Exercise Interventions for the
Shoulder Girdle
Anatomy of the Shoulder Girdle
Complex
Joint Positions and Capsular
Patterns
Loose-Packed
Closed-Packed
Position/ resting Position
position
Capsular
Pattern
Glenohumeral
Joint
55 deg. abduction,
30 deg. horizontal
adduction
Abduction and
lateral rotation (ER)
Lateral Rotation,
abduction, medial
rotation
AcromioClavicular
Joint
Arm resting at side
in normal
physiological
position
Arm abducted to
90 degrees
Pain at extreme
range of movement
Scapular and Glenohumeral Joint
Motions
• Scapular motions: elevation,
depression, protraction,
retraction
(combined motions: upward /
downward rotation, tipping)
• GH motions: flexion, extension,
abduction, adduction, IR,ER,
horizontal abduction and
horizontal adduction
Figure 17.5 Kisner & Colby page 485
‘Pattern for idiopathic frozen
shoulder’
1) Freezing= intense pain, even at rest, limited motion (may last 10-36
weeks)
2) Frozen= pain with movement, adhesions and substitute motion of the
scapula , atrophy of muscle (may last 4-12 months)
3) Thawing= no pain / inflammation, but significant capsular restrictions
from adhesions (may last 2-24 months or longer)
-Idiopathic (unknown cause) frozen shoulder = adhesive capsulitis
-dense adhesions, capsular thickening / restrictions especially in the
deep folds of the capsule
-slow onset, usually in the 40-60 year old population
-may see spontaneous recovery at around 2 years after onset
Glenohumeral Joint Hypomobility
Managment
• PROTECTION PHASE (ACUTE)
*Control pain, edema, muscle guarding
-may use immobilization, such as a sling (temporary)
-intermittent PROM / AAROM within pain-free ranges
*Maintain soft tissue, joint integrity, and mobility
-PROM all planes, progress to AAROM
-Pendulum Exercises (Codman’s)- uses gravity to distract the
humeral head from the fossa (no use of weight at this phase)
-gentle muscle setting
*Maintain Integrity and Function of Associated Areas
-keep unaffected joints mobile (neck, elbow, wrist/hand, etc)
See HEP handouts for examples of shoulder muscle setting / isometrics as well as
Codman’s exercises
Pendulum (Codman’s) Exercises
•
•
•
•
•
•
•
It is important that the patient uses
the momentum from their body
weight rocking back and forth.
No active shoulder motion!
For gentle distraction (acute
phase) do not use weight
Using a light weight causes grade
III (stretching) distraction force
Motion can be side to side,
clockwise, or counterclockwise
See HEP handouts for other diagrams
Figure 17.22 Kisner and Colby page 530
Multiple-Angle Muscle Setting
•
•
Multi-angle muscle setting without
resistance then progress to lowintensity resisted isometrics
In later phases the patient can
complete with greater resistance
once further healing has occurred
* Also see HEP handouts
Figures 17.39 and 17.40 Kisner & Colby pg. 539
Glenohumeral Joint Hypomobility
Managment
• CONTROLLED MOTION PHASE (SUBACUTE)
*Control pain, edema
-PROM, progressing to AAROM (i.e. ‘wand’, ‘table top’ exercises)
-may continue Codman’s
*Progressively increase joint and soft tissue mobility
-patient can be taught self-mobilization (caudal glide, anterior glide,
and/or posterior glide)
-manual stretching by PT/PTA
-self-stretching exercises
*Inhibit muscle spasm and correct faulty mechanics
-avoid “hiking the shoulder”
-strengthen RTC to prevent impingement
*Improve muscle performance (correct faulty spine posture if needed)
Wand Exercises
•
•
•
•
•
The involved extremity in this
picture is the left UE (upper
extremity)
Placing a towel roll under the
distal humerus decreases stress
on the anterior joint capsule by
decreasing extension at the GH
(glenohumeral) joint
The motion involved in both
pictures is external (lateral)
rotation
See HEP handouts for further wand exercises
Figure 17.21 Kisner and Colby pg. 530
Precautions
• When progressing a therapy program, avoid
exacerbation of symptoms – if symptoms do
increase, decrease the intensity of the activity or
withhold the activity altogether for now (may be
able to re-address at a later time). Consult PT!
Glenohumeral Joint Hypomobility
Management
• RETURN TO FUNCTION PHASE (CHRONIC STAGE)
*Progressively Increase Flexibility and Strength
-progressive stretching and strengthening as the tissue
tolerates
-emphasis is on correct mechanics, safe progression, and
home exercise strategies
-if capsular tissue is still restricting motion at this point consult
with the PT (POC may need modification, i.e. PT may need to
do joint mobilizations if they haven’t been already)
-prepare for work or recreational activities (i.e. work hardening)
-occasionally a patient may need to undergo manipulation under
anesthesia to regain motion
Self-Stretching Techniques
Upper Extremity Plyometrics
• Pictures depict a progression
through a plyometric scenario
• Begin with patient supported in
a stable position, then
progress to standing in one
plane, followed by diagonal
patterns through short and
then full ranges of motion
• Weight of the ball should start
off light and can later become
heavier as strength progresses
•
Figure 17.57 Kisner & Colby page 550
Glenohumeral Arthroplasty
• Total Shoulder Replacement Arthroplasty (TSR)= both glenoid and
humeral surfaces are replaced
• Hemireplacement Arthroplasty (hemiarthroplasty)= one surface is
replaced
- Different ‘designs’ are used for these surgeries, may include:
unconstrained, semi-constrained, and reverse ball and socket
*each design has it’s own limitations and precautions
(***close communication with PT is crucial to be compliant with
the surgeon’s recommendations and to get the best outcomes)
- Surgeon may give therapy a set of guidelines to follow, but the
PTA should never progress a patient without consulting PT first.
Glenohumeral Arthroplasty
• If the rotator cuff was torn and
also needed to be repaired,
rehab will be slower and more
caution must be used
• Intraoperative ROM: surgeon
“tests” the ROM of the
shoulder before suturing back
up, therapy goals are based on
these findings (communication
is very important!)
http://www.akhanddoc.com/total_shoulder_replacement
Glenohumeral Arthroplasty
Postoperative Managment
• Correct faulty posture to prevent impingement (may see
forward head / shoulder posturing)
• MAXIMUM PROTECTIONS PHASE (MAY be 1-6
weeks)
– Patient education regarding precautions and HEP
– Control Pain
– Maintain mobility of adjacent joints
– Gradually restore shoulder mobility (follow MD
guidelines for when PROM, AAROM, etc are allowed
and to what degrees)
– Minimize muscle guarding and atrophy
Glenohumeral Arthroplasty
Postoperative Management
• MODERATE PROTECTION / CONTROLLED MOTION PHASE
(MAY begin around 4-6 weeks post-op and last 12-16 weeks +/-)
*emphasis is on gaining active control, dynamic stability, and
strength while continuing to increase ROM
-
-
PT/ MD determines when patient is ready for this phase
PT may order use of heat before tx to increase tissue stretch with
ROM and may end with cryotherapy to decrease any inflammation
and/or pain (no heat when patient is acute post-op)
Gradual progression through PROM, AAROM, AROM as well as
muscle setting and isometrics, progressing to light resistance when
allowed (keep resistance exercises below 90 deg shoulder
elevation)
Precautions
• When progressing a therapy program, avoid
exacerbation of symptoms – if symptoms do
increase, decrease the intensity of the activity or
withhold the activity altogether for now (may be
able to re-address at a later time). Consult PT!
Glenohumeral Arthroplasty
Postoperative Management
• RETURN TO FUNCTIONAL ACTIVITY PHASE
(MAY begin around 12-16 weeks and can last several months)
*Pain-free strengthening for dynamic stability and functional use of the
UE
- PT/ MD determines when patient is ready for this phase, generally:
full PROM (based on intraoperative ranges), AROM in the scapular
plane to at least 100-120 deg. without substitutions, RTC 4/5 MMT
- Patient may have to modify or eliminate certain functional and
recreational activities indefinitely
- gradual progression through end-range self stretching, PRE’s,
weight bearing through the UE, dynamic stability, etc.
Stop and Think!
*Your patient is 4 days post-op left TSA
1)
What does TSA stand for?
2)
You should use a moist hot pack on her shoulder before tx, T/ F?
3)
What ‘phase’ of rehab is she in?
4)
What precautions do you need to educate her about?
*She is now 6 weeks post-op and the physician’s written ‘guidelines’
suggest patient begin the moderate protection phase. The patient
has been achieving all her goals so far….what do you do?
•
•
What is the general progression for ROM activities?
What is the general progression for strengthening activities?
Shoulder Impingement
Primary Impingement:
Wearing of the RTC against
the acromion during shoulder
elevation
*Supraspinatus Tendonitis
Secondary Impingement:
Results when there are faulty
mechanics due to
hypermobility or instability of
the GH head
http://www.bostonpaincare.com/shoulder_impingement_s
yndrome
Faulty Posture
• Forward head, increased
thoracic kyphosis, forward tilt
of the scapula, IR of the
humerus
• Causes Muscle Imbalances
-tight pectoralis minor, levator
scapulae, scalenes, IRs
-weak serratus anterior or
trapezius muscles, ERs
*Impingement occurs during UE
elevation
Figure 17.6 Kisner & Colby page 485
Painful Arc
• Commonly seen with
impingement syndromes
• Can be due to compression of
the RTC tendons and/or
subacromial bursa within the
subacromial space during
elevation of the humerus
http://www.watkinson.co.nz/painful_arc.htm
Subacromial Decompression
Surgery
-
Most decompression surgeries
are now done arthroscopically
May include:
*Bursectomy (subacromial)
*Release of the coricoacromial
ligament
*Acromioplasty (resection)
*Removal of any osteophytes
Rehab may be quicker if the RTC
is intact and procedure is
arthroscopic
http://www.leadingmd.com/shoulder2_seaport/treat.asp
Rotator Cuff Arthroscopic Repair
Keep in Mind:
-PROM (and later A/AAROM) only
through “safe” (MD ordered)
ranges and pain-free
-Later in rehab, do not allow
active shoulder elevation if the
patient is hiking their shoulder
-It is crucial to follow PT / MD
restriction guidelines for ROM
and allowed activities to
prevent damaging the surgical
repair
http://rehabstudents.com/2010/05/shoulder-post-surgic
Rotator Cuff ‘open’ Repair
-
Keep in Mind:
-Overall rehab and progression
through the stages / phases
will be longer vs arthroscopic
repair
-Greater caution during rehab
is indicated for these patients
-Follow ROM / activities
carefully and do not progress
unless PT / MD approves
http://www.adnetinc.net/images.htm
Shoulder-Bankart Lesion Repair
• Anterior shoulder dislocation
usually results from a blow to
the humerus when in
abduction and ER causing
damage to the anterior GH
joint capsule and likely tearing
the RTC
• May also have a Hill-Sachs
lesion (compression fx of the
posterolateral edge of the
humerus
• Avoid strain to the anterior
shoulder during early rehab
(very limited ER & Extension)
•
http://www.sportsarthroscopyindia.com/ds.aspx
Shoulder SLAP Lesion / Repair
SLAP
• Involves tearing of the Superior
Labrum, Extending Anterior to
Posterior
• Can have a tear of the long
head of the Biceps
• During repair the surgeon may
also need to perform anterior
stabilization if there is
instability
http://www.shoulderdoc.co.uk/patient_info/shoulder-slap
Special Tests for Shoulder
Instability
“Special Tests” for Shoulder Instability
* Anterior apprehension Test
for anterior instability
http://accessmedicine.net/search/searchAMResultImg.aspx
*Inferior apprehension Test
for inferior instability
http://www.aceproindia.com/ACE%20Sample%20Projects
* Impingement Test
http://quizlet.com/3033389/shoulder-tests-flash-cards/
* + Sulcus Sign for inferior
instability
http://www.shoulderdoc.co.uk/article.asp?article=798
Case Study
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1)
2)
3)
4)
Your patient is a 15 year old baseball pitcher who has been
having right shoulder pain for the past 2 months when pitching.
During the initial evaluation the physical therapist observed a
forward head/shoulder (slump) posturing and noted weak serratus
anterior and supraspinatus musculature (4-/5). There is also
tenderness upon palpation of the supraspinatus tendon at it’s
insertion. The therapist has ordered modalities to decrease pain
and inflammation, strengthening of the involved muscles, and
patient education.
Which modalities might the therapist have included in the plan of
care?
Give 3 exercises to strengthen the weak muscles and describe
how you would progress them
What information would you include in your patient education?
Which muscle or muscles might be tight? How would you stretch
them?