorly lies the supraspinatus tendon, the long head of the biceps tendon, and the subacromial bursa. Each of these structures is subject to irritation and inflammation resulting either from excessive humeral head translation or from impingement during repeated overhead activities. In asymptomatic individuals, the subacromial space is approximately 11 mm with this decreasing to 5.7 mm at 90 degrees of abduction.⁴⁶

Glenohumeral Joint

The glenohumeral joint is an enarthrodial, or ball-in-socket, synovial joint in which the round head of the humerus articulates with the shallow glenoid cavity of the scapula. The cavity is deepened slightly by a fibrocartilaginous rim called the glenoid labrum. The humeral head is larger than the glenoid, and at any point during elevation, only 25% to 30% of the humeral head is in contact with the glenoid.^97,170 The glenohumeral joint is maintained by both static and dynamic restraints. Position is maintained statically by the glenoid labrum and the capsular ligaments, and dynamically by the deltoid and rotator cuff muscles.

Surrounding the articulation is a loose, articular capsule that is attached to the labrum. This capsule is strongly reinforced by the superior, middle, and inferior glenohumeral ligaments and by the tough coracohumeral ligament, which attaches to the coracoid process and to the greater tuberosity of the humerus.¹⁷⁸

The long tendon of the biceps muscle passes superiorly across the head of the humerus and then through the bicipital groove. In the anatomical position, the long head of the biceps moves in close relationship with the humerus. The transverse humeral functional anatomy and biomechanics ligament maintains the long head of the biceps tendon within the bicipital groove by passing over it from the lesser and the greater tuberosities, converting the bicipital groove into a canal.

Scapulothoracic Joint

The scapulothoracic joint is not a true joint, but the movement of the scapula on the wall of the thoracic cage is critical to shoulder joint motion.^72,73 The scapula is capable of 5 degrees of freedom movement, including 3 rotations (orientations) and 2 translations (positions).^67,105 Rotation of the scapula can occur around its 3 orthogonal axes, with upward/downward rotation occurring around an anteroposterior axis, internal/external rotation occurring around a superoinferior axis, and anterior/posterior tipping occurring around a mediolateral axis. In addition to rotating, the scapula can translate superoinferiorly (scapular elevation and depression) and anteroposteriorly on the thorax. Because anterior/posterior translation is limited by the rib cage, protraction/retraction results from the anterior/posterior translation (Figure 17-2). During humeral elevation (flexion, scaption, or abduction), the scapula and humerus must move in a synchronous fashion to maintain glenohumeral joint congruency, length–tension relationships for the numerous muscles attaching on the scapula, and adequate subacromial space clearance. Commonly termed scapulohumeral rhythm, as the humerus elevates, the scapula synchronously upwardly rotates, posteriorly tips, externally rotates, elevates, and translates posteriorly (retracts). Alterations in these scapular movement patterns have been identified in individuals with varying degrees of rotator tendinopathy (subacromial impingement and rotator cuff tears),41,93,98,108,139 pathologic internal impingement,⁸² glenohumeral instability,¹²¹ frozen shoulder,^44,136 and osteoarthritis,⁴⁴ as well as highly influenced by fatigue,^{37,38,154,163} upper quarter posture and tightness,^11–13 and even history of participation in overhead athletics.^{34,84,116,126}

Stability in the Shoulder Joint

Maintaining stability, while the 4 articulations of the shoulder complex collectively allow for a high degree of mobility, is critical in normal function of the shoulder joint. Instability is very often the cause of many of the specific injuries to the shoulder that are discussed later in this chapter. In the glenohumeral joint, the rounded humeral head articulates with a relatively flat glenoid on the scapula. During movement of the shoulder joint, it is essential to maintain the positioning of the humeral head relative to the glenoid. Likewise, it is also critical for the glenoid to adjust its position relative to the moving humeral head while simultaneously maintaining a stable base. The glenohumeral joint is inherently unstable, and stability depends on the coordinated and synchronous function of both static and dynamic stabilizers.^29,90,178

Static Stabilizers

The primary static stabilizers of the glenohumeral joint are the glenohumeral ligaments, the posterior capsule, and the glenoid labrum.

The glenohumeral ligaments appear to produce a major restraint in shoulder flexion, extension, and rotation. The anterior glenohumeral ligament is tight when the shoulder is in extension, abduction, and/or external rotation. The posterior glenohumeral ligament is tight in flexion and external rotation. The inferior glenohumeral ligament is tight when the shoulder is abducted, extended, and/or externally rotated. The middle glenohumeral ligament is tight when in flexion and external rotation. Additionally, the middle glenohumeral ligament and the subscapularis tendon limit lateral rotation from 45 to 75 degrees of abduction and are important anterior stabilizers of the glenohumeral joint.¹⁷⁸ The inferior glenohumeral ligament is a primary check against both anterior and posterior dislocation of the humeral head and is the most important stabilizing structure of the shoulder in the overhead patient.¹⁷⁸

Figure 17-3. Shoulder complex ligaments and rotator cuff muscle and tendons—posterior view.

The tendons of the rotator cuff muscles blend into the glenohumeral joint capsule at their insertions about the humeral head (Figure 17-3). As these muscles contract, tension is produced, dynamically tightening the capsule and helping to center the humeral head in the glenoid fossa. This creates both static and dynamic control of humeral head movement.

The posterior capsule is tight when the shoulder is in flexion, abduction, internal rotation, or any combination of these. The superior and middle segments of the posterior capsule have the greatest tension, while the shoulder is internally rotated.

The bones and articular surfaces within the shoulder are positioned to contribute to static stability. The glenoid labrum, which is tightly attached to the bottom half of the glenoid and loosely attached at the top, enhances the stability at the glenohumeral joint through increasing glenoid depth and joint congruency.^90,178 The scapula faces 30 degrees anteriorly to the chest wall and is tilted upward 3 degrees to enable easier movement on the anterior frontal plane and movements above the shoulder.⁷ The glenoid is tilted upward approximately 4 degrees to help control inferior instability.²²

The Dynamic Stabilizers of the Glenohumeral Joint

The muscles that cross the glenohumeral joint produce motion and function to establish dynamic stability to compensate for a bony and ligamentous arrangement that allows for a great deal of mobility. Movements at the glenohumeral joint include flexion, extension, abduction, adduction, horizontal adduction/abduction, circumduction, and humeral rotation.

The muscles acting on the glenohumeral joint may be classified into 2 groups. The first group consists of muscles that originate on the axial skeleton and attach to the humerus; these include the latissimus dorsi and the pectoralis major. The second group originates on the scapula and attaches to the humerus; these include the deltoid, the teres major, the coracobrachialis, the subscapularis, the supraspinatus, the infraspinatus, and the teres minor (Figures 17-3 and 17-4). These muscles constitute the short rotator muscles whose tendons insert into the articular capsule and serve as reinforcing structures. The biceps and triceps muscles attach on the glenoid and affect elbow motion.

Figure 17-4. Shoulder complex ligaments and rotator cuff muscle and tendons—anterior view.

The muscles of the rotator cuff, the subscapularis, infraspinatus, supraspinatus, and teres minor along with the long head of the biceps function to provide dynamic stability to control the position and prevent excessive displacement or translation of the humeral head relative to the position of the glenoid.9,94,168

Stabilization of the humeral head occurs through coactivation of the rotator cuff muscles. This creates a series of force couples that act to compress the humeral head into the glenoid, minimizing humeral head translation. A force couple involves the action of 2 opposing forces acting in opposite directions to impose rotation about an axis. These force couples can establish dynamic equilibrium of the glenohumeral joint regardless of the position of the humerus. If an imbalance exists between the muscular components that create these force couples, abnormal glenohumeral mechanics occur.

In the frontal plane, a force couple exists between the subscapularis anteriorly and the infraspinatus and teres minor posteriorly. Coactivation of the infraspinatus, teres minor, and subscapularis muscles both depresses and compresses the humeral head during overhead movements.

In the coronal plane, there is a critical force couple between the deltoid and the inferior rotator cuff muscles. With the arm fully adducted, contraction of the deltoid produces a vertical force in a superior direction, causing an upward translation of the humeral head relative to the glenoid. Coactivation of the inferior rotator cuff muscles produces both a compressive force and a downward translation of the humerus that counterbalances the force of the deltoid, stabilizing the humeral head. The supraspinatus compresses the humeral head into the glenoid and, along with the deltoid, initiates abduction on this stable base. Dynamic stability is created by an increase in joint compression forces from contraction of the supraspinatus and by humeral head depression from contraction of the inferior rotator cuff muscles.^9,29,94,168

The long head of the biceps tendon also contributes to dynamic stability by limiting superior translation of the humerus during elbow flexion and supination.

Scapular Stability and Mobility

Like the glenohumeral muscles, the scapular muscles play a critical role in normal function of the shoulder. The scapular muscles produce movement of the scapula on the thorax and help to dynamically position the glenoid relative to the moving humerus. They include the levator scapula and upper trapezius, which elevate the scapula; the middle trapezius and rhomboids, which retract the scapula; the lower trapezius, which retracts, upwardly rotates, and depresses the scapula; the pectoralis minor, which depresses the scapula; and the serratus anterior, which protracts and upwardly rotates the scapula (in combination with the upper and lower trapezius). Collectively, they function to maintain a consistent length–tension relationship with the glenohumeral muscles.72,73,113

The only attachment of the scapula to the thorax is through these muscles. The muscle stabilizers must fix the position of the scapula on the thorax, providing a stable base for the rotator cuff to perform its intended function on the humerus. It has been suggested that the serratus anterior moves the scapula while the other scapular muscles function to provide scapular stability.^72,73 The scapular muscles act isometrically, concentrically, or eccentrically, depending on the movement desired and whether the movement is speeding up or slowing down.

In an asymptomatic individual, upward rotation, posterior tipping, and decreased internal rotation, retraction, and elevation is the common movement pattern as the humeral angle increases.^67,95 Upward rotation of the scapula serves to elevate the lateral acromion in order to prevent impingement and is the primary scapular motion.⁹⁶ Posterior tipping of the scapula is a secondary scapular motion and moves the anterior acromion posteriorly in order to prevent impingement of the rotator cuff tendons.⁹⁶ External rotation moves the acromion posteriorly to decrease contact with the rotator cuff tendons.⁹⁶

Normal movements of the scapula have been found to be altered in individuals who present with shoulder pain.⁷¹ Several studies have shown alterations in scapular kinematics with the presence of impingement syndrome.^41,93,96,99 Patients with impingement syndrome were found to have decreased upward rotation, decreased posterior tilt, and increased internal rotation between symptomatic and asymptomatic individuals.⁹³ While alterations in scapular kinematics may be related to injury, they also may present as an adaptation to overhead throwing. Throwing athletes present with increased upward rotation, internal rotation, and retraction of the scapula during humeral elevation tasks when compared with non-throwing athletes.¹¹⁶ Although these alterations have been found to be associated with subacromial impingement, alterations in 3-dimensional kinematics in baseball players were present even in the asymptomatic athlete, indicating that these adaptations occur from repetitive overhand activity.¹²⁶ These findings are important in understanding scapular kinematics in overhead athletes that may be injurious, as normal scapular kinematics in overhead athletes may already have alterations that could predispose them to injury. Any subsequent alterations in scapular kinematics, such as weak or altered activation patterns, tightness of the pectoralis minor and major, or tight posterior shoulder, lead to further scapular protraction, anterior tilting, and downward rotation, which causes the scapula to tilt downward and places the acromion in a more horizontal position.^11,17 This, in effect, lowers the roof of the coracoacromial arch and provides mechanical compression to the tissues in the subacromial space.¹⁵⁰

Posture

Faulty postural alignment due to forward head posture and thoracic kyphosis can lead to abnormal stress on tissues that may contribute to shoulder pain. Altered postural alignment may be implicated in shoulder pain indirectly through muscle imbalances. These muscle imbalances may alter biomechanics and ROM, contributing to secondary impingement, joint instability, and muscular fatigue. Individuals with forward head rounded shoulder posture presented with alterations in scapular kinematics and muscle activation during overhead tasks, including greater scapular internal rotation and upward rotation, and decreases in serratus anterior activation compared to those with ideal posture.¹⁵⁹ In addition, shoulder external rotation strength has been shown to decrease after sitting just 5 minutes in slouched posture.¹²⁸ The alterations in scapular kinematics and decreased muscle strength associated with a slouched, forward shoulder posture have been theorized to decrease the subacromial space distance, thus increasing the risk of impingement.^{12,15,145,150} In the rehabilitation of all shoulder injuries, the clinician should incorporate education strategies and strengthening and stretching exercises for the improvement of posture.

REHABILITATION EXERCISES FOR THE SHOULDER COMPLEX

Early Stage Stretching Exercises

Figure 17-5. Static hanging. Hanging from a chinning bar is a good general stretch for the musculature in the shoulder complex.

Figure 17-6. Codman’s circumduction exercise. The patient holds a dumbbell in the hand and moves it in a circular pattern, reversing direction periodically. This technique is useful as a general stretch in the early stages of rehabilitation when motion above 90 degrees is restricted.

Figure 17-7. Sawing. The patient moves the arm forward and backward as if performing a sawing motion. This technique is useful as a general stretch in the early stages of rehabilitation when motion above 90 degrees is restricted.

Figure 17-9. Rope and pulley exercise. This exercise may be used as an active assisted exercise when trying to regain full overhead motion. ROM should be restricted to a pain-free arc.

Active-Assisted Stretching Exercises

Figure 17-10. Wall/corner stretch. (A) Place elbows at or below shoulder level on a wall and press chest toward the corner. Used when there is limited horizontal adduction or rounded shoulders posture to stretch the pectoralis major and minor, anterior deltoid, coracobrachialis, and the anterior joint capsule. (B) Can also be performed single sided against a wall.

Figure 17-12. Sleeper stretch. Stack shoulders to stabilize scapula and provide gentle pressure toward the table to stretch posterior shoulder. Used when posterior shoulder tightness and limited internal rotation ROM is present to stretch the infraspinatus, teres minor, posterior deltoid, and posterior joint capsule. Important for overhead athletes, as they are at risk of losing internal rotation due to throwing.

Figure 17-13. Horizontal abductors stretch. Pull arm into horizontally abducted position to stretch posterior shoulder. Used to stretch the posterior deltoid, infraspinatus, teres minor, rhomboids, and middle trapezius muscles and the posterior capsule. This position might be uncomfortable for patients with shoulder impingement syndrome. Consider performing this in a side-lying position to stabilize the scapula against a table.

Figure 17-14. Inferior capsule stretch. (A) Self-stretch done with the arm in the fully elevated overhead position. Used to stretch the inferior joint capsule and triceps brachii in a limited arc. This position might be uncomfortable for patients with shoulder impingement syndrome. (B) Inferior capsule stretch can also be done using a stability ball.

Figure 17-16. Shoulder internal rotators stretch using an L-bar. Used to stretch the subscapularis, pectoralis major, latissimus dorsi, teres major, and anterior deltoid muscles and the anterior joint capsule. This stretch should be done at (A) 0 degrees, (B) 90 degrees, and (C) 135 degrees of shoulder abduction, depending on the stage of rehabilitation.

Figure 17-17. Shoulder external rotators stretch using an L-bar. Used to stretch the infraspinatus, teres minor, and posterior deltoid muscles and the posterior joint capsule. This stretch should be done at (A) 90 degrees and (B) 135 degrees of shoulder abduction.

Clinician-Assisted Strengthening Techniques

Figure 17-19. Perform an isometric hold to initiate strengthening through a limited ROM. (A) Isometric medial rotation and (B) isometric lateral rotation should be used to reintroduce strengthening while in a limited ROM or when returning from surgery rehabilitation program when full ROM isotonic exercise is likely to exacerbate a problem.

Figure 17-20. Rhythmic stabilization. Using either a diagonal 1 or diagonal 2 pattern. The patient uses an isometric cocontraction to maintain a specific position within the ROM while the athletic trainer repeatedly changes the direction of passive pressure.

Figure 17-21. Proprioceptive neuromuscular facilitation technique for scapula. Clinician applies resistance to the appropriate scapular border while the patient moves through a diagonal 1 or diagonal 2 pattern. Used to increase neuromuscular control of scapular stabilizers and facilitate scapular muscle strengthening.

Implement-Based Proprioceptive Neuromuscular Facilitation Exercises

Figure 17-23. PNF with implement. Perform a diagonal 1 or diagonal 2 pattern using (A) Body Blade, (B) centrifugal ring blade, or (C) tubing or cable. Used to increase neuromuscular control and improve strength through a full ROM.

Press-Based Shoulder Strengthening Exercises

Press exercises are designed to create strength in the anterior shoulder and superficial back. These exercises can be performed with a barbell, free weights, or resistance bands. Consider performing these exercises in various positions or on a stability ball.

Figure 17-25. Chest press. Used to strengthen the pectoralis major, anterior deltoid, and triceps, and secondarily the coracobrachialis muscles. (A) Performing this exercise with the feet on the floor helps to isolate these muscles. (B) An alternate technique is to use dumbbells on an unstable surface such as a stability ball. (C) May also be done in a standing position using cable or tubing.

Figure 17-27. Decline bench press. Used to strengthen the pectoralis major (lower fibers), triceps, anterior deltoid, coracobrachialis, and latissimus dorsi muscles.

Figure 17-28. Military press. Used to strengthen the middle deltoid, upper trapezius, levator scapula, and triceps. (A) Performed in a seated position on a bench. (B) In a standing position using dumbbells. (C) In a seated position using cable or tubing.

Shoulder-Specific Resistance Exercises

Figure 17-29. Shoulder flexion. Used to strengthen primarily the anterior deltoid and coracobrachialis, and secondarily the middle deltoid, pectoralis major, and biceps brachii muscles. Note that the thumb should point upward. May also be done seated.

Figure 17-30. Shoulder abduction to 90 degrees. Used to strengthen primarily the middle deltoid and supraspinatus, and secondarily the anterior and posterior deltoid, and serratus anterior muscles. Note that the thumb should point upward. May also be done seated.

Figure 17-31. Shoulder extension. Used to strengthen primarily the latissimus dorsi, teres major, and posterior deltoid, and secondarily the teres minor and the long head of the triceps muscles. Note that the thumb should point downward. May be done (A) standing using a dumbbell, (B) lying prone using cable or tubing, or (C) using dumbbells prone on a stability ball.

Figure 17-33. Shoulder rows (shoulder horizontal abduction). Used to strengthen primarily the posterior deltoid, and secondarily the infraspinatus, teres minor, rhomboids, and middle trapezius muscles. (A) May be done lying prone using dumbbells, (B) prone on a stability ball, and (C) standing using cables or tubing. Note that with the thumb pointed upward the middle trapezius is more active, and with the thumb pointed downward the rhomboids are more active.

Figure 17-35. Alternative supraspinatus exercise. Used to strengthen primarily the supraspinatus, and secondarily the posterior deltoid. In the prone position with the arm abducted to 100 degrees, the arm is horizontally abducted in extreme lateral rotation.Note that the thumb should point upward.

Figure 17-36. Shoulder shrugs. Set shoulders down and back and then perform a shoulder shrug in either a standing or sitting position. Used to strengthen primarily the upper trapezius and the levator scapula, and secondarily the rhomboids.

Figure 17-37. Shoulder internal rotation. This exercise may be done isometrically or isotonically, either lying supine using a dumbbell or standing using tubing. Placing a towel under the arm in standing forces the patient to contract the rotator cuff to hold the towel in place thus enhancing stability. Used to strengthen primarily the subscapularis, pectoralis major, latissimus dorsi, and teres major, and secondarily the anterior deltoid. Strengthening should be done with the arm fully adducted at 0 degrees, and also in 90 degrees and 135 degrees of abduction.

Scapular Strengthening Exercises

Figure 17-39. “Y”s. Patient lies prone on a stability ball and maintains a stable position. The patient squeezes the scapulae together and then raises the arms overhead into a “Y” position. Used to strengthen the lower trapezius, rhomboids, and serratus anterior.

Figure 17-40. “T”s. Patient lies prone on a stability ball and maintains a stable position. The patient squeezes the scapulae together and then horizontally abducts the arms to a “T” position. Used to strengthen the rhomboids, middle trapezius, and posterior deltoid.

Figure 17-41. “W”s. Patient lies prone on a stability ball and maintains a stable position. The patient should perform a row and external rotation to create a “W” position. Used to strengthen the supraspinatus, anterior deltoid, and middle deltoid.

Figure 17-43. Superman. May be done lying prone using either dumbells or tubing. Used to strengthen primarily the inferior trapezius, and secondarily the middle trapezius.

Figure 17-44. Rhomboids isometric exercise. Should be done with patient lying prone, hand resting on the back at the level of the sacrum with manual resistance applied by the clinician at the elbow. Used to strengthen primarily the rhomboids, and secondarily the lower trapezius.

Figure 17-45. Push-ups with a plus. (A) Patients can perform this on all fours. Patients will perform a standard push-up and then round shoulders at the top of the push-up. (B) Can also be performed in a supine position with a free weight. Used to strengthen the serratus anterior.

Figure 17-46. Lat pull-downs. This exercise should be done by pulling the bar down in front of the head. Used to strengthen primarily the latissimus dorsi, teres major, and pectoralis minor, and secondarily the biceps muscles. Pull-ups done on a chinning bar can also be used as an alternative strengthening technique.

Push-Up Exercises

Figure 17-48. Push-ups. (A) Patient starts with toes on the ground, weight supported on feet. Maintain straight core throughout push-up. Progress by adding a stability ball under the feet or the hands. (B) Modified push-up. Patient starts with knees on the ground. Progress by moving to an unstable surface under the knees. (C) Wall push-ups. Patient places hands on wall and performs push-up. Progress by increasing angle against the wall.

Figure 17-49. Seated push-up. Done sitting on the end of a table. Place hands on the table and lift weight upward off of the table isotonically.

Figure 17-50. Push-ups on a stability ball. An advanced closed chain strengthening exercise that requires substantial upper body strength. Patient starts with toes on a plyobox and hands on a stability ball. Maintain balance and straight core throughout push-up.

Figure 17-51. Push-ups on boxes. When performing a plyometric push-up on boxes, the patient can stretch the anterior muscles, which facilitates a concentric contraction.

Figure 17-52. Push-ups with a clap. The patient pushes off the ground, claps his hands, and catches his weight as he decelerates.

Figure 17-53. Push into wall. The athletic trainer stands behind the patient and pushes her toward the wall. The patient decelerates the forces and then pushes off the wall immediately.

Plyometric Exercises

Figure 17-54. Cable or tubing. To strengthen the medial rotators, use a quick eccentric stretch of the medial rotators to facilitate a concentric contraction of those muscles. Used to increase muscular power and enhance neuromuscular control at end-range positions.

Figure 17-55. Plyoback. The patient should bounce a plyoball off of a trampoline, catch the ball, decelerate it, then immediately accelerate in the opposite direction. (A) Single-arm toss. (B) Two-arm toss with trunk rotation. (C) Standing single-leg and single-arm toss on an unstable surface.

Figure 17-56. Seated single-arm weighted ball throw. The patient should be seated with the arm abducted to 90 degrees and the elbow supported on a table. The athletic trainer tosses the ball to the hand, creating an overload in lateral rotation that forces the patient to dynamically stabilize in that position.

Exercises to Reestablish Neuromuscular Control

Figure 17-58. Weight shifting on a stable surface may be done kneeling in a 2-point position. The athletic trainer can apply random directional pressure to which the patient must respond to maintain a static position. In the 2- and 3-point positions, the arm that is supported in a closed kinetic chain is using shoulder force couples to maintain neuromuscular control.

Figure 17-59. Weight shifting on a ball. In a push-up position with weight supported on a ball, the patient shifts weight from side-to-side and/or backward and forward. Weight shifting on an unstable surface facilitates cocontraction of the muscles involved in the force couples that collectively maintain dynamic stability.

Figure 17-60. Weight shifting on a Fitter. In a kneeling position, the patient shifts weight front to back using a Fitter. Weight shifting on an unstable surface facilitates cocontraction of the muscles involved in the force couples that collectively maintain dynamic stability. (Reprinted with permission from Fitter International, Inc.)

Figure 17-62. Weight shifting on a stability ball. With the feet supported on a bench, the patient shifts weight from side-to-side and/or backward and forward using a stability ball. Weight shifting on an unstable surface facilitates cocontraction of the muscles involved in the force couples that collectively maintain dynamic stability.

Figure 17-63. Slide board exercises. (A) Forward and backward motion. (B) Wax-on/wax-off motion. (C) Lateral motion. The patient shifts weight from side-to-side and/or backward and forward using a slide board. Weight shifting on an unstable surface facilitates cocontraction of the muscles involved in the force couples that collectively maintain dynamic stability.

Figure 17-65. Body Blade exercises. The patient is in a 3-point kneeling position holding an oscillating Body Blade in one hand while working on neuromuscular control in the weightbearing shoulder.

Isokinetic Strengthening Exercise Techniques

Figure 17-66. When using an isokinetic device for strengthening the shoulder, the patient should be set up such that strengthening can be done in a scapular plane. (A) Shoulder abduction/adduction. (Reprinted with permission from Biodex Medical Systems.) (B) Internal and external rotation. (C) Diagonal 1 PNF pattern. (Reprinted with permission from Biodex Medical Systems.)

Plane of the Scapula

The concept of the plane of the scapula refers to the angle of the scapula in its resting position, usually 35 to 45 degrees anterior to the frontal plane toward the sagittal plane. When the limb is positioned in the plane of the scapula, the mechanical axis of the glenohumeral joint is in line with the mechanical axis of the scapula. The glenohumeral joint capsule is lax, and the deltoid and supraspinatus muscles are optimally positioned to elevate the humerus. Movement of the humerus in this plane is less restricted than in the frontal or sagittal planes because the glenohumeral capsule is not twisted.39 Because the rotator cuff muscles originate on the scapula and attach to the humerus, repositioning the humerus into the plane of the scapula optimizes the length of those muscles, improving the length–tension relationship. This is likely to increase muscle force.³⁹ It has been recommended that many strengthening exercises for the shoulder joint complex be done in the scapular plane.¹⁷⁷

REHABILITATION TECHNIQUES FOR SPECIFIC INJURIES

Sternoclavicular Joint Sprains

Pathomechanics

Sternoclavicular joint sprains are not commonly seen as athletic injuries.^100,141 Although they are rare, the joint’s complexity and integral interaction with the other joints of the shoulder complex warrant discussion. The sternoclavicular joint has multiple axes of rotation and articulates with the manubrium with an interposed fibrocartilaginous disc. Pathology of this joint can include injury to the fibrocartilage and sprains of the sternoclavicular ligaments and/or the costoclavicular ligaments.⁶³

As stated earlier, the sternoclavicular joint is extremely weak because of its bony arrangement. It is held in place by its strong ligaments that tend to pull the sternal end of the clavicle downward and toward the sternum. A sprain of these ligaments often results in either a subluxing sternoclavicular joint or a dislocated sternoclavicular joint.¹⁴¹ This can be significant because the joint plays an integral role in scapular motion through the clavicle’s articulation with the scapula. Combined movements at the acromioclavicular and sternoclavicular joints have been reported to account for up to 60 degrees of upward scapular rotation inherent in glenohumeral abduction.^72,178

When this joint incurs an injury, a resultant inflammatory process occurs. The inflammatory process can cause an increase in the joint capsule pressure, as well as a stiffening of the joint due to the collagen tissue being produced for the healing tissues. The pathogenesis of this inflammatory process can cause an alteration of the joint mechanics and an increase in pain felt at the joint. This often results adversely on the shoulder complex.

Injury Mechanism

After motor vehicle accidents, the most common source of injuries to the sternoclavicular joint is sports participation.¹²³ The sternoclavicular joint can be injured by direct or indirect forces, resulting in sprains, dislocations, or physical injuries.¹⁴¹ Direct force injuries are usually the result of a blow to the anteromedial aspect of the clavicle and produce a posterior dislocation.5,100,141 Indirect force injuries can occur in many different sporting events, usually when the patient falls and lands with an outstretched arm in either a flexed and adducted position or an extended and adducted position of the upper extremity. The flexed position causes an anterior lateral compression force to the adducted arm, producing a posterior dislocation. The extended position causes a posterior lateral compression force to the adducted arm, leading to an anterior dislocation. Lesser forces can also lead to varying degrees of sprains to the sternoclavicular joint.

Additionally, repetitive microtrauma to this joint may occur in sports such as golf, gymnastics, and rowing. In golf, an example of mechanism of injury occurs during the backswing.¹⁰³ For a right-handed golfer, the sternoclavicular joint is subject to medially directed forces on the left at the top of the backswing and on the right at the end of the backswing. When the right arm is abducted and fully coiled at the end of the backswing and the beginning of the downswing, there is a posterior retraction of the shoulder complex, resulting in an anterior sternoclavicular joint stress. As a result of the repetitive nature of golf, this can cause repetitive microtrauma leading to irritation of the joint. Over time the joint may become hypermobile relative to its normal stable condition, allowing for degeneration of the soft tissue and fibrocartilaginous disc. This often results in a painful syndrome affecting the mechanics of the joint and muscular control of the shoulder complex. Similar examples are found in gymnastics and rowing.

Rehabilitation Concerns

In addressing the rehabilitation of a patient with a sternoclavicular joint injury, it is important to address the function of the joint on shoulder complex movement. The sternoclavicular joint acts as the sole passive attachment of the shoulder complex to the axial skeleton. As noted earlier in the chapter, the clavicle must elevate to allow upward scapular rotation.²⁹

In most cases, the primary problem reported by the injured patient is discomfort associated with end-range movement of the shoulder complex. It is important to identify the cause of the pain (ie, ligamentous instability, disc degeneration, or ligamentous trauma).

In cases where there is ligamentous instability as well as disc degeneration, the rehabilitation should focus on strengthening the muscles attached to the clavicle in a range that does not put further stress on the joint.⁵ Muscles such as the pectoralis minor, sternal fibers of the pectoralis major, and upper trapezius are strengthened to help control the motion of the clavicle during motion of the shoulder complex (Figure 17-35). Exercises include incline bench press, shoulder shrugs, and the seated press-up, in a limited ROM (Figures 17-26, 17-36, and 17-49). In addition to addressing the dynamic supports of the sternoclavicular joint, the athletic trainer should employ the appropriate modalities necessary to control pain and the inflammatory process. It is also noteworthy, in cases where dislocation or subluxation has occurred, to consider the structures in close proximity to the sternoclavicular joint. In the case of a posterior dislocation, signs of circulatory vessel compromise, nerve tissue impingement, and difficulty swallowing may be seen. If these symptoms persist during rehabilitation, the patient should be referred back to the treating physician.

When dealing with ligamentous trauma that lacks instability, the athletic trainer should also address the associated pain with the appropriate modalities and use exercises that strengthen muscle with clavicular attachments. In all of the above scenarios, it is important to address the role of the sternoclavicular joint on shoulder complex movement. A full evaluation of the shoulder complex should be performed to address issues related to scapular elevation. Exercises such as bent-over row, Superman, rhomboids, and push-ups with a plus should be included to help control upward rotation of the scapula (Figures 17-42 through 17-45). Appropriate progression should be followed while addressing the healing stages for the appropriate tissues.

Rehabilitation Progression

In the initial stages of rehabilitation, the primary goal is to minimize pain and inflammation associated with shoulder complex motion. The athletic trainer should limit activities to midrange exercises and incorporate the use of therapeutic modalities along with the use of nonsteroidal anti-inflammatory drug (NSAID) intervention from the physician. Ultrasound is often useful for increasing blood flow and facilitating the process of healing. Occasionally a shoulder sling or figure 8 strap can help minimize stress at the joint. During this phase of the rehabilitation progression, the therapist should identify the sport-specific needs of the patient to tailor the later phases of rehabilitation to the patient’s demands. The patient should also continue to work on exercises that maintain cardiorespiratory fitness.

When the pain and inflammation have been controlled, the patient should gradually engage in a controlled increase of stress to the tissues of the joint. This is a good time to begin low-grade joint mobilization resistance exercises for the muscles attaching to the clavicle. Exercises in this phase are best done in the midrange to minimize pain. As the patient’s tolerance increases, the resistance and ROM can be increased. During this phase, it is also important to address any limitations there might be in the patient’s ROM. Emphasis should be placed on restoring the normal mechanics of the shoulder complex during shoulder movements.

As the patient begins to enter the pain-free stages of the progression, the athletic trainer should gradually incorporate sport-specific demands into the exercise program. Examples of this are proprioceptive neuromuscular facilitation (PNF) with rubber tubing for the golfer (Figure 17-22), push-ups on a stability ball for the gymnast (Figure 17-50), and rowing machine for the rower.

Criteria for Returning to Full Activity

The patient may return to full activity when (a) the rehabilitation program has been progressed to the appropriate time and stress for the specific demands of the patient’s sport, (b) the patient shows improved strength in the muscles used to protect the sternoclavicular joint when compared to the uninjured side, and (c) the patient no longer has associated pain with movements of the shoulder complex that will inevitably occur with the demands of the sport.

Acromioclavicular Joint Sprains

Pathomechanics

The acromioclavicular joint is composed of a bony articulation between the clavicle and the scapula. The soft tissues included in the joint are the hyaline cartilage coating the ends of the bony articulations, a fibrocartilaginous disc between the 2 bones, the acromioclavicular ligaments, and the costoclavicular ligaments. The acromioclavicular joint provides the bridge between the clavicle and the scapula. When an injury occurs to the joint, all soft tissue should be considered in the rehabilitation process. Rockwood classically described acromioclavicular joint injuries based on the soft tissue that is involved in the injury (Table 17-1).^85,134 Through evaluation by X-ray, the patient’s injury should be categorized to provide the athletic trainer with a guideline for rehabilitation.

Injury Mechanism

Type I or type II acromioclavicular joint sprains are most commonly seen in athletics as a result of a direct fall on the point of the shoulder with the arm at the side in an adducted position or falling on an outstretched arm.^60,127 The injury mechanism for type III and type IV sprains usually involves a direct impact that forces the acromion process downward, backward, and inward while the clavicle is pushed down against the rib cage. The impact can produce a number of injuries such as (a) fracture of the clavicle, (b) acromioclavicular joint sprain, (c) acromioclavicular and coracoclavicular joint sprain, or (d) a combination of the previous injury with concomitant muscle tearing of the deltoid and trapezius at their clavicular attachments.

Rehabilitation Concerns

Management of acromioclavicular injuries is dependent on the type of injury. Age, level of play, and the demand on the patient can also factor into the management of this injury. Most physicians prefer to handle type I and type II injuries conservatively; however, conservative management may result in problems later in life, including joint instability, residual pain, and/or degenerative changes.¹¹⁴ These injuries might require surgical excision of the distal 2 cm of the clavicle. The athletic trainer should consider when developing a treatment plan (a) the stability of the acromioclavicular joint; (b) the amount of time the patient was immobilized; (c) pain, as a guide for the type of exercises being used; and (d) the soft tissue that was involved in the injury. Rehabilitation of these injuries should focus on strengthening the deltoid and trapezius muscles. Additional strengthening of the clavicular fibers of the pectoralis major should also be done (Figures 17-25 and 17-32). Other muscles that help restore the proper mechanics to the shoulder complex should also be strengthened.

Table 17-1 Acromioclavicular Sprain Classification

Type I	Sprain of the acromioclavicular ligaments Acromioclavicular ligament intact Coracoclavicular ligament, deltoid, and trapezius muscles intact
Type II	Acromioclavicular joint disrupted with tearing of the acromioclavicular ligament Coracoclavicular ligament sprained Deltoid and trapezius muscles intact
Type III	Acromioclavicular ligament disrupted Acromioclavicular joint displaced and the shoulder complex displaced inferiorly Coracoclavicular ligament disrupted with a coracoclavicular interspace 25% to 100% greater than the normal shoulder Deltoid and trapezius muscles usually detached from the distal end of the clavicle
Type IV	Acromioclavicular ligaments disrupted with the acromioclavicular joint displaced and the clavicle anatomically displaced posteriorly through the trapezius muscle Coracoclavicular ligaments disrupted with wider interspace Deltoid and trapezius muscles detached
Type V	Acromioclavicular and coracoclavicular ligaments disrupted Acromioclavicular joint dislocated and gross displacement between the clavicle and scapula Deltoid and trapezius muscles detached from the distal end of the clavicle
Type VI	Acromioclavicular and coracoclavicular ligaments disrupted Distal clavicle inferior to the acromion or the coracoid process Deltoid and trapezius muscles detached from the distal end of the clavicle

TYPE I

Treatment for the type I injury consists of ice to relieve pain and a sling to support the extremity for several days. The amount of time in the sling usually depends on the patient’s ability to tolerate pain and begin carrying his or her involved extremity with the appropriate posture. The athletic trainer can have the patient begin active assisted ROM immediately and then incorporate isometric exercises to the muscles with clavicular attachments. This will help restore the appropriate carrying posture for the involved upper extremity. When the patient is able to remove the sling, the athletic trainer should increase the exercise program to incorporate progressive resistance exercise (PRE) for the muscles with clavicular attachments and add exercises to encourage appropriate scapular motion. This will help prevent related shoulder discomfort due to poor glenohumeral mechanics after return to activity.

TYPE II

The treatment for type II injuries is also nonsurgical. Because this type of injury to the acromioclavicular joint involves complete disruption of the acromioclavicular ligaments, immobilization plays a greater role in the treatment of these patients. It has been reported that tissue mobilized too early shows a greater amount of type III collagen than the stronger type I collagen.66 The time needed to heal the soft tissues involved in this injury must be considered prior to beginning exercises that stress the injury. Heavy lifting and contact sports should be avoided for 8 to 12 weeks.

TYPE III

Treatment of type III acromioclavicular joint sprains remains controversial. Many clinicians recommend a nonoperative approach for this type of injury, suggesting that a sling is adequate for allowing the patient to rest comfortably and heal. Use of this nonoperative technique is reported to have limited success. Cox reported improved results without support of the arm in 62% of his patients, whereas only 25% had relief after 3 to 6 weeks of immobilization and a sling.28 Surgical management of type III acromioclavicular joint sprains may result in better functional outcomes in young adults than conservative treatment; however, time for rehabilitation and rate of complications is greater in surgical treatment.⁷⁹ The treating clinician should evaluate time of season (if an athlete), functional limitations, and pain in making a recommendation of conservative or surgical treatment. Operative management of this type of injury can be summarized with the following options:

• Stabilization of clavicle to coracoid with a screw
  
• Resection of distal clavicle
  
• Transarticular acromioclavicular fixation with pins
  
• Use of coracoclavicular ligament as a substitute acromioclavicular ligament

Taft et al found superior results with coracoclavicular fixation. They found that patients with acromioclavicular fixation had a higher rate of posttraumatic arthritis than those managed with a coracoclavicular screw.¹⁵⁷

TYPES IV, V, AND VI

Types IV, V, and VI injuries require open reduction and internal fixation. Operative procedures are designed to attempt realignment of the clavicle to the scapula. The immobilization for this type of injury is longer and therefore the rehabilitation time is longer. After immobilization, the concerns are similar to those previously discussed.

Rehabilitation Progression

Early in the rehabilitation progression, the athletic trainer should be concerned with application of cold therapy and pressure for the first 24 to 48 hours to control local hemorrhage. Fitting the patient for a sling is also important to control the patient’s pain. Time in the sling depends on the severity of the injury. After the patient has been seen by a physician for differential diagnosis, the rehabilitation progression should be tailored to the type of sprain according to the diagnosis.

Types I, II, and III sprains should be handled similarly at first, with the time of progression accelerated with less severe sprains. Exercises should begin with encouraging the patient to use the involved extremity for activities of daily living and gentle ROM exercises. Return of normal ROM in the patient’s shoulder is the first objective goal. The patient can also begin isometric exercises to maintain or restore muscle function in the shoulder. These exercises can be started while the patient is in the sling. Once the sling is removed, pendulum exercises can be started to encourage movement. In type III sprains, the athletic trainer should hold off doing passive ROM exercises in the end ranges of shoulder elevation for the first 7 days. The patient should have full passive ROM by 2 to 3 weeks. Once the patient has full active ROM, a program of PRE should begin. Strengthening of the deltoid and upper trapezius muscles should be emphasized. The athletic trainer should evaluate the patient’s shoulder mechanics to identify problems with neuromuscular control and address specific deficiencies as noted. As the patient regains strength in the involved extremity, sport-specific exercises should be incorporated into the rehabilitation program. Gradual return to activity should be supervised by the patient’s coach and athletic trainer.

Surgery should be considered to type III acromioclavicular sprains that do not respond to 6 to 12 weeks of rehabilitation and pain and decreases in function are still present.²⁶ In the case of types IV, V, and VI acromioclavicular sprains, a postsurgical progression should be followed. The athletic trainer should design a program that is broken down into 4 phases of rehabilitation with the goal of returning the patient to activity as quickly as possible. Contact with the physician is important to determine the time frame in which each phase may begin as adequate timing for tissue healing must be allowed, even if the athlete is pain-free. Common surgeries for this injury include open reduction with pin or screw fixation and/or acromioplasty.

The early stage of rehabilitation should be designed with the goal of reestablishing pain-free ROM, preventing muscle atrophy, and decreasing pain and inflammation. ROM exercises may include Codman’s exercises (Figure 17-6), sawing exercise (Figure 17-7), shoulder flexor stretch (Figure 17-11), rope and pulley exercises (Figure 17-9), L-bar exercises (Figures 17-15 through 17-18), and self-capsular stretches (Figures 17-10B, 17-13, and 17-14A). Strengthening exercises in this phase may include isometrics in all of the cardinal planes and isometrics for medial and lateral rotation of the glenohumeral joint at 0 degrees of elevation (Figure 17-19).

As rehabilitation progresses, the athletic trainer has the goal of regaining and improving muscle strength, normalizing arthrokinematics, and improving neuromuscular control of the shoulder complex. Prior to advancing to this phase, the patient should have full ROM, minimal pain and tenderness, and a 4/5 manual muscle test for internal rotation, external rotation, and flexion. Initiation of isotonic PRE should begin. Shoulder medial and lateral rotation (Figures 17-37 and 17-38), shoulder flexion and abduction to 90 degrees (Figures 17-29 and 17-30), scaption (Figure 17-34), bicep curls, and triceps extensions should be included. Additionally, a program of scapular-stabilizing exercises should begin. Exercises should include Superman exercises (Figure 17-43), rhomboids exercises (Figure 17-44), shoulder shrugs (Figure 17-36), and seated push-ups (Figure 17-49). To help normalize arthrokinematics of the shoulder complex, joint mobilization techniques should be used for the glenohumeral, acromioclavicular, sternoclavicular, and scapulothoracic joints (see Figures 13-10 through 13-20). To complete this phase the patient should begin neuromuscular control exercises (Figures 17-58 through 17-65), trunk exercises, and a low-impact aerobic exercise program.

During the advanced strengthening phase of rehabilitation, the goals should be to improve strength, power, and endurance of muscles as well as to improve neuromuscular control of the shoulder complex and prepare the patient to return to sport-specific activities. Prior to advancing to this phase, the therapist should use the criteria of full pain-free ROM, no pain or tenderness, and strength of 70% compared to the uninvolved shoulder. The emphasis in this phase is on high-speed strengthening, eccentric exercises, and multiplanar motions. The patient should advance to surgical tubing exercises (Figure 17-54), plyometric exercises (Figures 17-51 through 17-57), PNF diagonal strengthening (Figures 17-20 through 17-24), and isokinetic strengthening exercises (Figures 17-66 and 17-67).

When the patient is ready to return to activity, the athletic trainer should progressively increase activities that prepare the patient for a fully functional return. An interval program of sport-specific activities should be started. Exercises from stage III should be continued. The patient should progressively increase the time of participation in sport-specific activities as tolerated. For contact and collision sport patients, the acromioclavicular joint should be protected.

Criteria for Returning to Full Activity

Prior to returning to full activity, the patient should have full ROM and no pain or tenderness. Isokinetic strength testing should meet the demands of the patient’s sport, and the patient should have successfully completed the final phase of the rehabilitation progression.

Clavicle Fractures

Pathomechanics

Clavicle fractures are one of the most common fractures in sports.¹³² The clavicle acts as a strut connecting the upper extremity to the trunk of the body. Forces acting on the clavicle are most likely to cause a fracture of the bone medial to the attachment of the coracoclavicular ligaments.⁷ Intact acromioclavicular and coracoclavicular ligaments help keep fractures nondisplaced and stabilized.

Injury Mechanism

In athletics, the mechanism for injury often depends on the sport played. The mechanism can be direct or indirect. Fractures can result from a fall on an outstretched arm, a fall or blow to the point of the shoulder, or less commonly a direct blow as in stick sports like lacrosse and hockey.^144,151

Rehabilitation Concerns

Early identification of the fracture is an important factor in rehabilitation. If stabilization occurs early, with minimal damage and irritation to the surrounding structures, the likelihood of an uncomplicated return to sports is increased. Other factors influencing the likelihood of complications are injuries to the acromioclavicular, coracoclavicular, and sternoclavicular ligaments. Typically, patients with an acute clavicle fracture will return to sports activity, with around four-fifths of all patients able to return to their preinjury level of sports activity.132 Those with displaced mid-shaft fractures treated conservatively demonstrate decreased return rates and increased return times to sport compared to those managed surgically, suggesting that some clavicle fractures may be better suited for surgical intervention.¹³² Conservative treatment for clavicle fractures includes approximation of the fracture and immobilization for 6 to 8 weeks. Most commonly a figure 8 wrap is used, with the involved arm in a sling.

When designing a rehabilitation program for a patient who has sustained a clavicle fracture, the athletic trainer should consider the function of the clavicle. The clavicle acts as a strut offering shoulder girdle stability and allowing the upper extremity to move more freely about the thorax by positioning the extremity away from the body axis.⁵⁵ Mobility of the clavicle is therefore very important to normal shoulder mechanics. Joint mobilization techniques are started immediately after the immobilization period to restore normal arthrokinematics. The clavicle also serves as an insertion point for the deltoid, upper trapezius, and pectoralis major muscles, providing stability and aiding in neuromuscular control of the shoulder complex. It is important to address these muscles with the appropriate exercises to restore normal shoulder mechanics.

Rehabilitation Progression

For the first 6 to 8 weeks, the patient is immobilized in the figure 8 brace and sling. If good approximation and healing of the fracture is occurring at 6 weeks, the patient may begin gentle isometric exercises for the upper extremity. Use of the involved extremity below 90 degrees of elevation should be encouraged to prevent muscle atrophy and excessive loss of glenohumeral ROM. After the immobilization period, the patient should begin a program to regain full active and passive ROM. Joint mobilization techniques are used to restore normal arthrokinematics (see Figures 13-10 through 13-12). The patient may continue to wear the sling for the next 3 to 4 weeks while regaining the ability to carry the arm in an appropriate posture without the figure 8 brace. The patient should begin a strengthening program using progressive resistance as ROM improves. Once full ROM is achieved, the patient should begin resisted diagonal PNF exercises and continue to increase the strength of the shoulder complex muscle, including the periscapular muscles, to enable normal neuromuscular control of the shoulder.

Criteria for Return

The patient may return to activity when the fracture is clinically united, full active and passive ROM is achieved, and the patient has the strength and neuromuscular control to meet the demands of his or her sport.

Glenohumeral Dislocations/Instabilities (Surgical vs Nonsurgical Rehabilitation)

Pathomechanics

Dislocations of the glenohumeral joint involve the temporary displacement of the humeral head from its normal position in the glenoid labral fossa. From a biomechanical perspective, the resultant force vector is directed outside the arc of contact in the glenoid fossa, creating a dislocating moment of the humeral head by pivoting about the labral rim.

Shoulder dislocations account for up to 50% of all dislocations. The inherent instability of the shoulder joint necessary for the extreme mobility of this joint makes the glenohumeral joint susceptible to dislocation. The most common kind of dislocation is that occurring anteriorly. Posterior dislocations account for only 1% to 4.3% of all shoulder dislocations. Inferior dislocations are extremely rare. Following dislocation, regaining stability can be challenging due to injury to static and dynamic stabilizers of the glenohumeral joint. Between 40% to 50% of patients with a dislocation will experience recurrent instability.122,124

In an anterior glenohumeral dislocation, the head of the humerus is forced out of its anterior capsule in an anterior direction past the glenoid labrum and then downward to rest under the coracoid process. The pathology that ensues is extensive, with torn capsular and ligamentous tissue, possibly tendinous avulsion of the rotator cuff muscles, and profuse hemorrhage. A tear or detachment of the glenoid labrum might also be present. Healing is usually slow, and the detached labrum and capsule can produce a permanent anterior defect on the glenoid labrum called a Bankart lesion. Another defect that can occur with anterior dislocation can be found on the posterior lateral aspect of the humeral head called a Hill-Sachs lesion. This is caused by compressive forces between the humeral head and the glenoid rim while the humeral head rests in the dislocated position. Additional complications can arise if the head of the humerus comes into contact with and injures the brachial nerves and vessels. Rotator cuff tears can also arise as a result of the dislocation.

Posterior dislocations can also result in significant soft tissue damage. Tears of the posterior glenoid labrum are common in posterior dislocation. A fracture of the lesser tubercle can occur if the subscapularis tendon avulses its attachment.

Glenohumeral dislocations are usually very disabling. The patient assumes an obvious disabled posture and the deformity itself is obvious. A positive sulcus sign is usually present at the time of the dislocation, and the deformity can be easily recognized on an X-ray. As detailed previously, the damage can be extensive to the soft tissue.

Injury Mechanism

When discussing the mechanism of injury for dislocations of the glenohumeral joint, it is necessary to categorize the injury as traumatic or atraumatic and anterior or posterior. An anterior dislocation of the glenohumeral joint can result from direct impact on the posterior or posterolateral aspect of the shoulder. The most common mechanism is forced abduction, external rotation, and extension that forces the humeral head out of the glenoid cavity. An arm tackle in football or rugby or abnormal forces created in executing a throw can produce a sequence of events resulting in dislocation. The injury mechanism for a posterior glenohumeral dislocation is usually forced adduction and internal rotation of the shoulder or a fall on an extended and internally rotated arm.

The 2 mechanisms described for anterior dislocation can be categorized as traumatic or atraumatic. The following acronyms have been described to summarize the 2 mechanisms.⁶⁸

Traumatic	Atraumatic
Unidirectional	Multidirectional
Bankart lesion	Bilateral involvement
Surgery required	Rehabilitation effective
	Inferior capsular shift recommended

The AMBRI group can be characterized by subluxation or dislocation episodes without trauma, resulting in a stretched capsuloligamentous complex that lacks end-range stabilizing ability. Several authors report a high rate of recurrence for dislocations, especially those in the TUBS category.^122,124

Rehabilitation Concerns

Management of shoulder dislocation depends on a number of factors that need to be identified. Mechanism, chronology, and direction of instability all need to be considered in the development of a conservatively managed rehabilitation program. No single rehabilitation program is an absolute solution for success in the treatment of a shoulder dislocation. The athletic trainer should thoroughly evaluate the injury and discuss those objective findings with the team physician. The initial concern in rehabilitation focuses on maintaining appropriate reduction of the glenohumeral joint. The patient is immobilized in a reduced position for a time, depending on the type of management used in the reduction (surgical vs nonsurgical). To date, an association between length of immobilization and rate of reoccurrence has not been established,⁵³ thus length of immobilization following subluxation and dislocation should be based on patient symptoms and tolerance to pain.

Table 17-2 Exercise Modification Per Direction of Instability

For the purpose of this section, the discussion will continue with conservative management in mind. The principles of rehabilitation, however, remain constant regardless of whether the physician’s management is surgical or nonsurgical. Surgical rehabilitation should be based on the healing time of tissue affected by the surgery. The limitations of motion in the early stages of rehabilitation should also be based on surgical fixation. It is extremely important that the athletic trainer and physician communicate prior to the start of rehabilitation. After the immobilization period, the rehabilitation program should be focused on restoring the appropriate axis of rotation for the glenohumeral joint, optimizing the stabilizing muscle’s length–tension relationship, and restoring proper neuromuscular control to the shoulder complex. In the uninjured shoulder complex with intact capsuloligamentous structures, the glenohumeral joint maintains a tight axis of rotation within the glenoid fossa. This is accomplished dynamically with complex neuromuscular control of the periscapular muscles, rotator cuff muscles, and intact passive structures of the joint. Because the extent of damage in this type of injury is variable, the exercises employed to restore these normal mechanics should also vary. As the athletic trainer helps the patient regain full ROM, a safe zone of positioning should be followed. Starting in the plane of the scapula is safe because the axis of rotation for forces acting on the joint fall in the center of this plane. The least provocative position is somewhere between 20 and 55 degrees of scapular plane abduction. Keeping the humerus below 55 degrees prevents subacromial impingement, while avoiding full adduction minimizes excessive tension across the supraspinatus/coracohumeral and/or capsuloligamentous complex. As ROM improves, the therapist should progress the exercise program into positions outside the safe zone, accommodating the demands that the patient will need to meet. Specific strengthening exercises should be given to address the muscles of the shoulder complex responsible for maintaining the axis of rotation, such as the supraspinatus and rotator cuff muscles. The periscapular muscles should also be addressed to provide the rotator cuff muscles with their optimal length–tension relationship for more efficient usage. In the later stages of rehabilitation, neuromuscular control exercises are incorporated with sport-specific exercises to prepare the patient for return to activity.68

Rehabilitation Progression

The first step in a successful rehabilitation program is the removal of the patient from activities that may put the patient at risk for reinjury to the glenohumeral joint. A reasonable time frame for return to activity is about 12 weeks, with unrestricted activity coming closer to 20 weeks. This is variable, depending on the extent of soft tissue damage and the type of intervention chosen by the patient and physician. Some exercises previously used by the patient might produce undesired forces on noncontractile tissues and need to be modified to be performed safely. Push-ups, pull-downs, and the bench press are performed with the hands in close and avoiding the last 10 to 20 degrees of shoulder extension (Figures 17-25, 17-46, and 17-48). Pull-downs and military presses are performed with wide bars and machines are kept in front rather than behind the head. Supine fly exercises (Figure 17-32) are limited to 30 degrees in the coronal plane while maintaining glenohumeral internal rotation. Table 17-2 provides further modifications dependent on directional instability.¹⁷⁵

During phase 1, the patient is immobilized in a sling. This lasts for up to 3 weeks with first-time dislocations. The goal of this phase is to limit the inflammatory process, decrease pain, and retard muscle atrophy. Passive ROM exercises can be initiated along with low-grade joint mobilization techniques to encourage relaxation of the shoulder musculature. Isometric exercises are also started. The patient begins with submaximal contractions and increases to maximal contractions for as long as 8 seconds. The protective phase is a good time to initiate a scapulothoracic exercise program, avoiding elevated positions of the upper extremity that put stability at risk. Patients should begin an aerobic training regimen with the lower extremity, such as stationary biking.

Phase 2 begins after the patient has been removed from the sling. This phase lasts from 3 to 8 weeks post injury and focuses on full return of active ROM. The program begins with the use of an L-bar performing active assisted ROM (Figures 17-15 through 17-18). Manual therapy techniques can also begin using PNF techniques to help reestablish neuromuscular control (see Figures 12-3 through 12-10). Exercises with the hands on the ground can help begin strengthening the scapular stabilizers more aggressively. These exercises should begin on a stable surface like a table, progressing the amount of weightbearing by advancing from the table to the ground (Figure 17-58). Advancing to a less stable surface like a BAPS board (Figure 17-61) or stability ball (Figure 17-62) will also help reestablish neuromuscular control.

At 6 to 12 weeks, the athletic trainer should gradually enter phase 3 of the rehabilitation progression. The goal of this phase is to restore normal strength and neuromuscular control. Prophylactic stretching is done, as full ROM should already be present. Scapular and rotator cuff exercises should focus on strength and endurance. Weightbearing exercises should be made more challenging by adding motion to the demands of the stabilization. Scapular exercises should be performed in the weight room with guidance from the athletic trainer to meet the challenge of the patient’s strength. Weight shifting on a fitter (Figure 17-60) and push-ups on a stability ball (Figure 17-50) for endurance are started. Strengthening exercises progress from PRE to plyometric. Rotator cuff exercises using surgical tubing with emphasis on eccentrics are added. Progression to multiangle exercises and sport-specific positioning is started. The Body Blade is a good rehabilitation tool for this phase (Figure 17-65), progressing from static to dynamic stabilization and single-position to multiplanar dynamic exercises.

Phase 4 is the functional progression. Patients are gradually returned to their sport with interval training and progressive activity increasing the demands on endurance and stability. This can last as long as 20 weeks, depending on the patient’s shoulder strength, lack of pain, and ability to protect the involved shoulder. The physician should be consulted prior to full return to activity.

Criteria for Return to Activity

At 20 to 26 weeks, the patient should be ready for return to activity. This decision should be based on (a) full pain-free ROM, (b) normal shoulder strength, (c) pain-free sport-specific activities, and (d) ability to protect the patient’s shoulder from reinjury. Some athletic trainers and physicians like the patient to use a protective shoulder harness during participation.

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