Rehabilitation of Primary and Secondary Rotator Cuff Impingement

Kamkar and colleagues²⁰ have identified scapular weakness as leading to “function scapular instability,” which affects scapular position during activities that cause a “relative decrease in the subacromial space.” This secondary impingement requires the scapulothoracic muscles to be strengthened and stabilized before specific rotator cuff weakness can be addressed. Scapula thoracic articulation is known to many clinicians as the true core of the upper extremity. To effectively stabilize the humeral head so that it does not migrate superiorly, causing “winging” or “tipping,” the scapular muscles (serratus anterior; upper, middle, and lower trapezius; levator scapulae; and rhomboid muscles) must be strengthened.^17,20,42 Thein⁴² describes the clinical features of humeral head migration (secondary impingement) as possibly confusing the typical impingement picture. She reports, “If the supraspinatus is overworked trying to stabilize the humeral head, then it is unable to effectively function to depress the humeral head. The resultant upward movement decreases the subacromial space and irritates the subacromial soft tissues, thus perpetuating the impingement process.”

The initial evaluation performed by the PT is crucial in determining which exercises are to be performed to help stabilize the scapula and which should be avoided initially to reduce rotator cuff irritation with glenohumeral instability or superior migration of the humeral head.

Scapular stabilization exercises are only one component of a successful rehabilitation program.⁹ In general a comprehensive rehabilitation program to address rotator cuff impingement, rotator cuff tendinitis (supraspinatus tendinitis), and degenerative tears of the rotator cuff tendons include modification of activities, local and systemic methods to control pain and swelling (nonsteroidal antiinflammatory drugs [NSAIDs], corticosteroid injections, ice, ultrasound, iontophoresis, phonophoresis), stretching and strengthening exercises, and a return to normal function after reevaluation by the PT and with continued maintenance of protective positions and general conditioning.^13,15

The nonoperative treatment of impingement and symptomatic rotator cuff tears focuses on a three-phase, criterion-based rehabilitation program. The three phases of rehabilitation are as follows: (1) phase I, prefunctional; (2) phase II, return to function; and finally, (3) phase III, return to activity. Phase I, prefunctional, concentrates on relief of symptoms and initiating exercises to improve or maintain motion. Because impingement symptoms are usually made worse with overhead activities, the patient must modify activities of daily living (ADLs) and all other motions that may place the shoulder at or above 80° to 90° elevation. Home activities that require modification include cleaning hard-to-reach places and painting overhead. Work site tasks that must be adapted include heavy overhead lifting, manual labor, reaching, and climbing. Sporting activities such as tennis, golf, swimming, and baseball also must be modified to avoid impingement. The key to remember in each case is modification, not elimination, of compromising activities. For example, for a recreational tennis player, overhead serving should be avoided but all other ground strokes may be able to be maintained. For household activities and work site modifications, rearrangement and advanced planning of overhead tasks may be all that is needed to minimize the aggravating position of elevation past 80° or 90°. The PTA must constantly reinforce the concept of protective positioning and should encourage compliance throughout the course of rehabilitation.

In addition to activity modification, management of pain and swelling can be achieved with various physician-prescribed oral NSAIDs and physical therapy agents. Usually ice packs, ultrasound, some type of pharmacophoresis (iontophoresis and phonophoresis), and most recently, infrared laser application, are used to help control symptoms.

Throughout phase I, stretching exercises are performed to increase blood flow and contractility¹⁵ and improve motion. The PTA must pay particular attention to performing all stretching activities, because many generalized shoulder stretches involve full forward shoulder elevation and abduction maneuvers. All phase I stretching should encourage nonballistic, slow, controlled, pain-free motion at less than 80° to 90° of elevation. Capsular mobility has been shown to be very helpful in increasing motion and preparing the surrounding muscles to assist in shoulder elevation in all planes of motion.^26,34 However, once symptoms are managed the patient can perform all stretches involving elevation and abduction if these stretches do not produce symptoms. Depending on the initial evaluation data gathered by the PT, the patient may be instructed in two specific stretches that authorities¹⁵ suggest are effective in addressing posterior capsular tightness. Shoulder adduction across the chest (cross-body stretching) and internal shoulder rotation are used cautiously to improve posterior capsular tightness and overcome the limitations on motion of internal rotation of the shoulder. The effective use of the sleeper stretch to increase posterior capsular mobility has been reported. The concept of anterior capsular mobility has been presented as important for shoulder mobility to treat or prevent impingement while regaining horizontal abduction to prepare for tri-plane overhead motion.²⁵

Initial strengthening activities that can begin during phase I generally include scapula stabilization exercises and light rotator cuff strengthening. The use of closed kinetic chain loading such as wall push-ups can be an effective pain-free low level muscle recruitment exercise. Closed kinetic chain (CKC) exercises will provide co-contraction and tri-plane stabilization with lower muscle contraction load than open kinetic (OKC) chain exercises.5,46 Once the patient demonstrates improved motion and can do ADLs without pain, a progression through a series of OKC muscle strengthening can begin. Prone extension to the hip, side-lying external rotation, and scaption elevation without pain are some recommended exercises for rotator cuff recruitment toward strengthening (Fig. 21-2).³⁸ Specific rotator cuff strengthening exercises should focus on the supraspinatus muscle.³⁸ Studies demonstrate that the supraspinatus, infraspinatus, subscapularis, deltoid, latissimus dorsi, and pectoral muscles are effectively strengthened by arm elevation in the transverse plane, shoulder elevation with neutral rotation in the plane of the scapula (Fig. 21-3), prone horizontal shoulder abduction with external rotation (Fig. 21-4), and seated press-ups.³⁰

Phase II, return to function, progresses with advanced scapular stabilization exercises that are encouraged as part of a comprehensive glenohumeral and scapulothoracic strengthening program. This phase of program uses progressive resistive strengthening via increased resistance while using OKC exercises. Electromyographic studies³³ have identified four basic scapular stabilization exercises that strengthen the upper, middle, and lower trapezius; the levator scapula; the rhomboid major; the pectoralis minor; and the middle and lower serratus anterior muscles.⁸ The exercises are rowing, scapular plane elevation (scaption), press-ups, and push-ups followed by scapular protraction. As strength improves and when motion increases, a gradual return to normal function signifies the beginning of phase III, return to activity.⁴⁴

The process of functional recovery is slow and must be done cautiously; overhead activities are introduced incrementally as the patient is able to demonstrate pain-free motion and the ability to perform strengthening activities. Some advanced return to activity phase exercises can include oscillatory training (Bodyblade) using tri-plane positioning (Fig. 21-5).⁴⁰

Surgical Management of Shoulder Impingement and Rotator Cuff Tears

When physical therapy interventions fail to provide long-lasting relief and in cases of rotator cuff tears (Neer’s stage III impingement, tendon degeneration, and cuff tears), various surgical procedures can be used to correct the underlying pathologic condition. With subacromial impingement not involving a specific rotator cuff tear, subacromial decompression (SAD) can be used to eliminate or diminish the abnormality causing the impingement between the humeral head and the undersurface of the acromion, allowing freer movement of the tendons without irritation. Acromioplasty includes beveling or reshaping of the acromion with detachment of the coracoacromial ligament. Distal clavicle excision (DCE) may also be involved.³⁹ If there is an associated rotator cuff tear (small tear less than 1 cm, medium tear less than 3 cm, large tear greater than 5 cm), a SAD procedure is used in conjunction with direct repair of the rotator cuff defect. The SAD procedure can be performed as an open arthrotomy or as an arthroscopic procedure.³⁹

Rehabilitation after SAD or rotator cuff repair closely parallels nonoperative rehabilitation of rotator cuff impingement. However, time must be allowed for healing of the soft tissues and bone after surgery. Some clearly identified differences exist between rehabilitation procedures used for decompression and small cuff tears (less than 1 cm) and repairs of medium (less than 2 to 3 cm) and large (greater than 4 to 5 cm) cuff tears with SAD.³⁹ With a small cuff tear repaired in conjunction with a decompression procedure, active motion and pain-free exercise can begin as soon as the patient can tolerate these activities.^39,44 However, if the rotator cuff tear is between 2 and 5 cm, tissue protection must be longer to allow for extensive soft-tissue healing. If full active range of motion (AROM) is allowed too early, healing of the rotator cuff may be compromised because of the stresses placed on the repaired tissues. The type of surgical procedure used, mini-open procedure or arthroscopic approach; the healing constraints must be considered for proper beginning of successful rehabilitation. Large cuff tears may require longer periods of time for recovery to achieve improved healing.¹⁵

Generally, recovery after SAD with or without rotator cuff repair follows a prescribed three-phase rehabilitation program.42,44 Phase I, the prefunctional phase, lasts approximately 3 to 4 weeks^39,44 and focuses on control of pain and swelling with NSAIDs, oral analgesics, ice packs, ultrasound, phonophoresis (if needed), infrared therapy, and various degrees and durations of manual range of motion (ROM), depending on the extent of tissue injury. The concept of early protected manual motion applies depending on the precise nature of the injury and which surgical procedure is used. The prefunctional phase should include increasing ROM, scapula stabilization beginning with retraction, and adding protraction when the patient has pain-free arm control.

With small rotator cuff repairs (less than 1 cm), isometric submaximal muscle sets of the shoulder extensors, flexors, abductors, external rotators, and internal rotators can begin as early as pain allows. Active assisted ROM (AAROM) activities beginning with manual exercise must be performed pain free. Active biceps and triceps exercises are performed in the neutral humerus position beginning with isometrics then progress to light resistive exercises. ROM and strength gradually increase as pain and swelling are controlled.

At the end of this phase, the initial use of the upper body ergometer (UBE) may be introduced. The early use of CKC activity with double-arm wall push-ups may be helpful for low level recruitment of shoulder muscles.44,46 With increased arm control strength and motion, phase II, the return to function phase, can begin. It generally lasts from weeks 5 through 12 after surgery. During this phase, progressive motion can be used, although with caution for repetitive shoulder abduction and forward elevation above 90°. The use of Thera-Band strengthening of the rotator cuff should be performed in a short-arc pattern of motion, normally in the standing positions.^18,44 In addition, dumbbell isotonic concentric and eccentric exercises for recruitment of the humeral head decompression (rotator cuff) may begin using short-arc pain-free ROM. This program is known as positional recruitment for the purpose of low-level strengthening and progresses according to the tolerance of the patent and demonstration of arm control.⁴⁴ During phase II, progressive strengthening exercises for elevation in scaption are performed in allowing for what is known as shoulder hike. Prone positional exercise, such as prone extension to hip (Fig. 21-6) and short-arc prone scaption at 100°, and eccentric training of scaption has been very useful in treating shoulder hike.^30,38,44 Progressive resistive exercises (PREs) are a major part of the return to function phase. With some patients, based on good pain-free response to all rotator cuff exercise, advanced scapula stabilization and oscillatory training such as the Bodyblade may begin (see Fig. 21-5).

Phase III, the return to activity phase, can begin once the patient can demonstrate normal motion without symptoms and with improved strength. This phase lasts approximately from week 12 to beyond. Return to activity always includes the continuation of PREs. This aspect of rehabilitation is for the long haul.⁴⁴ Advanced CKC exercises such as single-arm wall push-ups on an uneven surface may be introduced. For the advanced patient, plyometric activity with plyo-toss exercise may be used (Fig. 21-7).

During the return to activity phase the core rotator cuff strengthening exercises of forward elevation, scaption, prone horizontal abduction with external rotation, and press-ups, as well as scapular stabilization exercises of seated rows, prone scaption at 120° (Fig. 21-8), scaption, and press-ups for scapular protraction (push-ups with a plus)^20,33,38,44 form the foundation of improving strength that eventually leads to full functional recovery.

The prefunctional phases and periods of passive or manual control motion are extensive for rehabilitation after surgical repair of massive rotator cuff tears. Generally, no active shoulder motion or active concentric or eccentric strengthening is allowed for 2 to 3 months after surgery.¹¹ Extensive soft-tissue healing must proceed unabated to foster the recovery of functional motion and strength.

Initially the patient is placed in abduction pillow or shoulder immobilization after surgery to allow the repaired tissues of the rotator cuff and deltoid to be placed in a shortened position. Early active muscle strengthening and active motion are avoided to allow for appropriate healing. Generally, manual control passive ROM with full motion restriction is allowed during the first several weeks of recovery. AAROM activities, can begin 2 months after surgery.¹¹

Submaximal isometrics and scapular stabilization exercises must be added cautiously 4 to 12 weeks after surgery.11,44 Specific rotator cuff strengthening exercises¹¹ performed isotonically with dumbbells, Thera-Band, and similar devices are reserved until 3 months after surgery to accommodate the healing constraints of the tendons and muscles of the rotator cuff and deltoid. Full functional recovery of motion and strength may take up to several months after the repair of massive rotator cuff tears.^11,44

Nonoperative Management

The initial management of acute shoulder dislocations (anterior and posterior) calls for a period of protection lasting for up to 4 to 6 weeks.16,36 All positions that may reproduce the mechanism of dislocation are avoided. In some cases immobilization is needed to promote healing.

Management of pain and swelling is addressed with physician-prescribed NSAIDs, analgesics, ice packs, electrical stimulation, or other physical agents such as ultrasound and infrared. During the protection period, the hand, wrist, and elbow of the affected shoulder must receive active motion and strengthening exercises that do not compromise the shoulder. Also, a general conditioning program of strength, flexibility, and endurance activities can begin. With an anterior shoulder subluxation (spontaneous reduction of the humeral head) or dislocation, the patient must avoid shoulder abduction and external rotation to allow proper capsular scarring and soft-tissue healing to occur. It is interesting to note that patients older than age 40 years who are not at significant risk of recurrent dislocation because of a relatively sedentary lifestyle may only need minimal protection for a couple of weeks before rehabilitation can begin and motion can be regained.16,36

The prefunctional phase of rehabilitation begins with manual control ROM, active assistive stretching for elevation, and assisted ROM exercises to help the patient regain lost motion if a relatively lengthy period of protection was warranted.

Initial strengthening begins with submaximal isometric exercises that can be safely started while the patient’s shoulder is placed in the neutral humeral position. Isometric shoulder adduction and abduction, internal and external rotation, and elevation and extension can be performed at a pain-free level. Once the patient can demonstrate an increase from submaximal isometric contractions to near-maximal contractions, progressive internal and external rotation can begin with the affected shoulder in a minimal degree of abduction. When the symptoms of pain are reduced and the intensity and quality of muscle contractions are improved, the patient may increase ROM activities to forward elevation, extension, scapular mobility, and internal and external rotation and abduction. As the patient progresses to the return to function phase, combined shoulder abduction and external rotation are avoided. In fact, some authorities recommend avoiding extremes of shoulder abduction and external rotation for 3 months after removal of the sling.16,36 The hallmark of the return to function phases of recovery after anterior shoulder dislocation or subluxation is progressive strengthening of the rotator cuff, anterior shoulder muscles, and scapular stabilizers, with particular attention given to eccentric strengthening of the posterior rotator cuff (infraspinatus and teres minor).^22,42,44 Thera-Band and handheld dumbbell weights are effective because of the wide variety of motions that can be addressed and can carry over to home exercises. Please refer to the previous section on rotator cuff exercises for a recommended home program.

Synchronous shoulder motion, or scapulohumeral rhythm, must be addressed before and throughout recovery from a shoulder dislocation. The 2:1 ratio of motion between the scapula and glenohumeral joint (meaning that for every 2° of glenohumeral flexion or abduction after the first 30° of shoulder motion, the scapula must rotate upwardly 1°)²⁴ must be addressed early to prevent the facilitation of abnormal motions between the scapula and glenohumeral joint during strengthening activities. This can be accomplished adequately by focusing on normalized scapular motion and stabilization exercises during the return to function phase as long as symptoms of pain and harmful glenohumeral joint positions are avoided.

Throughout each phase of recovery, various tissues that contain the humeral head in the glenoid fossa (glenoid labrum, capsule, and ligaments; superior, middle, and inferior glenohumeral ligaments; and musculotendinous rotator cuff) can be stressed or torn. By definition, glenohumeral instability identifies ligamentous and capsular restraints as being “attenuated”27,28; therefore the appropriate progressive application of strengthening activities for the rotator cuff and scapulothoracic muscles becomes central to the recovery of motion and function.

One way the PTA can address functional motions and stimulate the afferent neural input system is through CKC activities. CKC activities can enhance proprioception and promote dynamic joint stability.16,28 Rhythmic stabilization through manual exercises and progression to other oscillation training such as the Bodyblade may be helpful.

Isotonic resistance exercises are quite challenging and stressful to the glenohumeral joint; consequently, many appropriate exercises must be modified to accommodate limitations of motion, pain, and the provocative positions of abduction and external rotation. The seated or supine chest press is an example of isotonic exercise that promotes anterior shoulder strength. However, this particular exercise can place the shoulder in a horizontally abducted position that stresses the anterior shoulder capsule, causing the head of the humerus to translate forward within the glenoid (Fig. 21-9). Progressive positional recruitment for strengthening using the PRE method is always continued throughout this phase of recovery.

Local muscle endurance activities are done using an UBE, CKC exercise with the use of hands on the stair-stepper (Fig. 21-10, A).⁴⁴ Weight-bearing closed-chain exercises such as wall push-ups (Fig. 21-10, B) for tri-plane strengthening can be introduced. These exercises provide proprioceptive stimulation to the mechanoreceptor system. Gradually, more challenging weight-bearing activities that demand progressive control of the glenohumeral joint in multiplane and diagonal motions are added (Fig. 21-11, A–C). A balance board also can help train the shoulder muscles to respond and fire quickly for sufficient stabilization (Fig. 21-11, D-E).

Cable systems offer various exercises and positions that duplicate functional activities. Cable systems are particularly useful in athletic patients, because sport-specific tasks can be reproduced with this equipment. In addition, a plyo-toss (plyometric) exercise for stabilization is part of the return to activity phase. Plyometric ball toss against a rebounder is an excellent exercise for advanced patterns (Fig. 21-12).⁴

The process of recovery after shoulder dislocation matches the degree of injury. Full functional recovery is not always possible. In some cases, minor stress causes the shoulder to dislocate again after acute traumatic dislocation. With repeated episodes of shoulder dislocation or subluxation, recurrent anterior instability can result.12,16 If patients fail to respond to an aggressive physical therapy program, the physician may choose one of several operative procedures to correct the instability. Patients with recurrent dislocations may receive an anterior capsulolabral reconstruction.⁷ Patients with multidirectional instability may require a procedure known as a capsular shift.²³

Operative Management and Rehabilitation

Because posterior shoulder dislocations account for only 2% to 4% of all shoulder dislocations,³⁶ this discussion focuses on repairs and rehabilitation procedures to enhance joint stability and promote function in patients with anterior glenohumeral instability. Surgical procedures for shoulder instability can be classified as open or arthroscopic techniques.^7,23,36

The anterior capsulolabral reconstruction procedure essentially reattaches the capsule to the glenoid. Sometimes this is referred to as corrective surgery for capsular redundancy. All labral lesions are also repaired. A superior labrum, anterior to posterior (SLAP) repair, which is the repairing of the superior labral lesion, may also be involved.

Patients with anterior shoulder instability corrected via arthroscopy normally experience less postoperative pain and reduced soft-tissue damage.⁴⁴ Rehabilitation after open or arthroscopic stabilization for anterior glenohumeral instability requires a prefunctional phase of rehabilitation that emphasizes protected ROM. Slow and protective external rotation is performed up to 12 weeks postoperative to ensure healing of all soft tissue. A recommended external rotation incrimination is as follows:

Initial postoperative care begins with a period of immobilization in a shoulder immobilizer to allow for appropriate soft-tissue healing.⁷ During this period, medications for pain and swelling may be prescribed by the physician. Frequently, ice packs are applied to the shoulder for 20 minutes, three to five times daily, as part of the home program to control postoperative pain and swelling. Also the patient can actively perform finger, hand, wrist, and elbow mobility exercises. In addition, submaximal isometric exercises can be initiated while the arm is still in the immobilizer. These must be performed pain free.

The degree and direction of shoulder motion allowed are specific to the surgical procedure, the wishes of the physician, and the direction of the PT. Generally, scapular protraction and retraction, manual control ROM, and assisted ROM exercises are performed to increase motion. The initiation of motion exercises is important because faulty scapulothoracic and glenohumeral mobility can be affected early. Care must be taken to encourage scapular motion, as well as glenohumeral mobility, and to identify any limitations affecting normal scapulohumeral rhythm. Progressive elevation and scapula control is recommended early in this phase of rehabilitation. Elevation is normally progressed to 135° to tolerance after 6 weeks postoperative. Slow progression of abduction is recommended. Therefore the PTA must be aware of the exact rationale behind limiting early active or passive shoulder abduction and external rotation.⁴⁴

Progressive motion and strengthening exercises are allowed as the patient progresses to the return to function phase. Progressive shoulder strengthening must address both the glenohumeral and scapulothoracic joints. To recover functional mobility of the shoulder, a program of positional recruitment is suggested. Because the scapula forms the base of support for glenohumeral motion, stabilization exercises must be advanced. As the patient demonstrates improved mobility without complaints of pain, the quality of muscle contraction (from submaximal to maximal) must be encouraged gradually. PREs using a Thera-Band, dumbbells, or both within an active, pain-free ROM can begin, along with more challenging flexibility exercises, between 6 and 8 weeks after surgery.⁷

The eccentric contraction phase of each exercise must be encouraged. Applying this concept during the return to function phase involves emphasizing the eccentric loading phase of all internal rotation, abduction, external rotation, adduction, and shoulder elevation exercises.⁴ Local muscle endurance also must be considered once the patient has achieved improved motion and strength. Usually an UBE or some other form of low-intensity, high-repetition shoulder-specific activity is appropriate. Functional activities, proprioception, and CKC exercises, are necessary for functional recovery.

During the return to activity phases of recovery, in order to stimulate the mechanoreceptor system, a complete program of advanced CKC exercises, plyo-toss (plyometrics) and sports specific training is designed. Generally the total length of rehabilitation after surgical stabilization of the glenohumeral joint ranges from 3 to 5 months.⁷

Total Shoulder Arthroplasty

With severe four-part fractures of the proximal humerus, AVN of the humeral head, osteoporosis, rheumatoid arthritis, and advanced osteoarthritis, the proximal humerus may be replaced with a prosthesis, or a total shoulder arthroplasty may be indicated.14,41 The condition of the rotator cuff is a significant feature in patients receiving a hemiarthroplasty or total shoulder arthroplasty. Goldstein¹⁴ reports that in patients suffering from rheumatoid arthritis, as many as 38% have a torn rotator cuff. If a rotator cuff tear is repaired in addition to the arthroplasty, postoperative immobilization may be as long as 4 to 6 weeks, with the affected arm held in an abduction splint to allow for healing of the repaired cuff.^2,14,47 When a patient has a massive rotator cuff tear or has had a revision of failed arthroplasty with rotator cuff tear a reverse prosthesis procedure may be needed. This procedure requires the surgeon to place the humeral component in the glenoid socket and the glenoid component into the proximal humerus. The rehabilitation objectives are usually the same as a regular arthroplasty,⁶ but in some cases the progress will be slower.⁴⁷

Thus a rotator cuff repair added to shoulder arthroplasty guides the course of rehabilitation and dictates the need for protective of limited motion, which leads to a longer program of rehabilitation.⁵ In terms of restoration of shoulder motion, if the rotator cuff is not repaired, progressive range of motion though goal setting of the PT is carefully guided to regain functional motion.⁴⁹

The prefunctional phase of rehabilitation after shoulder arthroplasty usually allows for early manual control assisted ROM and isometric exercises. Slow return toward external rotation is used to protect the healing of the subscapularis.⁴⁴ Isometric exercise may depend on soft-tissue healing and patient tolerance. Usually during the first postoperative week, the patient is allowed active exercise of the wrist, hand, and elbow of the affected shoulder. The postoperative immobilizer also is frequently removed for hygiene and exercises.¹⁴ By the end of the first week, the immobilization device may be removed and manual control exercises initiated and AAROM exercises are continued. At the end of the second postoperative week, the patient is introduced to scapular motion and stabilization exercises while the quantity and quality of isometric exercises and motion exercises are progressed.¹⁴ The assistant must encourage compliance with a comprehensive home exercise program of motion and strength. Wand-assisted exercises and pulley systems can be used as part of the home ROM program. Return to function phase will include light resistive strengthening, and more advanced scapula stabilization Thera-Band exercises are useful for the home exercise program. This usually begins between 4 and 6 weeks. Because the subscapularis has been taken down as part of this procedure, precaution is taken to protect against a return of external rotation that is too rapid. Additionally, early strengthening of the subscapularis is avoided to allow adequate heading of this muscle.⁴⁴

If the patient has received a rotator cuff repair or neural prosthesis, the sequence of care and initiation of resistance exercise and active shoulder motion may be delayed. Functional use of the affected arm can be expected around 4 months postoperatively. However, Goldstein¹⁴ suggests that for optimal results, the patient should participate in an active home exercise program long after discharge of rehabilitation.

Mobilization of the Scapulothoracic Joint

While the patient is in a side-lying position on the unaffected side, the scapula can be effectively mobilized in a superior and inferior direction, as well as distracted from the thorax. To distract the scapula, the PTA should stand facing the patient. The PTA should firmly grasp the medial or vertebral border of the affected scapula and purposefully distract the scapula away from the thorax (Fig. 21-13). To glide the scapula superiorly and inferiorly, the PTA should assume the same position and support the inferior border of the scapula. The PTA should use the hand on the inferior border to direct a force to glide the scapula in a superior direction, then use the hand on the superior border to direct a force to glide the scapula in an inferior direction.^21,44 In the same position the PTA can perform a lateral scapula glide. This technique is helpful to loosen subscapular soft tissue that may have become hypomobile during the postoperative or prefunctional phase of rehabilitation.

Mobilization of the Glenohumeral Joint

Anteroposterior glide of the glenohumeral joint can be accomplished with the patient supine. The PTA should sit near the affected shoulder. Wooden⁵¹ recommends putting towels under the elbow of the affected shoulder in this position, to place the humerus in a more horizontal position. The humeral head should be grasped firmly with the thumb and fingers of one hand while the scapula is actively stabilized with the other hand. If the glenohumeral joint is stiff and motion is applied to the joint without stabilizing the scapula, the glenohumeral joint and scapula will move as a single unit. While stabilizing the humerus with one hand, the other hand is used on the humeral head to provide an inferiorly or posteriorly directed force (Fig. 21-14).

Lateral distraction of the humeral head can also be achieved while the patient is supine. The PTA should sit near the affected shoulder, then abduct the affected shoulder to 45° and the arm is supported by the PTA’s hands. The PTA can use one or both hands to grasp the proximal humerus and direct a straight lateral force, effectively translating the humeral head from the glenoid (Fig. 21-15). Mild inferior glides of the glenohumeral joint may be helpful in regaining motion due to superior migration of the head of humerus.⁴⁴

GLOSSARY

Bankart lesion Dislocation of glenohumeral joint or repetitive subluxation may lead to fractures of the anteroinferior aspect of the glenoid rim.

Glenohumeral joint Greatest range of motion and least stable of any joint. Center core of motion.

Hill-Sachs lesion Glenohumeral joint dislocation or repetitive subluxation, may lead to bone defect on posterolateral aspect of humeral head. Hill-Sachs lesion is also called impression fracture.