The most common complaint in patients with advanced osteoarthritis (OA) of the shoulder is pain—more specifically, night pain. Most often, the pain is insidious in its onset, although an occasional patient will report acute symptomatology only to discover severe osteoarthritic changes in the glenohumeral (GH) joint. In many cases night pain is a major problem; specifically, difficulty with lying on the affected side is a common complaint.1

A careful history should be taken with respect to prior injuries and prior surgical procedures. For a total shoulder replacement to be viable and functional, an intact rotator cuff is necessary. In certain patients with long-standing rotator cuff disruption, the initial clinical signs are progressive pain that comes with the developing secondary arthropathy.²

Another area of concern is whether the patient has undergone any prior stabilization procedures. The reason this is important to remember is that preferential wear of certain parts of the glenoid can occur in long-standing cases that have undergone excessive capsular-tightening procedures.³ Most commonly, this is posterior wear. In addition, in certain types of stabilization procedures, a variety of bony transfer procedures are performed, including a lateralization of the lesser tuberosity and a transfer of the coracoid transfer. As a result, the surgical exposure in these cases can be difficult because of the distorted anatomy.

The most important predictor of the outcome of a total shoulder replacement is the preoperative range of motion (ROM).4,5 It is therefore incumbent on the physician to document all directions of the patient’s motion and to discuss the implications of lack of mobility on the overall outcome. Another important aspect is the integrity of the rotator cuff; a successful standard replacement depends very heavily on the presence of an intact cuff. The supraspinatus, infraspinatus, teres minor, and the subscapularis should all be carefully examined. If any doubt exists as to the function of the cuff, magnetic resonance imaging (MRI) is indicated. In cases in which a rotator cuff disruption coexists with severe OA, a determination should be made as to the possibility of repairing the cuff. In those cases in which significant chronicity of the cuff is noted, either by history or MRI examination, a simple hemiarthroplasty or a reverse total shoulder replacement (in cases in which pseudoparalysis of the arm exists) should be considered.⁶

Patient examination following surgery typically occurs on day 0 (day of surgery) or on postoperative day 1. The therapist will note IV lines for postsurgical fluid intake, sanguineous drains, postoperative dressing, and the upper extremity in a sling for comfort. Physical examination should include cognitive testing for orientation to name, time, place, and reason and vital sign assessment on the noninvolved extremity in supine, sitting, and standing. Testing specific to the involved upper extremity should adhere to the postoperative restrictions according to the patient’s chart (Box 7-3).

Neural screening should be completed as allowed within the postsurgical restrictions, including myotome, dermatome, and deep tendon reflex (DTR) testing. Active range of motion (AROM) of the cervical spine, thoracic spine, and elbow, wrist, and fingers should be assessed. PROM of the shoulder should be assessed with the patient in supine, understanding that some limitation in mobility may be contributable to the dressing or IV lines. Girth measurements should be noted at the elbow and at the wrist for comparison with the uninvolved extremity. Additionally, the anterior and posterior chest wall should be monitored for ecchymosis.

Functional mobility assessment should be initiated with instructions cautioning against direct pushing or pulling of the involved upper extremity during transferring. Patients must be assessed for independent mobility from supine to sit to stand and vice versa. Once standing is achieved, balance must be assessed for single limb support without loss of balance. Frequently, postoperative day 0 or day 1 will require the patient to use a temporary single upper extremity support (IV pole or single point cane) because of anxiety and a deconditioned state. Monitoring of vitals and orientation during the transfer and gait assessment is necessary due to risk of hypotensive episodes. The clinician should encourage the use of coughing and incentive spirometry throughout the hospital stay because of the greater level of inactivity following surgery intervention.

TIME: 2 to 6 days after surgery13

GOALS: Protection of healing structures, pain control, independent functional mobility for transfers, dressing and ambulation, education, and the institution of a home exercise program within the surgical restrictions (Table 7-1)

Treatment during the hospital phase of rehabilitation focuses on the achievement of appropriate pain control, independent functional mobility for transfers, dressing and ambulation, education, and the institution of a home exercise program within the surgical restrictions. Length of hospital stay depends on multiple factors including the volume and experience of the hospital and the surgeon experienced in the total shoulder procedure. Home support, comorbidities, and demographic features play a smaller role. Unlike the total knee arthroplasty where a certain objective measure of knee flexion is often one of the impairment goals for discharge, common discharge goals regarding functional level, pain control, and impairment objective measurements for total shoulder procedures have not been established in the literature.^12,13

Typically, PROM is initiated on day 0 or 1, with a progression to self-assisted ROM exercises including pendulum or table top activities.

The home exercise program should be completed multiple times per day for short durations of 5 minutes maximum per bout of exercise.¹⁸ If there is a strict passive ROM restriction in place, then this will require the education of a caregiver or family member to assist with the execution of the home program. This caregiver must understand all postsurgical restrictions that limit ROM. Self-assisted ROM exercises can be based on patient comfort or surgeon preference.

Pendulum exercises involve a static position of forward flexion of the trunk with movement of the hips and trunk to drive the dangling upper extremity into multiple planes of motion (Fig. 7-11). The benefits of this activity for this patient population includes the addition of traction to the joint, stretching of the capsule, and avoidance of active muscular contraction at the shoulder joint.²¹ Overall, the goal is prevention of soft tissue contracture and possible modulation of pain via the rhythmic movement of the upper extremity through a PROM.^17,22 There are several challenges with the correct performance of this exercise as it applies to the patient with a recent TSA. Frequently, the patient demonstrates inappropriate performance by recruiting excessive muscular action at the deltoid and pectoralis major muscles. The recommended posture for pendulum exercises emphasizes poor mechanical alignment of the scapula on the thorax with promotion of scapular abduction. And lastly, the excessive and unopposed stretching of the recently repaired musculature and tissues from the surgical procedure may actually generate greater pain response.

The Neer protocol for TSA²³ placed wall slides in the same phase as pendulum activities with literary evidence of low muscular activity about the healing structures.²¹ Modification of this position to a lower gravitational demanding position would be self-assisted ROM using a table top. This table top modification is frequently used before wall slides during this early intervention phase. The patient stands at a table top with bilateral upper extremities resting at a comfortable placement. The hands maintain a static position and then ROM is attained by the lower extremity stepping into the various planes of motion.¹⁷ There are several benefits to this type of exercise prescription. The position of weight bearing promotes ROM gains through planar lower extremity motion. The trunk is moving underneath the scapula, which promotes interaction of the scapula and thorax in preparation for later stages of rehabilitation (Fig. 7-12). The patient is able to control the excursion of the ROM of the shoulder via decreasing the step size. The supported position of the shoulder via the hand decreases the unopposed stress on the healing tissue that may be achieved in the open kinetic chain position of the pendulum. Finally, closed kinetic chain activities at the shoulder reap similar benefits as stated for other extremities including: muscular cocontraction, decrease of shear forces, increased joint compression, and increased stability about the joint.^3,24

The home exercise program should require AROM of the cervical and thoracic spines through the cardinal planes and active movement of the elbow, wrist, and hand. If the patient is supine then flexion of the elbow should occur only with the humerus supported by a towel underneath it to decrease the strain on the biceps tendon at its insertion. Frequent bouts of exercise for short durations are recommended for the earlier stages of rehabilitation.

The home exercise program contains education for passive and/or self-assisted ROM at the shoulder, active ROM for proximal and distal structures, and education on sleeping postures. This should include positional support via the use of pillows or an immobilizer to support the healing structures during the night. The encouragement of experimentation to attain the best possible sleeping posture should be discussed. Anecdotally, patients following shoulder surgery feel better sleeping in a semireclined posture with the involved upper extremity supported by pillows or bolsters (Fig. 7-13).

GOALS: Protection of healing structures, pain control, uninterrupted sleep pattern, normalized circumference measurements between upper extremities, mobilization of scar, ability to demonstrate normalized posture, and increased ROM (Table 7-2)

Outpatient rehabilitation begins as a progression of the home exercise program given during the hospital stay. It is recommended to incorporate the use of a self-reported outcome measure tool, such as the simple shoulder test (SST) or the disability assessment of shoulder and hand (DASH) to monitor functional changes through rehabilitation.⁷ It is important to remind the patient that their rehabilitation will continue past discharge from formal physical therapy as functional return may proceed for 1 to 2 years after surgical intervention.²⁵

The focus of the first 6 weeks of rehabilitation is twofold: protection of the healing structures and progression of ROM for prevention of muscular contracture and joint capsule stiffness. A limited amount of literature is available to support the variety of intervention plans employed during this phase.^18,26–28 Adherence to postsurgical precautions is paramount. Treatment of the postsurgical impairments of pain, edema, and scar mobility will naturally lead to increased ROM in the shoulder.

Pain control should be assisted via the adherence to medications prescribed by the surgeon and alleviating positions. Use of the sling should be gradually removed as the patient progresses through this phase. Control of pain will also be gained via the interventions to address the postsurgical inflammation and edema, and those interventions to improve the limited functional use of the upper extremity. Edema may be present in the distal upper extremity and ecchymosis may be present in the thorax from the overload of the lymphatic system following surgery. Modality use including ice, elevation, and electric stimulation are appropriate for edema management.²⁹ Diaphragmatic breathing followed by localized lymphatic massage techniques beginning at the proximal segments of the thorax and ipsilateral axilla and progressing distally in sequential order may also be employed for effective management.

Sleeping postures should be recommended to include positional support of the humerus via the use of pillows or a bolster. As mentioned, patients following shoulder surgery may prefer sleeping in a semireclined posture; the therapist should encourage the patient to experiment.

Progression of ROM may be elicited via soft tissue mobilization. Soft tissue mobilization, a form of massage, has the support of an animal model for potential cellular changes.³⁰ Initiation of soft tissue mobilization techniques at the posterior cuff and the deltoid will promote appropriate muscular length. Because of the probable postsurgical hypersensitivity, care should be taken at or near the surgical scar. For each of these techniques, the upper extremity position should be adjusted to ensure the muscle or area of skin being addressed is relaxed and in a protected posture. Initial positioning should address the targeted muscle in a position of a passively shortened length. This will decrease sensitivity and spasm at the introduction of this type of intervention.

The external rotation limitation is in place to promote soft tissue healing and protection of those structures injured during the surgical procedure, specifically the subscapularis muscle. As outlined previously, the subscapularis is taken down and reattached during the arthroplasty procedure. Direct passive ROM to “stretch” this tissue is contraindicated during the early phases of rehabilitation and soft tissue mobilization is an appropriate intervention to address the inflammatory condition of this muscle and prevent adhesion development. The technique of soft tissue mobilization promotes change to the myofascia via proposed realignment of the scar tissue and collagen. Slow, deep strokes to the myofascia of the subscapularis will assist in improvement of external rotation ROM, pain control, and eventual overhead reach.³¹ The best patient position for improvements to the subscapularis length is approximately 45° of humeral abduction with a neutral rotation of the humerus.

Consideration of the other joints of the shoulder complex should be initiated during this phase. During the hospital stay, the patient had been instructed in cervical and thoracic AROM. Distally, the elbow and hand should be used during daily functional activities, thereby limiting the extent of distal disuse atrophy. Realization of the influence of the scapulothoracic juncture on GH motion can assist with restoration of this motion early in rehabilitation.

Protective posturing from the postsurgical sling typically places the scapula in an abducted and down rotated position. Lack of humeral motion in all of the planes through the initial weeks of rehabilitation leads to further disuse of the scapula and its contribution to shoulder ROM. Scapular mobilization on a stable thorax with the GH joint in its resting position for greatest volume prepares the scapula and its connecting tissue for future shoulder ROM (Fig. 7-14). Because of the typical postural dysfunction of scapular abduction and down rotation, many patients will require facilitation of adduction, upward rotation, and elevation. The lack of a true joint capsule about the scapula places this type of intervention into a mobilization of the myofascial connections. The clinician should recall the scapulohumeral rhythm and carefully monitor the position of the humerus when facilitating positions of the scapula (Box 7-4). For example, scapular mobilizations into upward rotation should only occur with the humerus passively flexed greater than 60° or abducted greater than 30°, as these are the ranges at which the scapula and humerus begin a more associated phase of motion.³²

PROM via a family member in a gravity-eliminated position of supine or self-assisted ROM during table top weight bearing will be the primary method to promote ROM during this time frame (see Fig. 7-12). Progression should be dictated by the report of pain. PROM performed by the therapist, patient, or caregiver should not exceed any precautions or restrictions given by the surgeon. A tip for improved pain tolerance for motion of the upper extremity is to bias toward the plane of the scapula instead of true sagittal plane flexion.³³ A recommendation for moving into passive external rotation is the alignment of the humerus perpendicular to the center of the glenoid. This occurs at approximately 30° of abduction and ensures that the capsular structures will relax, achieving a better outcome.¹⁸

Self-assisted activities for ROM can be varied by direction, surface, and patient position. These types of exercise promote the mobility of the proximal segments over the involved upper extremity in a stable position. The trunk may move away from the upper extremity in various directions to promote the cardinal planes.²⁶ For example, in the early stages when the patient may still be most comfortable in the sling or supported position, relative external rotation and facilitation of scapular control may be achieved via contralateral trunk rotation and a return to neutral.³⁴ In an advanced stage of self-assisted exercises, the involved upper extremity may rest on a stability ball and the patient rolls the stool away from the stability ball in the frontal plane, promoting self-assisted abduction of the involved extremity. Or the patient may progress to gravity-dependent positions using the wall as the support and the trunk moving under the body to facilitate various planes of motions (Fig. 7-15).

Other self-assisted activities that have been recommended during this time include wand activities and pulley stretches.^18,26–28 Examination of pulley and wand activities compared to therapist-assisted exercises³⁵ indicate that therapist activities elicit less muscular activity of the supraspinatus, infraspinatus, anterior deltoid, and trapezius muscles. Therefore, therapist-assisted activities should be used initially during this phase with a progression to wand or pulley activities as pain or surgical restrictions allow (Figs. 7-16, 7-17, and 7-18).^18,26–28

Progression from the initial outpatient phase (phase II) to the late ROM phase (phase III) is listed in Box 7-5. The most significant requirement is physician clearance for AROM, especially into external rotation. Many patients’ restrictions will be lifted between weeks 2 and 6, thereby blurring the activities of phase II and phase III. The therapist should monitor the patient’s ROM to assist with “staging” the patient’s rehabilitation. This is one of the most challenging components of the transition from phase II to phase III. As noted, the passive motion goal of phase II is 40° while the patient will have achieved full PROM at the end of phase III. Additionally at the end of phase III, the patient should have active external rotation ROM of 45°. This ROM measure is the key to successful overhead motion.

Recall that optimal GH and scapular mechanics require near normal ROM of external rotation of the GH joint to complete functional tasks, such as touching the back of the head, reaching overhead, and donning/doffing shirts.³⁶ If the GH joint ROM into external restriction is restricted to 45°, then a significant loss of function occurs, dramatically impacting a patient’s quality of life. As the patient will not have near normal external rotation ROM at the end of phase II, it is ill-advised to focus on repetitive or strengthening activities that are overhead because the mechanics will be less than optimal. To prevent complications of overuse or tissue irritation, exercises and activities should be performed with the correct mechanics and without symptoms before progression to the next phase.

GOALS: Return to everyday activities below 90° of shoulder flexion, increased ROM, improved muscle flexibility, improved neuromuscular control, increased strength, protection of healing structures (Table 7-3)

As the patient’s ROM progresses, the patient will enter a mixed phase that consists of stretching to gain motion and strengthening to use the range gained. Exercise selection should place the protection of the healing structures as the primary concern. This may include protection of the anterior joint capsule and the subscapularis via limit of external rotation when the humerus is in 0° of abduction and a limitation of hyperextension of the humerus when in the supine position for resting or exercise positioning.^18,26 Communication with the surgeon will assist with determining which restrictions need to be maintained.

The emphasis of this phase is use of ROM and progression to muscle strengthening. Interventions to address muscular flexibility of the rotator cuff, deltoid, and scapular stabilizers should be continued from the previous phase. Pain has been found to inhibit muscular strength and therefore can be a limitation for achievement of active ROM.⁶ Consideration that the source of pain may be from structures other than the traumatized muscle tissue will provide options for other interventions. Gentle joint mobilizations (grade I to II oscillatory) to the GH joint may be used to decrease possible capsular adhesions and to alter nociceptive input.^18,26

There can be considerable discussion on the most appropriate exercises to initiate strengthening activities following a TSA. The clinician should always consider how mobility is achieved and what movement patterns may be adopted during this time period. As the body transitions from limited mobility and muscular inhibition, the patient is at risk of developing faulty movement patterns that may later impede the ability to achieve active ROM in gravity-resisted positions. It is strongly encouraged to instruct the patient in activities that promote the correct scapulohumeral rhythm for overhead activities. Application of this movement reasoning includes activities that emphasize the separation of scapular and the humeral motion during the initial phases and late phases of flexion and abduction and then emphasize coordination of the motion of the scapula and the humerus during the mid phases of motion.

Isometric training is supported for early strength training, especially in the cases where muscular contraction is desired yet the patient lacks sufficient strength for mobility through ROM.²⁶ The clinician should be aware that significant muscular contraction can be elicited during isometric contraction exercises and therefore these exercises may be inappropriate during a healing phase where maximum tissue protection is required.²¹ Initiation of isometric training of the deltoids with a contraction of the rotator cuff establishes a muscular cocontraction or force couple that is required for motion (Figs. 7-19 and 7-20).

Isometric training of the scapular stabilizers with an eccentric contraction of the deltoid and rotator cuff from a prone position is an option for the introduction of strength training below 90° of shoulder flexion. A slow lowering toward the floor after a passive preposition into horizontal abduction at 90° will activate each of these key muscles. Introduction of concentric flexion and abduction may be introduced by progressively tilting supine positioning toward upright with and without weights (Figs. 7-21 and 7-22).¹⁹

If the patient is demonstrating significant difficulty performing an active contraction of targeted muscles in the absence of a neurologic injury, neuromuscular electric stimulation (NMES) may be used. Though specific parameters are outside the scope of this chapter, dual channel stimulation to provide for the deltoid activation and the scapular rotation necessary to achieve shoulder motion greater than 90° is recommended. Scapular rotation may be stimulated via the lateral rotator cuff muscles on the scapula or by stabilizing the scapula by stimulating the muscles with attachments to the medial border of the scapula. Electrode size and placement are key points for effective use of NMES.²⁹

Progression to the final phase requires an improvement in passive and active ROM. The patient must be able to perform all home exercises with the correct form and minimal correction by the therapist (Box 7-7).

GOALS: Return to normal activities including overhead, increased ROM, improved neuromuscular control and strength. Full potential of function achieved between 6 and 12 months (Table 7-4).⁷

The goal of this phase of rehabilitation is strengthening of targeted muscles for use of the AROM gained and to establish a home exercise program that promotes continued strengthening upon discontinuation of therapy. Interventions addressing pain control and edema should be progressively phased out as they are no longer needed. Mobility of the scapula should occur with the humerus positioned into greater ranges of motion into shoulder flexion or abduction or completed in a mobilization with a movement model, with the patient performing the motion and the clinician providing overpressure to engage scapular motion at the appropriate time. The intention of mobilizations to the GH joint should change from addressing pain relief to the residual capsular stiffness or asymmetry through oscillation grades III and IV. Strengthening activities should address the dynamic stabilization system of the shoulder that is necessary for overhead movement.

Several underlying impairments may be responsible for the continued limited ability of the patient to demonstrate appropriate sequential motion when attempting to raise the arm above shoulder height. A number of factors may create barriers to successful progression. These include appropriate and timely surgical intervention, a rehabilitation course that has minimal medical complications, and/or appropriate motivation by the patient. If no barriers are apparent to progress, the primary impairment for limited overhead motion is due to inadequate motor performance of the force couples of the shoulder. The force couple between the deltoid muscles and the rotator cuff musculature is the primary focus.^17,27 If the AROM demonstrated in the supine position is approaching the ROM goals for therapy—yet the patient is unable to demonstrate similar range in sitting—then this type of motor control and/or pattern of weakness should be considered (Box 7-8).

Though specific rehabilitation parameters for those patients exhibiting weakness because of neural injury will not be included in this discussion, this impairment should be considered as a possible contributor to a continued movement dysfunction. Typically, a neural injury associated with the trauma that predates the surgery or a neural injury from a recent surgical intervention is difficult to identify because of the amount of surgically induced trauma during the procedure. Neural injury may be identified via atrophic changes to the muscle, inability of the patient to elicit an isometric contraction of the muscle with the humerus positioned in neutral, and possible sensory changes in the upper extremity. Isolated neural injuries following shoulder arthroplasty are considered a low risk because of the transient nature of the injuries and the tendency for resolution without eventual operative intervention.³⁸ When denervation of the shoulder musculature is present before surgery, the patient will most likely be placed in a limited goals category.²³ This category and the goals will be discussed later in this chapter.

Evaluation of weakness in patients with adequate innervation of the shoulder musculature should include manual muscle testing and the presence of coordination between the two primary force couples that move the shoulder. As a review, there is a delicate balance that must be maintained to move the shoulder through its full ROM. The muscular contribution to this coordinated effort is via the force couple of the deltoid muscles and the rotator cuff muscles, and the scapular stabilizer muscles with the deltoid muscles. Both of these force couples must have a balanced contraction to facilitate shoulder flexion and abduction without impingement of the humerus at the subacromial arch.³⁹

Strengthening should respect the force couples of the shoulder while addressing both the concentric and eccentric functions of the targeted muscles. The force couple of the shoulder between the deltoid and the rotator cuff can be progressed from earlier examples of exercise (Fig. 7-23) into a standing exercise that maintains humeral external rotation through an isometric contraction and a concentric contraction of the deltoid. An example of an eccentric exercise progression is demonstrated through an alteration of the wand activity. The patient can complete a sitting or standing overhead wand activity initially shown in supine in Fig. 7-24. At the highest point of the wand lift, the patient releases the involved upper extremity from the wand and slowly lowers the involved extremity back toward the waist.⁴⁰ This type of training can also be initiated for strengthening into abduction.

As a final example, consider that strengthening must also address specific deficits in the targeted muscles. Fig. 7-24 demonstrates an exercise targeting the function of the low trapezius. The exercise emphasizes an isometric contraction of the upward rotation and a concentric action of the low trapezius as a scapular depressor. A movement dysfunction at greater than 120° in either flexion or abduction or inadequate strength as noted in a manual muscle testing would assist in determining the necessity of this exercise.

Return to recreational activities should have been a goal from the initial evaluation. Closer scrutiny to the movements necessary for the patient’s chosen recreation will be strong consideration for formulation of the home program and strengthening program during this final phase. Successful return to recreation has been noted especially with the sports of swimming, tennis, and golf. Though the timeframe of return will vary, successful return has been noted as early as 6 months.⁴

The goals for a patient with a TSA secondary to trauma are the same as that for a patient with a TSA secondary to degeneration: pain relief and resumption of daily function in both patient populations. The most important preoperative factors that influence postrehabilitation function are the timing of the surgery in relation to the injury and the skill of the surgeon. The outcome worsens the longer the delay is between the date of the trauma and the initiation of surgery. The skill of the surgeon directly relates to the ability to align the humeral tuberosities. Finally, there are improved outcomes with larger surgery centers and higher volume surgeons.52

For patients with a traumatic reason for their total shoulder surgery, rehabilitation may be a longer period of immobilization with passive ROM only. This is to ensure appropriate boney healing. Additional time with significant precautions may exist up to 6 weeks, further delaying the potential resumption of ROM.⁵² The most common complication following a TSA procedure for a traumatic injury is superior migration of the humeral head, which the clinician may observe as unopposed scapular elevation or “shoulder hike” as described in the next section or in Box 7-11. There are several reasons why this may occur: failure of the rotator cuff muscles, muscular imbalance with inappropriate muscular force couple production at the shoulder, or loosening of the glenoid component.⁵⁵

A patient who has decreasing ROM in conjunction with pain or increasing pain should alert the clinician to possible infection.⁹ Infection may present in up to 15% of all total shoulder cases⁵³ and may occur more than 1 year following the surgical procedure.⁵ Though pain and loss of ROM may be the most objective signs during therapy, the therapist should be alert for drainage, warmth at the site, erythema, and effusion. Interviewing questions regarding the presence of night sweats, fever (as noted by taking body temperature), chills, remote sites of infection, or any recent invasive procedures should be asked.¹⁰ Early intervention in the acute phase of the infection yields the best result, therefore the therapist should recommend an urgent return visit to the physician for blood laboratory testing.⁹

Biceps tendon tendonitis is a preventable complication during the rehabilitation process. The biceps has a role in shoulder flexion and is a primary humeral depressor.37 Following total shoulder surgery, the rotator cuff typically demonstrates muscular inhibition, thus increasing the demand on the biceps as the primary humeral depressor during shoulder motion. Presentation of biceps tendon tendonitis indicates continued overuse of this muscle, therefore implicating inadequate contribution from the rotator cuff muscles. Beyond regional treatment for the inflammation of the biceps tendon such as modalities, active rest, and taping, the rotator cuff muscles should be evaluated for length, neuromuscular control, and strength. The patient will have pain during active ROM, especially with shoulder flexion and shoulder abduction. Limited shoulder extension may be noted secondary to irritation as the biceps tendon is placed at a lengthened position or required to activate eccentrically. Manual muscle testing of the biceps activates this muscle for its role as an elbow flexor and forearm supinator, therefore it may be pain free and strong despite the irritation at the tendon. Attempts at special tests for tendonitis may be inconclusive because of the surgical trauma to the area and the inability of the patient to attain the necessary positions for testing.