Activity modifications/rest

• •
  

  Most patients have already begun to modify their activities based upon pain and symptoms. However, if their occupation or hobbies require overhead repetitive movements work restrictions or a discussion on specific modifications may be helpful. In most circumstances this will be combined with additional treatment.

Physical therapy

• •
  

  Helpful in restoring full and symmetric motion, preventing muscle atrophy, and improving pain. In the event of a rotator cuff tear, therapy can still be helpful in achieving full range of motion prior to any surgical intervention to avoid postoperative complication of adhesive capsulitis.

Nonsteroidal antiinflammatory medicines

Patients with evidence of stage I or stage II impingement are offered an antiinflammatory medicine.

Subacromial injection

• •
  

  Diagnostic injection with anesthetic can help to assess strength in an acutely inflamed shoulder that is examining with weakness. An injection with corticosteroid and anesthetic can be diagnostic as well as therapeutic. An injection is not indicated in the presence of a rotator cuff tear and should not be used indiscriminately. Due to damaging effects of atrophy and decreased quality of tissue, no more than three injections are recommended and they should be spaced at least three months apart.

Length of symptoms and amount of dysfunction

Age of patient

Comorbidities affecting anesthesia clearance

The patient’s desire to return to sports/hobbies or a physically demanding profession

In the presence of a rotator cuff tear the amount of atrophy or fatty infiltration of the muscle belly, tendon retraction and elevation of the humeral head

Coracoacromial arch morphology

Symptomatic acromioclavicular arthrosis

Concomitant pathology including involvement of biceps tendon and/or labrum

Arthroscopic versus open rotator cuff repair and distal clavicle resection

Benefit of tendon transfers for irreparable tendon tears

Risks and benefits of concomitant versus staged surgery when there is a component of adhesive capsulitis associated with rotator cuff tendon tear

Type of fixation for repair (anchor configuration, stitch configuration, anchor material, etc.)

Techniques used are evaluation based.

• •
  

  Glenohumeral joint mobilizations are

  
  
  
  
  • •
    

    Empty end feels—Use grades I and II mobilizations for pain control and relaxation

    
    
  • •
    

    Firm capsular end feels—Use grades III and IV to address motion deficits

  
  
  
  
• •
  

  Thoracic spine mobilization/manipulation is often necessary and should be included in this phase in patients who demonstrate increased thoracic kyphosis. Thoracic kyphosis causes an anterior tilt of the scapula, which reduces the subacromial space.

  
  
  
  
  • •
    

    Thoracic spine extension exercises/flexibility exercises should be encouraged as part of a home excercise program

    
    
  • •
    

    Patient education on proper sitting posture to maintain thoracic spine extension

  
  

Some research supports the use of deep friction massage to the rotator cuff tendon insertion and radial nerve stretching for pain management in patients with impingement syndromes.

Stretching and flexibility exercise prescription is evaluation based. Can include exercises for flexion, scaption, internal rotation and external rotation.

Manual PROM, stretching and exercise prescription of stretching/flexibility for glenohumeral internal and external rotation should be ONLY done when patient has loss of total shoulder joint motion (external rotation ROM plus internal rotation ROM) compared to contralateral side. Note: IR/ER measurements should be done in the scapular plane at 90° abduction avoiding scapular compensation. Place hand on coracoid to feel for compensation ( Figure 6-6 ).

Technique for measuring glenohumeral joint internal rotation with scapular stabilization at 90° abduction.

Stretching/flexibility exercises should be modified to limit pain or avoid subacromial impingement with endrange stretching.

• •
  

  Keep in mind that glenohumeral internal rotation deficiency (GIRD) or loss of internal rotation and increased external rotation caused by humeral retroversion in overhead athletes is normal and provided the patient does not lack total arc of motion, internal rotation should not be stretched.

  
  
• •
  

  Note end feel of ROM to determine if the patient truly has tightness. An empty end feel is limited by pain, and stretching and aggressive joint mobilizations are not necessarily appropriate. Address capsular end feel and treat firm capsular end feels with grades III and IV joint mobilizations or firm muscular end feels with stretching. Oftentimes patients with motion loss have tightness of both noncontractile tissue (i.e., capsule, fascia) and contractile tissue (i.e., musculo-tendon) unit and both joint mobilizations and stretching exercises are appropriate.

  
  
• •
  

  Gentle range of motion exercises to address motion deficits. Motion exercises should be only done in a manner that limits symptoms and may need to be done initially as passive or active-assisted motions.

  
  
• •
  

  Pure abduction usually leads to increased symptoms and is usually avoided in the early phases. Stretching should be done in the scapular plane to avoid impingement of the structures in the subacromial space. (This may require a towel roll under elbow to stretch internal and external rotation.)

  
  
• •
  

  Stretching, particularly the posterior capsule, is often necessary in patients presenting with glenohumeral joint hypomobility and should be made a part of the HEP in this phase. There is little evidence supporting frequency and duration of flexibility exercises, but common practice encourages 3 times 60-second stretches for each exercise, 2 to 3 times per day.

  
  
  
  
  • •
    

    Stretches may include the posterior capsule sleeper’s stretch ( Figure 6-7 ), the cross body stretch ( Figure 6-8 ), the rope IR stretch ( Figure 6-9 ), the T-bar ER stretch and passive/active assisted flexion stretch ( Figure 6-10 )

    
    

    
    

    
    

    

    
    

    
    

    Posterior capsule/sleeper stretch to improve internal rotation range of motion and posterior capsule tightness.

    
    

    
    

    
    

    

    
    

    
    

    Cross arm stretch to improve posterior capsule tightness.

    
    

    
    

    
    

    

    
    

    
    

    Internal rotation stretch with hand behind back using a rope and handle to improve internal rotation range of motion.

    
    

    
    

    
    

    

    
    

    
    

    Flexion AAROM and stretching exercise to improve flexion range of motion.

    
    

  
  

Address flexibility of lower extremities, trunk and contralateral arm and prescribe a program to be done 3 times a week.

Lower extremity strengthening and cardiovascular exercise should continue and be encouraged especially in athletes planning to return to sport. Typically, strengthening and cardiovascular exercise for an athlete should be done 3 times a week at a minimum.

Choices of strengthening exercises should be made on an evaluation-based approach.

Scapular dyskinesis

• •
  

  Defined as alterations in dynamic scapular motion patterns

  
  
• •
  

  Alterations of resting position may also exist and need to be addressed

  
  
• •
  

  Three axes of rotation of the scapula provide three individual motions:

  
  
  
  
  • •
    

    Upward/downward rotation about a horizontal axis perpendicular to the plane of the scapula, near the center of the scapula

    
    
  • •
    

    Internal/external rotation about a vertical axis through the plane of the scapula

    
    
  • •
    

    Anterior/posterior tilt about a horizontal axis through the scapula

  
  
  
  
• •
  

  The most common scapular dyskinesis patterns involve a downward rotation, internal rotation, and anterior tilt of the scapula. Lack of proprioception and delayed or decreased activity of the serratus anterior and lower trapezius are thought to contribute to scapular dyskinesis.

  
  
• •
  

  Some degree of scapular dyskinesis is evident in the majority of injured shoulders.

  
  
• •
  

  The physical examination should determine whether an altered resting position and scapular dyskinesis exist.

  
  
• •
  

  Restoring normal scapular position and control is a vital portion of a successful rehabilitation program for the shoulder joint.

  
  
  
  
  • •
    

    Identify if the scapular dyskinesis is a result of poor neuromuscular recruitment or decreased muscle strength.

    
    
  • •
    

    Phase 1 of scapular muscle training involves restoring normal resting position and proprioception exercises with the arm at the side.

    
    
  • •
    

    Phase 2 focuses on muscle control and normalizing muscle imbalances. Typically, the upper trapezius (UT) is overactive in comparison to the lower trapezius (LT), middle trapezius (MT) and serratus anterior (SA). Exercises that minimize the UT/LT, UT/MT and UT/SA ratios by selectively activating the less active muscle are ideal for this phase.

    
    
  • •
    

    Phase 3 of scapular muscle training includes general scapular muscle strengthening.

  
  
  
  
• •
  

  Exercises appropriate for this phase of rotator cuff impingement:

  
  
  
  
  • •
    

    Prone shoulder extension with external rotation. Focus on posterior tilting scapula and middle trap recruitment. Work endurance by encouraging 10-second static hold with each repetition and repeat 10 times; 1 to 2 times per day ( Figure 6-11 ).

    
    

    
    

    
    

    

    
    

    
    

    Prone extension with external rotation for middle trapezius and lower trapezius neuromuscular reeducation, strengthening and restoration of trapezius muscle imbalances.

    
    
    
    
  • •
    

    Side-lying external rotation with rolled towel under arm in a pain-free range of motion. Perform 3 sets of 10 to 15 repetitions. Perform 1 time per day. ( Figure 6-12 ).

    
    

    
    

    
    

    

    
    

    
    

    Side-lying external rotation with dumbbell.

    
    
    
    
  • •
    

    Scapular orientation exercises to focus on correcting faulty resting position should be performed several times per day to make it habit.

  
  

Manual therapy techniques should continue until patient has full, nonpainful ROM.

Aggressive endrange joint mobilizations for patients with hypomobility may be required

Continue as in Phase I

To restore normal, pain-free AROM

Stretching/flexibility exercises should continue until patient has full, nonpainful ROM.

Continue exercises from Phase I as needed. Emphasis should be on self-capsular stretching and HEP during this phase.

Once patient achieves this pain-free ROM, stretching/flexibility exercises should continue for maintenance of ROM and should be encouraged as part of HEP.

Progressive scapular stabilizer exercises that address patients’ neuromuscular control deficits, weaknesses, or muscular imbalances.

• •
  

  Exercises focusing on lower trap facilitation and strengthening with low upper trap/lower trap ratio

  
  
  
  
  • •
    

    Forward flexion in side-lying with dumbbell.

    
    
  • •
    

    Prone horizontal abduction with external rotation. Add a dumbbell when appropriate.

  
  
  
  
• •
  

  Exercises focusing on middle trap strengthening with low upper trap/middle trap ratio

  
  
  
  
  • •
    

    Prone extension with external rotation with dumbbells.

  
  
  
  
• •
  

  Wall pushup plus for serratus anterior ( Figure 6-13 )

  
  

  
  

  
  

  

  
  

  
  

  Wall pushup for serratus anterior strengthening.

  
  

Progressive rotator cuff isotonics. Exercise prescription should be 3 sets of 15 to 20 reps to create a fatigue response as these muscles are designed to be fatigue resistant, and restoring muscular endurance is important for shoulder stabilization with repetitive overhead movements.

• •
  

  Progress side-lying external rotation with dumbbell and towel roll under elbow

  
  
• •
  

  Begin standing Thera-Band internal and external rotation ( Figures 6-14 and 6-15 )

  
  

  
  

  
  

  

  
  

  
  

  Thera-Band internal rotation at 0° abduction with towel roll to increase the subacromial space.

  
  

  
  

  
  

  

  
  

  
  

  Thera-Band external rotation 0° abduction with towel roll to increase subacromial space and optimize infraspinatus muscle activity.

  
  

Once patient can demonstrate good scapular control and minimal fatigue with 3 full sets of 20 of the progressive scapular stabilizer exercises and progressive rotator cuff isotonics, progress to the following exercises. The patient must be able to perform the following exercise with perfect scapular control. If the patient cannot demonstrate perfect control, the patient may need to begin with AROM with or without gravity.

• •
  

  Standing and/or prone full can scaption with dumbbell for supraspinatus

  
  
• •
  

  Prone external rotation at 90° abduction with dumbbell for infraspinatus

Final progression includes the start of multiple angle submaximal strengthening such as D2 flexion PNF with Thera-Band with good scapular control ( Figure 6-16 ).

Thera-Band diagonal 2 flexion PNF for combined glenohumeral joint flexion, external rotation, and horizontal abduction and scapular upward rotation.

Muscle activation/strengthening of lower trap, middle trap, and serratus anterior muscles to improve scapular mechanics/upward rotation with overhead activities.

Strengthening of the rotator cuff muscles are necessary to improve or normalize glenohumeral joint stability and arthrokinematics. Since impingement syndrome often leads to specific weakening of the supraspinatus and infraspinatus muscles caused by impingement on their tendons in the subacromial space, special attention should be given to these muscles.

Begin with rhythmic stabilization—3 sets for 30 to 60 seconds

Progress to higher level closed kinetic chain (CKC) stabilization exercises—3 sets for 30 to 60 seconds

• •
  

  Stabilization exercises using small medicine ball against the wall with manual perturbations ( Figure 6-17 ).

  
  

  
  

  
  

  

  
  

  
  

  Rhythmic stabilization with medicine ball against the wall at 90° abduction using the scapular plane. Perturbations applied until fatigue.

  
  

Continue as in Phases I and II for maintenance of ROM as needed.

Continue as in Phases I and II for maintenance of ROM as needed.

Continue as in Phases I and II for maintenance of ROM as needed.

Progress rotator cuff isotonics

• •
  

  Increase weight or resistance of side-lying ER, Thera-Band IR/ER at neutral but keep repetitions high (3 sets of 10 or more repetitions, 3 times a week) as the rotator cuff is an endurance group of muscles.

  
  
• •
  

  Progress to Thera-Band IR/ER at 90° abduction—3 sets of 10 or more repetitions. Do 3 times a week.

  
  
• •
  

  Prone horizontal abduction in 135° abduction with external rotation—10 times 10-second holds, once a day

Progress serratus anterior strengthening to quadruped or plank position—3 times 10 reps; 3 times a week

Progress scapular stabilizer strengthening exercises

• •
  

  High and low rows for upper trap, middle trap and lower trap strengthening—3 times 10 reps; 3 times a week

  
  
• •
  

  Military press for upper trap strengthening—3 times 10 reps; 3 times a week

Progression of exercises should be towards doing exercises at 90° abduction in scapular plane especially when preparing an athlete to return to overhead sports.

Stabilization on wobbleboard in quadruped or plank position with manual perturbations—3 times 30-second holds; 3 times a week

Perturbations throughout range with many exercises (D2 flexion, ER/IR with Thera-Band, etc.)

Stabilization on stability ball—3 times 30-second holds; 3 times a week

Progress rotator cuff endurance exercises

• •
  

  Thera-Band external rotation stabilization exercise in 90°/90° position and manual perturbations by therapist—3 times 30- to 60-second holds with good scapular positioning.

  
  
• •
  

  Isokinetic internal and external rotation strengthening if available

Initiate upper extremity plyometrics late in this phase of rehab only if patient plans to return to overhead athletics/vocation.

• •
  

  Trampoline toss and catch with light medicine ball—shoulder in 90°/90° position ( Figure 6-20 )

  
  

  
  

  
  

  

  
  

  
  

  Medicine ball toss using rebounder for upper extremity plyometric training.

  
  
  
  
• •
  

  Supine catch and toss with medicine ball with shoulder in 90°/90° position

  
  
• •
  

  Eccentric internal and external rotation TB exercises with medicine ball or Thera-Band focusing on both cocking and follow-through phases of throwing/overhead sports

Regional anesthesia can create issues with rebound pain and other unique complications to this anesthetic

Ancillary procedures performed, such as labral or rotator cuff repair, may impose restrictions on early mobilization.

If case is performed open, additional restrictions may apply to protect from injury to the attachment of the deltoid.

Codman’s Pendulum exercises are generally adequate

Exercises for hand, wrist and elbow can be initiated

Stationary biking can begin immediately after surgery

LE strength training with machines

Treadmill walking in sling as tolerated

Patients are instructed in active-assisted ROM exercises with a pulley and stick ( Figure 6-24 )

Use of pulleys to improved external rotation.

These are to be performed several times a day

Exercises for hand, wrist, and elbow to continue

Passive stretching to be avoided

Done as needed, primarily for patients having trouble with ROM. If needed, a prescription for 1 to 2 times per week normally will start at 3 weeks if not improving. Less than 20% of patients should need help.

Pulley and wand exercises continue, with table slides, and wall walking exercises. All ROM exercises are done for 3 minutes 3 times per day. ROM work usually lasts for 1 to 2 months.

Passive stretching to continue if indicated

Coaches and trainers can be helpful in assessing specific sport rehab issues

Although no hard and fast rules apply, most patients without appropriate supervision return too soon, and reinjure or inflame previously injured or operated structures

The initial sport-specific concepts to be addressed in this program are to make sure lower extremity flexibility and spinal mobility are maintained or improved. The exercises and manual therapy skills to be initiated are determined through the evaluation process described above.

Specific techniques used to address the posterior chain restrictions include:

• •
  

  Hamstring progressions in a True Stretch device ( Figure 6-28 ).

  
  

  
  

  
  

  

  
  

  
  

  Hamstring progressions in a True Stretch device during Phase I.

  
  
  
  
• •
  

  In addition to the athlete performing these motions in the True Stretch, the therapist can assist in providing additional stability or manual contacts to address specific limitations ( Figure 6-29 ).

  
  

  
  

  
  

  

  
  

  
  

  Therapist providing additional stability and manual contact for athlete while in True Stretch device during Phase I.

  
  
  
  
• •
  

  Furthermore, as part of the regular shoulder stretch routine, a general spinal stretch can be included ( Figure 6-30 ).

  
  

  
  

  
  

  

  
  

  
  

  General spinal stretch during Phase I.

  
  

Typical limitations seen in the overhead athlete include, but are not limited to, posterior chain myofascia, hip internal and external rotation, and spinal motion in positions of side bending and rotation.

It is important to maximize functional range of motion for baseball. However with the progression of mobility that is created from these activities, it will be important to perform strengthening within the newly gained motions. As stated by Gary Gray, “do not create mobility without sufficient stability”.

With the mobility program in place, exercises to include multiplanar actions and core stability need to be initiated. There are several options for exercises in this area with many modifications that can be made, limited only by the imagination of the therapist. Some particular concepts that are beneficial are multiplanar lunges with progressions of upper body and spinal movements. Even within these simple exercises, there are endless options of progressions. It is important that the lunges are performed in each plane and that one progression is the addition of either bilateral overhead flexion ( Figure 6-31 ) or opposite lunge side rotations ( Figure 6-32 ). These types of exercises involve multiple, coordinated movements, and special attention should be paid to activation of the core/transverse abdominis muscles during their completion by the athlete.

Bilateral overhead flexion while lunging during Phase I.

Opposite lunge side rotation while lunging during Phase I.

Often pitching is considered to be an endurance activity that has inspired many to advise their athletes to complete long distance running. However, the activity of a starting pitcher is an interval activity. It is composed of an average of 15 to 17 pitches in an inning followed by a rest period of approximately 5 to 10 minutes.

Therefore, it appears to be more appropriate to progress toward interval training as the athlete approaches return to game situations.

Lastly within this program is the most functional activity of long toss and pitching. The progression from long tossing to pitching on the mound is the paramount exercise of the entire rehabilitation program.

It is crucial that the athlete is reevaluated prior to initiating a throwing program to ensure that the athlete is ready for this phase. Once it has been determined that a throwing program can be initiated, the trainer or therapist will need to consider the number of throws, distance, intensity, and frequency of the program.

There are many well-documented throwing programs and there is no research indicating one program is better than another. Therefore, the following program is a guideline, identifying important considerations as the athlete progresses in the throwing program.

Manual therapy in Phase I is indicated if there is palpable muscle spasm, tightness, and point tenderness to anterior, posterior, superior, and inferior structures of the glenohumeral joint.

Manual therapy techniques to include contract/relax PNF and muscle energy. The authors have found better results with using contract-relax techniques during both self-stretching and therapist-assisted stretching versus passive stretching alone.

Begin gentle mobilization of posterior and inferior capsule if patient has tight posterior capsule and/or restrictive inferior glenohumeral ligament complex. Use manual therapy for the scapulothoracic joint, lumbar, thoracic, cervical spine, and pelvis if range of motion is limited and lacks necessary mobility.

Soft tissue massage/mobilizations, IASTM (instrumental assisted soft tissue mobilization), and trigger point dry needling are all indicated to reduce spasm, tightness, reset muscle tendon units, and improve joint restrictions. Cross friction massage is indicated for biceps tendon and teres minor tenderness/tendonitis which are common secondary side effects of internal impingement.

Other soft tissue therapy techniques include using foam rolls, myofascial/lacrosse balls, and massage sticks. These are all also effective objective measurements of effectiveness and produce increased ROM and decreased pain level.

This does not need to be a “passive” treatment. Be sure to include active movement while using these tools. Moving the joint or contracting the muscle while applying the pressure of the modality will educate the patient as to where there are soft tissue restrictions, muscle spasm/tightness, as well as trigger points. This “active” approach is effective while working on the pec minor, rhomboids, and posterior cuff (taking the shoulder through flexion, IR/ER, and abduct), as well as deep soft tissue structures in the hip (taking it through IR/ER and flexion).

The common muscle tendon units/soft tissue that tend to be hypomobile lack pliability and/or are joints that lack mobility with internal impingement, such as pectoralis minor, levator scapulae, scalenes, upper trap, teres minor/infraspinatus, posterior capsule, scapula-thoracic joint, thoracic spine, and contralateral hip.

Be sure to evaluate horizontal adduction, internal rotation, and the sleeper stretch position ( Figure 6-43 ) bilaterally. While looking at horizontal adduction be sure the scapula is immobilized and in a neutral position (not retracted or protracted). The scapula needs to be fixed against the thorax before horizontally adducting the humerus.

Sleep stretch at 90°.

The intent of treatment during this phase is to address any and all soft tissue restrictions surrounding the shoulder and throughout the kinetic chain.

Muscles that when tight affect, or can contribute to, scapular dyskinesis:

• •
  

  Pectoralis minor

  
  
• •
  

  Levator scapulae

  
  
• •
  

  Upper trapezius

  
  
• •
  

  Infraspinatus/teres minor

  
  
• •
  

  Latissimus dorsi

Techniques include, but are not limited to, if indicated:

• •
  

  Inferior and posterior glides during horizontal adduction and internal rotation of the humerus on the glenoid (low grade end range mobilization glides; performed by therapist)

  
  
• •
  

  Side-lying horizontal adduction stretch (self-stretch)

  
  
• •
  

  Standing with scapula pinned against wall; horizontally adduct humerus (self-stretch)

  
  
• •
  

  Standing with scapula pinned against wall; internally rotate humerus with shoulder abducted at 70° and at 90° (self-stretch)

  
  
• •
  

  Supine horizontal adduction stretch (therapist assisted)

  
  
• •
  

  Sleeper stretch/modified sleeper stretch at 70°, 90° and 110° (self and therapist assisted)

If there is any anterior or subacromial pain while performing the sleeper stretch, modify the position by performing 1), 2) and/or 3), as the stretch should only be felt in the posterior and posteriolateral shoulder:

• 1)
  

  Rotate torso away from elbow 10° to 20° then reattempt stretch.

  
  
• 2)
  

  Increase the angle of the elbow from 90° out to 120° to 135°.

  
  
• 3)
  

  Lower position of humerus from 90° abducted to 50° to 70°.

  
  
• •
  

  Corner stretch (self-stretch) ( Figure 6-44 )

  
  

  
  

  
  

  

  
  

  
  

  Corner stretch.

  
  
  
  
• •
  

  Doorway pectoralis major/pectoralis minor stretch (self-stretch)

  
  
• •
  

  Pectoralis minor on foam roll stretch (self and assisted technique)

  
  
• •
  

  Side-lying, supine, and prone flexion stretch (therapist-assisted)

  
  
• •
  

  Side-lying on foam roll and actively flexing and extending shoulder ( Figure 6-45 )

  
  

  
  

  
  

  

  
  

  
  

  Side-lying on foam roller.

  
  
  
  
• •
  

  Standing shoulder extension (self-stretch)

  
  
• •
  

  Supine shoulder extension (therapist assisted)

  
  
• •
  

  Backscratch/Apley’s stretch (self-stretch with Thera-Band or towel)

  
  
• •
  

  Subscapularis release (therapist assisted)

  
  
• •
  

  Standing latissimus/thoracolumbar fascia stretch

  
  
• •
  

  Supine angular (diagonal) with rotation stretches (therapist assisted)

Aerobic/cardiovascular conditioning to begin right away, however running should not begin until full pain-free range of motion in the shoulder is achieved

Improve postural awareness

Address SICK scapula and scapula dyskinesis if present

• •
  

  Initiate activity of the serratus anterior, rhomboids, and mid-lower trapezius

  
  
• •
  

  Low row

  
  
• •
  

  Active assistive shoulder flexion and in scaption with cane, pulley, UE Ranger, tubing, or cable

  
  
• •
  

  Sternal lift: While seated or standing, on exhalation, force sternum toward ceiling while performing scapular retraction and depression. Hold 5 seconds and return to normal resting position.

  
  
• •
  

  Shoulder dump: While standing in split stance (normal stride length distance), slowly perform a throwing motion (without a ball or other object) emphasizing depression and retraction of scapula when torso is upright, and performing elevation and protraction of scapula when torso is flexed and rotated over forward stride leg; then reverse the exercise slowly. (Arm can remain at side or can begin in abducted/externally rotated position depending on symptoms of patient.)

Functional core stabilization exercises

• •
  

  Pelvic tilts

  
  
• •
  

  Partial crunches

  
  
• •
  

  Bridging ( Figures 6-46 and 6-47 )/single leg bridge ( Figure 6-48 )/bridge marching

  
  

  
  

  
  

  

  
  

  
  

  Double leg bridge.

  
  

  
  

  
  

  

  
  

  
  

  Double leg bridge with leg extension.

  
  

  
  

  
  

  

  
  

  
  

  Single leg bridge.

  
  
  
  
• •
  

  Quadruped (alternate arms, alternate legs, alternate arms and legs) ( Figure 6-49 )

  
  

  
  

  
  

  

  
  

  
  

  Quadruped diagonals. A, Start. B, Finish.

  
  
  
  
• •
  

  Dead bugs (alternate arms, alternate legs, alternate arms and legs)

  
  
• •
  

  Supermans

  
  
• •
  

  Physio ball wall squats

Evaluate for and treat deep neck flexor inhibition (may need tissue work on suboccipitals, cervical extensors, and scalenes)

• •
  

  Supine active chin tuck

  
  
• •
  

  Supine cervical flexion

Teach diaphragmatic/belly breathing

Dynamic lower extremity exercises

• •
  

  Body weight squats

  
  
• •
  

  Lunges (in the sagittal, frontal, and transverse planes)

  
  
• •
  

  Step-ups

  
  
• •
  

  Lateral step-ups

  
  
• •
  

  Step-downs

  
  
• •
  

  Trendelenburg exercise

  
  
• •
  

  Thera-Band walking (forward, backward, side-step)

  
  
• •
  

  Romanian deadlift (RDL) (body weight only) ( Figure 6-50 )

  
  

  
  

  
  

  

  
  

  
  

  Deadlift. A, Start. B, Finish.

  
  
  
  
• •
  

  Single leg RDL

  
  
• •
  

  Good morning exercise (body weight only)

  
  
• •
  

  Single-leg excursions (in the sagittal, frontal, and transverse planes)

  
  
• •
  

  Calf exercises

  
  
• •
  

  Hiking/incline on treadmill

All exercises and stretches should be done pain free. If the patient experiences soreness and/or stiffness in the injured shoulder, these side effects from exercise should resolve within 24 to 48 hours.

If they do not, then the clinician needs to reevaluate the exercise, treatment, and recovery programs of the patient as well as the quality of the reinforcement, movement, and mechanics when working on posture and scapular control.

It is critical to achieve good scapular control by minimizing scapular dyskinesis during overhead ROM before increasing volume and intensity of strength training, or the underlying issue of scapular dyskinesis and poor scapular control will either slow the athlete’s return to play or will significantly increase the athlete’s predisposition to reinjury.

As part of the muscle reeducation process, the patient needs to learn to recruit proximal musculature (trunk/core/pelvis/hip) before recruiting distally (extremities). The purpose is to improve motor control.

Avoid hyper-horizontal abduction, ER at 90/90 and ER above 90 ABD, and avoid any reproduction of symptoms.

Using proprioceptive neuromuscular facilitation (PNF) for the scapula, manually cue the scapula to elevate/depress, upwardly rotate/downwardly rotate, retract/protract.

These activities are advisable and critical as soon as an axial load or perturbations can be performed without pain.

Performing upper and lower extremity proprioception and balance exercises will activate, improve, and control muscle patterns which in turn will improve postural and neuromuscular control.

They include, but are not limited to, single-leg stance on contralateral leg and single-leg stance on ipsilateral leg (eyes open and progress to eyes closed).

If more challenge is needed, add upper extremity row and scapular retraction with tubing during SL stance.

Kneeling, half-kneeling or standing with hand of injured arm on physio ball on floor or against wall doing up-and-down, left-and-right movement patterns, circles, rhythmic stabilization, and perturbations.

Quadruped weight shifts, quadruped with hand of injured arm on ball or wobble board (all exercises must not elicit, reproduce pain, or compromise good scapular/postural position).

Upper extremity sensorimotor exercises also include lying supine and balancing an object such as a kettlebell or dumbbell in the hand of injured arm. Be sure to “pack the shoulder,” consciously contracting all periscapular musculature as if to squeeze tight one’s armpit. The latissimus must be tonic. Each repetition is to be done for 15 to 30 seconds in length.

Then move to side-lying with the arm extended toward the ceiling or sky and again “pack the shoulder.” (Discontinue if painful.) This can also be executed with the arm outstretched while kneeling, half-kneeling, or standing, depending upon the patient’s ability to maintain good core/trunk stability while performing the exercise ( Figures 6-51 and 6-52 ).

Packing the shoulder (supine).

Packing the shoulder (side-lying).

Closed kinetic chain (CKC) activities should take precedent over open kinetic chain (OKC) activities early on in the program, caused by their functionability and avoidance of unwanted stresses. CKC exercises improve sensorimotor function, joint proprioception and centralization, and stability.

Perform multiplanar, frontal, sagittal, and transverse planes exercises and focus on the weakest, the most easily fatigued and poorest performing planes of motion.

In Phase I all humeral movements should be kept below 90° of shoulder flexion and below 90° abduction.

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  CKC exercises include, but are not limited to:

  
  
  
  
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    Weight shifts left and right, up and down, forward and back, as well as diagonal and circular patterns with elbows at 90° or with elbows extended against wall, table, or floor

    
    
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    Pushup plus (slow and controlled concentric and eccentric components) on forearms or with elbows extended

    
    
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    Scapular clocks with arm extended against fixed surface, controlling movement of scapula/glenohumeral joint clockwise and counterclockwise

    
    
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    Ball/physio ball oscillations with arm outstretched

    
    
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    Seated towel slides protracting and retracting scapula

    
    
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    Seated towel slides upwardly rotate and downwardly rotate scapula (putting contralateral hand behind neck and actively cocontracting the contralateral scapula usually yields better dynamic scapular results)

    
    
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    Thumbtacks: Imagine gripping a thumbtack on the wall with each hand, then upwardly and downwardly rotate humerus/scapula and getting a scapular pinch end range external rotation)

    
    
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    Pulley exercise: This is an active exercise, not a passive one. Be sure the patient is firing their humeral and scapular depressors during both flexion/extension, scaption and abduction/adduction movement patterns. If pain free above 90°, you can take shoulder through full available pain-free ROM.

  
  

In Phase I, work begins on lower extremity muscle strength, power and endurance.

Kneeling and half-kneeling (with narrow base) modified lifts and chops with or without resistance depending upon ability to stabilize hips and trunk ( Figures 6-53 and 6-54 )

Half-kneeling chop. A, Start B, Finish.

Half-kneeling lift A, Start B, Finish.

Quadruped (on all fours): Alternate arms, alternate legs, alternate opposite arms and legs

Bridging/single-leg bridge/bridge marching

Dead bugs: Alternate arms, alternate legs, alternate opposite arms and legs

Low-level lower extremity plyometrics can begin in the final 1 to 2 weeks of Phase I

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  Low-intensity dot drills, box drills, cone/footwork drills, jump rope, one- and two-legged hops, skipping, low-level bounding

Ground-based exercises for the lower extremities (that do not load, compromise, or force the shoulder into flexion or abduction above 90°). Many are listed above, however the athlete should add additional exercises that incorporate movement patterns specific to the athlete’s sport.

Review all sport-specific exercises related to the athlete’s sport. Consider each exercise, movement pattern, or sport-related activity that does not invoke stress on the injured shoulder. Examples of this might include taking groundballs without throwing, foot work, and body positioning drills that do not involve the affected shoulder.

Maintain indoor and outdoor cardiovascular/aerobic fitness.

Manual therapy techniques used in Phase I are also indicated in Phase II to not just maintain what has been accomplished, but to address any new issues that may arise or be uncovered.

Take advantage of this time to periodically evaluate the patient’s strength and range of motion, as well as the firing patterns of motor recruitment.

The same soft tissue techniques listed in Phase I certainly can apply in Phase II to not only maintain what’s been achieved soft-tissue wise, but also to evaluate the tissue as new issues and changes in tissue tension, capsular, and muscular tightness emerge.

Although the patient has moved on to Phase II, it is critical that both the therapist and patient remain aware and on top of the patients kinetic chain mobility.

Many flexibility goals have been met up to this point, however the patient’s body type, posture, sport, and genetics are still programmed to return that athlete to the state of flexibility the athlete was in before the injury occurring. That being said, working on stretching and being “routine” with it needs to continue well beyond this program, much less beyond Phase I.

At this point identifying the few stretches to help maintain the patient’s flexibility would be beneficial because it is probably a bit of overkill to perform all of the stretches every day.

Commonly the horizontal adduction stretch and modified sleeper stretch need to be continued 3 to 5 times per week. More aggressive techniques (such as active assistive and active isolated stretching with the use of a band, tubing or towel) can be used.