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Designing Rehabilitation Programs for the Shoulder

FUNCTIONAL REHABILITATION OF THE SHOULDER

Open Kinetic Chain Rehabilitation Challenge

• Mobility – range of motion

• Recruitment – neuromuscular control

• Stabilization – tri-plane functionality

Three Phases of Rehabilitation

• Pre-functional – Mobility

• Return to Function – Recruitment

• Return to Activity – Tri-Plane Stabilization

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Concepts of the Three P’s

• Pivoters – scapular stabilizers i.e. rhomboids, trapezius, pectoralis minor and serratus anterior

• Protectors – rotator cuff

• Positioners – deltoids, latissimus dorsi, pectoralis major

Reference: Ellen m, Rogers DP, Gilhoal JJ: Practitioner Flexibility Strengthens Shoulder Rehabilitation Protocol. Biomechanics, January 2000; 45-52.

True Function of the Rotator Cuff

• Dynamic decompression of the humeral head by providing balance of the upper pull of the deltoids

• Steer and stabilize the humerus to the glenoid

• Result = smooth rotational movement to allow shoulder elevation

CKC vs. OKC Exercises: Shoulder

• Moveable – No Load (MNL) = passive

• Moveable – External Load (MEL) = OKC• Concentric – Acceleration W=F(+D)• Eccentric – Deceleration W=F(-D)

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↓ATP↓EMG Activity

• Fixed – External Load (FEL) = CKC

Reference: Dillman C. Murray, T., Hintermeister, R. Biomechanical Differences of Open and Closed Chain Exercises with Respect to the Shoulder. Journal of Sports Rehabilitation, 1994, 3:228-238.

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Clinical Examination Motion

Mobility:• Short lever arm rotation

– External rotation in modified scaption– Internal rotation – spine level

• Long lever arm movement– Elevation – transverse plane– Horizontal abduction at 90°– Abduction – modified scaption

Reference: Lin HT, Hsu AT, Chang GL, et al. Determining the resting position of the glenohumeral joint in subjects who are healthy. Phys Ther. 2007; 87:1669-1682.

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Early Motion Concerns

• Why pendulum exercises need to be reconsidered

• Self-ROM with cane/wand is usually performed incorrectly

• Manual motion should begin in scaption• Rotation before elevation

Reference: Ellsworth A., Mullaney M., Tyler T., McHugh M., Nicholas S. Electromyography of Selected Shoulder Musculature During Un-Weighted and Weighted Pendulum Exercises. No Am J Sports Phys Ther 2006;1(2):73-79.

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Passive Micro-Mobility – Primary

• Scapular Release with diagonals• Lateral Glide and Tilt

• Glenohumeral Inferior Glide– Over the top– Finger mobility with passive rotational shift

• Glenohumeral posterior glide

Reference: Kumbhare DA, Basmajian JV. Decision Making and Outcomes In Sports Rehabilitation. Chapter 19, 2000. Philadelphia, Churchill Livingstone.

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Passive Micro-Mobility –Secondary

• AC and SC joints A-P micro-mobility

• Glenohumeral lateral glide

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Four Levels – EMG Activity Based on MVIC

• Level One: 20% of MVIC – low• Level Two: 21% to 40% of MVIC – Moderate• Level Three: 41% to 60% of MVIC – High• Level Four: More than 60% of MVIC – Very High

Precaution Concerning RehabilitationTherapeutic value of EMG Based Recruitment is a Dynamic Activity Level and Not a Measurement of Tendon Stress.

Reference: DiGiovine NM, Jobe FW, Pink M, Peppy J. An Electromyographic Analysis of the Upper Extremity in Pitching. J Shoulder Elbow Surg 1992;1(1):15-25.

Positional Recruitment

Evidence based – EMG Studies

• Sidelying External Rotation

• Prone Extension to hip

• Prone Horizontal Abduction with External Rotation

• Prone 90/90 External Rotation

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Positional Recruitment

• Scaption – thumb-down internal rotation• Scaption – neutral thumb-up position – Flexion• Bench Press• Press-up (chair dips)

References:Townsend, H. Jobe FW, Pink M., Perry J: Electromyographic

Analysis of the Glenohumeral Muscles During A Baseball Rehabilitation Program. Am. Journal of Sports Medicine, Vol. 19, No. 3, 1991 pp. 264-271

Reinold M, Macrina L, Wilk K, Fleisig G, Dun S, Barrentine S, Ellerbusch M, Andrews J. Electromyographic Analysis of the Supraspinatus and Deltoid Muscles During 3 Common Rehabilitation Exercises. J of Athl Train 2007;42(4);464-469.

Manske RC. Electomyographically Assessed Exercises For The Scapular Muscle. ATT 2006 11(5) 19-23.

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Modified Super Eight Therapeutic Value

• Sidelying external rotation• Scaption – Standing to 90°, 120°• Prone extension to hip• Prone scaption - 100°, 120°• Prone horizontal abduction with rotation• Prone external rotation 90/90 position• Push-ups• Chair-dips (press-ups)

Reference: Reinold MM, Wilk KE, Fleisig GS, Et Al: Electromyographic Analysis of the Rotator Cuff and Deltoid Musculature During Common Shoulder External Rotation Exercises. J Orthop Sports Phys Ther. 34 (7), 2004; 385-393.

Macrina L, Reinold M. Arm Forces. Training-Conditioning. July-August 2008:46-51

Levels of EMG Based Exercises for the Shoulder

• Level One – Low EMG– Clinician Assisted Forward Elevation

– Pendulum (Codman)

– Weight Shifts on Table (CKC)

– Gravity Eliminated Forward Elevation• UE Ranger™

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Levels of EMG Based Exercises for the Shoulder

• Level Two – Moderate EMG– Wall Push-ups

– Thera-Band® - Short Arc Rotation – Low Color (yellow)

– Sidelying Internal Rotation

Levels of EMG Based Exercises for the Shoulder

• Level Three – High EMG– Sidelying External Rotation– Scaption – Thumb-up Elevation– Thera-Band® Standing Rotation (Red-Green)– Prone Extension to Hip– Prone Scaption

• Level Four – Very High EMG– Scaption to 120° and Higher– Press-up – Chair Dips– Prone Horizontal – Abduction – Ext. Rot.– Bench Press

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CLOSED KINETIC CHAIN RECRUITMENT

• Ball on the Wall – Not true CKCMuscle Re-educationBall on the table – geriatric perspective

• Wall push-ups – Sagittal plane– Transverse plane– Modified frontal plane

• Wall push-up plus add resistance

Reference: Ellenbecker TS, Davies GJ: Closed Kinetic Chain Exercises: A Comprehensive Guide to Multiple-Joint Exercises. Champaign, IL. Human Kinetics, 2001.

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University of Kentucky Studies

• Electromyographical Differences between slow and fast closed and open chain shoulder exercises– Fast speed OKC > CKC

– CKC produced less EMG Activity than OKC

– Supraspinatus Activity > in OKC than CKC

Reference: Uhl TL, Wise MB, Mattacola CG, Nitz AJ: Division of Athletic Training

MODIFIED CLOSED KINETIC CHAIN RECRUITMENT

• Push-up on uneven surface – ball on the wall• Wall push-ups while standing on uneven surface

– balance pad or BOSU• Hands on Stepper – straight/flexed elbow

References:1. Ellenbecker TS, Davies GJ: Closed Kinetic Chain Exercises: A

Comprehensive Guide to Multiple – Joint Exercise. Human kinetics: 2001 . 87-98.

2. Uhl TL, Carver TJ, Matacola CG, Mair SD. Nitz AJ, Shoulder Musculature Activation During Upper Extremity Weight Bearing Exercise. Jour. Orhto Sports Physical Therapy. Vol 33, No 3, March 2003, pp. 109-117

3. Pontillo M, Orishimo KF, et al: Shoulder Musculature Activity and Stabilization During Upper Extremity Weight Bearing Activities. No. Am. Journal Sports Phys Ther: 2007 Vol 2, No 2, pp.90-96.

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ROTATOR CUFF REPAIR

1. Small to medium sized tearsPartial thickness lesions (1cm – 3cm)

2. Large to massive tearsFull thickness > 4cm – 5cm

Complete rupture

Arthroscopic vs. Mini-Open Repairs

Factors used to determine type of surgery

• Tear size

• Mobility of the tissue

• Tissue quality

• Age and activity level

Survey Conducted by Wilk, 2003

Reference: Manske RC. Post Surgical Orthopedic Sports Rehabilitation Knee and Shoulder. Chapter 33. 2006 St. Louis. Mosby-Elevier.

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Arthroscopic vs. Mini-Open Repairs

• Less deltoid injury

• Visualization of tear

• Secondary pathology

• Less post-op pain

• Improved motion

Reference: Ghodadra NS, Provencher MT, Nikhil VN, Wilk KE, Romeo AA. Open, Mini-open, and Arthroscopic Rotator Cuff Repairs Surgery: Indications and Implications for Rehabilitation. J OrthopSports Phys Ther; 2009: 39(2):81-89

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Mini-Open

• More deltoid injury

• Possible too much SAD

• Nerve damage (Axillary Nerve?)

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Rotator Cuff RepairPartial thickness Lesions – small to medium tearsPhase I Pre-functional – 1-3 weeks

• Immobilization as needed abduction pillow brace in scaption plane

• Manual control range of motion– ER 45° at 45° of abduction

– Positional internal rotation

– Elevation – short to long lever arm motion

• Scapular retraction sets

• Wrist and grip exercises

• Biceps and Triceps curls – neutral humerus - begin with isometrics

• Ball on the wall/table – early closed kinetic chain

• Sub-max isometrics – week 3

Manske RC. Post Surgical Orthopedic Sports Rehabilitation Knee and Shoulder. Chapter 33. 2006 St. Louis. Mosby-Elevier

Rotator Cuff RepairFull-thickness Tears – Large (massive)Pre-functional phase 1-4 weeks

• Immobilization – abduction brace at 30° modified scaption

• Manual control ROM

• Gripping exercises

• Scapular retraction sets

• Elbow ROM with neutral Humerus – light strengthening at 3 to 4 weeks– Begin Isometrics

• Sub-max Isometrics – end of week three/four

Rotator Cuff RepairFull-thickness Tears – Large (massive)Early Post-op R.O.M.

• External rotation in scapular plane 30° - 60°– Less tension on repair

• Repaired supraspinatus increased tension in 30° to 60°of internal rotation

• Elevation in scapular plane

– Neutral Humeral position with progressive external rotation

• Positional internal rotation to hip

Ref: Manske, R. 2009

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Rotator Cuff RepairPartial thickness Lesions – small to medium tearsPre-Functional Phase 4 – 6 weeks

• Manual control range of motion– ER – progressive to 90° at 45° abduction to 90° abduction

– Positional internal rotation to spine level

– Elevation 140° to WNL

• Standing Extension to hip

• Resistive strengthening – scapular retraction– Add protraction when ready

• Manual exercises – rhythmic stabilization – short lever arm

• Wall push-ups (double arm) – closed kinetic chain exercises

• UBE when ready

• Begin prone series with prone extension to hip

• Thera-band® short-arc rotation

Rotator Cuff RepairsFull-thickness Tears – Large (massive)Pre-functional phase 4-8 weeks

• Manual control ROM progress with elevation

• Isometrics – deltoids and rotators – sub-max – 4+ weeks

• Scapular stabilization – retraction – Thera-band ®

• Elbow strengthening – biceps/triceps PRE – Neutral Humerus

• Rhythmic stabilization – short lever arm – 6+ weeks

• UBE – 6 weeks

• Thera-band® rotation short-arc at end of this phase

• Standing extension to hip – 3+ weeks

• Prone extension to hip – 5+ weeks

• Closed kinetic chain – ball on the wall – progress to double arm push-ups

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Rotator Cuff Repair

Partial thickness Lesions – small to medium tearsReturn to function Phase

• Isotonic strengthening with positional recruitment– Prone series – prone extension to hip, prone scaption 100°,

prone scaption 120°, prone horizontal ABD – ER

– Scaption to 70° then to 90° - (Full Can)

– Sidelying external rotation to neutral

• Elevation strengthening – Supine position

• Protraction PRE – manual applied force distally (CKC)

• Single arm wall push-ups

• Placement eccentrics

• Advanced scapular stabilization

• Rhythmic stabilization (perturbation – long lever arm)

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Rotator Cuff Repairs

Full-thickness Tears – Large (massive)Return to Function Phase

• Continue manual ROM

• Advanced scapular stabilization

• Delayed positional recruitment – sidelying external rotation – prone scaption – standing scaption

• Closed Kinetic Chain exercises –double arm progress to single arm

Interactive Outcomes

• Pain report

• Mobility needs – ROM goals met

• Elevation control – muscle recruitment

• ADL dysfunction

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Placement Eccentrics

• Scaption

• Sidelying External Rotation

• Prone Scaption

Recommended exercise progression2 sets of 53 sets of 52 sets of 10

Guard against overload

Muscle Recruitment

• Isometric muscle recruitment assist with synergistic recruitment– Rhythmic stabilization is an effective means of functional based

strengthening

• Placement Eccentric– Isometric to eccentric isotonic activity is more likely to create

functional carryover– Holding isometric to muscle lengthening (Eccentric) leads to

controlled mobility– The goal for the patient is to develop automatic controlled

mobility during functional performance

Reference: Hertling D. Management of Common Musculoskeletal Disorders: Physical Therapy Principles and Methods. 3rd Ed. Philadelphia: Lippincott-Raven;2005.

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Rotator Cuff RepairsReturn to function Phase

• Closed kinetic chain exercises – wall push-ups– Three planes – single arm – uneven surface

• Manual PNF exercises

• Plyo-toss – double arm – plyometrics

• BodyBlade® – three planes – oscillation training

Delayed for large tears – based on clinical interactive outcomes.

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Rotator Cuff RepairsReturn to activity Phase

• Advanced strengthening – vital five program – updated home program

• Endurance training i.e. bodyblade® – impulse training

• Plyo-toss – plyometrics – single arm

• Progress to single leg balance

• Sports or job specific training

• Interval throwing (if needed)

Delayed for large tears based on clinical interactive outcomes

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Rotator Cuff Repairs

• Vital Five Exercises – Home Program– Scapula Stabilization

– Single arm wall push-up

– Prone series

– Scaption strengthening

– Sidelying external rotation

Rehabilitation Summary

• Tri-Planar Stabilization – end product of function• Positional Recruitment

– Vital Five – Based on Therapeutic Value

Strengthening• Scapula-cuff stabilization using the three “p’s”

– Pivotors – scapular stabilizers, i.e., rhomboids & trapezius – serratus anterior

– Protectors – rotator cuff → decompression– Positionors – deltoids, latissimus dorsi, pectoralis

major → controlled elevation

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Designing Rehabilitation Programs for the Shoulder

Terry Trundle, PTA, ATC, LAT

Cross Country EducationLeading the Way in Professional Development.

www.CrossCountryEducation.com

To comply with professional boards/associations standards:• I declare that I or my family do not have any financial relationship in any amount, occurring in the last 12 months with a commercial interest whose products or services are discussed in my presentation. Additionally all Planner’s involved do not have any financial relationship.•Requirements for successful completion is attendance for the full session along with a completed session evaluation form.•Cross Country Education and all current accreditation statuses does not imply endorsement of any commercial products displayed in conjunction with this activity.

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