A thorough examination of the shoulder should include evaluation of the cervical spine and an upper extremity neurologic examination. The opposite shoulder must also be examined for comparison. Inspection, palpation for tenderness, and range of motion (ROM) tests should be completed. Palpation should include the AC joint, sternoclavicular (SC) joint, subacromial space, biceps tendon, trapezius muscle, and cervical spine. Impingement sign tests as described by Hawkins, Misamore, and Hobeika13 (i.e., forward flexion to 90° and internal rotation) and by Neer and Welch¹⁴ (forward elevation and internal rotation) are performed to elicit pain. If these tests produce pain, then they are considered positive signs of impingement and suggest rotator cuff dysfunction. The rotator cuff muscles are tested for strength. Subscapularis muscle strength tests include the lift-off test and the belly-press test. The lift-off test places the arm behind the back and up the spine. The patient is then asked to lift the hand off the back against restriction. The belly-press test places the arms onto the elbows bent to 90°, and the elbows are then lifted anteriorly against resistance. Examination for instability is performed. Apprehension sign, a positive-relocation test, or inferior sulcus sign are all indicative of instability. Stability testing should be performed in different positions (i.e., seated, supine) to eliminate instability as the cause of secondary impingement. Evidence of rotator cuff pathology includes painful impingement signs or weakness and a painful arc of motion.⁵

Convention radiography is an important tool in the evaluation of rotator cuff tear pathology and is used to rule out arthritis and fractures, assess the morphology of the acromion, and look for calcifications about the shoulder. Arthrography is no longer the gold standard for identification of rotator cuff tears. Although reliable for the diagnosis of complete rotator cuff tears, it is less reliable for the evaluation of partial-thickness rotator cuff tears. MRI has evolved to provide an excellent noninvasive tool in the diagnosis of rotator cuff pathology and the shoulder labrum and is the modality of choice for the evaluation of cuff tear pathology, followed by ultrasonography. MRI provides information not available by other diagnostic testing, including muscle atrophy, amount of rotator cuff retraction in full-thickness tears, bursal swelling, the status of the AC joint, and the shoulder articular cartilage. The combination of intraarticular contrast (gadolinium) and MRI (magnetic resonance arthrography) has been developed to better delineate abnormalities of the rotator cuff and labrum including partial surface rotator cuff tears.15,16 Ultrasonography of the shoulder has increased in popularity, and as technical advances continue to improve, it has become an increasingly useful tool in the diagnosis of cuff pathology. Ultrasonography has several advantages. These include a relatively low cost, the lack of the contraindications as with MRI, and its use in the examination of the patient both statically and dynamically. Unfortunately, the accuracy of ultrasonography is operator dependent and typically requires a long learning curve.

Nonoperative treatment programs usually continue for 3 to 6 months. Success varies from 50% to 90%.17–21 Approximately 50% of patients with complete symptomatic rotator cuff tears have satisfactory results with nonoperative measures, but these results may deteriorate with time.²² This wide range of outcomes is likely the result of lack of uniformity in classification, indications, and treatment. Some individuals have rotator cuff tears with no pain and normal function, whereas others may have debilitating pain. This demonstrates a need for better understanding of the factors that lead to symptoms.

Indications for rotator cuff surgery include failure of 3 to 6 months of conservative care or an acute full-thickness tear in an active patient younger than 50 years. Failure of treatment can be determined before an entire rehabilitation course is completed. Indications for earlier surgical treatment can include return to full strength with persistent symptoms, failure to tolerate therapy because of pain, or plateau of initial improvement with persistent symptoms. Early surgical intervention is also indicated for patients sustaining acute trauma with full-thickness tears associated with significant rotator cuff weakness and posterior cuff involvement, particularly in young patients with higher functional demands. In addition, patients with acute tears or extension of chronic cuff tears may benefit from early surgery.23

In general, the duration of nonoperative treatment must be individualized based on pathology involved, the patient’s response to treatment, and individual functional demands and expectations.

Surgical management for impingement syndrome generally involves open anterior acromioplasty as described by Neer63 or arthroscopic subacromial decompression (SAD) with release or partial release of the coracoacromial ligament. The coracoacromial ligament is released from the undersurface of the anterior and lateral acromion. An acromioplasty is performed using a burr to achieve a flat acromion. If osteophytes are present on the inferior surface of the AC joint, they are removed from the distal clavicle. Partial thickness cuff tears may be bursal or articular sided. Partial thickness cuff tears may be treated with débridement alone, débridement and acromioplasty, or rotator cuff repair. A subacromial decompression/acromioplasty is generally indicated if the partial tear is bursal sided or there are signs of mechanical impingement. Partial rotator cuff tears greater than 50% of the width of the tendon generally are treated with arthroscopic repair insitu or transtendineus repair, or may be treated with takedown and repair of the rotator cuff either miniopen or arthroscopic.²⁴ Repair of partial-thickness tears improves results compared with débridement alone in this patient group. The overhead throwing athletes with rotator cuff disease have different requirements. Acromioplasty is rarely necessary in the throwing athlete.

Results of surgical treatment of low-grade (<50%) partial-thickness rotator cuff tears after débridement with and without acromioplasty have reported 75% to 88% satisfactory outcome on short-term follow-up.^18,25–27 Repair of a high-grade (>50%) partial-thickness tear has had similar outcome to débridement of a low-grade partial-thickness tear or repair of a small full-thickness cuff tear.²⁸

In the miniopen procedure, the lateral subacromial portal incision is extended either longitudinally or transversely to expose the deltoid fascia. The deltoid fascia is then split in line with its fibers directly over the tear. The anterior deltoid insertion of the anterior acromion is preserved. The deltoid fibers should not be split more than 4 cm lateral to the lateral acromion to avoid axillary nerve injury (Fig. 5-1). Rotation of the arm provides access to the tear. Digital palpation can be used to assess the adequacy of the acromioplasty. A bony trough is prepared in the greater tuberosity of the humerus. The rotator cuff may then be repaired through a bony bridge or with suture anchors. The permanent sutures are tied, pulling the rotator cuff down into its trough on the humerus.

Tears that are fixed, retracted, but reparable, may be repaired open using principles developed by Neer.5,6 An oblique incision in Lagers line from the anterior edge of the acromion to a point about 2 cm lateral to the coracoid process is made. The anterior deltoid is released from the anterior aspect of the acromion and splitting the deltoid no more than 4 cm lateral to the acromion (Fig. 5-2). The deltoid origin over the acromion is elevated subperiosteally. The coracoacromial ligament is released.

The anterior acromion is osteotomized. The acromion anterior to the anterior aspect of the clavicle is removed, and the undersurface of the acromion is flattened from anterior to posterior. The AC joint may be removed if arthritic and symptomatic. The distal clavicle is excised parallel to the AC joint so that no contact occurs with adduction of the arm.

The cuff tear is visualized and mobilized. A bony trough 0.5 cm in width parallel to the junction of the humeral articular cartilage and greater tuberosity of the humerus is made. The rotator cuff tear is repaired to bone with suture anchors or through a bony bridge in the greater tuberosity using permanent sutures (Fig. 5-3). The goal is to repair the cuff with minimal tension with the arm at the side.

Watertight repairs are not necessary for good functional outcome. Excellent and good results have been shown in patients with residual cuff holes.^29,30 The anterior deltoid is repaired back to the acromion by preserved periosteum or through drill holes with permanent sutures. Routine skin closure is performed.

Postoperative management of cuff repairs must be individualized to incorporate tear size, tissue quality, difficulty of repair, and patient goals. Passive motion is initiated immediately. In general, supine active-assisted motion is started on the first postoperative day. Waist-level use of the hand can usually be started after surgery. Active ROM and isotonic strengthening are started 6 to 8 weeks after surgery. Progress of strengthening is individualized with full rehabilitation taking from 6 to 12 months. Function can continue to improve for 1 year after surgery.

GOALS: Comfort, maintain integrity of repair, increasing ROM as tolerated without progressing to full range, decreased pain and inflammation, minimal cervical spine stiffness, protection of the surgical site, maintenance of full elbow and wrist ROM (Table 5-1)

Refer to Box 5-2 for a shoulder evaluation following a rotator cuff repair. The therapist must maintain the protection of the patient and the surgical repair while obtaining an evaluation; therefore, some tests will need to be deferred until later in the treatment process.

To reduce pain and swelling, use cryotherapy. Electrical stimulation may also be used for pain reduction. Instruct the patient in posturing for comfort. Encourage the patient to experiment with different positions. Usually a loose packed GH position (shoulder in some flexion, abduction, and internal rotation) with the arm supported by pillows while supine or sitting is more comfortable. Usually patients cannot sleep much after surgery in the supine position. Therefore suggest sleeping semireclined in a recliner chair with the upper extremity supported in the loose packed position. The patient may also try the supine position in bed, with the arm supported by pillows in a loose packed position.

Gentle mobilizations using grades I and II oscillations, and distractions may help reduce pain, muscle guarding, and spasms. These mobilizations also help maintain nutrient exchange and therefore prevent the painful and degenerating effects that long periods of immobilization produce (i.e., a swollen and painful joint).¹⁸ Occasionally, some people produce increased levels of scar tissue and tighten up quickly. For these cases, passive exercises provide nourishment to the articular cartilage and assist in collagen tissue synthesis and organization.^49–51 The organization of collagen may then follow stress patterns, and adverse collagen tissue formation may be minimized. Limited periods of PROM and pendulum exercises are initiated during this initial stage. For large to massive tears, consider withholding PROM exercises until 4 weeks postsurgery. Recently, it has been suggested that early ROM or excessive ROM treatment of the GH joint may delay tissues from healing. Therefore, when conducting PROM treatments, be careful to protect healing tissues from too much stress from ROM exercises. PROM exercises are done in protected planes. PROM exercises for shoulder flexion are initiated in the scapular plane with the elbow flexed 90°, and external rotation is done with the palm facing the patient and beginning at 45° of abduction.⁵² Performing PROM exercises in the scapular plane is beneficial because of decreased tension on the capsuloligament-tendon complex.⁵² “Rotation exercises should be initiated at 45° of abduction to minimize tension across the repair.”⁵²

Remember to avoid horizontal adduction, extension, and internal rotation during this phase. Also advise patients to avoid leaning on the elbow, sleeping on the affected side, sudden movements, pushing/pulling, lifting, and carrying for 12 weeks.⁵³

A general guideline to use in judging the force being applied is slight discomfort with a slight increase in motion after several repetitions. Remain sensitive and aware of the feedback the patient’s body is exhibiting during ROM or mobilization techniques. The patient’s response will dictate the amount of force applied or the plane of movement chosen. If muscle guarding continues to increase after several repetitions, the force being applied should be reduced or the plane of movement chosen needs to be slightly altered or decreased (or both need to be done) to avoid pinching sensations or increased pain. The therapist usually can find a groove (i.e., line of movement that can be progressed more easily) or line of motion with less muscle guarding. Therefore, constantly assess treatment application while treating the patient with manual PROM. Vary the treatment application as the patient’s feedback dictates (i.e., exact plane of movement, force, and repetitions). An increase in ROM will often accompany a decrease in pain if executed with a sensitive hand. However, general treatment soreness may be expected. Treatment soreness is usually more pronounced when progressing the patient from PROM to active range of motion (AROM) and then again when progressing to resisted ROM exercises. Remember during this stage we do not want full ROM. The superseding goal is to provide an environment where the tissues can heal while preventing stiffness.

Patients usually exhibit protective muscle guarding from the necessary insult of the surgery and the preceding shoulder pathology. Muscle guarding is present in the cervical region and the shoulder musculature. Therefore patients perform cervical AROM exercises and stretches. Appropriate cervical spine mobilization techniques may be valuable for decreasing cervical joint stiffness and muscle guarding, allowing more unrestricted movement of the shoulder complex.

GOALS: Protection of surgical site, improvement of ROM, increase in active strength, decrease in pain and inflammation, maintenance of elbow and wrist ROM, and minimizing of cervical stiffness (Table 5-2)

During the second phase, the therapist should avoid overstretching muscles into positions that could compromise the repaired tissues (e.g., horizontal adduction, internal rotation beyond 70°, shoulder extension).

Strength should begin to improve, with the patient progressing from PROM to active assistive range of motion (A/AROM) to AROM movements against gravity. A/AROM can begin at 6 weeks, and AROM can be initiated as able after 7 to 8 weeks. Submaximal isometrics can be initiated to eliminate neuromuscular inhibition, reiterate muscle firing, and retard muscle atrophy. The therapist can incorporate active assistive proprioceptive neuromuscular facilitation (PNF) D1 and D2 patterns to mimic functional movements and strengthen the areas in functional planes.15 In the D1 pattern, the shoulder moves into flexion-abduction-external rotation. With the D2 pattern, the shoulder moves into extension-adduction-internal rotation.^21,41 Initiate these exercises in the supine position with the assistance of the therapist using PROM. Then progress to A/AROM in D1 and D2 patterns. Near the end of this phase, use independent performance of the PNF patterns in the supine position, advancing to a standing position when able. Eventually, active shoulder flexion, external rotation, and scaption exercises (Fig. 5-4) are performed after 7 weeks. Active shoulder flexion and scaption are usually initiated between zero and 70° (with the elbow bent at 90°) and progress according to the patient’s ability to execute these exercises correctly. Incorrect performance of shoulder elevation exercises can lead to impingement problems. Again evaluate for cervical spine (C/S) and thoracic spine (T/S) issues that may be causing secondary issues of pain and muscle tightness. Address joint or soft tissue issues.

Precautions at this stage include no resisted exercises for 8 weeks. Between 6 and 12 weeks, advise patient to only perform waist level activities and no heavy lifting for 4 to 6 months. Marked increases in swelling, pain, or wound drainage (or the presence of red, streaking marks) must be reported immediately, and exercises should be discontinued.

GOALS: Expansion of ROM, avoidance of impingement problems, gaining of near full ROM, increased strength, alleviation of pain, increased function, and decreased soft tissue restrictions and scarring (Table 5-3)

To advance to this phase, the patient should have minimal pain, near full ROM, and greater than three over five for strength generally throughout the shoulder movements. Often when progressing a patient to a new level of exercises (i.e., going from A/AROM to AROM) muscle soreness will be more pronounced initially. The patient will usually adapt to the new demands of the program within the first week.

During the period from 9 to 12 weeks after surgery, the patient should progress to full ROM. By 12 weeks the repaired tissues are now strong enough to tolerate stretching within the patient’s tolerance level. Passive stretching of the internal and external rotators is important. Tightness in these areas could promote abnormal shoulder mechanics, particularly in the throwing athlete. Tight external rotators lead to anterior translation and superior migration of the humeral head, which can produce impingement problems.⁵⁴ ROM will normally progress without much difficulty.

AC joint pain is common in many patients who have undergone rotator cuff repair. The symptoms may result from a previous trauma, be caused by primary generalized osteoarthritis (OA), or follow abnormalities in the GH joint, such as degeneration and rupture of the rotator cuff.¹⁷ The AC joint will especially be tender if an acromioplasty was performed. When the AC joint is hypomobile and symptomatic, mobilization can help alleviate a portion of the symptoms and allow greater mobility (Fig. 5-5).

After the incision is healed and closed, the therapist can apply soft tissue mobilization over the incision areas and instruct the patient in massaging the scarred area. Early movement minimizes tightness from scarring. Normal skin mobility allows normal movement to occur.⁹

Resistance exercises are initiated around 10 weeks. Patients should demonstrate correct active movements before resistance is added in a particular range. The patient must perform the resisted exercises correctly or the movement needs to be altered. Isotonic exercises are important for strengthening and promoting dynamic shoulder stabilization. The humeral head stabilizers are used during this phase. The supraspinatus, infraspinatus, teres minor, and subscapularis muscles pull the humeral head securely into the glenoid and control humeral rotation so that the humeral head stays in good alignment with the glenoid.⁴⁹ In addition, it should be noted that the primary depressors of the humeral head during shoulder elevation are the infraspinatus, teres minor, and subscapularis muscles. Because the infraspinatus is involved in two critical force couples about the GH joint, the quality of shoulder motion is directly related to its function.⁵²

When resisted exercises are initiated, begin external rotation with hand-held weights with the patient in a side-lying position on the unaffected side. The elbow is maintained in 90° of flexion, and the patient starts with the shoulder in internal rotation, then moves into external rotation (Fig. 5-6, A and B). Eventually the patient can be progressed to concentric-eccentric movements using a Thera-Band for external rotation and internal rotation. An axillary roll can be placed under the shoulder to avoid a fully adducted position, which can cause a vascular stress on the supraspinatus and biceps tendon.^10,26 Resisted elbow flexion exercises can be done with exercise tubing for the biceps. The long head of the biceps brachialis has been revealed as a strong humeral head depressor and acts to steer.⁵² Baylis and Wolf⁵⁵ described a “four square” combination of tubing-resisted exercises for shoulder flexion, shoulder extension, internal rotation, and external rotation (see Fig. 5-6), followed by stretching of the external rotators and abductors.

Remember that proximal stability is essential for controlling distal mobility.⁴¹ Moseley and associates⁵⁶ reported that four exercises appeared to significantly enhance recruitment of the scapular muscles. These exercises included shoulder elevation in the scapular plane, upright rowing, a press-up, and a push-up with a “plus.”⁵² Shoulder flexion and abduction exercises in the scapular plane (instead of the straight planes) are more functional and less problematic to the rotator cuff. Prone rowing can also be done (Fig. 5-7). Rowing is excellent for all portions of the trapezius, levator scapula, and rhomboids. These muscles help maintain the scapula in good alignment during shoulder movements. The higher and the lower trapezius musculature stabilizes the scapula for overhead activities. In addition, prone horizontal abduction can be incorporated to strengthen the rhomboid major and minor and the middle trapezius muscles (Fig. 5-8).⁵⁶ Dynamic hug exercises are a good way to begin strengthening the serratus anterior muscle. Progressive push-up exercises will strengthen the serratus anterior and the pectoralis minor muscles. A seated push-up with a plus was found to be effective in recruiting the serratus anterior with less activity of the trapezius musculature.⁵⁶ At this stage patients should use their legs to assist themselves with the exercise (Fig. 5-9). Push-ups are initiated into the wall at this time; later they can be progressed to table height, then performed on the floor “ladies’ style,” and finally some patients are progressed to a complete push-up. Press-ups and seated push-ups are done with active patients. They can be initiated with support from the lower extremities and eventually progressed to only balance assisted by the lower extremities. These exercises help strengthen the serratus anterior muscle, which encourages humeral head depression with shoulder elevation. Older, more sedentary patients can strengthen their serratus anterior muscle using a Swiss ball (Fig. 5-10).

Resisted exercises also are performed in PNF patterns to strengthen the muscles in functional patterns. A frequently used pattern is the D2 pattern using both concentric and eccentric contractions. This is particularly effective in throwers. Manual resistance is again incorporated for rhythmic stabilization exercises and slow reversal hold techniques.^21,41 If strength is not sufficient to overcome light resistance then begin with a hold pattern or a hold position in the weak area of the range. During rhythmic stabilization, the most commonly used angles are 30, 60, 90, and 140 of shoulder elevation.⁵² This movement will stimulate muscle contractions around the GH joint, promoting the joint force couples to work more efficiently and encouraging better dynamic stabilization of the humeral head.⁵² Good angles to work on with rhythmic stabilization are areas of increased weakness; therefore one can specifically strengthen at the weakest point, allowing improvement for the entire movement.

Strengthening begins with normalizing AROM while initiating light resistance into an appropriate arc of motion. AROM for shoulder elevation begins with the elbow flexed. The patient can add light resistance when he or she performs active elevation correctly with the elbow extended. Resistance may be added for elevation up to 70° of motion and progressed as the patient is able to perform AROM correctly through 80° and progressing to 150° of elevation. The patient must also demonstrate good scapular humeral mechanism without pain and perform 20 repetitions. This must be executed correctly before resistance is added.⁵³ If challenged by 10 repetitions but able to do 20, then maintain the level of resistance. Do not train for power. The patient needs good muscle endurance over time, therefore do 30 repetitions before gradually increasing the load.⁵³ When using resistance, begin abduction movement to 45°. Shoulder flexion can be performed between 70° and 80°. External rotation can be initiated in a supported position, then advanced to unsupported. When using a Thera-Band, have the patient begin with yellow and do 10 repetitions. If challenged and eager to rest, then go to another exercise. If easy then do 10 more repetitions. If still easy then do another set of 10 repetitions and move on. If the patient executes 30 repetitions well, the therapist may gradually increase resistance.⁵³ Even today, the low intensity resistance, high repetitions technique may be the best regimen for athletes with injuries of insidious onset and during early rehabilitation phases.⁵⁷ By 20 weeks, the athlete can advance to heavier weight lifting.⁴⁸

In my experience, the Body Blade has been helpful for active patients. Exercises with the Body Blade are initiated with the shoulder and upper arm against the trunk. Eventually patients progress to operating the Body Blade with the arm extended away from the body and elevated. In even more advanced stages, patterns of motion can be followed while maintaining the oscillations of the blade and proper body mechanics. These exercises enhance contractions around a joint, increase strength, a increase proprioception, as well as improve coordination and increase endurance. The Body Blade has also been shown to produce greater scapular activity than traditional resistance techniques.⁵⁸

Often times, older patients with fair tissue status and massive tears have difficulty progressing to active shoulder flexion against gravity. Eccentric shoulder flexion exercises without weights help provide these patients with a transition to active shoulder flexion. Help patients lift their arms in the scapular plane above their heads; then instruct them to lower their arms without allowing them to fall. These patients also need to emphasize strengthening of their humeral head depressors. Finally, have them exercise in front of a mirror so that they can readily correct the tendency to hike their shoulder.

Strengthening of the trunk and legs is important for athletes. Numerous studies indicate that the trunk and legs are responsible for more than 50% of the kinetic energy expended during throwing (see Chapter 13). Endurance training also begins during this phase. Patients begin on the upper body ergometer with short-duration and low-intensity bouts, and then they advance to longer durations and higher intensity bouts. Modalities are minimally used during this stage. Pain is generally minimal but will increase with moderate to dramatic changes in activity levels.

Precautions are necessary when initiating isotonic shoulder elevation exercises. All exercises should be performed with little or no joint pain. Complaints of muscle discomfort are acceptable and even desirable.¹⁹ However, if the patient complains of sharp pain through particular ranges, then the therapist needs to modify the exercises to avoid a painful arc.

GOALS: Maintenance of full ROM, increased strength and endurance, improved function (Table 5-4)

The patient should have full ROM by 13 to 16 weeks. If this is not the case, then progressing with ROM needs to be the primary focus during treatments until this has been achieved. The therapist can emphasize more aggressive mobilization using grades +3 and +4 on the GH capsule to stretch the specific areas of capsular restrictions, thereby normalizing arthrokinematics at the GH joint. These mobilizations also can be performed near the physiologic end ROM, and they can be performed near end of ranges in conjunction with combined movements (refer to the question-and-answer scenario for an application example). Adequate capsule laxity is necessary to allow normal rolling and gliding between the bony surfaces of a joint. Patients should continue the necessary stretches to gain and maintain ROM in restricted areas (Figs. 5-11 through 5-13 illustrate some of the suggested stretches).

It should be noted that with throwing athletes the anterior capsule does not need to be stretched as much. Patients with anterior instability issues should not exercise near extreme ranges of abduction and external rotation. Those with posterior GH instabilities should avoid extreme ranges of horizontal adduction and internal rotation.

If the patient cannot elevate the arm without shoulder hiking (i.e., scapulothoracic substitution), then continue to focus on the humeral head–stabilizing exercises and exercise the humeral head depressors. Remember the primary function of the rotator cuff is to provide good humeral head alignment with the glenoid fossa; this must be mastered before any complex movements are initiated. The efficiency of the GH force couples is vital for success. The primary couples of the GH joint are the subscapularis counterbalanced by the infraspinatus and teres minor and the anterior deltoid and supraspinatus counterbalanced by the infraspinatus and teres minor.

Strengthening exercises are progressed with progressive resistance exercises (PREs) progressing to 3 to 5 lb or the green Thera-Band if able. See Fig. 5-16 for exercises using the Thera-Band. The supraspinatus and infraspinatus muscles (also known as decelerators) produce slow, controlled movements. These muscles are subjected to larger stresses and also are injured more frequently in overhead sporting activities.⁵⁹ Through the use of electromyographic studies, Blackburn found that the best isolation for the infraspinatus and teres minor muscles occurs during prone exercises incorporating horizontal abduction and external rotation. An optimal exercise for athletes who need GH congruity and stability is prone external rotation with the shoulder at 90° abduction and the elbow flexed to 90°.⁶⁰ These exercises should be performed at a functional speed starting without weight then adding resistance.⁶¹ Resisted external rotation with abduction is another good strengthening exercise for athletes.

Continue with push-ups while leaning into a wall and progress to ladies’ style push-ups if able. More active patients or athletes can progress to the standard push-ups on the floor, as previously mentioned. Closed-chain exercises help promote cocontractions and enhance dynamic joint stability.⁶²

Therapists must also consider the neuromuscular system that provides joint stability through proprioceptive awareness, because proprioceptive training of the shoulder can lead to improved neuromuscular control, which can improve the overall dynamic stability of the GH joint.⁶³ Appropriate shoulder exercises using the Body Blade provide proprioceptive training, dynamic-stabilization training, and endurance training. Eventually (during the later stages of rehabilitation) the patient can be progressed using the Body Blade through a vast range of shoulder movements, allowing athletes and workers to train and exercise in specific patterns or postures. These movements mimic a pattern of movement or a position used during a sport or work activity. In a later phase, resistance can be added to these movement patterns with the use of a Thera-Band (see Fig. 5-17). Caution must be used while progressing the patient from 10 to 18 weeks because pain is usually absent.

GOALS: Maintenance of full ROM, increased strength and endurance, improvement of neuromuscular control, return to functional activities, initiation of sport-specific activities (Table 5-5)

The therapist can continue the stretching program and instruct the patient in self-mobilization techniques if indicated. The patient can maintain a shoulder-strengthening program and continue PREs with increasing hand weights. Isokinetic training can also be beneficial. These exercises can be performed throughout the range because of the accommodation factor in isokinetic training. If a patient cannot move through the resistance at a particular arc of motion, he or she still can train with resistance throughout the whole range.

Athletes and other appropriate patients can begin plyometric exercises, which involve a stretch-shortening cycle of the muscle. Plyometrics can be performed two times a week. All sporting movements involve this explosive stretch-shortening cycle (e.g., jumping, throwing, running, swimming).⁴⁵ Progressive plyometric exercises are done with appropriate patients who exhibit correct execution of the exercises. Recreational and competitive athletes perform exercises at higher speeds, using more eccentric muscle contractions and higher level progressions. These exercises are excellent intermediate steps between traditional strengthening exercises and training activities before initiating throwing drills.⁶³

Resisted exercises using tubing with concentric-eccentric contractions, isokinetics, and scapulothoracic strengthening can be done. Athletes or workers required to do continuous overhead activities can perform exercises with a Thera-Band for external rotation, starting with an axillary pillow between the trunk and arm, then to the scapular plane position, and then to the 90°/90° position if able. D2 diagonal patterns can be executed with tubing. Latissimus strengthening and scapular retraction exercises can be performed using a Thera-Band.⁶⁴ Athletes and higher level patients can perform these exercises at a faster and higher speed while maintaining control over the movement. They can also perform at a slower and more deliberate pace. Specific applications of eccentric training to the posterior cuff using a Thera-Band and/or isokinetics are essential to pitchers and ball players.

Later, when the patient is ready, initiate sport-specific drills for athletes along with an interval sports program (see Chapter 13). Throwing techniques need to be evaluated.

If the patient is using bad body mechanics, using improper techniques while throwing, or both, then tissues may be overstressed, eventually causing rotator cuff problems once again. Older, sedentary patients should work on specific ADLs. As appropriate, patients may progress to more difficult tasks.

In general golfers can usually start putting at 14 to 16 weeks and then progress as able. At 20 to 22 weeks tennis players can begin hitting their forehand and backhand strokes and progress to serving. And swimming can be initiated between 20 and 26 weeks. By 7 to 9 months the athlete may be able to reengage in sports activities competitively.

During weeks 22 to 26 patients maintain a stretching and strengthening program. Athletes continue on strengthening and on a sports interval program. Others gradually progress to recreational activities. Older individuals continue to progress with PREs and work on more advanced ADLs. The ability to return to more high-level activities ranges from 26 weeks to more than 1 year after surgery. After 26 weeks, patients continue with their stretching and strengthening program as long as they anticipate using the shoulder aggressively in ADLs or sports. The patient can maintain a shoulder-strengthening program and continue PREs with increasing hand weights up to 6 to 10 lb for athletes or 1 to 5 lb for more sedentary people. Isokinetic exercises may be initiated with athletes when they are able to lift 5 to 10 lb in external rotation and 15 to 20 lb in internal rotation without pain or significant edema.38 The patient should begin strength and endurance training at 200°/second.^38,72

Common patterns in cervical pathology are addressed to assist clinicians with differentiating shoulder and cervical symptoms because they frequently occur together. Spinal disorders may cause referred pain (Fig. 5-14). Joint movement disorders may cause joint pain and be associated with an altered range of cervical spine joint movement or shoulder movement. Therefore the cervical spine should be assessed for additional joint disorders that may be causing local pain or pain that is referred into the shoulder and arm region.³² (Suggested readings for treatment of the cervical spine are Practical Orthopedic Medicine by Corrigan and Maitland³² and Vertebral Manipulation by Maitland.³⁶)

Thoracic mobility affects shoulder mobility. During unilateral shoulder flexion, contralateral side flexion of the spine occurs; bilateral shoulder flexion produces spinal extension.22 Therefore decreased thoracic extensibility or increased thoracic kyphosis can inhibit shoulder ROM.⁶⁵

Postural education is important, especially with patients who can voluntarily correct and maintain good posture. Maintaining an erect posture while performing upper extremity activities allows greater ROM at the shoulders. Better posture decreases the amount of impingement, which a patient can see in the following maneuver:

The patient will be able to lift the arm higher when maintaining a more upright posture. A slouched position causes depressed forward-displaced shoulders and GH internal rotation. The potential for shoulder impingement increases with this type of posture.⁶⁵

Evaluation and treatment of the thoracic spine may prove helpful for patients having difficulty progressing in ROM in the latter stages. Addressing issues of hypomobility and decreased ROM of the thoracic spine and treating them appropriately allows for better progress. Mobilization of a hypomobile thoracic spine and ROM exercises to increase thoracic extension (e.g., supine on a Swiss ball) can be beneficial. A foam roll also may be used when appropriate to increase thoracic spinal extension and mobility (Fig. 5-15). (Vertebral Manipulation³⁶ offers instruction on evaluation and treatment of the thoracic spine.) With regard to positioning, the therapist also must consider protection of the shoulder and the surgery site.

If complaints of pain persist in the cervical spine region, then assess for contributing factors arising from the thoracic spine. Mobilization to a stiff thoracic spine (if warranted) may alleviate some or all of the cervical pain that continues to persist.⁶⁶

The nervous system can be directly mobilized through tension tests and their derivatives.40 Adhesions in neural tissue can affect shoulder movement and strength, and may influence the patient’s progress. However, the therapist must be aware of any precautions or contraindications. A good evaluation is necessary for addressing adverse neural tension issues. Neural tissue mobilization can be effective when used with appropriate patients to help relieve some of the symptoms and potentially improve ROM and strength. These issues may be better addressed during the latter phases of rehabilitation when the tissue repair has healed and shoulder ROM is only minimally limited or not restricted. Clinicians trained in neural tissue mobilization should only perform treatment to the nervous system. Avoid placing a stretch on the nerves.

The objective is to move the nerves, mobilizing them without stretching them. Increase in symptoms such as pain, numbness, tingling, and paresthesias down the arm may indicate the nerves are being stretched.⁷³

OA in the AC joint is not uncommon.67 It may result from previous trauma or be part of a primary generalized OA, impingement, or capsulitis. OA in the AC joint also may follow other abnormalities in the GH joint (e.g., degeneration and rupture of the rotator cuff) that allow the head of the humerus to sublux upward.³² In our experience, many patients with repaired and unrepaired rotator cuff tears have some symptoms arising from the AC joint.

Because the movement of all of the joints affects the shoulder complex, it is essential to evaluate and treat the entire shoulder complex to improve upper extremity function.⁶⁸ Table 5-6 shows some of the joint movements that occur within the shoulder complex. Restrictions in one area will affect other areas of the shoulder complex.

Complaints of AC joint pain are usually localized over the joint. An active movement that may best implicate this joint as a source of pain is horizontal adduction of the arm across the chest. The therapist may determine whether the AC joint is hypomobile or hypermobile by passive accessory movement tests of the joint.⁶⁹ If the AC joint is stiff and tender, then its mobilization often relieves a portion of the symptoms and promotes better shoulder ROM. The AC joint may also be tender from an acromion osteotomy if performed with the rotator cuff. Eventually gentle movements of the AC joint may be beneficial when the patient can tolerate the treatment. If the AC joint has been removed because it is arthritic or symptomatic then do not attempt to mobilize the area.

Accessory movements can be applied to the clavicle or acromion. When applied to the clavicle, they affect only the AC joint; however, when applied to the acromion, they affect both the AC and GH joint.⁶ Accessory AC joint movements should be used within the limits of pain. To increase motion at the AC joint, the therapist can use an anterior glide to the acromion through the posterior spine of the scapula while stabilizing the midclavicle. This allows mobilization of the AC joint without direct manual pressure over the joint or inflamed tissues.

As the available shoulder ROM progresses, this same technique can be applied with the shoulder in some degree of available flexion or in horizontal adduction (see Fig. 5-5).

Corrigan and Maitland³² describe a similar technique for the AC joint. In this method an anterior-posterior movement is produced by applying pressure over the anterior surface of the outer third of the clavicle with counter pressure along the spine of the scapula.

Degenerative changes are not found as commonly in the SC joint as in the AC joint but may occur as the result of trauma or overuse of the shoulder.70 Movements such as shoulder abduction or flexion may increase pain originating from this joint because of rotation of the inner end of the clavicle. SC joint pain is usually localized to the SC area, but it may radiate to other areas. Signs that implicate the SC joint as a contributing factor include reproduction of pain with horizontal flexion and passive accessory movements of the SC joint. The capsule and surrounding ligaments are likely to be thickened and tender.⁶⁹

Treatment of the SC area includes rest, modalities, and mobilization, depending on the condition of the joint.³² A hypomobile SC joint may be correctly mobilized in several ways depending on its restrictions. To increase shoulder elevation, a caudal glide to the proximal clavicle can be used.^32,37

Scapular muscles have been included in the rotator cuff repair protocol. However, some patients require more intense conditioning of these muscles. The scapula moves with concentric-eccentric motions. Patients with poor eccentric control of the scapular stabilizers demonstrate scapula winging on the return from full shoulder flexion. The serratus anterior is essential for stabilizing the medial border and inferior angle of the scapula, preventing scapula internal rotation (winging) and anterior tilt.60 These same patients may have full ROM and normal movement during flexion. If muscle weakness is apparent, then ensuring normal muscle strength around the scapulothoracic and GH joints is the goal. If the scapular muscles are weak and overstretched, then scapular motion during arm elevation may result in excessive lateral gliding of the scapula. Abnormal scapular muscle firing patterns, weakness, fatigue, or injury causes the shoulder to function less efficiently and the risk of injury increases.⁶⁰

The therapist can use various PNF techniques, such as scapular slow reversal holds, rhythmic stabilization, and timing for emphasis, to intensify the dynamic control and kinesthesia of the scapulothoracic joint. Other recommended exercises are scapular protraction, retraction, elevation, and depression against manual resistance.⁷¹

Exercises are encouraged that enhance dynamic control of the scapulothoracic musculature.⁷¹ These should be directed to the scapular rotator muscles (i.e., the serratus anterior, rhomboid, trapezius, levator scapula) to position the glenoid and coracoid appropriately for the humerus. Exercises that mimic the rowing motion and shoulder horizontal abduction are both excellent for all portions of the trapezius and for the levator scapulae and rhomboid muscles. Flexion and scaption (i.e., scapular plane elevation) exercises are valuable for most of the scapular muscles (see Fig. 5-4). In addition, shoulder shrugs and press-ups with a plus are essential exercises for the levator scapula, upper trapezius, serratus anterior, and pectoralis minor muscles. Also refer to the “Prone Program Plus” for more exercise ideas.