TIME: Day 1 to 2 weeks (Table 4-1)

For 2 to 4 weeks, the arm will be in an abduction sling. Protection of the surgically repaired tissue is essential for a successful long-term outcome. Many of these patients have some joint laxity and rarely have difficulty regaining motion with a normal course of rehabilitation. The inflammatory and initial fibroblastic/granulation stages of physiologic healing occur during the first 2 weeks following surgery.^1–3 Taking care not to extend the inflammatory phase with overly aggressive treatments will allow maximal collagen fiber deposition with minimal disruption leading to better healing in the end. Avoid stressing the anterior capsule with your interventions.

On the first visit, remove the sling and measure passive range of motion (PROM) in flexion and abduction in the scapular plane (scaption). Do not move into external rotation past zero degrees at this time to prevent excessive stress to the anterior capsule. Measure internal rotation to the limits permitted by pain tolerance because there is no concern about disrupting healing tissue in this direction. Assess wrist and elbow motion at the first visit as well. Early mobilization has been shown to improve tissue healing following surgery.^4,5 Without mobilization the patient is less likely to regain full motion; therefore, it is important to begin ranging the shoulder within the limits of discomfort immediately. Because pain typically prevents independent active range of motion (AROM) in the first few days after surgery, perform passive or manual active-assisted range of motion (AAROM). Independent AAROM can be safely initiated using wand exercises, table slides, and wall walks into flexion and scaption. When the postoperative pain subsides, measure active elevation in the scapular plane.

Assess scapular positioning and active scapular mobility immediately and begin scapular positioning exercises. Emphasis should be placed on activation of the serratus anteriors and the middle and lower trapezius muscles to promote retraction and upward rotation of the scapula.⁶ Exercises may include (1) proprioceptive neuromuscular facilitation (PNF) interventions for scapular positioning, which are very effective and safe immediately postoperatively⁷; and (2) prone or standing scapular retraction. Avoid excessive activation of upper trapezius or latissimus dorsi, which leads to improper scapular elevation or depression, respectively.⁶

A home exercise program should begin immediately (Box 4-2). Remove the sling three to four times per day to perform exercises for 15 minutes including: scapular retraction, AROM elbow flexion/extension, pronation/supination, wrist flexion, extension, radial and ulnar deviation, and squeezing a gripper ball. Follow this routine with ice and return to the sling. Codman’s pendulum exercises are also appropriate at home if the patient has no contraindications due to extreme laxity.⁸

Pain management modalities, such as electrical stimulation and cryotherapy, may be used as needed throughout the course of therapy. If the patient is having an excessive amount of pain, assessment and treatment of the cervical spine may be appropriate. Preoperative compensations, intraoperative positioning, and postoperative guarding can lead to joint and soft tissue dysfunction in the neck. Comparable objective findings locally at cervical levels 3, 4, and 5 may explain excessive pain, muscle inhibition, or excessive tightness in the shoulder and the therapist should intervene appropriately.⁹

Begin core strengthening exercises immediately. Abdominals, lumbar extensor muscles, and gluteals are all critical components in the kinetic chain for athletes and physical laborers alike. Core and lower body strengthening are safe and easy to incorporate into the training program. Once the patient is safe and independent, transition these exercises into a home exercise program to allow more time for close supervision of the shoulder exercises during therapy sessions.

TIME: 2 weeks to 4 weeks (Table 4-2)

TABLE 4-2

Anterior Capsular Reconstruction

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Rehabilitation Phase	Criteria to Progress to This Phase	Anticipated Impairments and Functional Limitations	Intervention	Goal	Rationale
Phase 1B   Postoperative   2-4 wk • Postoperative protection • ROM initiation and muscle activation	• No signs of infection • Pain controlled with medication or modalities • No loss of ROM from initial assessment	• Patient comes out of sling • Limited ROM • Limited strength • Minimal functional use of arm for self-care and ADLs due to weakness and discomfort • Full elbow and wrist AROM	• Modalities: • Continue modalities as needed by pain and edema • AAROM: as needed • AROM: • Shoulder—Flexion, scaption, and internal rotation to tolerance; external rotation to 45° • Avoid stress on the anterior capsule • Continue with elbow and wrist as needed • Isometrics: • Shoulder—Progressive load isometrics • Isotonics:  Scapular stabilization exercises standing and prone • Prone extension • Side-lying series • Static serratus press • Static hold “row” • Manual Intervention: • Soft tissue mobilization • GH and scapulothoracic mobilization	• Modalities: • Manage pain and edema • AAROM/AROM: • Shoulder—Flexion, scaption, and internal rotation 70% of uninvolved side for functional requirements • External rotation limited to 45° to avoid stress on the anterior capsule • Continue with elbow and wrist as needed • Isometrics: • Strong, tonic contraction of rotator cuff without pain • Isotonics: • Good scapular control in standing and prone exercises without cues • Prone and side-lying series: good form maintained through 3×10 repetitions • Manual Intervention: • Maximize ROM • Maximize mechanical alignment • Function: • Independent for self-care and ADLs below shoulder height • Participation in core and lower body strengthening	• Modalities: • Minimize edema to minimize discomfort and inhibitory effects on local musculature • AAROM/AROM: • Shoulder—Progress with ROM quickly but safely • Avoid stress on the anterior capsule • Isometrics: • Once good muscle activation is achieved, quickly progress into more advanced exercises if able • Isotonics: • Scapular control is required to advance into more challenging rotator cuff exercises • Through range motions in safe positions to build strength and endurance • Manual Intervention: • Decrease mechanical barriers preventing normal ROM and strength • Function: • Minimize dependency for functional activities • Maintain fitness to minimize losses

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AAROM, active-assisted range of motion; ADLs, activities of daily living; AROM, active range of motion; ROM, range of motion; GH, glenohumeral; UE, Upper extremity.

GOALS:

Typically, the arm comes out of the sling during this phase. Physiologic healing is progressing from the granulation stage into the proliferative/fibroblastic stage.^1–3 Due to the deposition of collagen fibrils, the healing tissues are developing some internal integrity enabling them to tolerate gentle stresses. The skin wounds should be healing and pain should be minimal.

Measure active range of motion to the onset of discomfort including: flexion, scaption, and internal rotation. Measure external rotation to 45° or onset of discomfort, whichever comes first. Assess scapular mobility and quality of motion during AROM looking for abnormalities in scapular winging, scapulothoracic or scapulohumeral rhythm, and quality of muscle contraction. Gentle strength assessment of the rotator cuff in all planes from a neutral position is also appropriate as pain tolerance allows. The goal is to assess muscle activation rather than to perform break testing, which would require maximal force production and potentially damage the surgically repaired tissue and cause pain.

Active-assisted ROM exercises can include wand flexion and abduction in the scapular plane, external rotation to 45°, and hand behind the back. The patient should move into the ROM until he or she begins to feel an initial stretch. Make certain the patient understands that the goal of therapy in this phase is to initiate range of motion without stressing the anterior capsule. These exercises can be incorporated into a home program.

During this phase the patient must learn to actively control the position of the scapula without cues. The goal is to maximize scapular stability and minimize scapular winging. Proper control of scapular position is required to progress with rotator cuff exercises. Three key muscles to activate are the middle trapezius, lower trapezius, and serratus anterior. Progress prone or standing scapular retractions to a static row using an exercise band. The patient grasps an exercise band with two hands, and performs a scapular retraction creating tension in the band, while the elbows remain bent to 90° and in the plane of the body. The patient then walks slowly backward to increase tension in the band while maintaining a scapular retraction to load the posterior scapular stabilizers. Static rows can be performed with an isometric hold in the loaded position or simply by moving repeatedly through the motion to load and relax the muscles. Early activation of the serratus anterior can be achieved with a static hold serratus press in a modified push-up position at the wall (Fig. 4-2, A). This position is similar to the “plus” position of the traditional “push-up plus,” which demonstrates high EMG activity in the serratus anterior.^10,11 The patient places the hands on the wall at shoulder height, with the head and spine in neutral alignment. Instruct the patient to press the hands into the wall and the body away from the hands using a scapular protraction motion to achieve the “plus” position. Progress into a more challenging position by lowering the hands to the height of a table, thereby increasing gravitational forces and increasing the workload on the serratus (Fig. 4-2, B). These are safe exercises to add to the patient’s home program because there is no active motion being performed at the glenohumeral joint (see Box 4-2).

Once scapular positioning can be achieved and maintained by the patient, slowly progress rotator cuff strengthening as tolerance, strength, and proper form allow. Caution the patient that the elbow should never be behind the plane of the body to avoid stressing the anterior capsule. To begin, submaximal isometric strengthening exercises can be performed in a neutral position into shoulder flexion, extension, internal and external rotation, and abduction (Fig. 4-3). Progression of these initial rotator cuff exercises includes variable load isometrics using resistance bands. The patient stands holding the band as if to perform classic isotonic internal and external rotation exercises. Yet rather than move the arm, the patient holds the arm still while stepping away from the anchor point of the band, thereby increasing resistance and loading the rotator cuff muscles in a safe manner. Another technique for safe early strengthening is performing active motion from the prone position with a stable scapula. Prone extension is an excellent exercise for initiating dynamic scapular stabilization and activation of the middle trapezius (cools) (Fig. 4-4, A). The elbow should remain in full extension and the motion ends at the plane of the body to protect the anterior capsule.

Posterior shoulder soft tissue restriction or posterior capsule tightness can accompany anterior shoulder instability. If restriction is present, as determined by the Tyler test¹² and available horizontal adduction ROM,¹³ it may lead to aggravation of the anterior shoulder structures and stress the anterior capsular repair. Stretching the posterior capsule may be a project that requires both manual interventions and home self-stretching exercises over the course of many weeks to normalize. Manually address posterior capsule tightness with soft tissue mobilization and anterior-posterior GH joint mobilizations.^14,15 The physical therapist should take care to avoid excessive compression forces on the anterior shoulder with hand-holds because this can be very painful for the patient. Cross-body stretching of the posterior capsule can be included in the home program if appropriate for the patient (Fig. 4-5).^16,17

Grade II manual GH mobilizations in the anterior-posterior and cephalad/caudad directions can be used for pain management¹⁸ and to prevent excessive adhesion formation during this phase.¹⁴

Nighttime discomfort may continue to be a problem and the therapist can advise the patient regarding sleeping positions. Pillow support under the elbow maintains the shoulder in the scapular plane while sleeping and reduces stress on the anterior capsule. Pillows should not be placed under the shoulder directly because this forces the scapula into a more protracted and anteriorly tipped position.

TIME: 4 weeks to 8 weeks (Table 4-3)

GOALS:

Physiologically, the healing tissue is well advanced into the proliferative/fibroblastic stage during this phase.^1–3 There is an abundance of collagen fibers in the region and the surgical repair has fair integrity. At a cellular level, the goal of physical therapy is to align these collagen fibers in the proper orientation along lines of normal stress.¹⁵ This phase is the optimal time period for elongating tissue with a progressively lessening amount of risk for damage. Moving the arm through a large pain-free range of motion will allow appropriate stresses to the healing tissue, resulting in an optimal outcome.

Typical manual muscle testing and active range of motion assessment in all directions are appropriate at this time. Include strength testing of the rotator cuff and scapular stabilizers to be certain all aspects of the kinetic chain are progressing as required. Do not force motion into extension, external rotation, or horizontal abduction to avoid stretching the anterior capsule.

Functional mobility begins to return during this phase. Overhead reaching into flexion typically is the most comfortable direction and most easily regained after surgery. Often, patients continue to complain of pain with functional activities involving extension and external rotation, such as putting on a jacket. The patient should have full PROM and nearly full AROM by two months following surgery with the exception of external rotation, which may lack approximately 10°.²⁰ Slowly begin exercises that gently stretch the anterior capsule through the active range rather than forcing a stretch by passive manual interventions, for example, wand scaption or external rotation. If by 6 weeks postsurgery a deficit in external rotation of 25° or larger remains, incorporate more aggressive manual techniques or self-stretching exercises to regain full motion. It is the authors’ opinion that a 5° to 10° loss of external rotation in a neutral position and at 90° of abduction at 8 weeks postoperative is not uncommon and not detrimental to the final outcome. The surgical reconstruction will continue to stretch over the next 2 to 4 months. Keep in mind that the goal of the surgery was to decrease pathologic laxity. Aggressively stretching the repair site can put the patient back into their preoperative state of excessive laxity and should be avoided during this phase. The patient should continue with ROM exercises at home as needed (see Box 4-2).

During this phase, emphasis must be on proper dynamic scapulothoracic and scapulohumeral rhythm. Allowing excessive motion at the glenohumeral joint as a compensation for improper scapulothoracic motion can overstress the anterior capsule and the repair. It is best to observe scapulothoracic and scapulohumeral rhythm with the patient shirtless to ensure proper mechanics are present before advancing the program. The scapular slide test,²¹ although inconsistently validated in the literature, can be used as an assessment tool early in the rehabilitation process to quantify gross differences in scapular motion. The physical therapist measures the distance from the inferior angle of the scapula to the midline of the thoracic spine at the level of the inferior angle of the scapula. The measurements should be symmetrical for the involved and uninvolved shoulders at zero degrees hands at sides, 45° hands on hips, and 90° of abduction with internal rotation. Assess the quality of the motion in addition to the quantity of motion. The goal is to have a smooth contraction and appropriate firing patterns on both the concentric and eccentric phases of motion. A jerky pattern with visible muscle fasciculations would be considered abnormal and needs to be addressed before progressing into more difficult exercises.

Proper function of the serratus anterior muscle is critical to normal shoulder function and is essential if the patient is to avoid an external impingement problem. Progress the serratus press exercise into one-handed stabilization at table height (see Fig. 4-2, C). Further progression moves to the floor in a kneeling plank position (Fig. 4-6, A), and finally a full plank position on the floor (Fig. 4-6, B). The serratus dynamic hug below 90° of elevation is an excellent progression into functional through range serratus activation¹⁰ (Fig. 4-7).

Prone horizontal abduction (see Fig. 4-4, B) and prone row (Fig. 4-8) target the middle and lower trapezius muscles²² and posterior rotator cuff.²³ Begin with AROM only to retrain proper scapular control and progress to light weight to increase the demand on the muscle. Because the patient is retrained in a manner minimizing risk to the anterior shoulder, these are excellent exercises for building muscle endurance.

Once dynamic scapular control is achieved, advance with more specific rotator cuff muscle-strengthening exercises. Side-lying external rotation,²³ abduction, and horizontal forward flexion,²⁴ all limited to body plane range of motion, require more dynamic scapular stability while maintaining a safe range of motion for the shoulder. Watch carefully to ensure excessive scapular adduction and trunk rotation do not substitute for proper stabilization by the middle and lower trapezius.

Progress to through-range external and internal rotation with resistance bands, emphasizing scapular stability to ensure proper rotator cuff activation.^25,26 Use an axillary towel roll to reinforce proper positioning, increase muscle activation, and to improve synergistic function of the adductors and external rotators.²³

Begin open kinetic chain exercises in standing, including shoulder scaption in a full can position,²³ flexion, and abduction using gravity as resistance. These exercises can be used to train proper scapulohumeral rhythm through AROM and are less effective for specific muscle strengthening. Add light-weight or resistance bands as movement patterns, scapular stability, and overall strength increase. Poor eccentric control and scapular winging tend to be limiting factors in progression with added resistance.

The upper body ergometer (UBE) may be incorporated early in rehab. Initially the involved arm is passive to focus on mobility, with the uninvolved arm doing the majority of the work. An easy five-minute program alternates forward and backward revolutions at a comfortable pace. With repeated use, the involved arm may begin to participate more as tolerance allows, progressively increasing the effort until the patient is predominantly using the involved arm by 2 months postoperation.

If anterior shoulder pain, a protracted scapula,²⁷ or an anteriorly translated humeral head are noted, reassess for possible restriction in the posterior shoulder. If capsular or muscular restriction is present, incorporate more aggressive manual interventions and home exercises. Grade IV+ posterior mobilizations in varying angles of humeral flexion and rotation may be indicated to redress this dysfunction and normalize mechanics.¹⁴ The sleeper stretch (Fig. 4-9) is a good home exercise to improve the extensibility of the posterior capsule.^17,28 Additionally, the excursion and pliability of the subscapularis muscle often becomes restricted following surgery and prevents the patient from regaining full range of motion. Gentle soft tissue mobilization can ease this restriction, allowing the patient to actively move into increased range.

TIME: 2 to 3 months (Table 4-4)

GOALS:

Physiologically, the capsular tissue is progressing out of the proliferative/fibroblastic stage and into the remodeling/maturation stage.^1–3 As the collagen tissue matures, it becomes more resilient to stress, therefore more stress can be placed on the capsule without risk of damage. Because of this increasing tissue strength, the window of opportunity to increase ROM is closing during this phase. Be certain you have achieved the desired ROM, otherwise it may be very hard to regain later.

The primary goal of the third postoperative month of physical therapy is strengthening throughout the full active range of motion. The patient may add resistance to an exercise when (1) the motion can be performed with proper scapulohumeral and scapulothoracic motion patterns; (2) he or she can demonstrate good eccentric control through the range of motion; and (3) such motion is pain-free.

It is necessary to perform break testing in all planes of motion, including end range, to assess functional strength. Performing manual muscle tests only in neutral positions is not a sufficient assessment to ensure adequate functional strength and endurance in athletes. If weakness is present in overhead positions, many overhead athletes will be unable to regain all necessary function.

Adequate strength of the serratus anterior is critical to maintain scapular protraction and to prevent scapular winging throughout open and closed kinetic chain activities.⁶ Concentric and eccentric control must be evaluated during all exercises. A modified minirange push-up plus with a narrow grip and elbows hugged tightly to the body can be the next step in strengthening.¹¹ Begin these on the wall and progress to table height, then the floor. Do not jeopardize the anterior capsule by progressing too quickly. Patients should not be performing normal full range push-ups at this time, as the tensile strength of the healing tissue is inadequate. Many athletes view a push-up as a gold-standard of functional strength and will strive to return to push-ups too quickly, leading to pain or damage in the shoulder. The serratus also functions to upwardly rotate and posteriorly tip the scapula when the arm is overhead.²⁹ Use wall slides to train overhead motion, with the emphasis on pushing the hands into the wall and the body away from the wall (Fig. 4-10).³⁰ Once the motor pattern is learned, progress into a serratus punch at a 120° elevation (Fig. 4-11) which demonstrates high EMG activity through a functional overhead motion.¹⁰

Lower and middle trapezius muscle strength and endurance are progressed by moving the arm into different planes of motion. Prone full can (Fig. 4-12) emphasizes the lower trapezius while a prone row emphasizes the middle trapezius.²² Prone rows can be progressed by adding external rotation into the 90°/90° position (Fig. 4-13) when strength and eccentric control of the scapular stabilizers and rotator cuff are adequate. Avoid pain at end range external rotation because this is a position that stresses the anterior capsule.

Progress rotator cuff exercises described above by increasing either resistance or repetitions. Given their role as dynamic glenohumeral stabilizers^31,32 we must consider the rotator cuff muscles as muscles of endurance rather than power and focus on lighter weight with more repetition. This is a more appropriate training strategy than using heavier weight and fewer repetitions. The supraspinatus punch in midrange in the scapular plane is a good method of initiating overhead strengthening.¹⁰ Supine internal and external rotation with the arm positioned in 45° to 90° of abduction using resistance bands allows for a safe progression of range by moving the arm into more functional positions.

PNF continues to be a valuable manual tool in this patient population. The therapist can use PNF patterns to strengthen muscles in terminal ranges of motion, as well as for gross motor patterning throughout the range of motion.⁷ Minimal resistance is applied to focus the effort on proper muscle firing patterns more than gross power or speed.

Strengthening of the biceps, triceps, latissimus dorsi, deltoid, and pectoral muscles becomes more important once the therapist is certain there is adequate strength and endurance of the rotator cuff muscles and scapular stabilizers. Athletes often push toward lifting heavy weights for these larger muscle groups, yet progressing with light to medium weights is more appropriate. Remember that it has been several months since the last true training session was possible and the rotator cuff and scapular muscles must provide the necessary stability to the shoulder complex. Allowing a patient to return to 45 lb bicep curls on the first attempt simply because that is “what I was lifting before surgery” will cause shoulder discomfort.

Progress the UBE to using only the involved arm with emphasis on endurance training and increased speed.

TIME: 3 to 4 months (Table 4-5)

GOALS:

While tissue remodeling continues, we can be confident the surgical repair is strong and can tolerate increasing stresses. We become less and less concerned about damaging the surgical repair as time goes on. Full range of motion is expected at this time. Functionally, the patient should feel normal with the exception of overall gross power for heavier lifting and endurance for longer duration activities. Overhead sports and work specific activities likely remain challenging from a strength and endurance perspective.

Consider sport-specific activities and positional requirements to identify ongoing impairments that need continued attention. Have the patient move through patterns of motion similar to their sport, without speed or load. If the patient is a pitcher, assess objective ability and subjective tolerance to the cocking position of the arm, then with the full body pitching motion before allowing him or her to throw a ball. If the patient is a volleyball player, mimic the serving and blocking motions starting with just the arm and progressing into slow, purposeful full body motion. Look for the ability to control the concentric and eccentric phases of motion. Question the patient about any pain, restriction, or weakness with the action. Use this information to guide the next several weeks of treatment ensuring that the patient is ready to transition to sport-specific training at 4 months postoperation.

Advance serratus anterior strength with planks or walkouts on an exercise ball (Fig. 4-14), and continue to emphasize scapular protraction and upward rotation throughout the exercise. Pressing from a plank into a pike position (Fig. 4-15) on the floor will train closed chain overhead serratus control. Pikes can be performed using a stability ball (Fig. 4-16) and are a very challenging high-level exercise, which may be appropriate for only the strongest individuals near the end of this phase of rehab. Full-range, overhead, open kinetic chain exercises, such as forward flexion, full can, and supraspinatus press, can be used to train eccentric control of the scapula as the arm is lowered to the side. This is more of a neuromuscular retraining exercise than a true strength building exercise. Again, assess the quality of motion, not simply the quantity of motion or weight lifted.

If the patient is an overhead athlete or worker, endurance for maintaining the arms overhead can be critical to returning to these activities. Bounce a light ball, gym ball, or medicine ball overhead for 30 to 60 seconds, focusing on scapular stability in a retracted, posteriorly tipped, and upwardly rotated position.

It is essential to achieve good eccentric control of the rotator cuff muscles before returning to sports activity. This is particularly important when working with overhead athletes since the posterior rotator cuff is responsible for the eccentric deceleration of the arm in activities such as throwing, serving, or hitting.^33,34 Therapist-assisted prone external rotation can be used for eccentric strengthening of the posterior rotator cuff. A heavier but controllable weight is selected, and the therapist helps the patient preposition the arm into the 90°/90° position, then releases the weight, forcing the patient to control the weight in the negative direction. To eccentrically strengthen internal rotation, have the patient lie supine and perform the same therapist-assisted 90°/90° exercise. A home exercise for eccentric posterior rotator cuff strengthening is performed with resistance bands. The patient lies supine with a resistance band tied to the foot and the band wrapped around the hand (Fig. 4-17, A). The arm is positioned at 90° abduction in neutral rotation. With the band slack, the arm is externally rotated into the 90°/90° position, the thumb pointing toward the floor (Fig. 4-17, B). The leg is extended tensioning the band, while maintaining the arm in the 90°/90° position (Fig. 4-17, C). Slowly, the arm is returned to the neutral starting position in a controlled manner creating eccentric loading of the posterior cuff (Fig. 4-17, D).

Increase the speed and resistance applied when performing PNF patterns.⁷ Speed work into internal and external rotation in multiple planes in both the concentric and eccentric directions is effective training for overhead activities. Sports such as volleyball, tennis, swimming, water polo, and throwing sports can benefit greatly from D1/D2 patterning into end ranges of motion. These exercises can also be performed with resistance bands and transitioned into sport-specific warm-up drills as the patient progresses toward independence.

Power training for the deltoids, biceps, triceps, latissimus dorsi, and pectoral muscles becomes more important in this last phase of therapy before returning to sports activity. Whereas the rotator cuff and scapular stabilizers are control and endurance muscles, the prime movers of the arm are the power muscles.^33–35 Incorporate lat pull-downs, bicep curls, tricep extensions, and rows into the program with heavier weight and fewer repetitions.

TIME: 4 to 6 months (Table 4-6)

GOALS:

At this time, many patients have returned to normal activities including sports played below shoulder height or sports demanding very little of the upper extremity. Overhead athletes must have adequate strength and endurance to transition into sport-specific training.

Plyometrics are a critical part of rehabilitation for athletes. Ball toss to a trampoline while in tall kneel, half kneel, or standing can mimic required motions for sports. Playing catch with a light medicine ball allows concentric and eccentric training of the throwing motion. While lying prone the patient catches the ball in the 90°/90° position, eccentrically lowering the ball to 90° abduction with neutral rotation, then tosses the ball back to the therapist by externally rotating the arm back to the 90°/90° position. For larger motion patterns, throw a 5 to 10 lb medicine ball against a wall in a chest pass, side pass, or overhead toss. There is no limit to the options for ball related plyometrics that can be very sport-specific.

Isokinetic strength measurement is an excellent way to determine overall power and endurance compared with the uninvolved arm. Understand that the dominant arm is expected to be stronger, and this may alter the interpretation of strength testing. The authors of this chapter test isokinetic strength at 120° per second for internal rotation and 240° per second for external rotation. Sport-specific training begins when the involved arm demonstrates 70% to 80% strength of the uninvolved arm.

Sport-specific programs are indicated in Boxes 4-3 through 4-6.

If the patient is having difficulty gaining the last few degrees of shoulder flexion because of pain or stiffness and the physical therapist determines the glenohumeral and scapular mobility are normal, the problem may be in the spine. Assess the lower cervical and upper thoracic spine for hypomobility.36,37 The cervicothoracic junction is required to move into extension during end range shoulder flexion. At times, this region of the spine can become restricted and actually limits functional end range shoulder flexion. Mobilizing the spine into extension restores normal scapulothoracic and cervicothoracic motion and allows terminal functional flexion to be achieved.

Patients with anterior instability may have a tight posterior capsule. Despite surgical correction, the posterior tightness may remain and, if left untreated, lead to a recurrence of the original complaint. Two excellent self-stretching techniques for the posterior capsule are the cross body stretch with scapular stabilization (see Fig. 4-5) and the sleeper stretch (see Fig. 4-9).

Periscapular muscles that tend to be restricted include the pectoralis minor and levator scapula. Both of these muscles will contribute to an anteriorly tipped and downwardly rotated scapula, thus preventing normal rotation of the scapula and therefore contributing to shoulder impingement. The therapist should be suspicious if the patient has rounded shoulders and a protracted scapula. Stretching of both muscles can be performed manually or independently. Soft tissue mobilization can be very effective in treating these restrictions as well. Remember to protect the anterior capsule from being overstretched when addressing these issues.

The therapist must not stretch the anterior shoulder structures of any throwing athlete unless he or she is certain that tightness exists. By and large, all these patients can demonstrate anterior laxity in the dominant shoulder. Assess ROM carefully and consider all factors of the patient and physical demands before proceeding with any stretching of the anterior shoulder.