SHOULDER REHABILITATION STRATEGIES, GUIDELINES, AND PRACTICE

doi:10.1016/S0030-5898(05)70222-4

Orthopedic Clinics of North America

Volume 32, Issue 3, 1 July 2001, Pages 527-538

https://doi.org/10.1016/S0030-5898(05)70222-4 Get rights and content

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BASIC SCIENCE

The biomechanical model for striking and throwing sports is an open-ended kinetic chain of segments that work in a proximal-to-distal sequence.1, 2, 3 The goal of the kinetic chain activation sequence is to impart maximum velocity or force through the distal segment (the hand) to the ball, racquet, or other implement. The ultimate velocity of the distal segment is highly dependent on the velocity of the proximal segments. The proximal segments accelerate the entire chain and sequentially

GUIDELINE 1—COMPLETE AND ACCURATE DIAGNOSES

This guideline may seem obvious but is sometimes difficult to implement unless the entire kinetic chain is screened for alterations. The actual shoulder injury is the primary factor that determines treatment and rehabilitation. This may involve tendon injury or tear, instability, or joint internal derangement, whose overt clinical symptoms can be evaluated by standard diagnostic methods. However, both nonovert local alterations and distant alterations are frequently associated with shoulder

PRACTICE

The clinical evaluation should include some screening tests for hip/trunk posture and functional strength. Our screening examination includes standing posture evaluation of legs, lumbar, thoracic, and cervical spine, bilateral hip range of motion assessment, trunk flexibility assessment, and a one-leg stability series (Fig. 1), which assesses control of the trunk over the leg. Any abnormalities can be evaluated in more detail.

Scapular evaluation can be accomplished from behind the patient.¹⁹ It

GUIDELINE 2—PROXIMAL SEGMENT CONTROL

Optimum shoulder and arm function in both normal athletic activity and rehabilitation is dependent on activation of the proximal segments of the kinetic chain—the legs, pelvis, and spine. If these segments are altered in posture, flexibility, or strength, they should be corrected in the early stages of rehabilitation. If and when they are normal, they should be used to initiate scapular and arm activation. Early in rehabilitation, the inhibited scapular muscles or the injured or inhibited

PRACTICE

Specific exercises include step up/step down with trunk extension, front and side lunges, 1-leg and 2-leg squats, and hip flexions and extensions with trunk rotations (Fig. 4). These may be done on a stable surface and may progress to unstable surfaces for added difficulty and proprioceptive input.

GUIDELINE 3—SCAPULAR REHABILITATION

Optimal scapular muscle activation allows proper scapular motion and position while maintaining the glenohumeral instant center of rotation throughout arm motion.19, 30, 31 Scapular motion in retraction, protraction, and elevation is multiplanar, and optimal scapular motion maintains rotator cuff length tension ratios, thereby improving force production and reducing rotator cuff energy requirements during arm motion.25, 30 Scapular muscle activation precedes rotator cuff activation in the

PRACTICE

Hip and trunk extension patterns are used to initiate and facilitate scapular control. Scapular control exercises can be started in the preoperative or early healing stages of rehabilitation because they do not require shoulder or arm movement. Adjustments in arm position and arm load can occur as shoulder healing proceeds, and scapular control exercises should be continued throughout the intermediate recovery and sport-specific functional phases of rehabilitation.³⁵

Early stage exercises to

GUIDELINE 4—GLENOHUMERAL REHABILITATION

The 2 major glenohumeral rehabilitation problems are dynamic joint stability and rotator cuff deficiencies; often those are interdependent. Dynamic glenohumeral stability can be improved by eliminating joint mobility deficits, thereby decreasing abnormal joint translations in the mid range of shoulder motion, by positioning and moving the glenoid socket in a “ball on a seal's nose” relation to the moving humerus so that concavity/compression of the joint is maintained,¹⁹ and by active rotator

PRACTICE

Closed chain exercise practices may be started in early rehabilitation stages with the hand in a relatively fixed position, below shoulder level on a table (Fig. 10). Weight shifts on a table or balance board are safe in this position. When the arm may be raised toward shoulder height, scapular clock exercises (Fig. 7) are effective axial loading rotator cuff exercises. These exercises progress by placing the hand on unstable surfaces, such as a ball, or by using “wall washes” (Fig. 11), in

GUIDELINE 5—PLYOMETRIC EXERCISES

Power is required for shoulder function in throwing or striking. Plyometric training, through activation or stretch/shortening responses in muscles, is the most effective method of power development.³⁹ Because power is generated in the entire kinetic chain, plyometric training should be done in every segment. Plyometrics can be instituted in noninjured areas early in rehabilitation, but must be deferred to later stages in injured areas, because of the large range of required motions and large

PRACTICE

Lunges, vertical jumps, depth jumps, slides, and fitter exercises are some methods of lower extremity plyometrics.³⁵ Trunk and upper extremity plyometrics include rotation diagonals (Fig. 12), medicine ball rotations and pushes (Fig. 13), and dumbbell rotations.

GUIDELINES FOR PROGRESSION

Because this type of rehabilitation program focuses on functional return of kinetic chain patterns, there is less emphasis on specific stages or pathways or specific isolated exercises and more emphasis on flow and overlap between the acquisition of function of the various segments. The program must be flexible enough to be applied over a wide range of the individual aptitudes. New exercises are instituted when the segment function is appropriate. This is illustrated by the flow sheet diagram

GUIDELINES FOR RETURN TO PLAY

Return to play requires not only anatomic healing of the injured part but also restoration of the physiologic patterns and biomechanical motions in the appropriate kinetic chain of function. “Readiness to play” is indicated by clinical evidence of anatomic healing and completion of the “key points” listed in Table 2. Functional progressions of throwing or striking may be started from the readiness to play functional base. Return to play is dependent on completion of the functional progressions.

SUMMARY

This framework for rehabilitation is consistent with the proximal-to-distal kinetic chain biomechanical model and applies current concepts of motor control and closed chain exercises. This framework approaches the final goal—glenohumeral motion and function—through facilitation by scapular control, and scapular control through facilitation by hip and trunk activation.

This article supplies guidelines for rehabilitation and practices to implement the guidelines that have proved effective in our

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