Structural Injury to the Rotator Cuff

Although traumatic tears of the rotator cuff have been reported even in children, structural injury to the cuff is most characteristic in those older than age 40 years. Rotator cuff tears are so characteristic of the elderly population that anyone older than age 60 with shoulder pain can be presumed to have a rotator cuff tear until proved otherwise. Younger patients with cuff symptoms tend to have only irritation of the rotator cuff (tendinosis) rather than structural injury, with their pathology and symptoms frequently being the secondary manifestation of occult primary pathology such as glenohumeral instability, tears of the superior labrum, scapulothoracic dyskinesia, core stability deficits, or poor biomechanics.

Rotator cuff pathology may be of insidious onset, but it is most often produced by a traumatic event or acute overuse, particularly with an abduction/external rotation mechanism. In the elderly, rotator cuff tears frequently occur during falls. Night pain is characteristic of primary rotator cuff pathology and may be severe enough to prevent sleep or awaken the patient from sleep if she or he rolls onto the affected shoulder. Patients with cuff disease find relief by placing the affected arm overhead with the hand behind the head (the so-called Saha position). Pain is minimal with use of the arm below breast level and is maximal between 90 and 120 degrees of active elevation/abduction. Lowering the arm from the overhead position is often more painful than raising it. Patients may describe crepitus, which is associated with chronic full-thickness cuff tears or thickening of the cuff during chronic tendinosis and scarring of the subacromial space.

Pain is localized to the subacromial area or the anterior/lateral corner of the acromion, with radiation down the lateral arm to the vicinity of the deltoid insertion. The pain is characteristically of a dull aching quality, with the superimposition of a sharper stabbing pain with use of the arm in the overhead position or with internal rotation. Rotator cuff pain does not radiate distal to the elbow.

Rotator cuff pain is characteristically mitigated by anti-inflammatory medications, especially subacromial corticosteroid injections, but with diminishing returns over time.

Glenohumeral Instability

Glenohumeral instability is the most common underlying pathology producing shoulder symptoms in patients younger than 30 years of age. In children and teenagers, it is virtually the only likely pathology. In the elderly population, instability is associated with massive rotator cuff tears. In many instances, the symptoms reflective of glenohumeral instability had a traumatic origin of which the patient is aware. Apprehension with use of the arm in a specific position is a subjective sign of instability, but it is important to keep in mind that a great many patients with glenohumeral instability have no subjective awareness of that fact.

When the diagnosis of instability is suspected, an important goal when taking the history is to ascertain: (1) the degree of instability (subluxation versus dislocation), (2) the onset (traumatic versus atraumatic or overuse), (3) the direction or directions of instability (anterior, posterior, or multidirectional), and (4) whether there is a voluntary component.

The most common direction of instability, whether traumatic or occult, is anterior/inferior. The direction of instability can be determined during the history with specific questions related to the arm position that produces symptoms: external rotation, with or without abduction reflects an anterior/inferior laxity pattern (e.g., pain with the cocking position during throwing). Pain during the follow through when throwing or during activities that position the arm in forward flexion/adduction/internal rotation suggests posterior instability. Pain that is associated with activities that apply primarily inferior distraction force to the shoulder, such as carrying a heavy object like a suitcase or a pail of water, suggests inferior capsular laxity and multidirectional instability.

Subtle glenohumeral instability is associated with a nondescript level of discomfort and diffuse pain about the shoulder girdle. The discomfort is characteristically poorly localized and may be scapular and at the posterior joint line, or anterior subacromial mimicking rotator cuff discomfort. Often patients will relate that use of the arm overhead produces numbness and tingling radiating down the arm without a specific dermatomal distribution. This is known as the “dead arm syndrome.” A history of repetitive microtrauma, such as participation in swimming or throwing sports, without proper pre-participation conditioning is characteristically present when atraumatic glenohumeral instability produces symptoms in teenage athletes. Although labral pathology is often associated with glenohumeral instability, its presence cannot generally be predicted by specific questions during the history.

If occult glenohumeral instability was not recognized, there are associated deficits in scapulothoracic function and core stability, or poor technique was not adequately addressed during treatment, there may be a history of failed medication use, rehabilitation, or surgery.

Detachment of the Superior Glenoid Labrum

Tears of the glenoid labrum (i.e., SLAP lesion) do not generally produce unique primary symptoms that distinguish the pathology. Patients may describe pain generally located in the posterior shoulder or “deep inside” the joint. Large labral tears may produce “clicking” or “catching” sensations. Characteristically, they produce secondary rotator cuff symptoms or are associated with a history suggestive of glenohumeral instability. Patients often relate a history of trauma, such as a fall onto an outstretched hand, or a history of longstanding participation in an overhead throwing sport (the “peel-off” lesion associated with a tight posterior capsule).

Scapulothoracic Dyskinesia, Core Stability Deficits, and Other Fitness or Technique-Related Provocations

Scapulothoracic dyskinesia, core stability deficits, and other fitness issues commonly contribute to shoulder symptoms as a result of secondary irritation of the rotator cuff or other muscle–tendon units resulting from biomechanical overload. There is frequently a history of the atraumatic insidious onset of shoulder pain associated with participation in a new recreational or occupational activity.

Adhesive Capsulitis (“Frozen Shoulder”)

The typical “frozen shoulder” is not caused by trauma, although patients will often retrospectively recall some history of minor injury to which they ascribe the symptoms. Characteristically, patients first recognize the problem when they find it difficult to reach behind their back (secondary to an evolving internal rotation deficit). Symptoms are progressive, with “freezing,” “frozen,” and “thawing” stages having been defined to describe the natural history of the problem. Frequently, secondary rotator cuff pain will account for a substantial portion of the subjective symptoms. Patients may also describe posterior shoulder discomfort with a trapezius or periscapular location because those muscles become fatigued when compensating for poor glenohumeral motion. There is a significant association with diabetes and hypothyroidism, and patients should be questioned about those general health conditions. Adhesive capsulitis occurs bilaterally in this group.

Calcific Tendinitis

Calcific tendinitis is characterized by the insidious, but rapid, development of extremely severe subacromial or lateral-sided shoulder pain, characteristically in patients of middle age. Narcotics are often necessary to control the discomfort.

Biceps Tendinosis

With advancing age, pathology in the long head of the biceps becomes a frequent source of pain in the shoulder. Biceps tendinosis is often associated with rotator cuff disease. However, pain originating in the biceps is referred to the anterior arm, as opposed to cuff disease, which is characteristically lateral. It may radiate to the elbow but not typically beyond. Because the biceps is a supinator of the forearm, patients with biceps pathology may complain of symptoms related to rotation of the forearm (i.e., when turning a doorknob).

Acromioclavicular Degenerative Joint Disease

The symptom originating from the AC joint most typically is pain over the superior shoulder that increases with horizontal adduction of the arm toward the opposite side (because that compresses the AC joint) or use of the affected arm high overhead. Injury to the AC joint can occur with a fall onto the lateral shoulder, AC joint arthritis can develop insidiously over a lifetime of use or from prior trauma, and an inflammatory condition known as “osteolysis of the distal clavicle” is associated with weight lifting in young adults. AC joint disease may produce scapulothoracic dyskinesia and secondary rotator cuff discomfort.

Glenohumeral Degenerative Joint Disease

Glenohumeral arthritis is an uncommon condition producing generalized aching shoulder pain and progressive loss of motion. GH arthritis may be associated with a history of previous surgical procedures (open ligament stabilization, arthroscopic repair of large labral tears, and the use of implantable “pain pumps”) and massive rotator cuff tears (cuff tear arthropathy), particularly in elderly women. Symptoms are often maximal at night and more tolerable during daily activities. Systemic rheumatoid arthritis may affect the glenohumeral joint, but particularly in younger individuals, it involves the AC or SC joints.

Cervical Spine Pathology

Cervical spine disease typically produces pain radiating from the neck toward the posterior or superior shoulder. The pain is usually worse at the end of the day and relieved by support of the head at night. Generally, patients will experience pain and stiffness with neck motion. Especially in the elderly, a coincident association with rotator cuff disease is common. When cervical nerve root compression is present, most commonly C5 and C6 are affected, and radicular symptoms (“sharp,” “stabbing,” or “burning pain”) involving the forearm and hand radiate distal to the elbow in a typical dermatomal distribution.

Fractures

Fractures about the shoulder are not uncommon in all age groups. Typically, there is a specific history of trauma, but in the osteoporotic elderly or other special situations, the injury may seem to be of minimal force. The mechanism may be direct (a fall or blow to the shoulder) or indirect (a fall on an outstretched arm). Characteristically, pain is immediate after trauma, localized to the specific point of injury, and severe enough to leave little doubt as to the nature of the problem. Diagnosis is confirmed by radiographs.

Range of Motion

Once the intake evaluation is completed, the therapist should be more comfortable anticipating the patient’s response to the therapeutic regimen. One of the main keys to recovery is to normalize motion. Early professions relied on visual estimations or “quick” tests to assess shoulder motion. These tests include combined shoulder movements such as the Apley’s scratch test (Fig. 3-3), reaching across the body to the other shoulder (Fig. 3-4), or reaching behind the back to palpate the highest spinous process (Fig. 3-5). These quick tests are great to observe for overall asymmetry, but they cannot give an idea of isolated losses objectively.

Figure 3-3 Apley’s scratch test.

Figure 3-4 Reaching across the body to the other shoulder to determine range of motion.

Figure 3-5 Reaching behind the back to palpate the highest spinous process to determine range of motion.

Even more important is regaining normal arthrokinematic motions at the shoulder. Active shoulder range of motion is always gathered before passive motions (Manske and Stovak 2006). Active shoulder ROM is seen in Table 3-3 (Manske and Stovak 2006). Many times, gross overall shoulder motion may only appear to be slightly limited, whereas arthrokinematic motion is drastically dysfunctional. For example, it is not uncommon for a patient to have full glenohumeral motion, yet impinge as a result of altered scapulohumeral motion from a restricted inferior or posterior shoulder capsule creating obligate humeral translations.

Therefore, it is imperative to also ensure evaluation of isolated glenohumeral motions is performed. One of the more common problematic limited motions with a variety of shoulder conditions is that of the posterior or inferior shoulder structures. Debate continues as to whether this is a result of capsular or other soft tissues. Regardless, it becomes an issue whenever elevation of the glenohumeral joint is required because it may increase the risk of impingement. Assessment of the posterior shoulder can be done by measuring isolated glenohumeral internal rotation. To perform this test the humerus is taken into passive internal rotation while the scapular is stabilized by grasping the coracoid process and the spine and monitoring for movement (Fig. 3-6). When passive slack from the posterior shoulder is taken up, the humerus will no longer internally rotate or resistance to movement will allow the scapula to tilt forward. When motion is detected or internal rotation has ceased, the examiner measures isolated glenohumeral internal rotation. Wilk et al. (2009) have shown this to be moderately reliable, whereas Manske et al. using the same technique have proved excellent test–retest reliability (Manske et al. 2010). This motion should be compared bilaterally to assess for a deficit between involved and uninvolved shoulders. A difference of greater than 20 degrees of internal rotation is thought to be a precursor to shoulder pathology. Loss of shoulder internal rotation is not always pathologic because some of this motion may be lost as a result of bony changes in the humerus. The concept of total shoulder rotation ROM should also be mentioned. By adding the two numbers of GH internal rotation and external rotation together, a composite of total shoulder motion can be obtained (Fig. 3-7). Ellenbecker et al. (2002), measuring bilateral total rotation range of motion in professional baseball and elite junior tennis players, found that although a dominant arm may show increased external rotation and less internal rotation, the total ROM was not significantly different when comparing the two shoulders. Therefore, one needs to not only address the internal rotation loss, but also should ensure that the total range of motion is not limited. Using normative data from population specific research can assist the therapist in interpreting normal range of motion patterns and identify when sport-specific adaptations or clinically significant adaptations are present (Ellenbecker 2004).

Figure 3-6 Assessment of the posterior shoulder performed by measuring isolated glenohumeral internal rotation.

Figure 3-7 Total rotation range of motion concept.

(Redrawn from Ellenbecker TS. Clinical Examination of the Shoulder. Saunders, St. Louis, 2004, p. 54.)

Soon after soft tissue shoulder repairs passive motion may predominate. These passive ranges can be performed using Codman circumduction exercises, or passive motion can be gained by working with the therapist. Passive motions can be gained in all classical directions as long as there are no soft tissue limitations that need to be abided by. Other methods of gaining motion are through joint mobilizations from the therapist.

Passive and active assistive exercises initially begin with the patient in a supine position with the arm comfortably at the side with a small towel roll or cushion under the elbow and the elbow flexed. This position reduces the forces crossing the shoulder joint by decreasing the effect of gravity and shortening the lever arm of the upper extremity. As the patient begins to recover pain-free motion, the exercises can be progressed to sitting or standing.

Once active motion can be initiated, the patient is encouraged to work early on pain-free ranges below 90 degrees of elevation. For most patients an early goal is 90 degrees of forward flexion and approximately 45 degrees of external rotation with the arm at the side. For surgical patients, it is the responsibility of the surgeon to obtain at least 90 degrees of stable elevation in the operating room for the therapist to be able to gain this same motion after surgery. At this point in rehabilitation, methods to gain motion include active-assisted range of motion with wands or pulleys, passive joint mobilization, and passive stretching exercises (Figs. 3-8 and 3-9).

Figure 3-8 Exercises to regain motion. Active-assisted range of motion exercises using a pulley system (A) and a dowel stick (B).

Figure 3-9 Passive joint mobilization. A, Forward flexion. B, External rotation with the arm at the side. C, External rotation with the arm in 90 degrees of abduction. D, Cross-body adduction.

Pain Relief

Both shoulder motion and strength can be inhibited by pain and swelling, with pain being the major deterrent. Pain can be the result of the initial injury or from surgical procedures attempting to repair/replace the injured tissue. Pain relief can be achieved by a variety of modalities including rest, avoidance of painful motions (e.g., immobilization; Fig. 3-10), cryotherapy, ultrasound, galvanic stimulation, and oral or injectable medications (Fig 3-11). Previous literature substantiates that continuous cryotherapy following surgical procedures results in immediate and continued cooling of both subacromial space and glenohumeral joint temperatures (Osbahr et al. 2002) and decreases the severity and frequency of pain, which allows more normal sleep patterns and increases overall postoperative shoulder surgery comfort and satisfaction (Singh et al. 2001, Speer et al. 1996).

Figure 3-10 Immobilization of the shoulder for pain relief.

Figure 3-11 Modalities for pain relief. A, Ultrasound. B, Galvanic stimulation. C, Cryotherapy.

Muscle Strengthening

Appropriate timing for initiation of muscle strengthening exercises during shoulder rehabilitation is completely dependent on the diagnosis. A simple uncomplicated impingement syndrome may be able to commence strengthening exercises on day 1, whereas a postoperative rotator cuff repair may require up to 10 weeks before initiation of strengthening of the cuff, allowing the repaired tendon time to heal securely to bone of the greater tuberosity. Strengthening of the muscles around the shoulder can be accomplished through different exercises. Basic safe exercises include isometrics (Fig. 3-12), and closed kinetic chain exercises (Figs. 3-13 and 3-14). The advantage of closed chain exercises is a co-contraction of both the agonist and the antagonist muscle groups that help enhance stability of the glenohumeral joint. This co-contraction closely replicates normal physiologic motor patterns and function to help stabilize the shoulder and limit abnormal and potentially destructive shear forces crossing the glenohumeral joint. A closed chain exercise for the upper extremity is one in which the distal segment is stabilized against a fixed object. During shoulder exercises this stable object may be a wall, door, table, or floor. One example of a closed-kinetic-chain exercise used in an elevated, more functional position is the “clock” exercise in which the hand is stabilized against a wall or table (depending on the amount of elevation allowed) and the hand is rotated to different positions of the clock face (Fig. 3-13). This is done by creating an isometric contraction in the direction of the numbers around the clock face. Alternatively, the therapist can also give manual resistance in the same directions to the patient’s arm as they are stabilizing it by holding on to the wall (Fig. 3-14). These motions are thought to effectively stimulate rotator cuff activity. Initially, the maneuvers are done with the shoulder in less than 90 degrees of abduction or flexion. As healing tissues improve and motion is recovered, strengthening progresses to greater amounts of abduction and forward flexion.

Figure 3-12 Closed chain shoulder exercises. A, Isometric strengthening of the rotator cuff in abduction (pushing out against the wall). B, Isometric strengthening of the rotator cuff in external rotation.

Figure 3-13 Wall clock exercise.

Figure 3-14 Wall clock exercise with manual resistance.

Isometric exercises can also be performed in various ranges of shoulder elevation. It is easiest to do this with the patient in supine. The “balance position” is that of 90 to 100 degrees of forward flexion of the shoulder while supine (Fig. 3-15). This position requires little activation of the deltoid so that the rotator cuff can be worked without provoking a painful shoulder response. In this position a contraction from the deltoid will result in joint compression, helping to enhance joint stability. Rhythmic stabilization or alternating isometric exercises can be performed very comfortably in the supine position and can be done for both rotator cuff and shoulder muscles.

Figure 3-15 The “balance position” is that of 90 to 100 degrees of forward flexion of the shoulder while supine.

Strengthening of scapular stabilizers is important early on in the rehabilitation program. Scapular strengthening can begin in side lying with isometrics or isotonics or closed chain (Fig. 3-16) and progress to open-kinetic-chain exercises (Fig. 3-17).

Figure 3-16 Closed chain strengthening exercises of the scapula stabilizers. A, Scapular protraction. B and C, Scapular retraction.

Figure 3-17 Open chain strengthening exercises of the scapula stabilizers without (A–D) and with (E–H) lightweight dumbbells.

Recovery can be enhanced by utilizing proprioceptive neuromuscular facilitation (PNF) exercises. The therapist can apply specific sensory inputs to facilitate a specific activity or movement pattern. One example of this is the D2 flexion–extension pattern for the upper extremity. During this maneuver, the therapist applies resistance as the patient moves the arm through predetermined patterns. These exercises can be done in various levels of shoulder elevation including 30, 60, 90, and 120 degrees of elevation. These exercises are to enhance the stability of the glenohumeral joint through a given active range of motion (AROM).

As the patient progresses, more aggressive strengthening can be instituted by moving from isometric and closed-chain exercises to those that are more isotonic and open chain in nature (Fig. 3-18). Open chain exercises are done with the distal end of the extremity no longer stabilized against a fixed object. This results in the potential for increased shear forces across the glenohumeral joint. Shoulder internal and external rotation exercises are done initially standing or seated with the shoulder in the scapular plane. The scapular plane position is recreated with the shoulder between 30 degrees and 60 degrees anterior to the frontal plane of the thorax, or halfway between directly in front (sagittal plane) and directly to the side (frontal plane). The scapular plane is a much more comfortable plane to exercise in because it puts less stress on the joint capsule and orients the shoulder in a position that more closely represents functional movement patterns. Rotational exercises should begin with the arm comfortably at the patient’s side and advance to 90 degrees based on the patient’s injury, level of discomfort, and stage of soft tissue healing. The variation in position positively stresses the dynamic stabilizers by altering the stability of the GH joint from maximum stability with the arm at the side to minimum stability with the arm in 90 degrees of abduction.

Figure 3-18 Open chain isotonic strengthening of the rotator cuff (internal rotation) using Theraband tubing (A), lightweight dumbbells (B), and external rotation strengthening (C).

For those who participate in either competitive or recreational overhead sporting activities, the most functional of all open-chain exercises are plyometric exercises. Plyometric activities are defined by a stretch-shortening cycle of the muscle tendon unit. This is a component of almost all athletic activities. Initially the muscle is eccentrically stretched and loaded. Following the stretched position the shoulder/arm quickly performs a concentric contraction. These forms of exercises are higher level exercises that should only be included once the patient has developed an adequate strength base and achieved full ROM. Not all patients require plyometric training, and this should be discussed before their incorporation. Plyometric exercises are successful in development of strength and power. Theraband tubing, medicine ball training, or free weights are all acceptable plyometric devices for the shoulder (Fig. 3-19).

Figure 3-19 Plyometric shoulder strengthening exercises using Theraband tubing (A) and an exercise ball (B).

Nothing is more important when rehabilitating the shoulder than remembering the musculature of the upper extremity and core. Total arm strengthening is a must when rehabilitating the shoulder because injuries to the shoulder that limit normal functional movement patterns and use will result in strength deficits of other upper extremity muscles. Overall conditioning including stretching, strengthening, and endurance training of the other components of the kinematic chain should be performed simultaneously with shoulder rehabilitation.

Patient motivation is a critical component of the rehabilitation program. Without self-motivation, any treatment plan is destined to fail. For complete recovery, most rehabilitation protocols will require the patient to perform some of the exercises on his or her own at home. This requires not only an understanding of the maneuvers, but also the discipline for the patient to execute them on a regular basis. Patient self-motivation is even more crucial in the present medical environment with increased attention and scrutiny directed at cost containment. Many insurance carriers limit coverage for rehabilitation at the patient’s expense. As a result, a comprehensive home exercise program should be outlined for the patient early in the rehabilitation process. This allows patients to augment their rehabilitation exercises at home and gives them a feeling of responsibility for their own recovery.

Anatomy and Biomechanics

The rotator cuff is composed of four muscles: supraspinatus, infraspinatus, teres minor, and subscapularis. These four muscles take origin on the body of the scapula and insert on the tuberosities of the proximal humerus. The rotator cuff serves several functions in glenohumeral joint motion and stability. It provides joint compression, resistance to glenohumeral translation, and some rotation in all planes of motion. It is intricately involved in powering movement of the shoulder.

During overhead sports, extreme forces are placed on the rotator cuff. It is continuously challenged to keep the humeral head centered in the glenoid, preventing subluxations of the joint. If proper conditioning and sound mechanics are not used, the rotator cuff and posterior joint capsule can become inflamed and irritated. Chronic inflammation can become pathologic and lead to dysfunction of the rotator cuff. When the four cuff muscles fail to act in synchrony to keep the humeral head centered in the glenoid, dynamic stability can be compromised. Repeated microtrauma to the posterior rotator cuff and capsule leads to posterior capsule contracture. Posterior capsular tightness and loss of dynamic stability lead to increased subluxation and anterior–posterior (AP) translation of the humeral head on the glenoid, further contributing to irritation of the rotator cuff. Over time, this repetitive insult can cause tears of the rotator cuff and superior labrum.

The Throwing Cycle

The baseball pitch serves as the biomechanical model for many overhead throwing motions. The throwing cycle is a kinetic chain that derives energy from the lower extremities, transfers it through the pelvis and trunk rotation, and releases that energy through the upper extremity. The arm positions and motions of the throwing cycle serve as a good model for examination of rotator cuff function in overhead athletes. The throwing motion and its biomechanics have been divided into six stages: wind-up, early-cocking, late-cocking, acceleration, deceleration, and follow-through (Fig. 3-20).

Figure 3-20 The six phases of the throwing cycle.

(Adapted with permission from DiGiovine NM, Jobe FW, Pink M, Perry J. An electromyographic analysis of the upper extremity in pitching. J Shoulder Elbow Surg 1:15-25, 1992.)

Pathogenesis

Injury to the shoulder during the throwing cycle is thought to occur during the late-cocking phase, when the shoulder is in extreme external rotation and horizontal abduction. Abnormal motion of the humeral head relative to the glenoid can injure the superior and posterosuperior labrum and glenoid and the undersurface of the rotator cuff. This phenomenon has been called internal impingement of the shoulder or posterior superior glenoid impingement (Burkhart et al. 2003, Fleising et al. 1995, Jobe 1995, Kelly and Leggin 1999). Several factors have been implicated in the development of internal impingement, including traction on the biceps tendon, laxity of the anterior band of the inferior glenohumeral ligament caused by excessive external rotation, posterior capsular tightness, and scapular dyskinesia.

Muscle imbalance and capsular tightness contribute to rotator cuff pathology by allowing excess translation at the glenohumeral joint. Weakness of the supraspinatus or subscapularis can compromise compression of the glenohumeral joint during active shoulder motion. This, in turn, leads to increased translation across the joint.

Grossman et al. (2005) quantified glenohumeral motion following external rotation capsular stretch and subsequent posterior capsular shift to simulate a posterior capsular contracture in the thrower’s shoulder. In maximal external rotation in intact specimens, the humeral head moved in a posterior and inferior direction. A posterior capsular shift was performed to simulate posterior capsular contracture. Following posterior capsular shift, there was a trend toward a more superior position of the humeral head in maximal external rotation. Posterior capsular contracture causes a similar result as the head is pushed anterior–superior into the coracoacromial arch during flexion. Superior translation allows the head to migrate closer to the acromion, and an increase in the force transmitted to the rotator cuff results as the cuff is pressed between the humeral head and the overlying coracoacromial arch. The increased pressure on the cuff can lead to degradation and damage over time.

History and Physical Examination

Evaluation of overhead athletes, particularly at higher levels, should begin prior to the season and continue intermittently throughout the season. Subjective complaints regarding performance often precede complaints of pain in the shoulder or elbow. Common complaints include loss of command or control of the pitch, loss of pitching velocity, a subtle change in pitching mechanics, or even discomfort distant to the throwing arm. Early identification of these problems requires open communication among players, coaches, physicians, and athletic trainers.

Physical examination of the overhead athlete requires a global evaluation.

The physical examination of the shoulder and upper extremity should always begin with inspection.

Active and passive range of motion (PROM) should be assessed and compared to the contralateral side. The American Shoulder and Elbow Surgeons have recommended four functional ranges of motion that should be measured (Richards et al. 1994): forward elevation, internal rotation, and external rotation at the side and at 90 degrees of abduction are measured. Loss of the total arc of rotation, specifically with internal rotation, is a common finding in the glenohumeral joint of the injured pitcher (Burkhart et al. 2003). This loss is likely secondary to tightness of the posterior soft tissues, including the posterior rotator cuff and capsule.

Complete assessment of the shoulder should also include careful assessment of rotator cuff strength and glenohumeral joint laxity and provocative tests to identify intra-articular, subacromial, and acromioclavicular pathology.

Imaging

Management

Frequently, rotator cuff tendinitis in the overhead athlete can be successfully treated with a well-structured and carefully implemented nonoperative rehabilitation program (Rehabilitation Protocol 3-1). Rehabilitation follows a multiphase approach with emphasis on controlling inflammation, restoring muscle balance, improving soft tissue flexibility, enhancing proprioception and neuromuscular control, and efficiently returning the athlete to competitive throwing (Wilk et al. 2002). Treatment should focus on restoration of sound mechanics during the throwing cycle, core muscle strengthening of the trunk and lower extremities, and strengthening of periscapular stabilizers.

Figure 3-92 Phase I stretching of the shoulder. Exercises to be done 10 times each, two times per day. A, Active-assisted forward elevation: The arm is held with the elbow straight or flexed to 90 degrees. The elbow and forearm are raised away from the body using the opposite arm to assist. The arm is raised overhead until a stretch is felt and held for 10 seconds. The arm is then gently lowered back to the side. B, Active-assisted external rotation: Position the hand across the stomach with the elbow tucked firmly at the side. Pivot the hand away from the body until pointing straight ahead and continue until pointing away from the body. Use the opposite arm to assist. Both exercises should remain pain free.

Figure 3-93 Cross-body adduction: With the elbow straight, the affected arm is brought across the body at shoulder height. The unaffected arm can be used to pull the affected arm further across the body to stretch the posterior capsule and posterior rotator cuff.

Figure 3-94 Phase I strengthening of the shoulder. Exercises to be done 10 times each, two times per day. A, External rotation: With band at waist level, start with the upper arm at the side, elbow flexed to 90 degrees, and forearm across the stomach. While maintaining upper arm against the side and 90 degrees of elbow flexion, gently rotate the forearm away from the stomach and out to the side. Slowly return to starting position. B, Internal rotation: With band at waist level, start with the upper arm at the side, elbow flexed to 90 degrees, and forearm out to the side. While maintaining upper arm against the side and 90 degrees of elbow flexion, gently rotate the forearm in toward the stomach. Slowly return to starting position.

Figure 3-95 Phase I strengthening of the shoulder. Exercises to be done 10 times each, two times per day. A, Shoulder flexion (protraction): Attach band to door behind patient at waist level. Begin with hand in front of shoulder with elbow bent, hand and forearm at waist level. Press hand forward until the elbow is fully extended. Slowly return to starting position. B, Shoulder extension (retraction): Attach band to door in front of patient at waist level. Begin with arm straight forward, elbow extended, hand at waist level. Pull the elbow back until the hand is next to the body. Slowly return to starting position.

Figure 3-96 The sleeper stretch can be used to achieve end range of internal rotation. The patient lies on the affected side, with head level and trunk straight. The shoulder is brought to 90 degrees forward flexion, and the elbow is bent to 90 degrees. Squeeze scapulas together, keeping scapulas close to the spine. Use the unaffected hand to internally rotate shoulder, pushing the affected hand down toward the bed. Hold 10 to 20 seconds and repeat five times.

Figure 3-97 The wall stretch can be used to achieve end-range forward elevation or forward flexion. The patient stands facing a flat wall. The affected arm is raised to full forward elevation or full forward flexion. With the palm placed flat on the wall, the patient leans forward pressing the torso into the wall. This will stretch the inferior joint capsule and inferior glenohumeral ligaments.

Figure 3-98 Stretching the affected arm behind the head can also be used to achieve end-range forward elevation or forward flexion. The unaffected arm grasps the affected arm by the elbow, pulling the affected arm further behind the head to stretch the inferior joint capsule and inferior glenohumeral ligaments.

Summary

Rotator cuff tendinitis in the overhead athlete is a pathologic and debilitating process. The extreme forces placed on the glenohumeral joint complex during the overhead throwing motion can cause anterior ligamentous laxity and posterior capsular contracture. The repetitive trauma of excessive AP translation of the humeral head on the glenoid can lead to irritation of the dynamic stabilizers of the shoulder. If not corrected, this can ultimately lead to tears of the rotator cuff and posterior–superior labrum.

The key to treatment lies in early detection and prevention of further injury. A structured, multiphase rehabilitation protocol can be implemented focusing on stretching of posterior capsular contractures and strengthening of the rotator cuff and periscapular muscles. Conditioning and core strengthening are optimized while alterations in the mechanics of throwing are corrected. Treatment must be individualized to each athlete. Open communication among physicians, athletic trainers, coaches, and the athlete is paramount to recovery and return to play.

Type of Repair

Management of rotator cuff tendon tears continues to be a challenge. Few surgeons will still perform open repairs, especially in patients with anterior deltoid detachment for fear of postoperative deltoid avulsion (Gumina et al. 2008; Hata et al. 2004; Sher et al. 1997). Patients who have had a deltoid muscle detachment or release from the acromion or clavicle (e.g., traditional open rotator cuff repair) may not perform active muscle contractions of the deltoid for up to approximately 8 weeks following surgery. This is done to avoid the horrible outcome of an avulsion of the deltoid muscle. Typically three types of procedures are described with the open procedure being the oldest as it was described almost 100 years ago (Codman 1911). Next in line was the advancement of the mini-open procedure that utilizes a much smaller incision. Most recently all arthroscopic procedures have become popular. These three procedures can be thought of as an evolution or transition to newer and better techniques as biomechanics of surgery and soft tissue healing have been advanced with increasing amounts of scientific knowledge.

The open rotator cuff repair is very conservative compared to mini-open or arthroscopic repair procedures due to detachment of the deltoid. Because of the lack of use of this older procedure, a formal rehabilitation approach will not be described other than to say that active motion is not allowed until after 8 to 12 weeks depending on tissue quality and ability to reattach the required tendons. Actual gentle strengthening is not begun until after about 12 weeks at minimum. Patients are usually not even able to comfortably elevate above shoulder level before 6 months (Hawkins 1990; 1999).

The mini-open technique involves a small (less than 3 cm) vertical split with the orientation of the deltoid fibers, allowing mild, early deltoid muscle contractions. The mini-open technique is popular because it does not create the surgical morbidity of the open technique. The deltoid muscle is not taken down from the acromion so rehabilitation is progressed somewhat faster. Additionally, with the mini-open technique, transosseous fixation, which may lead to better footprint restoration, can be used. The downfalls to the mini-open include an increased incidence of stiffness (11%–20%) compared to an all arthroscopic technique (Nottage 2001; Yamaguchi et al. 2001).

The all-arthroscopic repair of the rotator cuff actually has a slower rate of rehabilitation progression owing to the weaker fixation of the repair as compared to that of the open procedures. This technique has to be one of the more demanding ways to operatively repair the rotator cuff. Advantages of the all-arthroscopic technique include preservation of the deltoid attachment, less postoperative pain, decreased surgical morbidity, and an earlier return of function following repair.

Regardless of the surgical approach performed, the underlying biology of healing tendons must be respected for all patients.

Tear Pattern

Lo and Burkhart (2003) have described four main types of tear patterns, and these include crescent-shaped tears, U-shaped tears, L-shaped and reverse L-shaped tears, and massive tears. Understanding of and recognition of the tear pattern is the first step in determining appropriate surgical treatment.

Crescent-shaped tears (Fig. 3-21). These are usually the easiest to repair. These tears rarely have a substantial amount of medial retraction; therefore, they are usually easily mobilized and able to be secured to the tuberosity without excessive tension placed upon them.

Figure 3-21 Crescent-shaped tear.

(From Miller MD, Sekiya JK. Sports Medicine. Core Knowledge in Orthopaedics. St. Louis, Mosby, 2006, pg. 305, fig. 36-17A.)

U-shaped tears (Fig. 3-22). These tears look like an extension of the crescent-shaped tear pattern that have retracted further medially. A large margin convergence is needed to secure this tear. Using a margin convergence procedure, the anterior and posterior edges of the tear are sutured back together so that the lateral edge can be more easily brought back to the greater tubercle.

Figure 3-22 U-shaped tear.

(From Miller MD, Sekiya JK. Sports Medicine. Core Knowledge in Orthopaedics. St. Louis, Mosby, 2006, pg. 306, fig. 36-17B.)

L-shaped and reverse L-shaped tears (Fig. 3-23). This tear pattern involves a tendon tear from the tuberosity with an additional longitudinal split posterior or anteriorly involving a portion being retracted.

Figure 3-23 L-shaped tear.

(From Miller MD, Sekiya JK. Sports Medicine. Core Knowledge in Orthopaedics. St. Louis, Mosby, 2006, pg. 307, fig. 36-17C.)

Massive tears. A massive tear is commonly seen in the elderly patient and involves more than one tendon. These tears tend to be problematic because of the significant amount of tendon retraction that occurs.

Size of the Tear

Functional outcome and expectations after rotator cuff repair are directly related to the size of the tear repaired. Numerous authors have reported age and tear size to be significant factors in healing after rotator cuff repair (Bigliani et al. 1992; Boileau et al. 2005; Cole et al. 2007; Gazielly et al. 1994; Harryman et al. 1991; Nho et al. 2009).

Tissue Quality

The quality of the tendon, muscular tissue, and the bone helps determine speed of rehabilitation. Thin, fatty, or weak tissue is progressed slower than excellent tissue. Of additional concern is the quality of the remaining rotator cuff muscles. The other cuff muscles (i.e., subscapularis, teres minor, and infraspinatus) play an important role in providing adequate force couples for the healthy shoulder.

Location of the Tear

Tears that involve posterior cuff structures require a slower progression of rehabilitation for gaining external rotation strengthening and should limit internal rotation mobility early. Rehabilitation after subscapularis repair (anterior structure) should limit resisted internal rotation for approximately 6 weeks to allow adequate soft tissue healing. Restriction of the amount of passive external rotation motion should also be restricted until early tissue healing has occurred. Most tears occur in and are confined to the supraspinatus tendon, the critical site of wear, often corresponding to the site of subacromial impingement.

Onset of Rotator Cuff Tear and Timing of the Repair

Acute tears with early repair may have a slightly greater propensity to develop stiffness, and a little more aggression in early ROM programs has proven beneficial. Cofield et al. (2001) noted that patients who underwent an early repair progressed more rapidly with rehabilitation than those with a late repair. It has been shown that early intervention of a single-tendon tear may optimize healing and not allow progression to a multiple-tendon tear (Nho et al. 2009).

Patient Variables

Several authors have reported a less successful outcome in older patients than young. This may be because of older patients typically having larger and more complex tears, probably affecting outcomes. Age and tear size are significant factors in tendon healing capabilities (Bigliani et al. 1992; Boileau et al. 2005; Cole et al. 2007; Constant and Murley 1987; Gazielly et al. 1994).

Multiple other authors agree that workers’ compensations patients tend to progress slower or have less than optimal return of function (Abboud et al. 2006; Bayne and Bateman 1984; McLaughlin and Asherman 1951; Hawkins et al. 1999; Iannotti et al. 1996; Misamore et al. 1995; Paulos and Kody 1994; Shinners et al. 2002; Smith et al. 2000). Kolgonen, Chong, and Yip (2007) found a strong association between workers’ compensation patients and poor outcomes after multiple shoulder surgeries.

Finally, researchers have noted a correlation between preoperative shoulder function and outcomes after surgical repair. Generally, patients who have an active lifestyle before surgery return to the same postoperatively. Furthermore, Henn et al. (2007) assessed preoperative expectations with an outcomes questionnaire and found that those who had a greater preoperative expectation for their recovery had better postoperative performance on several subjective outcome measures.

Rehabilitation Situation and Surgeon’s Philosophic Approach

Treatment with a skilled shoulder therapist rather than a home therapy program is recommended. Lastly, some physicians prefer more aggressive progression, whereas others remain conservative in their approach.

Rehabilitation after rotator cuff surgery emphasizes immediate motion, early dynamic GH joint stability, and gradual restoration of rotator cuff strength. Throughout rehabilitation, overstressing of the healing tissue is to be avoided, striking a balance between regaining shoulder mobility and promotion of soft tissue healing.

Acute Tears

Patients with acute tears of the rotator cuff usually present to their physician after a traumatic injury. They have complaints of pain and sudden weakness, which may be manifested by an inability to elevate the arm. On physical examination, they have a weakness in shoulder motion of forward elevation, external rotation, or internal rotation depending on which cuff muscles are involved. Passive motion is usually intact depending on the timing of presentation. If the injury is chronic and the patient has been avoiding using the shoulder because of pain, there may be concomitant adhesive capsulitis (limitation of passive shoulder motion) and weakness of active ROM (underlying rotator cuff tear).

Imaging

Imaging studies may be helpful in confirming the diagnosis of a chronic rotator cuff tear and may help to determine the potential success of operative treatment. A standard radiographic evaluation or “trauma shoulder series” should be obtained, including an anteroposterior (AP) view in the plane of the scapula (“true AP” of GH joint) (Fig. 3-24), a lateral view in the plane of the scapula (Fig. 3-25), and an axillary lateral view (Fig. 3-26). This may also show some proximal (superior) humeral migration, indicative of chronic rotator cuff insufficiency. Plain film radiographs can also show degenerative conditions or bone collapse consistent with a cuff tear arthropathy in which both the cuff deficiency and the arthritis contribute to the patient’s symptoms. These radiographs help to eliminate other potential pathologic entities such as a fracture or dislocation.

Figure 3-24 Radiographic evaluation of the shoulder: true anterioroposterior (AP) view. The beam must be angled 30-45 degrees.

(Redrawn from Rockwood CA Jr, Matsen FA III. The Shoulder, 2nd ed. Philadelphia, WB Saunders, 1988.)

Figure 3-25 Radiographic evaluation of the shoulder; lateral view in the plane of the scapula.

(Redrawn from Rockwood CA Jr, Matsen FA III: The Shoulder, 2nd ed. Philadelphia, WB Saunders, 1988.)

Figure 3-26 Radiographic evaluation of the shoulder: axillary lateral view. This view is important to avoid missing acute or chronic shoulder dislocation.

(Redrawn from Rockwood CA Jr, Matsen FA III. The Shoulder, 2nd ed. Philadelphia, WB Saunders, 1988.)

A magnetic resonance imaging (MRI) examination of the shoulder may help to demonstrate a rotator cuff tear, its size, and degree of retraction, thus confirming the clinical diagnosis. The MRI with or without contrast can also help assess the rotator cuff musculature. Evidence of fatty or fibrous infiltration of the rotator cuff muscles is consistent with a long-standing cuff tear and is a poor prognostic indicator for a successful return of cuff function.

Ultrasound and double-contrast shoulder arthrography are additional studies that are occasionally used to diagnoses rotator cuff tears, but they are less helpful for determining the age of the tear.

It is important to remember that the likelihood of an associated rotator cuff tear with a shoulder dislocation increases with age. In patients older than 40 years of age, an associated rotator cuff tear is present with shoulder dislocation in more than 30%; whereas in patients older than 60 years, it is present in more than 80%. Therefore, serial examination of the shoulder is necessary after a dislocation to evaluate the integrity of the rotator cuff. If significant symptoms of pain and weakness persist after 3 weeks, an imaging study of the rotator cuff is required. A torn rotator cuff after a dislocation is a surgical problem, so once the diagnosis is made, surgical repair is indicated.

Examination

On physical examination, some evidence of muscular atrophy may be seen in the supraspinatus or infraspinatus fossa. Atrophy will depend on the size and chronicity of the tear. Acute tears will rarely show signs of obvious muscle wasting. Observation looks for symmetry of shoulders. Shoulder height that is lower on the dominant side is normal and termed “handedness.” This occurs due to a combination of increased muscle mass and increased shoulder laxity. A shoulder that is higher on the involved side may be held there due to protective muscle spasm. Winging or tipping of the scapula is another common finding. Winging refers to the entire medial scapular border being elevated off of the posterior thorax, whereas tipping is when just the inferior medial border is elevated away from the posterior shoulder.

Passive motion is usually maintained, but it may be associated with subacromial crepitance. Smooth active motion is diminished, and symptoms are reproduced when the arm is lowered from an overhead position. Muscle weakness is related to the size of the tear and the muscles involved. More commonly with rotator cuff tears, both elevation and external shoulder rotation will demonstrate weakness and associated pain when performing manual muscle testing.

A subacromial injection of lidocaine may help to differentiate weakness that is caused by associated painful inflammation from that caused by a cuff tendon tear. Additionally, provocative maneuvers including the Neer impingement sign (Fig. 3-27) and the Hawkins sign (Fig. 3-28) may be positive with other conditions such as rotator cuff tendinitis, bursitis, or partial-thickness rotator cuff tears.

Figure 3-27 Neer impingement test.

Figure 3-28 Hawkins impingement test.

It is important that other potential etiologies be investigated as part of the differential diagnosis. Patients with cervical radiculopathy at the C5–6 level can have an insidious onset of shoulder pain, rotator cuff weakness, and muscular atrophy in the supraspinatus and infraspinatus fossa. Atrophy in these areas can also be seen with suprascapular nerve encroachment.

Treatment

Rehabilitation Protocol

Actual protocols for various tear sizes (partial tears/small; medium/large; massive) are seen in Rehabilitation Protocols 3-2, 3-3, and 3-4. Although protocols exist for open procedures, the protocols described herein will be for all arthroscopic rotator cuff repairs due to advancement in surgical technique. All protocols have similar outlines with four phases but are adjusted according to tear size. Clinicians should take into consideration all other comorbidities and risk factors related to postoperative stiffness.

Sling and initiation of active ROM are seen for all repairs in Table 3-7.

Table 3-7 Sling and Initiation of Active Motion

Immediate Postoperative Phase

Goals in the immediate postoperative phase are to (1) maintain and protect the integrity of the repair, (2) gradually increase passive range of motion, (3) diminish pain and inflammation, and (4) modify activities of daily living. The length of this phase depends upon size of repair. For partial to small tear repairs this phase may only last 3 to 4 weeks, whereas for medium and large tears it may last up to 6 weeks and for massive tears up to 8 weeks.

Because pain typically is elevated in this stage, cold therapy and electrical stimulation may be used to relieve discomfort. The initial position of immobilization is usually with the shoulder slightly abducted in the scapular plane, elbow flexed to 90 degrees, and shoulder internally rotated resting on an abduction pillow (see Fig. 3-10). Slight abduction as the immobilization placement does several things including allowing an increase in supraspinatus blood flow to decrease the “wringing out” or “watershed” effect that occurs with the arm in a completely adducted shoulder position. Secondly, it places the supraspinatus in a relaxed position decreasing the potential of placing excessive tension across the repair due to reflex muscular contractions.

Because limited shoulder motion following rotator cuff repair is one of the biggest complications, a reestablishment of passive motion without sacrificing repair integrity is important in this phase. Depending on repair size, passive ROM predominates in this early stage. A slower rate of motion progression is warranted for those with large or massive tears. Passive motion limitations are listed in the rehabilitation protocols. Passive pendulum exercises are beneficial and cause very little active muscular activity of the cuff. Dockery et al. (1998) and Lastayo et al. (1996) found that cuff muscle activity during pendulum exercises was not different than that during continuous passive motion (CPM) or manual therapy passive motion. Recently, Ellsworth et al. (2006) found that mean supraspinatus/upper trapezius activity during the pendulum exercise in patients with shoulder pathology was activated to 25% maximum voluntary isometric contraction (MVIC), and it was slightly lower at 20% with a suspended weight. This is an EMG amount that approaches the upper level of what is considered minimal. Therapists should ensure the patient is performing a relaxed pendulum exercise with minimal muscle activity. Pendulums that are painful to perform are more than likely not creating the relaxing effect wanted and should therefore be discontinued at this early time. The remainder of the upper extremity joints can be treated with active assisted exercises of the elbow, hand, wrist, and cervical spine.

Because of the importance of scapular stabilization and function of the rotator cuff, scapular muscle isometrics and active motion can usually begin early. Early gentle setting of the scapular muscles can be done in sidelying positions with the shoulder protected (Fig. 3-29). Motions of elevation/depression and protraction/retraction are effective to isolate scapular muscle recruitment.

Figure 3-29 Scapular isometrics.

Recent discussions have included use of complete removal of load to repaired tendons in an effort to improve healing. Galatz et al. (2009) using an animal model applied botulinum toxin to paralyze the supraspinatus following rotator cuff repair. They used botulinum A and immobilized one group, allowed free range in another group, and finally used saline injection and casting in a control group. Complete paralysis had a negative effect on cuff healing and proved that complete removal of loads from a healing rotator cuff tendon is detrimental. A low level of controlled force is probably beneficial for tendon healing.

Passive motion predominates this phase in an attempt to decrease adhesion formation, contractures, and limitations of periarticular structures (McCann et al. 1993; Dockery et al. 1998; Lastayo et al. 1996). These passive exercises are done to decrease the risk of forming selective hypomobilities (Harryman et al. 1990). An asymmetrical tightening of the capsule with prolonged immobilization or with disuse will cause an obligate translation in the direction opposite the tight tissue constraint. After those following rotator cuff repairs, the primary tissue that becomes tight is the posterior and anterior capsule. Furthermore, Hata et al. (2001) used arthrographic comparison between patients who had and those who did not have pain following rotator cuff repair. Patients with shoulder pain after repair had reduced capacity and motion of the GH joint. The initial postoperative treatment has a direct bearing on postoperative stiffness, and failure to begin passive ROM in the first week after the operation can lead to loss of motion.

Early rehabilitation should include both physiologic and accessory joint mobilizations. Manske et al. (2010) have determined that posterior glide accessory joint mobilization techniques with passive stretching are better than passive stretching alone for treatment of posterior shoulder tightness. Surenkok (2009) has recently shown that pain was decreased and shoulder motion was improved immediately following scapular mobilizations in those with painful shoulders.

An area that is oftentimes taken too lightly is the position in which to place the shoulder while performing mobilization. In cadaver studies of strain on the supraspinatus, Zuckerman et al. (Zuckerman et al. 1991; Muraki et al. 2007; Hatakeyama et al. 2001; Hersche and Gerber 1998) all concluded that strains are significantly less when the humerus is placed in at least 30 to 45 degrees of elevation. This becomes most important about 3 weeks after repair because it is at this time that the repaired tendon is at its weakest (Ticker and Warner 1998).

Massive Rotator Cuff Repairs

Careful attention should be paid to massive rotator cuff repairs because the repaired tissue may not be as compliant as that of a smaller tear. The progression is much slower in the massive tears because the risk of retearing is increased.

Sling immobilization is continued for a full 8 weeks or more depending on tissue quality. Motion is progressed slower than with smaller repairs to avoid placing excessive tension on the healing tissue. Active tension through the tissue is not done before 8 to 10 weeks. At this point, a gradual restoration of strength is also begun starting with the scapular muscles, progressing to the rotator cuff muscles, and finally to the deltoid. Obtaining a balance of posterior and anterior cuff musculature is the key for massive repairs. Once the normal or near normal force couples have returned, active shoulder motion can commence. A weakness of the posterior cuff muscles “uncouples” the rotator cuff force couple that allows normal arthrokinematics of normal shoulder motion. This uncoupling will allow an anterior superior translation of the humeral head with active shoulder elevation.

Conclusion

It should always be stressed to the patient that although they may be pain free and most substantial gains will be seen in the first 6 months, full unrestricted return to activity and full potential will not be achieved until about 1 full year (Matson et al. 2004; Rokito 1996). Rotator cuff rehabilitation is a long and slow process!

Introduction

Glenohumeral instability is a relatively common orthopaedic problem, encompassing a wide spectrum of pathological mobility at the shoulder joint ranging from symptomatic laxity to frank dislocation. The glenohumeral joint allows greater mobility than any other joint in the human body; however, this comes at the expense of stability. Perhaps more so than other joints, shoulder stability is predicated on adequate soft tissue (muscular and ligamentous) function and integrity, rather than bony congruity and alignment. Instability of the joint can easily result from impairments or imbalances in muscle function, ligamentous laxity, and/or bony abnormalities. Given this inherent laxity, it is not surprising that there is a relatively high incidence of instability events. A Danish registry study suggested a 1.7% overall incidence rate for the population as a whole (Hovelius et al 1996). Young, athletic populations are at even higher risk, with a study of cadets at the United States Military Academy demonstrating an overall incidence of shoulder instability of 2.8%. In this population, trauma was identified as the most common etiology, with more than 85% of patients reporting antecedent trauma. More than 90% of shoulder dislocations are in the anterior direction, particularly because the position of combined external rotation and abduction, common in many contact sports, places the shoulder in an extremely vulnerable position. Most concerning regarding first-time shoulder dislocations is the high recurrence rate, which has been reported as between 20% and 50% and as high as 90% in young patients. These epidemiologic findings highlight the importance of accurately identifying and appropriately treating shoulder instability. There is still, however, considerable controversy concerning appropriate treatment algorithms for shoulder instability. Prior to deciding on an appropriate treatment course, factors including patient age, type of activity/sport, activity/sport level, goals, and likelihood of compliance must be considered. In addition, the mechanism of injury and the type of damage incurred, which may include labral, capsule, biceps, and/or rotator cuff lesions, in addition to bony avulsions, will influence the most appropriate course of treatment for the patient.

Understanding these factors will permit the treating clinician to determine (1) whether nonoperative versus operative treatment is indicated, and (2) if operative intervention is required, what form this should take. In this section we briefly review the anatomy and biomechanics of the glenohumeral joint, describe the classification of instability events, discuss the available nonoperative and operative interventions for treating the spectrum of instability disorders, and provide rehabilitation protocols.

Anatomic Considerations

The range of motion permitted at the glenohumeral joint is a consequence of minimal bony constraint provided by the humeral head and glenoid articulation. The glenoid fossa is a shallow structure, covering only 25% of the humeral head surface. Stability in the joint is therefore primarily a consequence of its static and dynamic stabilizers. The static stabilizers consist of the bony anatomy, the glenoid labrum, and capsular and ligamentous complexes and are typically only improved with surgical intervention once injured. Of note, the superior, middle, and inferior glenohumeral ligaments (SGHL, MGHL, IGHL) are especially important structures with regard to shoulder instability and thus have major implications with regard to rehabilitation following injury and/or surgery (Fig. 3-30). Specifically, the SGHL (along with the coracohumeral ligament) and MGHL are important stabilizers with regard to limiting external rotation of the adducted arm (when the arm is at the side). The IGHL is especially important in preventing anterior translation of the shoulder when in the provocative position of abduction and external rotation. The dynamic stabilizers, including the rotator cuff muscles and long head of the biceps tendon, can often be improved with an appropriate nonoperative rehabilitation program after an instability event. In fact, proper strengthening of the rotator cuff musculature and scapular stabilizers are critical components of any rehabilitation protocol, including those for nonoperative management of shoulder instability and part of the rehabilitation following surgery.

Figure 3-30 A, The ligaments of the glenohumeral joint are shown, including the superior glenohumeral ligament (SGHL), inferior glenohumeral ligament (IGHL), and middle glenohumeral ligament (MGHL). B, An anterior (coronal) view of the rotator cuff and coracohumeral ligament (CHL) of the glenohumeral joint.

It is particularly important to note the integrity and condition of the subscapularis with regard to rehabilitation following shoulder surgery. In many open surgical techniques, the subscapularis is detached from the lesser tuberosity of the shoulder, requiring strict limitations in the amount of permitted postoperative external rotation and internal rotation strengthening, whereas this is not as much a concern when the subscapularis is left intact (such as through a subscapularis split). Ensuring excellent communication with the surgical team and the postoperative rehabilitation team of exactly what was performed during the surgery is critical to postoperative success.

Terminology

It is first important to differentiate laxity from instability. Instability is symptomatic laxity—as all shoulders have and require some level of laxity to move through a functional arc of motion. Instability refers to the patient experiencing symptoms of having a shoulder joint that is unstable in certain positions and is usually accompanied by increased laxity in that direction. Similar to other joints, shoulder instability varies in severity from microinstability to subluxation and ultimately to frank dislocation. Microinstability refers to pathologic motion of the humeral head, most often in multiple directions, secondary to generalized capsular laxity. Subluxation denotes translation of the humeral head beyond normal physiologic limits while still maintaining contact with the glenoid. Dislocation differs from subluxation in that the translation of the humeral head is significant enough to completely disassociate the articular surfaces of the humerus and the glenoid; this magnitude of instability will commonly require manual reduction.

Shoulder instability is typically described in relation to the direction of the instability event: anterior, posterior, and multidirectional. Anterior instability is the most common manifestation of unidirectional instability, comprising more than 90% of shoulder dislocations. This type of injury most commonly occurs as the result of a one-time traumatic episode to a shoulder in a vulnerable position of combined abduction and external rotation. The injury may involve an avulsion of the anteroinferior labrum from the glenoid, commonly referred to as the Bankart lesion. Occasionally a fragment of the underlying glenoid rim also may be fractured off; this lesion is referred to as a bony Bankart lesion. Other lesions can also present with symptoms of anterior instability, including subscapularis tears, humeral avulsions of the glenohumeral ligament (HAGL), superior labrum anterior to posterior (SLAP) injuries, and rotator interval lesions.

Posterior instability is far less common than anterior instability, accounting for 2% to 10% of shoulder dislocations. Posterior dislocations are often associated with axial loads applied to the adducted arm and are classically associated with electrocution and seizures. Structural changes associated with posterior instability include avulsions of the posterior labrum (a reverse Bankart lesion), which may be associated with a posterior glenoid rim fracture. Injuries to the SGHL, the posterior band of the IGHL, the subscapularis muscle, and the coracohumeral ligament (CHL) can also be seen in posterior instability. The most common form of posterior instability is recurrent posterior instability, usually resulting in a posterior labral tear and posteroinferior capsular stretch resulting from repetitive loading with the arm in flexion and internal rotation (i.e., the bench press exercise).

Finally, multidirectional instability (MDI) is not typically associated with traumatic episodes. Instead, the primary dysfunction here involves either congenital or acquired capsuloligamentous laxity. As such, it may be indicative of an underlying connective tissue disorder or a result of repeated minor stretching injuries to the capsuloligamentous complex. Presenting pathology typically consists of symptomatic, abnormal humeral head translation in more than one direction, which may include recurrent subluxations or even dislocations with minimal trauma. Often multidirectional instability may be associated with general ligamentous laxity signs such as hyperextension of the thumb to wrist and hyperextension of the elbows.

Diagnostic Evaluation: History, Physical Examination, and Imaging

Physical Examination

Following the history, a detailed physical examination should be completed, beginning with observation.

• The clinician should examine the entire body from head to toe to determine postural alignment, scapular position, and overall core strength.

• Progressing to the shoulders, it is important to note any asymmetry, muscular atrophy, abnormal motion, edema, or scapular winging.

• The structure, function, neurologic status, and strength of the injured shoulder should be compared with the contralateral shoulder.

• Palpation will alert the clinician to specific areas of tenderness, whereas both active and passive range of motion testing will demonstrate stiffness.

• In particular, if significant stiffness is noted, range of motion must be optimized prior to any operative stabilization procedure to avoid progressive loss of motion.

• Next, strength and sensation in all planes should be evaluated because weakness in one or more planes may be significant for concomitant pathology, including rotator cuff tears.

• Shoulder stability testing should also be addressed because provocative shoulder tests and maneuvers may be used to evaluate the extent and direction of any instability.

• Anterior and posterior apprehension, relocation, load and shift (to assess for posterior instability) (Fig. 3-31), and sulcus tests (Fig. 3-32) are widely used to assess shoulder anterior and/or inferior instability.

Figure 3-31 An example of a patient with posterior shoulder instability and a positive load and shift test.

Figure 3-32 An example of a sulcus finding demonstrating space between the acromion and the humeral head with downward traction on the arm at the side. This is not necessarily pathologic and is present in patients without documented instability and just normal laxity of the joint.

Imaging Studies

Finally, radiographs can be extremely helpful in the evaluation of shoulder instability. Generally, a series of radiographs including a true AP, scapular Y, and axillary view will provide significant information. Additionally, a Stryker notch view is helpful for evaluating Hill-Sachs lesions (bony injury of the humeral head from anterior dislocation), whereas the West Point view may be utilized to determine glenoid bone loss. Advanced imaging may be helpful, especially in evaluating an unstable but reduced shoulder. Computed tomography (CT) scanning is useful in evaluating glenoid hypoplasia, fracture, glenoid and humeral bone loss, and retroversion. MRI is useful in visualizing the integrity of soft tissue structures, allowing an assessment of the capsulolabral structures, the rotator cuff, the rotator interval, and the tendon of the long head of the biceps (Fig. 3-33).

Figure 3-33 Various imaging studies to demonstrate examples of glenohumeral instability. Anteroposterior (A) and axillary (B) radiographs that demonstrate an anterior bony Bankart injury sustained after an anterior shoulder dislocation. A magnetic resonance arthrogram that demonstrates an anterior labral tear (C). A computed tomography (CT) scan with three-dimensional reconstruction demonstrating a large Hill-Sachs injury (D). A CT scan sagittal oblique image that shows glenoid bone loss (approximately 25%) and bony Bankart injury with some attrition of the injured bone (E).

Treatment Options

Treatment options for shoulder instability include nonoperative and operative approaches. Nonoperative therapies aim to address instability symptoms by altering the pathologic mechanics of the unstable shoulder. These therapies therefore involve programs to address kinetic chain deficits, shoulder strength and flexibility, proprioception, neuromuscular control, and scapulothoracic mechanics. Surgical treatment, however, aims to directly address the structural deficiencies that may be contributing to instability through various reconstructive techniques.

Considerable controversy exists over the appropriate initial therapy for patients with instability. There is general agreement, however, on the appropriate treatment for an acute shoulder dislocation. Any unreduced dislocation must undergo closed reduction with radiographic confirmation of reduction. It is unknown whether reduction should be performed immediately (i.e., on the field after an athlete has dislocated) or after the patient has been seen in a controlled, emergency room setting with the aid of analgesics and radiographs. Regardless, it is imperative to perform a thorough pre-reduction and postreduction neurovascular examination, especially with regard to anterior shoulder instability where the axillary nerve is particularly vulnerable. In general, the shoulder should be reduced as soon as possible utilizing a variety of well-described reduction techniques.

Postoperative Treatment and Rehabilitation

Anterior Instability

Traumatic dislocations are often associated with significant structural injury. Despite this, studies have demonstrated that good clinical results can be obtained with nonoperative treatment in patients who are older and less active. However, the same cannot be said for patients who are young and active, particularly those involved in contact sports. In these patients, operative treatment has been shown to have a lower risk of recurrent dislocation as compared to nonoperative therapy. Patients with significant bone injury—glenoid defects (20% to 25% or more), displaced tuberosity fractures, and irreducible dislocations—should be treated with operative stabilization. Other indications for operative intervention include three or more recurrent dislocations in a year and dislocations that occur at rest or during sleep.

The open Bankart repair was once considered the gold standard in the treatment of anterior shoulder instability; however, proper patient selection combined with improvements in arthroscopic techniques and devices have allowed for postoperative results rivaling those of open stabilization. In the open procedure, the labrum is anatomically reduced and repaired to the anterior glenoid. Given the common coexistence of capsular injury and stretch, a concomitant capsular shift procedure is often performed. Various methods for the capsular shift have been described; the essential underlying goal is to repair the injured anteroinferior capsule and labral repair. Recurrence rate for open repair has been reported to be approximately 4%. As mentioned, both of these procedures are now increasingly performed arthroscopically (Figs. 3-34, 3-35). Although initial reports described a higher recurrence rate after arthroscopic repair, recent studies have shown that recurrence rates are nearly comparable to open repair, especially in those patients without significant glenoid bone loss or other structural abnormalities.

Figure 3-34 An arthroscopic image of an anterior labral tear (soft tissue Bankart) (black arrows).

Figure 3-35 The patient from Figure 3-34 after repair with four anchors and suture construct (capsulolabral repair). The anchors are located at the black arrows.

With the ultimate focus of regaining and then maintaining shoulder stability, the goals of postoperative rehabilitation commonly focus on avoiding common complications following anterior stabilization procedures. These complications include limited postoperative ROM related to residual stiffness; the development of recurrent instability; an inability to return to preinstability activity levels, especially in competitive overhead athletes; and, over the longer term, the development of osteoarthritis. Thus the goals of rehabilitation are to protect the surgical repair long enough to permit healing, restore full ROM, optimize stability by strengthening the dynamic stabilizers, and ultimately return to full preinjury activity.

See Rehabilitation Protocols 3-5 through 3-8 for specific rehabilitation programs.

REHABILITATION PROTOCOL 3-5 Nonoperative Management of Anterior Shoulder Instability

Phase I: Weeks 0–2

Goals

• Reduce pain and edema

Restrictions

• Avoid provocative positions of the shoulder that risk recurrent instability:

• External rotation

• Abduction

• Distraction

Immobilization

• Sling immobilization in neutral or external rotation.

• Duration of immobilization is age-dependent based on the theoretical advantage of improved healing of the capsulolabral complex:

• <20 years old—3–4 weeks

• 20–30 years old—2–3 weeks

• >30 years old—10 days–2 weeks

• >40 years old—3–5 days

Pain Control

• Medications

• Narcotics—for 5–7 days following a traumatic dislocation.

• Nonsteroidal antiinflammatories (NSAIDs)—to reduce inflammation.

• Therapeutic Modalities

• Ice (Fig. 3-99A), ultrasound, HVGS (high-voltage galvanic stimulation) (Fig. 3-99). Electric stimulation as shown in Fig 3-100.

• Moist heat before therapy, ice at end of session (cryotherapy as shown in Fig. 3-99A).

Exercises

1. Motion: Shoulder

• Begins during phase I for patients 30 years and older.

• Passive range of motion (PROM) (Fig. 3-87B) as per the ROM guidelines outlined in phase II.

• Active-assisted ROM exercises (Fig. 3-101).

2. Motion: Elbow

• Passive—progress to active

• 0–130 degrees of flexion.

• Pronation and supination as tolerated.

3. Muscle strengthening

• Scapular stabilizer strengthening begins during phase I for patients 30 years and older.

• Initiate scapular stabilization.

• Scapular retraction or posture correction (middle trapezius and rhomboids) in seated (gravity eliminated) position with upper extremity in neutral.

• Scapular protraction (serratus anterior).

• Grip strengthening.

Phase II: Weeks 3–4

Criteria for Progression to Phase II

• Reduced pain and tenderness.

• Adequate immobilization.

Goals

• 90 degrees of forward flexion.

• 90 degrees of abduction.

• 30 degrees of external rotation with the arm at the side.

Restrictions

• Avoid provocative positions of the shoulder that risk recurrent instability:

• >140 degrees of forward flexion.

• >40 degrees of external rotation with the arm at the side.

• Avoid extension—puts additional stress on anterior structures.

Immobilization

• Sling—as per criteria outlined in phase I.

Exercises

• Proprioceptive neuromuscular facilitation (PNF) (Figs. 3-106 and 3-107):

• Begin early rhythmic stabilization.

• Progress from arm at side to available flexion, external rotation positions.

• Stabilization:

• Advance scapular stabilization exercises by adding light resistance or in prone/gravity position (Figs. 3-102, 3-114, 3-115).

• Scapular retraction (rhomboids, middle trapezius).

• Scapular protraction (serratus anterior).

• Shoulder ROM:

• Passive ROM exercises.

• Internal rotation, external rotation (only <40 degrees), forward flexion.

• Active-assisted ROM exercises.

• Active ROM exercises.

• Strengthening:

• Initiate rotator cuff strengthening with upper extremity in neutral.

• Begin with closed chain isometric strengthening with the elbow flexed to 90 degrees and the arm comfortably at the side. Starting position is with the shoulder in the neutral position of 0 degrees of forward flexion, abduction, and external rotation. The arm should be comfortable at the patient’s side.

• Scapular depression (latissimus dorsi, lower trapezius, serratus anterior).

Phase III: Weeks 4–8

Criteria for Progression to Phase III

• Pain-free motion of 140 degrees of forward flexion and 40 degrees of external rotation with the arm at the side.

• Minimal pain or tenderness with strengthening exercises.

• Improvement in strength of rotator cuff and scapular stabilizers.

Goals

• 160 degrees of forward flexion.

• 40 degrees of external rotation with the arm in 30 to 45 degrees of abduction.

Restrictions

• Avoid positions that worsen instability (e.g., abduction–external rotation):

• >160 degrees of forward flexion.

• >40 degrees of external rotation with the arm in 30 to 45 degrees of abduction.

Exercises

• Continue PNF to scapular stabilizers, GHJ stabilizers and rotator cuff. Rhythmic stabilization, repeated contractions and slow reversals, and progressive varying speeds and resistances (Figs. 3-106 and 3-107).

• Shoulder ROM:

• Passive ROM exercises.

• Active-assisted ROM exercises.

• Active ROM exercises.

• Muscle strengthening:

• Strengthening of scapular stabilizers (as mentioned previously)

• Rotator cuff strengthening

• Progress to advanced closed chain isometric internal and external rotation strengthening with the arm in 35 to 45 degrees of abduction.

• Progress to strengthening with Therabands (Figs. 3-108 through 3-111). Theraband exercises permit concentric and eccentric strengthening of the shoulder muscles and are a form of isotonic exercises (characterized by variable speed and fixed resistance).

Exercises are performed through an arc of 45 degrees in each of the five planes of motion.

• Six color-coded bands are available; each provides increasing resistance from 1 to 6 pounds, at increments of 1 pound.

• Progression to the next band occurs usually in 2- to 3-week intervals. Patients are instructed not to progress to the next band if there is any discomfort at the present level or if they are unable to perform exercise without compensatory movement strategy or scapular control.

• Progress to light isotonic dumbbell exercises.

• Advance to open chain, isotonic strengthening exercises.

• Initiate deltoid strengthening in the plane of the scapula to 90 degrees of elevation.

Phase IV: Weeks 8–12

Criteria for Progression to Phase IV

• Pain-free motion of 160 degrees of forward flexion and 40 degrees of external rotation with the arm in 30 to 45 degrees of abduction.

• Minimal pain or tenderness with strengthening exercises.

• Continued improvement in strength of rotator cuff and scapular stabilizers.

• Satisfactory physical examination.

Goals

• Improve shoulder strength, power, and endurance.

• Improve neuromuscular control and shoulder proprioception.

• Restore full shoulder motion.

Restriction

• Avoid positions that exacerbate instability (e.g., abduction–external rotation).

Exercises

• Proprioceptive training:

• PNF patterns (Fig. 3-127).

• Shoulder ROM:

• Utilize passive, active-assisted, and active ROM exercises to obtain motion goals.

• Capsular stretching (Fig. 3-126):

• Especially posterior capsule.

• Muscle strengthening:

• Continue with rotator cuff, scapular stabilizers, and deltoid strengthening (Figs. 3-102 through 3-105; Figures 3-108 through 3-111). Advance dynamic shoulder stabilization (Figs. 3-112 and Figs. 3-113 and 3-119 through 3-121).

• Eight to 12 repetitions for three sets.

• Upper extremity endurance training:

• Incorporated endurance training for the upper extremity.

• Upper body ergometer (UBE).

Phase V: Weeks 12–16

Criteria for Progression to Phase V

• Pain-free ROM.

• No evidence of recurrent instability.

• Recovery of 70% to 80% of shoulder strength.

• Satisfactory physical examination (Fig. 3-118).

Goals

• Prepare for gradual return to functional and sporting activities.

• Establish a home exercise maintenance program that is performed at least three times per week for both stretching and strengthening.

Exercises

• Functional and sport specific strengthening:

• Plyometric exercises (Fig. 3-16). Progress dynamic stability to endrange (Fig 3-126).

Progressive, Systematic Interval Program for Returning to Sports

• Golfers (Table 3-14).

• Overhead athletes not before 6 months.

• Throwing athletes (Tables 3-12, 3-13, and 3-16).

Warning Signs

• Persistent instability.

• Loss of motion.

• Lack of strength progression—especially abduction.

• Continued pain.

Treatment of Complications

• These patients may need to move back to earlier routines.

• May require increased utilization of pain control modalities as outlined earlier.

• May require surgical intervention. Recurrent instability as defined by three or more instability events within a year, or instability that occurs at rest or during sleep, is a strong indication for surgical management.

Figure 3-99 A, Apply cryotherapy using shoulder cuff for pain and edema reduction. Position upper extremity with pillow, bolster, or sling for comfort. B, Eighty degrees day 4 picture: Therapist or athletic trainer performing passive glenohumeral joint range of motion. Above, in the scapular plane.

Figure 3-100 Electric stimulation to rotator cuff and scapular musculature for pain control.

Figure 3-87 Cross-arm stretch position.

Figure 3-101 Active assisted and passive bar exercises are safe to perform early, especially in the supine position.

Figure 3-102 Scapular stabilization, unilateral in prone with weight. Emphasis on lower trapezius and rhomboids. Begin lying prone, shoulder in neutral and elbow extended. Retract scapula to contract scapular stabilizers and follow with upper extremity motion. Repeat as indicated without allowing compensation and progress resistance with weights.

Figure 3-103 Scapular stabilization, unilateral in prone with weight. Emphasis on middle trapezius and rhomboids. Begin lying prone, shoulder in 90 degrees of abduction and externally rotated and elbow extended. Retract scapula to contract scapular stabilizers and follow with upper extremity motion. Repeat as indicated without allowing compensation and progress resistance with weights.

Figures 3-104 and 3-105 Scapular stabilization, unilateral in prone with weight. Begin lying prone, shoulder in 105 degrees of abduction and externally rotated and elbow extended. Depress scapula to contract lower trapezius and follow with upper extremity movement through the entire range of motion contracting supraspinatus. Repeat as indicated without allowing compensation and progress resistance with weights.

Figure 3-106 and 3-107 Proprioceptive neuromuscular facilitation: In this example, patient or athlete is lying supine with scapular stabilizers engaged. The therapist provides manual resistance into external rotation in available and allowable range of motion. Also may begin with isometric exercise in this manner.

Figures 3-108 and 3-109 Rotator cuff strengthening with resistance band for external rotation in 90 degrees of abduction. Stabilize scapula and pull resistance band toward 90 degrees of glenohumeral external rotation, while maintaining 90 degrees of abduction and advance resistance tubing as appropriate.

Figures 3-110 and 3-111 Rotator cuff strengthening with resistance band for internal rotation in 90 degrees of abduction. Begin in combined ABER position. Stabilize scapula and internally rotate by 90 degrees while maintaining 90 degrees of abduction. Repeat and advance resistance tubing as appropriate.

Figure 3-112 Shoulder stabilization: Isometric contraction in closed chain. Begin with 15 seconds and progress to 60 seconds. Advance to dynamic stabilization by performing a push-up on an unstable surface, (pictured), an inverted Bosu ball, when appropriate.

Figure 3-113 Shoulder stabilization: Isometric contraction in closed chain. Begin with 15 seconds and progress to 60 seconds. Advance to dynamic stabilization by performing a push-up on an unstable surface (pictured), a “plyo” or weighted ball, when appropriate.

Figure 3-119 Shoulder stabilization with Body Blade. Stabilize scapula and begin oscillating Body Blade in neutral. Begin with 30 seconds and progress to 60 seconds. Progress oscillation exercise in 45 degrees of glenohumeral joint abduction, 90 degrees of abduction, 90 degrees of flexion, and 145 degrees of scaption.

Table 3-14 Interval Golf Program

REHABILITATION PROTOCOL 3-6 Following an Arthroscopic Anterior Surgical Stabilization Procedure

Phase I: Weeks 0–4

Goals

• Protect healing structures.

Pain Control

• Understand management after surgical manipulation of subscapularis.

• Emphasis on assisted ROM and isometric exercises.

• Gradual progress of forward flexion to 140 degrees.

• 40 degrees of external rotation with arm at the side.

Restrictions

• Avoid early aggressive joint mobilization and any form of ROM.

• No internal rotation strengthening for open stabilization group with removal and subsequent repair of subscapularis insertion before 6 weeks.

Immobilization

• Sling immobilization: 2 to 4 weeks duration—during day and especially at night. Wean off at 2 weeks, as tolerated.

Shoulder Motion

• Restoration of ROM is the first goal of rehabilitation after surgery.

• 140 degrees of forward flexion.

• 40 degrees of external rotation initially with arm at the side.

• After 10 days, can progress to 40 degrees of external rotation with the arm in increasing amounts of abduction, up to 45 degrees of abduction.

• If takedown of the subscapularis insertion, then restricted from active internal rotation for 4 to 6 weeks.

• Avoid provocative maneuvers that recreate position of instability (e.g., abduction–external rotation).

Pain Control

• Refer to outline in phase I of Rehabilitation Protocol 3-5.

Exercises

Shoulder ROM

• After 10 days, can progress to external rotation with the arm abducted—up to 45 degrees of abduction.

• No active internal rotation for patients following an open stabilization procedure with removal and subsequent repair of the subscapularis insertion for 4 to 6 weeks.

• Passive ROM exercises.

• Passive internal rotation to stomach for those patients restricted from active internal rotation.

• Motion: Elbow

• Passive—progress to active.

• 0–130 degrees of flexion.

• Pronation and supination as tolerated.

Muscle Strengthening

• Facilitate scapulohumeral rhythm (Fig. 3-117).

• Rotator cuff strengthening (Figs. 3-108 through 3-111).

• Internal rotation. (No internal rotation strengthening for open stabilization group with removal and subsequent repair of subscapularis insertion before 6 weeks.)

Phase II: Weeks 4–8

Criteria for Progression to Phase II

• Minimal pain and discomfort with active ROM and closed chain strengthening exercises.

• No sensation or findings of instability with previously mentioned exercises.

Goals

• Continue to protect healing structures.

• Attain full ROM by week 8 except combined ABER in 90 degrees.

Restrictions

• Shoulder motion: early active ROM.

• 160 degrees of forward flexion.

• 60 degrees of external rotation.

• 70 degrees of abduction.

• Avoid provocative maneuvers that recreate position of instability.

• Abduction–external rotation.

• Note: For overhead athletes, the restrictions are less. Although there is a higher risk of recurrent instability, the need for full motion to perform overhead sports requires that most athletes regain motion to within 10 degrees of normal for the affected shoulder by 6 to 8 weeks after surgery.

Immobilization

• Sling—discontinue.

Pain Control

• Refer to outline in phase I of Rehabilitation Protocol 3-5.

Shoulder Motion

• 160 degrees of forward flexion.

• 50 degrees of external rotation.

• 70 degrees of abduction.

Exercises

• Exercises performed with the elbow flexed to 90 degrees.

• Starting position is with the shoulder in the neutral position of 0 degrees of forward flexion, abduction, and external rotation.

• Exercises are performed through an arc of at least 45 degrees in each of the five planes of motion—within the guidelines of allowed motion.

• Six color-coded bands are available; each provides increasing resistance from 1 to 6 pounds, at increments of 1 pound.

• Progression to the next band occurs usually in 2- to 3-week intervals. Patients are instructed not to progress to the next band if there is any discomfort at the present level.

Note: For overhead athletes, the motion goals should be within 10 degrees of normal for the affected shoulder.

Rotator cuff (Figs. 3-108 through 3-111) and scapular stabilizers strengthening (Figs. 3-102 through 3-105) and Theraband exercises.

Phase III: Weeks 8–12

Criteria for Progression to Phase III

• Minimal pain or discomfort with active ROM and muscle strengthening exercises.

• Improved strength of rotator cuff and scapular stabilizers.

• No sensation or findings of instability with previously mentioned exercises.

Goals

• Improve shoulder strength, power, and endurance.

• Improve neuromuscular control and shoulder proprioception (PNF).

• Restore full shoulder motion.

• Obtain full ABER 90 degrees by week 12.

• Restore proper scapulohumeral rhythm and eliminate faulty arthrokinematics.

• Establish a home exercise maintenance program that is performed at least three times per week for both stretching and strengthening.

Pain Control

• Refer to outline in phase I of Rehabilitation Protocol 3-5.

Exercises

• Proprioceptive training: PNF patterns.

Shoulder ROM

• Active-assisted ROM exercises.

• Active ROM exercises.

• Passive ROM exercises.

• Capsular stretching (especially posterior capsule).

• Facilitate scapulohumeral rhythm.

Muscle Strengthening

• Scapular stabilizer strengthening (Figs. 3-102 through 3-105).

• Rotator cuff strengthening—three times per week, 8 to 12 repetitions for three sets.

• Continue with closed chain strengthening (Figs. 3-113 and 3-114).

• Continue with advancing Theraband strengthening. (Figs. 3-108 through 3-111).

• Progress to light isotonic dumbbell exercises.

• Progress to open chain strengthening.

Upper Extremity Endurance Training

• Incorporated endurance training for the upper extremity.

• Upper body ergometer.

Functional Strengthening

• Plyometric exercises (Fig. 3-116).

Progressive, systematic interval program for returning to sports: same as Rehabilitation Protocol 3-5.

Maximum improvement is expected by 12 months; most patients can return to sports and full-duty work status by 6 months.

Terminal testing demonstrating resolution of apprehension testing (Fig. 3-118).

Warning Signs

• Refer to outline in phase V of Rehabilitation Protocol 3-5.

Treatment of Complications

• Refer to outline in phase V of Rehabilitation Protocol 3-5.

Figure 3-117 Facilitate scapulohumeral rhythm. Therapist or athletic trainer will manually facilitate proper glenohumeral to scapular movement ratio.

Figures 3-114 and 3-115 Scapular rowing: Scapular stabilization with resistance band. Adduct and depress scapulae, followed by upper extremity movement. Avoid glenohumeral abduction, and keep upper extremity adjacent to thorax. Emphasize scapular stabilizers.

Figures 3-116 Plyometric ball toss: Lying supine, two-hand chest toss with “plyo” or weighted ball. Progress to unstable surface to increase level of difficulty. For example, lying on Bosu Ball as above.

Figure 3-118 At around 4 to 6 months, once the patient has met postoperative goals, the apprehension test is performed to ensure that there is no recurrent instability findings (A and B).

REHABILITATION PROTOCOL 3-7 Postoperative Rehabilitation After Open (Bankart) Anterior Capsulolabral Reconstruction

Phase I: Weeks 0–4

Goals

• Protect healing structures.

• Reduce pain and edema.

• Avoid early “overly aggressive” PROM, AROM, and joint mobilization.

• Understand how the subscapularis was managed during the repair.

• Minimize effects of immobilization.

Restrictions

• 140 degrees forward flexion.

• 45 degrees external rotation (ER) in neutral position.

Immobilization

• Sling immobilization: 0 to 4 weeks duration—during day and especially at night. Wean at week 2 as tolerated but should be worn during sleep for minimum of 2 weeks.

Pain Control

• Refer to outline in phase I of Rehabilitation Protocol 3-5.

Exercises

• Elbow, hand, wrist, and grip ROM (progress from PROM to AAROM to AROM)

• Elbow ROM

• 0 to 130 degrees

• Pronation–supination.

• Shoulder ROM

• Passive internal rotation to stomach only (No active internal rotation strengthening for open stabilization group with removal and subsequent repair of subscapularis insertion before 4 to 6 weeks.)

• PROM to AAROM flexion

• to 90 degrees week 1.

• to 100 degrees week 2.

• to 120 degrees week 3.

• to 140 degrees by week 4.

• ER at 45 degrees of abduction in scapular plane:

• 15 degrees week 1 to 2.

• 30 to 45 degrees week 3.

• 45 to 60 degrees week 4.

• Proprioceptive neuromuscular facilitation (PNF) (Figs. 3-106 and 3-107).

• Begin early rhythmic stabilization.

• Progress from arm at side to available flexion, ER positions.

• Facilitate scapular stabilizers.

Strength

• Submaximal isometrics in neutral.

• Begin light Theraband resistance ER (in neutral to allowable ROM), scapular rows, and scapular depression week 3.

• PROM forward flexion, scaption (full can) minimal resistance to 90 degrees.

• Begin protraction closed chain.

• Prone scapular stabilizer strengthening (Fig. 3-102).

• Sidelying external rotation not >45 degrees.

Phase II: Weeks 4–8

Criteria for Progression to Phase II

• Minimal pain and discomfort with active ROM and closed chain strengthening exercises.

• No sensation or findings of instability with aforementioned exercises.

Goals

• Continue to protect healing structures.

• Discontinue immobilization.

• Facilitate full PROM in all planes (full external rotation by 8 weeks).

• Normalize arthrokinematics and scapulohumeral rhythm.

Pain Control

• Refer to outline in phase I of Rehabilitation Protocol 3-5.

Restrictions

• Avoid maneuvers that recreate position of instability.

• No forceful combined abduction–external rotation.

• No active internal rotation for patients following an open stabilization procedure with removal and subsequent repair of the subscapularis insertion for 4 to 6 weeks.

Immobilization

• Sling—discontinue.

Exercises

• ROM

• Flexion to 160 degrees.

• External rotation/internal rotation (ER/IR) at 90 degrees of abduction; IR to 75 degrees; ER to 75 degrees by week 6 and 90 degrees by week 8.

• PROM into combined motions, progress scaption to abduction plane.

• Rotator cuff and scapular stabilizers strengthening and Theraband exercises (no resisted IR until week 6) (Figs. 3-108 through 3-111, 3-114 and 3-115).

• Strength

• Initiate IR strength (PNF, light Therabands) at week 6.

• Progress all strength (Therabands) of rotator cuff, deltoid, biceps, and scapular muscles (Figs. 3-102 through 3-105 3-108 through 3-111, 3-114 and 3-115).

• Closed chain (wall push-ups).

• Dynamic stabilization exercises.

• Start light weights in open chain for deltoid, biceps, and ER sidelying.

• Progress closed chain weightbearing (isometric and push-up position) (Figs. 3-112 and 3-114).

• PNF diagonal patterns.

Phase III: Weeks 8–12

Criteria for Progression to Phase III

• Minimal pain or discomfort with strengthening through full ROM.

Goals

• Improve neuromuscular control and shoulder proprioception (PNF).

• Restore full combined AB/ER.

• Orient for sport-specific functional training.

Restrictions

• No throwing.

Exercises

• ROM

• Combined AB/EF passive “doorway” stretch.

• Combined AB/IR passive “doorway” stretch.

• Joint mobilization.

• Posterior–inferior glenohumeral (GH) mobilization.

• Anterior GH mobilization as needed after week 10.

• Capsular stretching (especially posterior capsule).

• Scapular mobilization.

• Facilitate scapulohumeral rhythm (Fig. 3-117).

Muscle Strengthening

• Light isotonic dumbbell exercises.

• Rotator cuff strengthening—exchange Therabands with weights.

• “Thrower’s 10” for overhead athletes.

• Begin push-up progression starting week 10.

• Lat pulls to front.

• Body blade in neutral.

• Begin agility drills.

Endurance Training

• Upper body ergometer and cardiac endurance.

Phase IV: Weeks 12–16

Goals

• Optimize throwing mechanics and overhead function.

Restrictions

• No full throwing.

Exercises

• ROM

• “Sleeper stretch” if limited IR or posterior capsule restrictions.

• Functional strengthening: Plyometric exercises.

• Progress Body Blade to 45 to 90 degrees of abduction (Figs. 3-119 through 3-121).

• Two-handed plyometrics (chest pass).

• Progress plyometrics to one handed (dribble).

• Begin one-handed toss (NO overhead throw).

Phase V: Weeks 16–20

Goal

• Restore overhead/serve/swing/throw by week 20.

Exercises

ROM

• Continue flexibility and full ROM exercises.

• Strength

• Start throwing progression.

• Plyometrics/rebounder.

• Swimming.

• Full push-ups.

• Sports-specific training.

• Progress overhead/serve/swing/throw by week 20.