The Shoulder and Shoulder
Girdle
Chapter 17
Part IV: Exercise Interventions by Body
Region
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STRUCTURE AND FUNCTION OF THE
SHOULDER GIRDLE
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Joints of the Shoulder Girdle
Complex
 Synovial Joints
– Glenohumeral joint
• Arthrokinematics
• Stability
– Acromioclavicular joint
• Arthrokinematics
• Stability
– Sternoclavicular joint
• Arthrokinematics
• Stability
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Joints of the Shoulder Girdle
Complex (cont'd)
 Functional Articulations
– Scapulothoracic articulation
• Motions of the Scapula
 Scapular Stability
– Postural relationship
– Active arm motions
– Faulty posture
– Suprahumeral (subacromial) space
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Shoulder Girdle Function
 Scapulohumeral Rhythm
 Clavicular Elevation and Rotation With
Humeral Motion
 External Rotation of the Humerus With Full
Elevation
 Deltoid: Short Rotator Cuff and Supraspinatus
Mechanisms
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Referred Pain and Nerve Injury
 Common Sources of Referred Pain in the
Shoulder Region
– Cervical spine
– Referred pain from related tissues
 Nerve Disorders in the Shoulder Girdle Region
– Brachial plexus in the thoracic outlet
– Suprascapular nerve in the suprascapular notch
– Radial nerve in the axilla
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MANAGEMENT OF SHOULDER
DISORDERS AND SURGERIES
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Joint Hypomobility:
Nonoperative Management
 Glenohumeral Joint
– Related pathologies and etiology of symptoms
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Rheumatoid arthritis and osteoarthritis
Traumatic arthritis
Post immobilization arthritis or stiff shoulder
Idiopathic frozen shoulder
Joint Hypomobility:
Nonoperative Management (cont'd)
 Glenohumeral Joint (cont’d)
– Clinical signs and symptoms
– Common structural and functional impairments
– Common activity limitations and participation
restrictions
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Joint Hypomobility:
Nonoperative Management (cont'd)
 Glenohumeral Joint Hypomobility:
Management—Protection Phase
– Maintain soft tissue and joint integrity and
mobility
– Maintain integrity and function of associated
regions
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Joint Hypomobility:
Nonoperative Management (cont'd)
 Glenohumeral Joint Hypomobility:
Management—Controlled Motion Phase
– Control pain, edema, and joint effusion
– Progressively increase joint and soft tissue
mobility
– Inhibit muscle spasm and correct faulty mechanics
– Improve joint tracking
– Improve muscle performance
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Joint Hypomobility:
Nonoperative Management (cont'd)
 Glenohumeral Joint Management: Return to
Function Phase
– Progressively increase flexibility and strength
– Prepare for functional demands
 Glenohumeral Joint Management:
Postmanipulation Under Anesthesia
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Joint Hypomobility:
Nonoperative Management (cont'd)
 Acromioclavicular and Sternoclavicular Joints
– Related pathologies and etiology of symptoms
• Overuse syndromes
• Subluxations or dislocations
• Hypomobility
– Common structural and functional impairments
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Joint Hypomobility:
Nonoperative Management (cont'd)
 Acromioclavicular and Sternoclavicular Joints
– Common activity limitations and participation
restrictions
– Nonoperative management of AC or SC joint strain
or hypermobility
– Nonoperative management of AC or SC joint
hypomobility
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Glenohumeral Joint Surgery and
Postoperative Management
 Glenohumeral Arthroplasty
– Indications for surgery
– Procedures
• Background
– Implant design, materials, and fixation
– Selection of procedure
• Operative procedures
• Complications
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Glenohumeral Joint Surgery and
Postoperative Management (cont'd)
 Glenohumeral Arthroplasty
– Postoperative management
• Special considerations
– Integrity of the rotator cuff
– Intraoperative ROM
– Posture
• Immobilization and postoperative positioning
• Exercise
– Maximum protection phase
– Moderate protection/controlled motion phase
– Minimum protection/return to function phase
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Glenohumeral Joint Surgery and
Postoperative Management (cont'd)
 Glenohumeral Arthroplasty (cont’d)
– Outcomes
• Pain relief
• ROM
• Functional use of the UE
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Painful Shoulder Syndromes (Rotator Cuff
Disease, Impingement Syndromes):
Nonoperative Management
 Related Pathologies and Etiology of Symptoms
– Intrinsic impingement: rotator cuff disease
– Extrinsic impingement: mechanical compression
of tissues
• Primary extrinsic impingement
• Secondary extrinsic impingement
• Internal extrinsic impingement
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Painful Shoulder Syndromes:
Nonoperative Management (cont'd)
 Related Pathologies and Etiology of Symptoms
(cont’d)
– Tendinitis/bursitis
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Supraspinatus tendinitis
Infraspinatus tendinitis
Bicipital tendinitis
Bursitis (subdeltoid or subacromial)
– Other impaired musculoskeletal tissues
– Insidious (atraumatic) onset
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Painful Shoulder Syndromes:
Nonoperative Management (cont'd)
 Common Structural and Functional Impairments
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Impaired posture and muscle imbalances
Decreased thoracic ROM
Rotator cuff overuse and fatigue
Muscle weakness secondary to neuropathy
Hypomobile posterior GH joint capsule
 Common Activity Limitations and Participation
Restrictions
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Painful Shoulder Syndromes:
Nonoperative Management (cont'd)
 Management: Protection Phase
– Control inflammation and promote healing
– Patient education
– Maintain integrity and mobility of the soft tissues
– Control pain and maintain joint integrity
– Develop support in related regions
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Painful Shoulder Syndromes:
Nonoperative Management (cont'd)
 Management: Controlled Motion Phase
– Patient education
– Develop strong, mobile tissues
– Modify joint tracking and mobility
– Develop balance in length and strength of
shoulder girdle muscles
– Develop muscular stabilization and endurance
– Progress shoulder function
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Painful Shoulder Syndromes:
Nonoperative Management (cont'd)
 Management: Return to Function Phase
– Increase muscular endurance
– Develop quick motor responses to imposed
stresses
– Progress functional training
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Painful Shoulder Syndromes: Surgery
and Postoperative Management
 Subacromial Decompression
– Indications for surgery
– Procedures
• Surgical approach
• Component procedures
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Painful Shoulder Syndromes: Surgery and
Postoperative Management (cont'd)
 Subacromial Decompression (cont’d)
– Postoperative management
• Immobilization
• Exercise progression
– Maximum protection phase
– Moderate protection phase
– Minimum protection/return to function phase
– Outcomes
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Painful Shoulder Syndromes: Surgery and
Postoperative Management (cont'd)
 Rotator Cuff Repair
– Indications for surgery
– Procedures
• Type of repair
• Components of a rotator cuff repair
• Selection of surgical procedures
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Painful Shoulder Syndromes: Surgery and
Postoperative Management (cont'd)
 Rotator Cuff Repair (cont’d)
– Postoperative management
• Immobilization
• Exercise
– Maximum protection phase
– Moderate protection phase
– Minimum protection/return to function phase
– Outcomes
– Pain relief, ROM, strength, functional abilities
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Shoulder Instabilities:
Nonoperative Management
 Related Pathologies and Mechanisms of Injury
– Atraumatic hypermobility
– Unidirectional instability
– Multidirectional instability
• Common structural and functional impairments
• Common activity limitations and participation
restrictions
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Shoulder Instabilities:
Nonoperative Management (cont'd)
 Related Pathologies and Mechanisms of Injury
(cont’d)
– Traumatic hypermobility
• Traumatic anterior shoulder dislocation
• Traumatic posterior shoulder dislocation
– Recurrent dislocation
• Common structural and functional impairments
• Common activity limitations and participation
restrictions
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Shoulder Instabilities:
Nonoperative Management (cont'd)
 Closed Reduction of Anterior Dislocation
– Management: protection phase
• Protect the healing tissue
• Promote tissue health
– Management: controlled motion phase
• Provide protection
• Increase shoulder mobility
• Increase stability and strength of rotator cuff and
scapular muscles
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Shoulder Instabilities:
Nonoperative Management
 Closed Reduction of Anterior Dislocation
(cont’d)
– Management: return to function phase
• Restore functional control
• Return to full activity
 Closed Reduction of Posterior Dislocation
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Shoulder Instabilities: Surgery and
Postoperative Management
 Glenohumeral Joint Stabilization Procedures
– Indications for surgery
– Procedures
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Bankart repair
Capsulorrhaphy (capsular shift)
Electrothermally assisted capsulorrhaphy (ETAC)
Posterior capsulorrhaphy
Repair of a SLAP lesion
Shoulder Instabilities: Surgery and
Postoperative Management (cont'd)
 Glenohumeral Joint Stabilization Procedures (cont’d)
– Postoperative management
• General considerations
• Immobilization
• Exercise progression
– Maximum protection phase
– Moderate protection phase
– Minimum protection/return to function phase
– Outcomes
• Recurrence of instability, ROM
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Acromioclavicular and Sternoclavicular Joint
Stabilization: Procedures and Postoperative
Management
 Acromioclavicular Joint Stabilization
 Sternoclavicular Joint Stabilization
 Postoperative Management
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EXERCISE INTERVENTIONS FOR THE
SHOULDER GIRDLE
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Exercise Techniques During Acute and
Early Subacute Stages of Tissue Healing
 Early Motion of the Glenohumeral Joint
– Wand exercises
– Ball rolling or table top dusting
– Wall (window) washing
– Pendulum (Codman’s) exercises
– “Gear shift” exercises
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Exercise Techniques During Acute and Early
Subacute Stages of Tissue Healing (cont'd)
 Early Motion of the Scapula
 Early Neuromuscular Control
– Multiple-angle muscle setting
– Protected weight bearing
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Exercise Techniques to Increase
Flexibility and Range of Motion
 Self-Stretching Techniques to Increase
Shoulder ROM
– To increase flexion and horizontal adduction
– To increase flexion and elevation of the arm
– To increase external (lateral) rotation
– To increase internal rotation
– To increase abduction and elevation of the arm
– To increase extension of the arm
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Exercise Techniques to Increase Flexibility
and Range of Motion (cont'd)
 Manual and Self-Stretching Exercises for
Specific Muscles
– To stretch the latissimus dorsi muscle
– To stretch the pectoralis major muscles
– To stretch the pectoralis minor muscle
– To stretch the levator scapulae muscle
– To stretch the upper trapezius muscle
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Exercises to Develop and Improve Muscle
Performance and Functional Control
 Isometric Exercises
– Scapular muscles
– Multiple-angle isometrics to the GH muscles
– Self-applied multiple-angle isometrics
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Exercises to Develop and Improve Muscle
Performance and Functional Control (cont'd)
 Stabilization Exercises
– Open-chain stabilization exercises for the scapular
muscles
– Open-chain stabilization exercises for the shoulder
girdle
– Static closed-chain (weight-bearing) stabilization
exercises
– Dynamic closed-chain stabilization exercises
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Exercises to Develop and Improve Muscle
Performance and Functional Control (cont'd)
 Dynamic Strengthening Exercises: Scapular
Muscles
 Dynamic Strengthening Exercises:
Glenohumeral Muscles
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Exercises to Develop and Improve Muscle
Performance and Functional Control (cont'd)
 Functional Progression for the Shoulder Girdle
– Exercises using combined movement patterns
with functional activities
– Equipment
– Integration of functional activities
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Independent Learning Activities
 Critical Thinking and Discussion
 Laboratory Practice
 Case Studies
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