REHABILITATION OF SHOULDERS

Rehabilitation of Shoulders

Benjamin D. Rubin

The primary goal of functional rehabilitation is to reestablish normal function rather than resolve symptoms. This is accomplished by restoring normal anatomy, physiology, and biomechanics to the glenohumeral joint and upper quarter. A team approach, involving open communication between the physician, the therapist, and the patient, is critical to accomplishing this goal. The physician must provide: (a) an accurate core diagnosis that explains the symptoms; (b) an operative report (when available) describing the quality of tissue and repair; (c) the expected progression; and (d) the patient’s goals regarding return to activities.

The guidelines outlined below relate to the unstable shoulder, which has been chosen as the model for this discussion. The following program is to be used as a guideline with modifications as necessary depending on the patient’s physiology, personality, and activity level; the specific injury and pathology; the type and quality of repair when surgery is performed; and physical therapist preference. Exercises and techniques are listed in the approximate order in which they are added during the course of each phase of rehabilitation. The recommendations with regard to strengthening are not intended to be an exhaustive list of specific exercises, but guidelines to direct the rehabilitation process.

General Rehabilitation Guidelines

1. Range of motion

a. The goal is to restore normal proprioception and movement patterns.

b. The usual progression is passive, then active assisted, then active range of motion.

2. Exercise

a. Should be relatively pain-free. If an exercise causes an increase in pain, it is most likely being done prematurely or incorrectly.

b. Learning speed and neuromuscular control differ in patients. Look for steady progress rather than meeting deadlines.

c. Do a little bit frequently rather than overloading muscle groups.

d. Quality is more important than quantity. Stop the exercise when fatigue causes an alteration in normal mechanics. Focus on good control rather than a specified number of repetitions. Exercise tolerance on a given day may vary.

e. The usual progression is isometric, then eccentric, then concentric. Closed chain exercises precede open chain.

f. Begin with submaximal and progress to maximal effort.

g. Train muscle groups to function in a coordinated, synchronous pattern rather than training individual muscles.

h. Restore dynamic stability.

Scapular Mechanics

1. Roles of the scapula

a. Provide an anatomic and kinematic link between the trunk and arm

b. Provide a stable socket for the humeral head

c. Allow acromial elevation

2. Scapulohumeral rhythm

a. The smooth, coordinated, synchronous interaction between the acromioclavicular, sternoclavicular, scapulothoracic, and glenohumeral joints

b. Allows mobility without compromising stability

3. Scapular dyskinesis

a. Primary causes

i. Neurologic injury, especially to the long thoracic or spinal accessory nerves

ii. Force couple imbalances—dyssynchronous firing patterns lead to abnormal scapular mobility, which results is increased stress on the capsule and rotator cuff

iii. Proximal kinetic chain weakness

b. Secondary causes

i. Pain from intraarticular or subacromial pathology causes muscle inhibition (especially the serratus anterior and lower trapezius), with subsequent loss of muscle activation and coordination.

ii. Altered ability to position the scapula properly.

iii. This usually occurs early in the pathologic process.

iv. This is observed in 65 to 100% of patients with instability or rotator cuff tears.

c. Differentiating primary from secondary dyskinesis

i. This may be difficult.

ii. This process is assisted by clinical evaluation, selective injections, and physical therapy.

iii. In chronic conditions, there may be overlap.

Guidelines for Functional Rehabilitation of Shoulders

1. Evaluate and correct postural alignment.

2. Correct lumbopelvic, thoracolumbar, scapulothoracic, and cervical dysfunctions.

3. Clear soft tissue restrictions, especially pectoralis major and minor, and subscapularis.

4. Scapulothoracic rehabilitation establishes proximal stability before distal mobility. It is essential to focus on scapular position and control throughout the program to control pain, decrease subacromial impingement, and facilitate proper muscle (re)education.

5. Reestablish force couples for scapular stabilization and elevation.

6. Closed chain exercises facilitate glenohumeral compression, allowing for proprioceptive feedback and rotator cuff muscle coactivation in physiologic patterns to reestablish normal scapulohumeral rhythm.

7. Begin aerobic conditioning (e.g., stationary bike, treadmill, etc.) when the patient is ready and advance as tolerated. Consider stair climbing at 3 to 4 weeks and jogging at 10 to 12 weeks postoperatively, as the patient’s own tolerance allows.

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