Shoulder disorders affect 7% to 27% of the general population and account for 1% to 2.5% of patients presenting to general medical practitioners annually.^1,2 It is the third most common cause of musculoskeletal consultation in primary care.³ Up to 53% of these patients are then referred to physical therapy.² A study to determine the course of shoulder disorders in general practice and the prognostic indicators of outcome revealed that 23% of all patients showed complete recovery after 1 month.⁴ After 1 year, 59% of patients showed complete recovery.⁴ A more rapid recovery seemed to be related to preceding overuse or slight trauma and early presentation. A high risk of persistent or recurrent complaints was found for patients with concomitant neck pain and severe pain during the day of presentation.⁴

This chapter discusses a rehabilitation approach for the most common shoulder disorders. Early intervention is a critical component to recovery of shoulder pathology. However, the quantity of rehabilitation does not always equate to quality. Each patient requires a different level of intervention. Supervised therapy three times per week is not necessary for all patients. Many patients need only instruction in a home program and periodic evaluation and progression of the rehabilitation program. Therefore, it is incumbent upon therapists, physicians, and the patient to administer the appropriate amount of rehabilitation following the onset of a shoulder injury.

The importance of patient education cannot be emphasized enough. The patient needs to be educated about the healing process and the importance of rest from positions or activities that may contribute to the inflammatory process. They should also be instructed in proper positioning of the arm for comfort. Many patients report that while at rest or sleeping, the most comfortable position is with the arm supported in the plane of the scapula. From a biomechanical standpoint, this also appears to be a more advantageous position. Patients should be instructed to perform activities such as working with a computer or driving with their affected arm supported at the elbow.

Range-of-motion (ROM) and stretching exercises are designed to prevent adhesions and/or fibrosis, reduce pain, allow collagen healing, and increase tissue length. When restoring normal ROM of the shoulder, one should consider which structure might limit the motion. Studies have shown that external rotation with the arm at the side is most limited by the subscapularis and the coracohumeral ligament.^5,6,7 External rotation with the arm at 45 degrees appears to be limited by the subscapularis and middle fibers of the anterior glenohumeral ligament.⁷ The inferior glenohumeral ligament limits external rotation when the arm is abducted to 90 degrees.⁷ Gerber et al. simulated capsular contractures in cadavers and measured changes in elevation and rotation ROM. They found that restriction of the anterior capsule restricted external rotation (ER) and posterior contractures restricted internal rotation (IR) ROM.⁵ Contracture of the superior capsular structures limited rotation motions with the arm adducted.⁵ Contracture of the inferior structures yielded restriction in abduction and rotation in the more elevated positions.⁵

We have divided our ROM exercises into phase I and phase II. Phase I exercises include supine passive or active assisted forward elevation and external rotation (Fig. 70-1). Phase II ROM exercises include extension, internal rotation, and cross body adduction (Fig. 70-2). The patient is asked to take the extremity to a position of tolerable stretch and hold the position for 10 to 20 seconds. Each exercise is repeated 10 times, two to three times per day at home.