Chapter 17: The Shoulder and Shoulder Girdle

The design of the shoulder girdle allows for mobility of the upper extremity. As a result, the hand can be placed almost anywhere within a sphere of movement, its range limited primarily by the length of the arm and the space taken up by the body. The combined mechanics of its joints and muscles provide for and control the mobility. When establishing a therapeutic exercise program for impaired function of the shoulder region, as with any other region of the body, the unique anatomical and kinesiological features must be taken into consideration as well as the state of pathology and functional limitations imposed by the impairments.

This chapter is divided into three major sections. The first section briefly reviews the structure and function of the shoulder girdle complex. The second section describes common disorders and guidelines for conservative and post-surgical management. The last section describes exercise techniques commonly used to meet the goals of treatment during the stages of tissue healing and phases of rehabilitation.

The shoulder girdle has only one boney attachment to the axial skeleton (Fig. 17.1). The clavicle articulates with the sternum via the small sternoclavicular joint. As a result, considerable mobility is allowed in the upper extremity. Stability is provided by an intricate balance between the scapular and glenohumeral muscles and the structures of the joints in the shoulder girdle.

Joints of the Shoulder Girdle Complex

Three synovial joints (glenohumeral, acromioclavicular, sternoclavicular) and two functional articulations (scapulothoracic, suprahumeral) make up the shoulder girdle complex.

Synovial Joints

Glenohumeral Joint

The glenohumeral (GH) joint is an incongruous, ball-and-socket (spheroidal) triaxial joint with a lax joint capsule. It is supported by the tendons of the rotator cuff and the glenohumeral (superior, middle, inferior) and coracohumeral ligaments (Fig. 17.2). The concave boney partner, the glenoid fossa, is located on the superior-lateral margin of the scapula. It faces anteriorly, laterally, and upward, which provides some stability to the joint. A fibrocartilagenous lip, the glenoid labrum, deepens the fossa for greater congruity and serves as the attachment site for the capsule. The convex boney partner is the head of the humerus. Only a small portion of the head comes in contact with the fossa at any one time, allowing for considerable humeral movement and potential instability.¹⁵⁶

Arthrokinematics

According to the convex-concave theory of joint motion (see Chapter 5), with motions of the humerus (physiological motions), the convex head rolls in the same direction and slides in the opposite direction in the glenoid fossa (Box 17.1).

Stability

Static and dynamic restraints provide joint stability (Table 17.1).^{33,48,183,224,227} The structural relationship of the boney anatomy, ligaments, and glenoid labrum and the adhesive and cohesive forces in the joint provide static stability. The tendons of the rotator cuff blend with the ligaments and glenoid labrum at their sites of attachment, so when the muscles contract, they provide dynamic stability by tightening the static restraints (Fig. 17.3). The coordinated response of the muscles of the cuff and tension in the ligaments provide varying degrees of support depending on the position and motion of the humerus.^172,183,208 In addition, the long head of the biceps and the long head of the triceps brachii reinforce the capsule with their attachments and provide superior and inferior shoulder joint support respectively, when functioning with elbow motions.¹⁰⁹ The long head of the biceps, in particular, stabilizes against humeral elevation¹⁰⁹ and contributes to anterior stability of the glenohumeral joint by resisting torsional forces when the shoulder is abducted and externally rotated.^11,172 Neuromuscular control, including movement awareness and motor response, underlies coordination of the dynamic restraints.^224,227

Acromioclavicular Joint

The acromioclavicular (AC) joint is a plane, triaxial joint that may or may not have a disk. The weak capsule is reinforced by the superior and inferior AC ligaments (see Fig. 17.2). The convex boney partner is a facet on the lateral end of the clavicle. The concave boney partner is a facet on the acromion of the scapula.

Arthrokinematics

With motions of the scapula, the acromial surface slides in the same direction in which the scapula moves, because the surface is concave. Motions affecting this joint include upward rotation (the scapula turns so the glenoid fossa rotates upward), downward rotation, winging of the vertebral border, and tipping of the inferior angle.

Stability

The AC ligaments are supported by the strong coracoclavicular ligament. No muscles directly cross this joint for dynamic support.

Sternoclavicular Joint

The sternoclavicular (SC) joint is an incongruent, triaxial, saddle-shaped joint with a disk. The joint is supported by the anterior and posterior SC ligaments and the interclavicular and costoclavicular ligaments (Fig. 17.4). The medial end of the clavicle is convex superior to inferior and concave anterior to posterior. The joint disk attaches to the upper end. The superior-lateral portion of the manubrium and first costal cartilage is concave superior to inferior and convex anterior to posterior.

Arthrokinematics

The motions of the clavicle occur as a result of the scapular motions of elevation, depression, protraction (abduction), and retraction (adduction) (Box 17.2). Rotation of the clavicle occurs as an accessory motion when the humerus is elevated above the horizontal position and the scapula upwardly rotates; it cannot occur as an isolated voluntary motion.

Stability

The ligaments crossing the joint provide static stability. There are no muscles crossing the joint for dynamic stability.⁴⁵

Functional Articulations

Scapulothoracic Articulation

Normally, there is considerable soft tissue flexibility, allowing the scapula to slide along the thorax and participate in all upper extremity motions.

Motions of the Scapula

• Elevation, depression, protraction, and retraction: These motions are seen with clavicular motions at the SC joint (Fig. 17.5 A and B). Elevation and depression occur in the frontal plane as the scapula moves upward and downward, respectively; protraction/retraction occur in the transverse plane as the scapula moves away from or toward the spinal column. They are also component motions when the humerus moves.

• Upward and downward rotation: These motions are seen with clavicular motions at the SC joint and rotation at the AC joint and occur concurrently in various planes with motions of the humerus (Fig. 17.5 C). Upward rotation (along with posterior tilting and external rotation of the scapula) are component motions that occur with full shoulder ROM of elevation (flexion, scapular plane abduction, and frontal-plane abduction of the humerus).^64,133

• Internal and external rotation and tilting (tipping): These motions are seen with motion at the AC joint concurrently with motions of the humerus (Fig. 17.5 D). Internal and external rotations are transverse plane motions in which the medial border lifts away from (wings) or approximates the rib cage, respectively. Anterior tilting of the scapula occurs in conjunction with internal rotation and extension of the humerus when reaching the hand behind the back, while posterior tilting occurs during humeral elevation.^64,133

Scapular Stability

Postural relationship. In the dependent position, the scapula is stabilized primarily through a balance of forces. The weight of the arm creates a downward rotation, protraction, and forward tilting moment on the scapula. These moments are balanced by the support of the upper trapezius, serratus anterior, rhomboids, and middle trapezius^120,184 (see Table 17.1).

Active arm motions. With active arm motions, the muscles of the scapula function in synchrony to stabilize and control the position of the scapula, so the scapulohumeral muscles can maintain an effective length-tension relationship as they function to stabilize and move the humerus. Without the positional control of the scapula, the efficiency of the humeral muscles decreases. The upper and lower trapezius along with the serratus anterior upwardly rotate the scapula whenever the arm elevates, and the serratus anterior protracts the scapula on the thorax to align the scapula during flexion or pushing activities. During arm extension or during pulling activities, the rhomboids function to downwardly rotate and retract the scapula in synchrony with the latissimus dorsi, teres major, and rotator cuff muscles. These stabilizing muscles also eccentrically control acceleration of upward rotation and protraction of the scapula.¹⁵⁸

Faulty posture. A slouched posture significantly alters scapular kinematics. Specifically, sitting or standing with increased thoracic kyphosis, significantly decreases posterior tilting and external rotation of the scapula during elevation of the arm.⁶⁴ Furthermore, with faulty scapular alignment, muscle length and strength imbalances occur not only in the scapular muscles but also in the humeral muscles, altering the mechanics of the glenohumeral joint. A forward tilt of the scapula (seen with a forward head posture and increased thoracic kyphosis) is associated with decreased flexibility in thepectoralis minor, levator scapulae, and scalenus muscles and weakness in the serratus anterior or trapezius muscles. This scapular posture also changes the posture of the humerus in the glenoid, which assumes a relatively abducted and internally rotated position with respect to the scapula (Fig. 17.6). The glenohumeral internal rotators may become less flexible, and external rotators may weaken, affecting the mechanics of the joint.

Suprahumeral (Subacromial) Space

The coracoacromial arch, composed of the acromion and coracoacromial ligament, overlies the subacromial/subdeltoid bursa, the supraspinatus tendon, and a portion of the muscle (Fig. 17.7).¹²⁰ These structures allow for and participate in normal shoulder function. Compromise of this space from faulty muscle function, faulty postural relationships, faulty joint mechanics, injury to the soft tissue in this region, or structural anomalies of the acromion lead to impingement syndromes.^{18,28,32,106,112,118,132,238} After a rotator cuff tear, the bursa may communicate with the glenohumeral joint cavity.⁴⁸

Shoulder Girdle Function

Scapulohumeral Rhythm

Motion of the scapula, synchronous with motions of the humerus, allows for 150° to 180° of shoulder ROM into flexion or abduction with elevation. The ratio has considerable variation among individuals but is commonly accepted to be 2:1 (2° of glenohumeral motion to 1° of scapular rotation) overall motion. During the setting phase (0° to 30° abduction, 0° to 60° flexion), motion is primarily at the glenohumeral joint, whereas the scapula seeks a stable position. During the mid-range of humeral motion, the scapula has greater motion, approaching a 1:1 ratio with the humerus; later in the range, the glenohumeral joint again dominates the motion.^43,120,191

• Early studies analyzed only upward rotation of the scapula. More recent three-dimensional research demonstrated component scapular motions to be upward rotation, posterior tilting, and scapular external rotation with full shoulder elevation (flexion, scapular plane abduction, and frontal-plane abduction of the humerus).^106,133

• During humeral elevation, the synchronous motion of the scapula allows the muscles moving the humerus to maintain an effective length-tension relationship throughout the activity and helps maintain congruency between the humeral head and fossa while decreasing shear forces.^43,120,191

• The upper and lower trapezius and the serratus anterior muscles cause the upward rotation of the scapula. Weakness or complete paralysis of these muscles results in the scapula being rotated downward by the contracting deltoid and supraspinatus as abduction or flexion is attempted. These two muscles then reach active insufficiency, and functional elevation of the arm cannot be reached, even though there may be normal passive ROM and normal strength in the shoulder abductor and flexor muscles.¹⁹¹

• During elevation of the humerus, the pectoralis minor is lengthened as the scapula upwardly rotates, retracts, and tips posteriorly. Restricted scapular movement during humeral elevation from a shortened pectoralis minor results in patterns similar to those seen in patients with impingement symptoms and could be a risk factor for development of the syndrome.¹⁸

Clavicular Elevation and Rotation with Humeral Motion

It is commonly accepted that initially the first 30° of upward rotation of the scapula occurs with elevation of the clavicle at the SC joint. Then, as the coracoclavicular ligament becomes taut, the clavicle rotates 38° to 55° about its longitudinal axis, which elevates its acromial end (because it is crank-shaped). This motion allows the scapula to rotate an additional 30° at the AC joint.¹²⁰ Loss of any of these functional components decreases the amount of scapular rotation and thus the ROM of the upper extremity.

External Rotation of the Humerus with Elevation

During elevation of the arm, the humerus externally rotates; this allows the greater tubercle of the humerus to clear the coracoacromial arch. Weak infraspinatus and teres minor muscles or inadequate external rotation may result in impingement of the soft tissues in the suprahumeral space, causing pain, inflammation, and eventually loss of function.

Deltoid–Short Rotator Cuff and Supraspinatus Mechanisms

Most of the force of the deltoid muscle causes upward translation of the humerus; if unopposed, it leads to impingement of the soft tissues in the suprahumeral space between the humeral head and the coracoacromial arch.

• The combined effect of the short rotator muscles (infraspinatus, teres minor, subscapularis) produces stabilizing compression and downward translation of the humerus in the glenoid.

• The combined actions of the deltoid and short rotators result in a balance of forces that elevate the humerus and control the humeral head.

• The supraspinatus muscle has a significant stabilizing, compressive, and slight upward translation effect on the humerus during arm elevation. It functions with the deltoid in humeral elevation.

• Interruption of the coordinated function of these mechanisms may lead to tissue microtrauma and shoulder complex dysfunction.

Referred Pain and Nerve Injury

For a detailed description of referred pain patterns, peripheral nerve injuries in the shoulder, thoracic outlet syndrome, and complex regional pain syndromes (including reflex sympathetic dystrophy) and their management, see Chapter 13.

Common Sources of Referred Pain in the Shoulder Region

Cervical Spine

• Vertebral joints between C3 and C4 or between C4 and C5

• Nerve roots C4 or C5

Referred Pain from Related Tissues

• Dermatome C4 is over the trapezius to the tip of the shoulder.

• Dermatome C5 is over the deltoid region and lateral arm.

• Diaphragm: pain perceived in the upper trapezius region.

• Heart: pain perceived in the axilla and left pectoral region.

• Gallbladder irritation: pain perceived at the tip of shoulder and posterior scapular region.

Nerve Disorders in the Shoulder Girdle Region

Brachial plexus in the thoracic outlet. Common sites for compression are the scalene triangle and the costoclavicular space and under the coracoid process and pectoralis minor muscle.¹¹⁷

Suprascapular nerve in the suprascapular notch. This injury occurs from direct compression or from nerve stretch, such as when carrying a heavy book bag over the shoulder.

Radial nerve in the axilla. Compression occurs from continual pressure, such as when leaning on axillary crutches.

To make sound clinical decisions when managing patients with shoulder disorders, it is necessary to understand the various pathologies, surgical procedures, and associated precautions and to identify presenting impairments, functional limitations, and possible disabilities. In this section, common pathologies and surgeries are presented and are related to corresponding preferred practice patterns (groupings of impairments) described in the Guide to Physical Therapist Practice² (Table 17.2). Conservative and postoperative management of these conditions are described in this section.

Joint Hypomobility: Nonoperative Management

Glenohumeral Joint

Restricted mobility of the glenohumeral joint may occur as a result of pathology, such as rheumatoid arthritis or osteoarthritis; from prolonged immobilization; or from unknown causes (idiopathic frozen shoulder). Associated impairments in muscle performance and connective tissue mobility may also be present in the cervical and shoulder girdle region.

Related Pathologies and Etiology of Symptoms

Rheumatoid arthritis and osteoarthritis. These disorders follow the clinical picture described in Chapter 11.

Traumatic arthritis. This disorder occurs in response to a fall or blow to the shoulder or to microtrauma from faulty mechanics or overuse.

Postimmobilization arthritis or stiff shoulder. This disorder occurs as a result of lack of movement or as a secondary effect from conditions such as heart disease, stroke, or diabetes mellitus.

Idiopathic frozen shoulder. This disorder, which is also called adhesive capsulitis or periarthritis, is characterized by the development of dense adhesions, capsular thickening, and capsular restrictions, especially in the dependent folds of the capsule, rather than arthritic changes in the cartilage and bone, as seen with rheumatoid arthritis or osteoarthritis. The onset is insidious and usually occurs between the ages of 40 and 60 years; there is no known cause (primary frozen shoulder), although problems already mentioned in which there is a period of pain and/or restricted motion, such as with rheumatoid arthritis, osteoarthritis, trauma, or immobilization, may lead to a frozen shoulder (secondary frozen shoulder). With primary frozen shoulder, the pathogenesis may be a provoking chronic inflammation in musculotendinous or synovial tissue, such as the rotator cuff, biceps tendon, or joint capsule.^{45,74,104,145,148} Faulty posture and muscle strength imbalances may be consistent with this, predisposing the individual to impingement and overuse syndromes.¹

Clinical Signs and Symptoms

Glenohumeral joint arthritis. The following characteristics are associated with the various types of glenohumeral (GH) joint arthritis that lead to hypomobility.

• Acute phase. Pain and muscle guarding limit motion, usually external rotation and abduction. Pain is frequently experienced radiating below the elbow and may disturb sleep. Owing to the depth of the capsule, joint swelling is not detected, although tenderness can be elicited by palpating in the fornix immediately below the edge of the acromion process between the attachments of the posterior and middle deltoid.

• Subacute phase. Capsular tightness begins to develop. Limited motion is detected, consistent with a capsular pattern (external rotation and abduction are most limited, and internal rotation and flexion are least limited). Often, the patient feels pain as the end of the limited range is reached. Joint-play testing reveals limited joint play. If the patient can be treated as the acute condition begins to subside by gradually increasing shoulder motion and activity, the complication of joint and soft tissue contractures can usually be minimized.^139,145

• Chronic phase. Progressive restriction of the GH joint capsule magnifies the signs of limited motion in a capsular pattern and decreased joint play. There is significant loss of function with an inability to reach overhead, outward, or behind the back. Aching is usually localized to the deltoid region.

Idiopathic frozen shoulder. This clinical entity progresses through a series of four stages following a classic continuum.^*

• Stage 1. Characterized by a gradual onset of pain that increases with movement and is present at night. Loss of external rotation motion with intact rotator cuff strength is common. The duration of this stage is usually less than 3 months.

• Stage 2 (Often referred to as the "Freezing" Stage). Characterized by persistent and more intense pain even at rest. Motion is limited in all directions and cannot be fully restored with an intra-articular injection. This stage is typically between 3 and 9 months.

• Stage 3 ("Frozen" Stage). Characterized by pain only with movement, significant adhesions, and limited GH motions, with substitute motions in the scapula. Atrophy of the deltoid, rotator cuff, biceps, and triceps brachii muscles may be noted. This stage is between 9 and 15 months.

• Stage 4 ("Thawing" Stage). Characterized by minimal pain and no synovitis but significant capsular restrictions from adhesions. Motion may gradually improve during this stage. This stage lasts from 15 to 24 months or longer. Some patients never regain normal ROM.

Some references indicate that spontaneous recovery occurs, on average, 2 years from onset,⁷⁴ although others have reported long-term limitations without spontaneous recovery.¹⁷⁷ Inappropriately aggressive therapy at the wrong time may prolong the symptoms.¹⁶ Management guidelines are progressed based on the continuum of stages¹⁰⁴ and are the same as for acute (maximum protection during stages 1 and 2), subacute (controlled motion during stage 3), and chronic (return to function during stage 4) joint pathology described in this section.

Common Structural and Functional Impairments

• Night pain and disturbed sleep during acute flares

• Pain on motion and often at rest during acute flares

• Mobility: decreased joint play and ROM, usually limiting external rotation and abduction with some limitation of internal rotation and elevation in flexion

• Posture: possible faulty postural compensations with protracted and anteriorly tilted scapula, rounded shoulders, and elevated and protected shoulder

• Decreased arm swing during gait

• Muscle performance: general muscle weakness and poor endurance in the glenohumeral muscles with overuse of the scapular muscles leading to pain in the trapezius, levator scapulae, and posterior cervical muscles

• Substitution for limited glenohumeral motion with increased scapular motion, especially elevation.

Common Activity Limitations and Participation Restrictions (Functional Limitations and Disabilities)

• Inability to reach overhead, behind head, out to the side, and behind back; thus, having difficulty dressing (putting on a jacket or coat or in the case of women, fastening undergarments behind their back), reaching hand into back pocket of pants (to retrieve wallet), reaching out a car window (to use an ATM machine), self-grooming (combing hair, brushing teeth, washing face), and bringing eating utensils to the mouth

• Difficulty lifting weighted objects, such as dishes into a cupboard

• Limited ability to sustain repetitive activities

Glenohumeral Joint Hypomobility: Management—Protection Phase

See 'General Guidelines for Management When Symptoms are Acute' in Chapter 10 and Box 10.1.

Control Pain, Edema, and Muscle Guarding

• The joint may be immobilized in a sling to provide rest and minimize pain.

• Intermittent periods of passive or assisted motion within the pain free/protected ROM and gentle joint oscillation techniques are initiated as soon as the patient tolerates movement in order to minimize adhesion formation.

• Gentle soft tissue mobilization to the cervical and periscapular muscles may improve patient comfort and minimize guarding, as may cervical range of motion and/or cervical grade I or II passive intervertebral mobilizations/manipulations.

Maintain Soft Tissue and Joint Integrity and Mobility

PRECAUTION: If there is increased pain or irritability in the joint after use of the following techniques, either the dosage was too strong or the techniques should be modified by decreasing the range of passive movement or delaying joint glides.

CONTRAINDICATION: If there are mechanical restrictions causing limited motion, appropriate tissue stretching should be initiated only after the inflammation subsides.

• Passive range of motion (PROM) in all ranges of pain-free motion (see Chapter 3). As pain decreases, the patient is progressed to active ROM with or without assistance, using activities such as rolling a small ball or sliding a rag on a smooth table top in flexion, abduction, and circular motions. Be sure the patient is taught proper mechanics and avoids faulty patterns, such as scapular elevation or a slumped posture.

• Passive joint distraction and glides, grade I and II with the joint placed in a pain-free position (see Chapter 5).

• Pendulum (Codman's) exercises are techniques that use the effects of gravity to distract the humerus from the glenoid fossa.^33,36 They help relieve pain through gentle traction and oscillating movements (grade II) and provide early motion of joint structures and synovial fluid. No weight is used during this phase of treatment (see Fig. 17.22).

• Gentle muscle setting to all muscle groups of the shoulder and adjacent regions, including cervical and elbow muscles because of their close association with the shoulder girdle. Instructions are given to the patient to gently contract a group of muscles while slight manual resistance is applied—just enough to stimulate a muscle contraction without provoking pain. The emphasis is on rhythmic contracting and relaxing of the muscles to help stimulate blood flow and prevent circulatory stasis.

Maintain Integrity and Function of Associated Regions

• Complex regional pain syndrome type I (reflex sympathetic dystrophy) is a potential complication after shoulder injury or immobility. Therefore, additional exercises, such as having the patient repetitively squeeze a ball or other soft object, may be given for the hand.

• The patient is educated on the importance of keeping the joints distal to the shoulder complex as active and mobile as possible. The patient or family member is taught to perform ROM exercises of the elbow, forearm, wrist, and fingers several times each day while the shoulder is immobilized. If tolerated, active or gentle resistive ROM is preferred to passive ROM for a greater effect on circulation and muscle integrity.

• If edema is noted in the hand, instruct the patient to elevate the hand above the level of the heart whenever possible.

• Cervical ROM (active and/or passive), intervertebral joint mobilizations, and soft tissue mobilization should also be considered.

GH Joint Hypomobility: Management—Controlled Motion Phase

When symptoms are subacute, follow the guidelines as described in Chapter 10, Box 10.2, emphasizing joint mobility, neuromuscular control, and instructions to the patient for self-care.

Control Pain, Edema, and Joint Effusion

• Functional activities. It is important to carefully monitor activities. If the joint is immobilized, the amount of time the shoulder is free to move each day is progressively increased.

• Range of motion. ROM for glenohumeral and scapula motions is progressed up to the point of pain. The patient is instructed in the use of self-assistive ROM techniques, such as the wand exercises or hand slides on a table.

PRECAUTION: With increased pain or decreased motion after these techniques, the activity may be too intense or the patient may be using faulty mechanics. Reassess the technique and modify it by restricting the joint to a safer range of motion, correcting faulty movements, or altering the intensity, frequency, and/or duration of the technique.

Progressively Increase Joint and Soft Tissue Mobility

Passive joint mobilization techniques. Grade III sustained or grade III and IV oscillations that focus on the restricted capsular tissue at the end of the available ROM are used to increase joint capsule mobility^100,150,211 (see Box 17.1 and Figs. 5.15 through 5.20 in Chapter 5). End-of-range techniques include rotating the humerus and then applying either a grade III distraction or a grade III glide to stretch the restrictive capsular tissue or adhesions (see Figs. 5.17, 5.21, and 17.20).

• Use a grade I distraction with all gliding techniques. If the joint is highly irritable and gliding in the direction of restriction is not tolerated, glide in the opposite direction. As pain and irritability decrease, begin to glide in the direction of restriction.¹⁰⁰

PRECAUTION: Carefully monitor the joint reaction to the mobilization stretches; if irritability increases, grade III or IV techniques should not be undertaken until the chronic stage of healing.

• Self-mobilization techniques. The following self-mobilization techniques may be used for a home program.

  • Caudal glide. Patient position and procedure: Sitting on a firm surface and grasping the fingers under the edge. The patient then leans the trunk away from the stabilized arm (Fig. 17.8).

  • Anterior glide. Patient position and procedure: Sitting with both arms behind the body or lying supine supported on a solid surface. The patient then leans the body weight between the arms (Fig. 17.9).

  • Posterior glide. Patient position and procedure: Prone, propped up on both elbows. The body weight shifts downward between the arms (Fig. 17.10).

• Manual stretching. Manual stretching techniques are used to increase mobility in shortened muscles and related connective tissue.

• Self-stretching exercises. As the joint reaction becomes predictable and the patient begins to tolerate stretching, self-stretching techniques are taught (see Figs. 17.24,17.25,17.26,17.27,17.28,17.29 in the exercise section).

Inhibit Muscle Spasm and Correct Faulty Mechanics

Muscle spasm may lead to a faulty deltoid-rotator cuff mechanism and scapulohumeral rhythm when the patient attempts arm elevation (Fig. 17.11). The head of the humerus may be positioned cranially in the joint, making it difficult and/or painful to elevate the arm because the greater tuberosity impinges on the coracoacromial arch. In this case, repositioning the head of the humerus with a caudal glide is necessary before proceeding with any other form of shoulder exercise. The patient also needs to learn to avoid "hiking the shoulder" when at rest or when elevating the arm. The following techniques may address these problems and faulty mechanics. See also 'Mobilization with Movement Techniques' in the next section.

• Gentle joint oscillation techniques to help decrease the muscle spasm (grade I or II).

• Sustained caudal glide joint techniques to reposition the humeral head in the glenoid fossa.

• Protected weight bearing, such as leaning hands against a wall or on a table, stimulates co-contraction of the rotator cuff and scapular stabilizing muscles and improves synovial fluid movement through hyaline cartilage compression. Techniques are progressed by gentle rocking forward/backward and side-to-side, moving from bilateral to unilateral, increasing the angle of the joint, or adding perturbations.

• GH internal/external rotation strengthening to facilitate stabilization of the humeral head (see Fig. 17.52).

• Movement retraining to minimize the substitution pattern of scapular elevation can be initiated by providing the visual feedback of a mirror or the tactile feedback of the opposite hand placed on the ipsilateral upper trapezius.

Improve Joint Tracking

Mobilization with movement (MWM) techniques may assist with retraining muscle function for proper tracking of the humeral head.¹³⁷

• Shoulder MWM for painful restriction of shoulder external rotation (Fig. 17.12).

  • Patient position: Supine lying with folded towel under the scapula; the elbow is near the side and flexed to 90°. A cane is held in both hands.

  • Therapist position and procedure: Stand on the opposite side of the bed facing the patient and reach across the patient's torso to cup the anteromedial aspect of the head of the humerus with reinforced hands. Apply a pain-free graded posterolateral glide of the humeral head on the glenoid. Instruct the patient to use the cane to push the affected arm into the previously restricted range of external rotation. Sustain the movement for 10 seconds and repeat in sets of 5 to 10. It is important to maintain the elbow near the side of the trunk and ensure that no pain is experienced during the procedure. Adjust the grade and direction of the glide as needed to achieve pain-free function.

• Shoulder MWM for painful restriction of internal rotation and inability to reach the hand behind the back (Fig. 17.13).

  • Patient position: Standing with a towel draped over the unaffected upper trapezius and affected hand at current range of maximum pain-free position behind back. The patient's hand on the affected side grasps the towel behind the back.

  • Therapist position and procedure: Stand facing the patient's affected side. Place the hand closest to the patient's back high up in the axilla with the palm facing outward to stabilize the scapula with an upward and inward pressure. With the hand closest to the patient's abdomen, hook the thumb in the cubital fossa and grasp the lower humerus to provide an inferior glide. Your abdomen is in contact with the patient's elbow to provide an adduction force to the arm. Have the patient pull on the towel with the unaffected hand to draw the affected hand up the back while the mobilization force is being applied in an inferior direction. Ensure that no pain is experienced during the procedure. Adjust the grade and direction of glide as needed to achieve pain-free function. Maximal glide should be applied to achieve end-range loading.

• Shoulder MWM for painful arc or impingement signs. If impingement signs are present in addition to the capsular restrictions, the MWM active elevation technique may be appropriate. (See Fig. 17.17 and description in the impingement section.)

Improve Muscle Performance

• Faulty postures or shoulder girdle mechanics, such as scapula elevation or protraction or excessive trunk movement, displayed when moving the upper extremity in various functional patterns should first be identified and corrected. Manual techniques, stretches, and strengthening exercises are initiated to correct muscle length or strength imbalances, followed by an emphasis on developing active control of weak musculature. As the patient learns to activate the weak muscles, progress to strengthening in functional patterns.

• Because faulty postures or shoulder girdle mechanics may be impacted by impaired trunk strength or control, an emphasis on trunk stability should also be considered. Exercises to manage faulty spinal posture are described in Chapter 16, with active cervical retraction and thoracic extension especially important for shoulder function.

• After proper mechanics are restored, the patient should perform active ROM of all shoulder motions daily and return to functional activities to the extent tolerated.

GH Joint Hypomobility: Management—Return to Function Phase

For joint impairments in the chronic stage, follow the guidelines described in Chapter 10, Box 10.4.

Progressively Increase Flexibility and Strength

• Stretching and strengthening exercises are progressed as the joint tissue tolerates. The patient should be actively involved in self-stretching and strengthening by this time, so emphasis during treatment is on maintaining correct mechanics, safe progressions, and exercise strategies for return to function. Progressions may include increasing resistance and repetitions, performing exercises through multiple planes, adding perturbations, and incorporating regional muscle groups (such as the trunk) into dynamic exercises.

• If capsular tissue is still restricting ROM, vigorous manual stretching and joint mobilization techniques are applied.

Prepare for Functional Demands

If the patient is involved in repetitive heavy lifting, pushing, pulling, carrying, or reaching, exercises are progressed to replicate these demands. See the last section of this chapter and Chapter 23 for suggestions.

GH Joint Management: Postmanipulation Under Anesthesia

Occasionally, no progress is made, and the physician chooses to perform manipulation under anesthesia. Following this procedure, there is an inflammatory reaction and the joint is treated as an acute lesion. If possible, joint mobility and passive ROM techniques are initiated while the patient is still in the recovery room. Surgical intervention with incision of the dependent capsular fold may be used if the adhesions are not broken with the manipulation.

Postoperative treatment is the same with the following considerations.¹⁴⁸

• The arm is kept elevated overhead in abduction and external rotation during the inflammatory reaction stage; treatment principles progress as with any joint lesion.

• Therapeutic exercises are initiated the same day while the patient is still in the recovery room, with emphasis on internal and external rotation in the 90° (or higher) abducted position.

• Joint mobilization procedures are used, particularly a caudal glide, to prevent readherence of the inferior capsular fold.

• When sleeping, the patient may be required to position the arm in abduction for up to 3 weeks after manipulation.

Acromioclavicular and Sternoclavicular Joints

Related Pathologies and Etiology of Symptoms

Overuse syndromes. Overuse syndromes of the AC joint may be from repeated stressful movement of the joint with the arm at waist level, such as with grinding, packing assembly, and construction work,⁷⁵ or repeated diagonal extension, adduction, and internal rotation motions, as when spiking a volleyball or serving in tennis. The AC joint is susceptible to overuse syndromes in conjunction with arthritis or following a traumatic injury.

Subluxation or dislocation. Subluxation or dislocation of either joint usually is caused by falling against the shoulder or against an outstretched arm. At the AC joint, the distal end of the clavicle often displaces posteriorly and superiorly on the acromion, and the ligaments supporting the AC joint may rupture.¹⁴⁷ Clavicular fractures may also result from a fall or other high force events such as a motor vehicle accident.¹⁴⁷ After trauma and associated overstretching of the capsules and ligaments of either joint, hypermobility is usually permanent because there are almost no muscles that provide direct stability to these joints.

Hypomobility. Decreased clavicular mobility may occur with SC joint osteoarthritis and may contribute to a thoracic outlet syndrome (TOS) with a compromise of space for the neuromuscular bundle as it courses between the clavicle and first rib (described in Chapter 13).

Common Structural and Functional Impairments

• Pain localized to the involved joint or ligament.

• Painful arc toward the end-range of shoulder elevation.

• Pain with shoulder horizontal adduction or abduction.

• Hypermobility in the joints if trauma or overuse is involved.

• Hypomobility in the joints if sustained posture, arthritis, or immobility is involved.

Common Activity Limitations and Participation Restrictions (Functional Limitations/Disabilities)

• Limited ability to sustain repeated forceful movements of the arm, such as with grinding, packing, assembly, and construction work.⁷⁵

• Inability to reach overhead or perform repetitive overhead activities without pain.

Nonoperative Management of AC or SC Joint Strain or Hypermobility

• Minimize joint loading by supporting the weight of the arm with a sling.

• Cross-fiber massage to the capsule or ligaments.

• Maintain ROM of the glenohumeral joint and scapulothoracic articulation.

• Instruction in self-application of cross-fiber massage if joint symptoms occur after excessive activity.

• Increase strength of shoulder complex, trunk, and legs.

• Gradually return to functional activities

Nonoperative Management of AC or SC Joint Hypomobility

Joint mobilization techniques are used to increase joint mobility (see Figs. 5.22 through 5.24).

Glenohumeral Joint Surgery and Postoperative Management

Severe deterioration of one or both surfaces of the GH joint or an acute or nonunion fracture of the proximal humerus often must be managed with surgical intervention. Underlying pathologies that cause advanced joint destruction include late-stage osteoarthritis (OA), rheumatoid arthritis (RA), traumatic arthritis, cuff tear arthropathy, and osteonecrosis (avascular necrosis) of the head of the humerus as the result of a fracture of the anatomical neck of the humerus or long-term use of steroids for systemic disease.

The most common surgical procedure used to treat advanced shoulder joint pathology is glenohumeral arthroplasty, often simply referred to as shoulder arthroplasty.³⁸ In rare situations, arthrodesis (surgical ankylosis) of the GH joint may have to be selected as an alternative to arthroplasty or as a salvage procedure.¹²⁶

The goals of these surgical procedures and the postoperative rehabilitation program are to: (1) relieve pain, (2) improve shoulder mobility or stability, and (3) restore or improve strength and functional use of the upper extremity. The extent to which these goals are achieved is predicated on the patient's participation in postoperative rehabilitation; the distinguishing features and severity of the underlying pathology; the prosthetic design and surgical techniques; the integrity of the rotator cuff mechanism and other soft tissues; and the age, overall health, and anticipated activity level of the patient.^{38,126,182,189}

Glenohumeral Arthroplasty

Arthroplasty of the GH joint falls into several categories, the most common of which are total shoulder arthroplasty (TSA),^{126,141,182,189} in which the glenoid and humeral surfaces are replaced (Fig. 17.14), and hemireplacement arthroplasty (hemiarthroplasty), in which one surface, the humeral head, is replaced.^{6,63,126,143,182,239} Reverse total shoulder arthroplasty (rTSA) is another type of arthroplasty, typically used when the rotator cuff integrity is compromised.^42,129,216 Other categories of shoulder arthroplasty include interpositional and resurfacing arthroplasties, which involve less extensive removal of bone.^{126,182,189,206}

Indications for Surgery

The following structural and functional impairments associated with these pathologies are widely accepted indications for GH arthroplasty.^*

• The primary indication is persistent and incapacitating pain (at rest or with activity) secondary to GH joint destruction.

• Secondary indications include loss of shoulder mobility or stability and/or upper extremity strength leading to inability to perform functional tasks with the involved upper extremity.

Procedures

Background

Implant design, materials, and fixation. Since the pioneering work of Neer during the 1960s and 1970s^141,143 and many other investigators,²⁹ prosthetic designs and surgical techniques for replacing the shoulder joint have continued to evolve. The designs of current-day TSA hardware, composed of a high-density polyethylene glenoid component (usually all plastic) and a modular inert metal humeral component, closely approximate the biomechanical characteristics of the human shoulder.²³² The exception to this is the rTSA, the design of which reverses the ball and socket location of the native shoulder. Specifically, the glenoid fossa is replaced with a convex, "glenospherical" component attached to a glenoid base and the humeral head with a stemmed cup.²¹³ Fixation of the prosthetic components is achieved with a press fit, bioingrowth, or cement. The type of fixation selected by the surgeon depends on the component (glenoid or humeral), the underlying pathology, and the quality of the bone stock. Cement fixation is most often necessary in patients with osteoporosis.^*

The designs of total shoulder replacements, ranging from unconstrained to semiconstrained to constrained, provide varying amounts of mobility and stability to the GH joint. Box 17.3 summarizes the characteristics of each of these designs.^{38,125,126,180,182,189,206}

NOTE: The description of constrained designs is included in Box 17.3 for historical purposes and for a comparison with less constrained designs. Because of the high rate of complications that occurs with constrained designs, these implant systems are rarely, if ever, used today.^38,126

Selection of procedure. Controversy exists over the specific criteria for selection of TSA versus rTSA versus hemiarthroplasty, but in general, it depends on the etiology and severity of the joint deterioration and the condition of the periarticular soft tissues, particularly the rotator cuff mechanism.^126,190 Several examples that follow underscore the complexity of the clinical decision-making process involved in the choice of operative procedure and prosthetic design.

In patients with late-stage primary OA, the GH joint typically exhibits loss or thinning of the articular cartilage of the head of the humerus and the posterior portion of the glenoid fossa. The rotator cuff is intact in approximately 90% to 95% of these patients, making them good candidates for either TSA or hemiarthroplasty.^{38,125,161,180,182,189} However, opinions vary on whether selection of an unconstrained TSA yields results that are better than or equal to those of hemiarthroplasty for shoulders with these characteristics.^{38,126,157,182,192}

Chronic synovitis, associated with RA and other types of synovium-based arthritis, tends to erode periarticular soft tissues in addition to the articular surfaces of a joint. As a consequence, a full-thickness tear of a rotator cuff tendon (typically the supraspinatus) develops in 25% to 40% of these patients and a rupture of the biceps tendon in an even greater percentage.^{63,180,189,197,206} If the soft tissues can be repaired and their functions improved, a semiconstrained TSA that may include bone grafting at the glenoid to improve prosthetic fixation may be indicated. If an effective cuff repair cannot be achieved, an rTSA is usually indicated. When there is insufficient bone stock for fixation of a glenoid implant, hemiarthroplasty is usually the procedure of choice.^{63,126,180,182,190,197,206}

Hemiarthroplasty is often used when the articular surface and underlying bone of the humeral head have deteriorated, but the glenoid fossa is reasonably intact, as seen with osteonecrosis of the head of the humerus.^38,126,189 A patient with severe, chronic pain and loss of function as the result of a massive, irreparable cuff tear and subsequent development of a cuff tear arthropathy typically is a candidate for rTSA. (First used by Neer, the term "cuff tear arthropathy" refers to deterioration and eventual collapse of the head of the humerus, an infrequent but debilitating long-term result of a primary, massive, and irreparable tear of the rotator cuff.)^{126,180,221,239}

Chronic deficiency of the rotator cuff mechanism leads to superior migration of the head of the humerus in the glenoid fossa. If a glenoid component is inserted under these conditions, the superior migration creates an incongruous articulation that accentuates the risk of loosening and premature wear of the glenoid implant.^37,82,180 The rTSA was developed to overcome this complication by eliminating translation between the glenosphere and humeral articular surface. Other features of the rTSA include reduced forces on the glenoid component, inherent stability owing to the congruency of the components, and increased deltoid moment arms. One limitation of the rTSA design is a decrease in glenohumeral range of motion.^23,129,213

Operative Procedures

TSA, rTSA, and hemiarthroplasty are open surgical procedures performed with the patient in a semi-reclining position. These operative procedures involve the following components^*: (1) anterior approach using a deltopectoral incision that extends from the AC joint to the deltoid insertion for adequate surgical exposure; (2) release (tenotomy) of the subscapularis tendon from its proximal attachment on the lesser tuberosity; (3) anterior capsulotomy; (4) exposure of the humeral head for a humeral osteotomy; and (5) preparation of the humeral canal for insertion of the prosthetic implant. The glenoid fossa is débrided and for a TSA is precisely contoured, so the glenoid implant can be placed flush within the fossa. The subscapularis is then reattached and may be lengthened (medial advancement or Z-plasty) if external rotation is limited.

Reconstruction and balancing of soft tissues is critical for optimal function after TSA, rTSA, and hemiarthroplasty. "Balancing" refers to the intraoperative lengthening or tightening of soft tissues to restore as near-normal resting tension in the tissues as possible, particularly in the rotator cuff, biceps, and deltoid muscle-tendon units.

Concomitant procedures that may be necessary during shoulder arthroplasty include:

• Repair of a deficient rotator cuff if the quality of the cuff tissue is sufficient.

• Capsular plication and tightening for chronic subluxation or dislocation (usually posterior) of the GH joint.

• Anterior acromioplasty for a history of impingement syndrome.

• Bone graft of the glenoid if bone stock is insufficient for fixation of the glenoid implant.

After implantation of the prosthetic component(s) and repair of soft tissues but before closure of the skin incision, the shoulder is passively moved through all planes of motion to visually evaluate the stability of the prosthetic joint and the integrity of the repaired soft tissues. This determines the anatomical ROM possible after surgery and how aggressive the postoperative program can be.^38,126

Complications

Although the incidence of intraoperative and postoperative complications after current-day arthroplasty is low, even a single complication can adversely affect the functional outcome. The incidence of complications after TSA tends to be higher in patients with a deficient rotator cuff mechanism, osteoporosis, and a preoperative history of chronic GH joint instability.⁸¹ Aside from medical complications, such as infection or a deep vein thrombosis, complications specific to shoulder arthroplasty are noted in Box 17.4.^37,81

Postoperative Management

NOTE: Effective patient education and close communication among the therapist, surgeon, and patient are the basis of an effective and safe rehabilitation program. Postoperative management is individualized to address the specific surgical procedures used and to meet the unique needs of each patient.

Special Considerations

Integrity of the rotator cuff. Regardless of the underlying cause of late-stage glenohumeral arthritis, the goals, components, and rate of progression of a rehabilitation program after TSA or hemiarthroplasty are influenced by the pre- and postoperative integrity of the rotator cuff mechanism. The rehabilitation program for a patient with an intact rotator cuff prior to shoulder arthroplasty can be progressed more rapidly than the program for a patient with coexisting rotator cuff deficiency requiring a concomitant cuff-tendon repair at the time of shoulder arthroplasty.

If the rotator cuff was intact prior to surgery, the emphasis of postoperative rehabilitation is to restore shoulder mobility and functional use of the arm as soon as possible while protecting soft tissues as they heal. In contrast, with a tenuous repair, or a preoperative history of recurrent GH dislocation, rehabilitation must place greater emphasis on improving or maintaining joint stability for functional use of the arm than on increasing shoulder mobility.^{47,52,57,103,126}

Intraoperative ROM. Goals for safe, stable postoperative ROM are based on intraoperative ROM measurements taken prior to closing the surgical incision. For a patient with an unconstrained TSA and sufficient postoperative shoulder stability (static and dynamic), the goal at the conclusion of rehabilitation is to achieve active ROM equal to intraoperative ROM—ideally, 140° to 150° of shoulder elevation and 45° to 50° of external rotation.^47,126 For a patient with more constrained TSA, a deficient rotator cuff mechanism, or capsuloligamentous laxity, intraoperative ROM is typically less, and postoperative goals focus more on developing dynamic stability and less on shoulder mobility. Following rTSA, ROM is limited to 0° to 20° external rotation and 90° to 120° elevation for 3 months.^23,129

Posture. If the postural changes associated with aging¹⁰⁸ (increased thoracic kyphosis and scapular protraction) are present, it is important to emphasize an erect sitting or standing posture during elevation of the arm and to incorporate spinal extension and scapular retraction exercises into the postoperative program.

Immobilization and Postoperative Positioning

At the close of the surgical procedure, the operated arm is placed in some type of shoulder immobilizer, usually a sling or sometimes a splint, to protect reattached and repaired soft tissues and for comfort.^{6,38,126,180,189,208} Early postoperative positioning that protects the operated shoulder is detailed in Box 17.5.

Initially, the sling or splint is removed only for exercise and bathing. A patient who did not require repair of the rotator cuff is weaned from the sling during the day as quickly as possible to prevent postoperative stiffness. However, a patient who has undergone a cuff repair or other soft tissue reconstruction may need to wear a sling or splint while out in crowded areas or during sleep for approximately 4 to 6 weeks to protect the repaired tissues until sufficient healing has occurred.^{24,27,38,47,52,53,103,126,198}

A patient who has undergone rTSA wears a shoulder immobilizer (sling and swathe) continuously for at least 3 to 4 weeks following surgery except for daily personal hygiene and periodic PROM (pendulum exercises) during the day.¹²⁹

Exercise Progression

The guidelines for progression of exercises during each phase of rehabilitation after TSA, rTSA, or hemiarthroplasty presented in this section are drawn from the limited number of published protocols available, all of which are based on clinical experience rather than evidence from controlled studies and none of which has been shown to be more effective than another.^* Almost all of these protocols are time-based, with few criteria reported for advancing a patient from one phase of rehabilitation to the next.

Recently, however, several resources have suggested such criteria.^{23,39,52,213,221} It is important to note that these criteria and suggested timelines for progression of exercises and functional activities must be adapted to each patient based on periodic evaluations of the patient's status and ongoing communication between the therapist and the surgeon.

NOTE: The exercise guidelines in this section are for patients without preoperative rotator cuff deficiency and who did not undergo a cuff repair during TSA or hemiarthroplasty. For patients with a poor quality rotator cuff mechanism or who underwent rTSA, modifications in guidelines are noted. A comparison of postoperative exercise guidelines and precautions following TSA versus rTSA are summarized in Table 17.3.

Exercise: Maximum Protection Phase

The maximum protection phase of rehabilitation following TSA begins on the first postoperative day and extends for 4 to 6 weeks. The emphasis of this first phase is patient education, pain control, and initiation of ROM exercises to prevent adhesions and restore shoulder mobility as early as possible to the ranges achieved during surgery. Early motion is permissible after uncemented and cemented shoulder arthroplasty.

While the patient is hospitalized (usually for 3 to 4 days after surgery), patient education includes reviewing early postoperative precautions and teaching the initial exercises in the patient's home program. Precautions during the first 4 to 6 weeks after TSA, when protection of soft tissues is crucial, are summarized in Box 17.6. A patient's adherence to these precautions is of the utmost importance during this phase of rehabilitation.

Goals and interventions. The first phase of rehabilitation includes the following.^{24,27,39,47,52,53,102,103,126,198}

• Control pain and inflammation.

  • Use of a sling or splint for comfort.

  • Use of prescribed analgesic and anti-inflammatory medication.

  • Use of cryotherapy, especially after exercise.

• Maintain mobility of adjacent joints.

  • Active movements of the spine and scapula (while wearing the shoulder sling and after it can be removed for exercise) to maintain motion and minimize muscle guarding and spasm. Incorporate "shoulder rolls" by elevating, retracting, and then relaxing the scapulae to reinforce an erect posture of the trunk. Emphasize active scapular retraction and spinal extension.

  • Active ROM of the hand, wrist, and elbow when the arm can be removed from the sling.

• Restore shoulder mobility.

  • Passive or therapist-assisted shoulder motions within the safe ROM limits determined during surgery. With the patient lying supine and the arm slightly away from the side of the trunk on a folded towel and the elbow flexed, perform elevation of the arm in the plane of the scapula to tolerance, external rotation to no more than 30° to 45°, and internal rotation until the forearm rests on the chest.

  • Pendulum (Codman's) exercises. Encourage the patient to periodically remove the sling and gently swing the arm during ambulation at home.

  • Later during this phase, progress to supine self-assisted shoulder ROM (elevation and rotation) by assisting with the sound hand and later using a wand or dowel rod. Add horizontal abduction to neutral and adduction across the chest holding a wand.

  • Self-assisted shoulder ROM with a wand in sitting or standing by performing "gear shift" exercises (see Fig. 17.23), resting the arm on a table and sliding it forward (see Fig. 17.25), or use of an overhead rope-pulley system to lessen the weight of the arm. Remind the patient to maintain an erect trunk when performing assisted shoulder motions while seated or standing.

  • Self-assisted reaching movements (to the nose, forehead, or over the head as comfort allows) to simulate functional movements.

  • For some patients, transition to active (unassisted) shoulder ROM is often possible by 4 weeks.

  • Functional activities with the elbow at waist level, such as hand to face and writing, are permissible.

• Minimize muscle inhibition, guarding, and atrophy.

  • Gentle muscle-setting of shoulder musculature (excluding the internal rotators) with the elbow flexed and the shoulder in the plane of the scapula or neutral. Teach these exercises prior to discharge from the hospital by having the patient practice isometric contractions of the muscles of the sound shoulder. Postpone setting exercises (light isometrics) of the operated shoulder until about 4 to 6 weeks after surgery.

  • Scapular stabilization exercises in nonweight-bearing positions. Target the serratus anterior and trapezius muscles.

NOTE: For a patient who underwent TSA with repair of a large tear or rupture of a rotator cuff tendon, it may not be permissible to begin ROM exercises immediately after surgery. When the sling or splint can be removed for exercise, perform only passive or assisted ROM throughout the first phase of rehabilitation. The range of shoulder elevation and external rotation initially permitted may be less than for shoulders that did not require cuff repair. Postpone active (unassisted), antigravity ROM and light isometrics until the second phase (approximately 6 weeks postoperatively, when repaired soft tissues are reasonably well healed).

Following rTSA, patients have a lifting limit of 1 lb or less for 6 weeks, and external rotation and elevation ROM are limited to 0° to 20° and 90° to 120°, respectively, for 3 months.^23,129 In addition, shoulder hyperextension, lifting, and supporting of body weight with the involved shoulder are all precautions following rTSA.²³ (Refer to Table 17.3 for additional precautions after rTSA.)

Criteria to progress. Criteria to advance to the second phase of rehabilitation following TSA are:

• ROM: At least 90° of passive elevation, at least 45° degrees of external rotation, and 70° of internal rotation in the plane of the scapula with minimal pain²²¹ or almost full, passive shoulder motion based on intraoperative measurements with little to no pain.^39,103

• No pain during resisted, isometric internal rotation of the subscapularis.³⁹

• Ability to perform most waist-level activities of daily living (ADLs) without pain.¹⁰³

• For rTSA, criteria include tolerance of assisted ROM and demonstration of the ability to isometrically activate the deltoid and periscapular musculature while the joint is positioned in the scapular plane.²³

Exercise: Moderate Protection/Controlled Motion Phase

Although suggested timelines vary from one resource to another, the moderate protection/controlled motion phase of rehabilitation, which typically begins at about 4 to 6 weeks postoperatively and extends to at least 12 to 16 weeks, focuses on gradually establishing active (unassisted) control, dynamic stability, and strength of the shoulder while continuing to increase ROM.^{24,27,47,52,102,103,126,198,221}

PRECAUTIONS: During this phase of rehabilitation, although it is safe to place increasing stresses (stretching or resistance) on periarticular soft tissues, it is important to do so gradually so as not to irritate these tissues, which are continuing to heal. Therefore, continue with short but frequent exercise sessions (preceded by application of heat and followed by cold) and avoid vigorous stretching or resistance exercises or overuse of the involved shoulder during functional activities.

Goals and interventions. The goals and exercises for this phase of rehabilitation are as follows.

• Continue to increase ROM of the shoulder.

  • Transition from passive or assisted ROM to low-intensity, pain-free stretching in all anatomical and diagonal planes of motion to achieve intraoperative ROM.

  • Gentle joint mobilization techniques for specific capsular restrictions.

  • In addition to therapist-assisted stretching, teach the patient how to perform gentle self-stretching exercises to increase elevation, internal/external rotation, extension, and horizontal adduction/abduction. Suggestions are pictured in the 'Exercise Techniques' section of this chapter.

• Develop active control and dynamic stability and improve muscle performance (strength and endurance) of the shoulder.

  • Continue or gradually transition to active shoulder ROM exercises, initiating antigravity abduction when the patient can perform the movement without elevating the scapula.

  • Scapular and GH joint stabilization exercises (alternating isometrics and rhythmic stabilization) progressing from nonweight-bearing to light weight-bearing positions.

NOTE: For patients who have had an rTSA, maintain nonweight-bearing precautions for up to 12 weeks postoperatively.²³

• Pain-free, low-intensity (submaximal) resisted isometrics of shoulder muscles, particularly the rotator cuff including the subscapularis or any other repaired muscle-tendon units.

• Dynamic resistance exercises for the scapula and shoulder musculature (between 0° and 90° of shoulder elevation) using light weights or light-grade elastic resistance. Begin in the supine position to support and stabilize the scapula and progress to the sitting position.

• Upper extremity endurance training with stationary ergometer or a portable reciprocal exerciser on a table. Emphasize progressive repetitions to increase muscular and cardiopulmonary endurance.

Criteria to progress. To advance to the final phase of rehabilitation, a patient should meet the following criteria.

• Full, passive ROM of the shoulder (based on intraoperative ranges)^39,103 or at least 130° to 140° of pain-free, passive or assisted shoulder flexion and 120° of abduction.²²¹

• In the plane of the scapula, at least 60° pain-free, passive external rotation and 70° internal rotation.²²¹

• Active (unassisted), antigravity elevation of the arm to at least 100° to 120° in the plane of the scapula while maintaining joint stability and using appropriate shoulder mechanics, particularly no scapula elevation prior to elevating the arm.²²¹

• 4/5 strength of rotator cuff and deltoid muscles.^52,103

• rTSA patients should have documented improvements in function and increasing strength of the deltoid and periscapular muscles prior to progressing to the next phase.²³

Exercise: Minimum Protection/Return to Function Phase

The minimum protection/return to functional activity phase usually begins around 12 to 16 weeks postoperatively (depending on rotator cuff tissue quality and function) and typically extends for several more months.^52,103,221 Pain-free strengthening of the shoulder girdle for dynamic stability and functional use of the upper extremity for progressively more demanding tasks are the primary focuses of this phase. For optimal results, the home exercise program may need to be continued for 6 months or longer, and functional and recreational activities may need to be modified.

Goals and interventions. Goals and activities for the final phase of rehabilitation include the following.^{24,27,39,52,53,102,103,221}

• Continue to improve or maintain shoulder mobility.

  • End-range self-stretching.

  • Grade III joint mobilization and self-mobilization, if appropriate.^24,27,39,103

• Continue to improve neuromuscular control and muscle performance of the shoulder.

  • Pain-free, low-load, high-repetition progressive resistive exercise (PRE) of shoulder musculature in anatomical and diagonal planes and in patterns of movement that replicate functional tasks throughout the available ROM. Position the patient in a variety of gravity-resisted positions.

  • Closed-chain, resisted shoulder exercises, gradually increasing the amount of weight bearing through the upper extremity.

  • Use of the involved upper extremity for lifting, carrying, pushing, or pulling activities against increasing loads.

• Return to most functional activities.

  • Use of the operated upper extremity for progressively more advanced functional activities.

  • Recreational activities, such as swimming and golf are possible.

  • Modification of high-demand, high-impact work-related or recreational activities to avoid imposing excessive forces on the GH joint that could lead to loosening or premature wear of prosthetic implants.

NOTE: For the patient whose rotator cuff was irreparable or continues to be significantly deficient because of a tenuous repair and who has limited but pain-free shoulder ROM, modification of the environment and use of assistive devices may be necessary for independence in functional activities.

Painful Shoulder Syndromes (Rotator Cuff Disease and Impingement Syndromes): Nonoperative Management

Mechanical compression and irritation of the soft tissues (rotator cuff and subacromial bursa) in the suprahumeral space (see Fig. 17.7) is called impingement syndrome and is the most common cause of shoulder pain.^83,112,121 Various etiological factors have been identified and therefore, have led to several classification systems, which are summarized in Box 17.7.

Related Pathologies and Etiology of Symptoms

The cause of impingement is multifactoral, involving both structural and mechanical impairments. Impingement syndrome is often used as the diagnosis when the patient's signs and symptoms are related to pain with overhead reaching, a painful arc mid-range, and positive impingement tests. Other test results may more specifically identify the tissue involved, the faulty mechanics associated with the condition, or the degree of instability or injury. Symptoms that derive from impingement are usually brought on with excessive or repetitive overhead activities that load the shoulder joint, particularly in the mid-range. Impingement syndromes are generally classified as intrinsic or extrinsic, with extrinsic further classified as primary, secondary, and internal.

Other types of musculotendinous strain in the shoulder region occur as the result of overuse or trauma, such as in the anterior pectoral region from racket sports or in the long head of the triceps and serratus anterior from impact trauma, such as holding onto a steering wheel in an automobile accident.

Intrinsic Impingement: Rotator Cuff Disease

Intrinsic factors are those that compromise the integrity of the musculotendinous structures and include vascular changes in the rotator cuff tendons, tissue tension overload, and collagen disorientation and degeneration.^65,136 These factors typically involve the articular side of the tendons and may progress to articular-side rotator cuff tears, seen most often in those older than 40 years of age.⁸⁰

Extrinsic Impingement: Mechanical Compression of Tissues

Extrinsic impingement is believed to occur as a result of mechanical wear of the rotator cuff against the anteroinferior one-third of the acromion in the suprahumeral space during elevation activities of the humerus (Fig. 17.15). Encroachment may be the result of anatomical or biomechanical factors that decrease the dimensions of the suprahumeral space. Extrinsic impingement can also occur at the posterior aspect of the supraspinatus tendon, mainly in athletes who throw repetitively.

Primary extrinsic impingement. Primary extrinsic impingement can result from anatomical or biomechanical factors. Anatomical factors that may cause primary extrinsic impingement include structural variations in the acromion or humeral head, hypertrophic degenerative changes of the AC joint, or other trophic changes in the coracoacromial arch or humeral head. All of these factors decrease the suprahumeral space and often have to be dealt with surgically.^{65,92,170,238} Biomechanical factors include altered orientation of the clavicle or scapula during movement, or increased anterosuperior humeral head translations as may occur with a tight posterior GH capsule.⁷⁷

Neer¹⁴² first suggested that the size and shape of the structures that make up the coricoacromial arch are related to rotator cuff impingement. In later studies, variations of the acromion were identified and classified into three shapes: type I (flat), type II (curved), and type III (hooked) (Fig. 17.16).¹⁵ Rotator cuff pathology is often associated with types II and III—but not type I—acromial shapes.^1,135,238

Secondary extrinsic impingement. Secondary impingement is used to describe mechanical compression of the suprahumeral tissues due to hypermobility or instability of the GH joint and increased translation of the humeral head. This instability may be multidirectional or unidirectional and can occur with compromised static restraints (GH ligaments) or with dynamic rotator cuff insufficiency (force imbalances or fatigue).

• Multidirectional instability. Some individuals have physiologically increased connective tissue extensibility, causing excessive joint mobility. In the GH joint, this increased extensibility allows larger than normal humeral head translations in all directions.^156,181 Many individuals, particularly those involved in overhead activities, develop laxity of the capsule from continually subjecting the joint to stretch forces.^65,98 A hypermobile GH joint may be supported satisfactorily by strong rotator cuff muscles; but with muscle fatigue, poor humeral head stabilization leads to faulty humeral mechanics, trauma, and inflammation of the suprahumeral tissues.^98,134 With multidirectional instability, the mechanical impingement of tissue in the suprahumeral space is, therefore, a secondary effect of the increased humeral head translations.⁶⁵

• Unidirectional instability with or without impingement. Unidirectional instability (anterior, posterior, or inferior) may be the result of physiological laxity of the connective tissues, but is often the result of trauma and usually involves rotator cuff tears. The tears can be classified as acute, chronic, degenerative, or partial- or full-thickness tears. Often, there is damage to the glenoid labrum and tearing of some of the supporting ligaments.

Internal extrinsic impingement. Internal impingement is a relatively recent type of extrinsic impingement that occurs in a position of elevation, horizontal abduction, and maximum external rotation, primarily in throwing athletes. This position and a posterior-superior shift of the humeral head on the glenoid results in a mechanical entrapment of the posterior supraspinatus tendon between the humeral head and the labrum. Internal impingement is associated with a combination of posterior GH capsule tightness and scapula kinematic alterations.^111,138

Tendonitis/Bursitis

Neer categorizes tendonitis/bursitis as a stage II impingement syndrome (see Box 17.7).¹⁴⁰ The following sections describe specific pathological diagnoses and presenting signs and symptoms.

Supraspinatus tendonitis. With supraspinatus tendonitis, the lesion is usually near the musculotendinous junction, resulting in a painful arc with overhead reaching. There is also pain with impingement tests and pain on palpation of the tendon just inferior to the anterior aspect of the acromion when the patient's hand is placed behind the back. It is difficult to differentiate tendonitis from subdeltoid bursitis because of the anatomical proximity of these two structures.

Infraspinatus tendonitis. With infraspinatus tendonitis, the lesion is usually near the musculotendinous junction, resulting in a painful arc with overhead, forward, or cross body motions. It may present as a deceleration (eccentric) injury due to overload during repetitive or forceful throwing activities. Pain occurs with palpation of the tendon just inferior to the posterior corner of the acromion when the patient horizontally adducts and externally rotates the humerus.

Bicipital tendonitis. With bicipital tendonitis, the lesion involves the long tendon in the bicipital groove beneath or just distal to the transverse humeral ligament. Swelling in the boney groove is restrictive and compounds and perpetuates the problem. Pain occurs with Speed's test and on palpation of the bicipital groove.¹²³ Rupture or dislocation of this humeral depressor may escalate impingement of tissues in the suprahumeral space.^140,149

Bursitis (subdeltoid or subacromial). When acute, the symptoms of bursitis are the same as those seen with supraspinatus tendonitis. Once the inflammation is under control, there are no symptoms with resisted motions.

Other Impaired Musculotendinous Tissues

The following are examples of other musculotendinous problems in the shoulder region.

• The pectoralis minor, short head of the biceps, and coracobrachialis are subject to microtrauma, particularly in racquet sports requiring a controlled backward, then a rapid forward swinging of the arm. The scapular stabilizers, particularly the retractors, are also susceptible to microtrauma, as they function to control forward motion of the scapula.¹¹⁴

• The long head of the triceps and scapular stabilizers may be injured in motor vehicle accidents, as the driver holds firmly to the steering wheel on impact.

• Injury, overuse, or repetitive trauma can occur in any muscle being subjected to stress.¹⁵² Pain occurs when the involved muscle is lengthened or when contracting against resistance. Palpating the site of the lesion causes the familiar pain.

Insidious (Atraumatic) Onset

Neer has identified rotator cuff tears as a stage III impingement syndrome, a condition that typically occurs in persons over age 40 after repetitive microtrauma to the rotator cuff or long head of the biceps.¹⁴⁰ With aging, the distal portion of the supraspinatus tendon is particularly vulnerable to impingement or stress from overuse strain. With degenerative changes, calcification and eventual tendon rupture may occur.^65,146,155 Chronic ischemia caused from tension on the tendon and decreased healing in the elderly are possible explanations, although Neer stated that, in his experience, 95% of tears are initiated by impingement wear rather than by impaired circulation or trauma.¹⁴⁰

Common Structural and Functional Impairments

Various impairments have been reported to be common in impingement syndromes; however, it is not known if they are the cause or effect of the faulty mechanics.^{33,118,121,158,218} A thorough examination of the cervical spine and shoulder girdle is necessary to differentiate signs and symptoms related to primary and secondary impingements or other causes of shoulder pain.^22,51,123 Common impairments associated with rotator cuff disease and impingement syndromes are summarized in Box 17.8.

Impaired Posture and Muscle Imbalances

Increased thoracic kyphosis, forward head, and protracted and forward-tilted scapula are often identified as related to impingement syndrome. Faulty scapular alignment may be one factor in decreasing the suprahumeral space and therefore leading to irritation of the rotator cuff tendons with overhead activities.¹¹⁸ Faulty upper quadrant posture leads to an imbalance in the length and strength of the scapular and GH musculature and decreases the effectiveness of the dynamic and passive stabilizing structures of the GH joint.²²⁷

Typically with increased thoracic kyphosis, the scapula is protracted and tilted forward, and the GH joint is in an internally rotated posture. With this posture, the pectoralis minor, levator scapulae, and shoulder internal rotators are tight; and the external rotators of the shoulder and upward rotators of the scapula may test weak and have poor muscular endurance. When reaching overhead, faulty scapular and humeral mechanics may result in alterations of scapular alignment and in the muscular control of the shoulder complex.

Decreased Thoracic ROM

Thoracic extension is a component motion that is needed for full overhead reaching. Incomplete thoracic extension decreases the functional range of humeral elevation.

Rotator Cuff Overuse and Fatigue

If the rotator cuff musculature or long head of the biceps fatigue from overuse, they no longer provide the dynamic stabilizing, compressive, and translational forces that support the joint and control the normal joint mechanics. This is thought to be a precipitating factor in secondary impingement syndromes when capsular laxity is present and increased muscular stability is necessary for stability.¹⁵⁹ The tissues in the subacromial space may then become impinged as a result of faulty mechanics. There is also a relationship between muscle fatigue and joint position sense in the shoulder that may play a role in impaired performance in repetitive overhead activities.³⁵

Muscle Weakness Secondary to Neuropathy

Muscle weakness may be related to nerve involvement. Long thoracic nerve palsy has been identified as a cause of faulty scapular mechanics, resulting from serratus anterior muscle weakness, leading to impingement in the suprahumeral region.¹⁸⁴

Hypomobile Posterior GH Joint Capsule

Tightness in the posterior GH joint capsule compromises the normal arthrokinematics and increases forces on the head of the humerus against the anterior capsule,⁷⁷ as demonstrated by increased anterior translation in the humeral head when there is a tight posterior capsule.

Common Activity Limitations and Participation Restrictions (Functional Limitations/Disabilities)

• When acute, pain may interfere with sleep, particularly when rolling onto the involved shoulder.

• Pain with overhead reaching, pushing, or pulling.

• Difficulty lifting loads.

• Inability to sustain repetitive shoulder activities (such as reaching, lifting, throwing, pushing, pulling, or swinging the arm).

• Difficulty with dressing, particularly putting a shirt on over the head.

Management: Painful Shoulder Syndromes

NOTE: Even though symptoms may be "chronic" in terms of long standing or recurring, if there is inflammation, the initial treatment priority is to get the inflammation under control.

Management: Protection Phase

Control Inflammation and Promote Healing

• Modalities and low-intensity cross-fiber massage are applied to the site of the lesion. While applying the modalities, position the extremity to maximally expose the involved region.^46,49

• Support the arm in a sling for rest.

Patient Education

The environment and habits that provoke the symptoms must be modified or avoided completely during this stage. The patient should be informed about the mechanics of the irritation and given guidelines for anticipated recovery with compliance.

Maintain Integrity and Mobility of the Soft Tissues

• Passive, active-assistive, or self-assisted ROM is initiated in pain-free ranges.

• Multiple-angle muscle setting and protected stabilization exercises are initiated. When exercising the shoulder, it is particularly important to stimulate the stabilizing function of the rotator cuff, biceps brachii, and scapular muscles at an intensity tolerated by the patient.

PRECAUTION: It is important to use caution with exercises during this stage to avoid the impingement positions. Often, the mid-range of abduction, with internal rotation, or an end-range position when the involved muscle is on a stretch (such as putting the hand behind the back) provokes a painful response.

Control Pain and Maintain Joint Integrity

Pendulum exercises without weights can be used to cause pain-inhibiting grade II joint distraction and oscillation motions (see Fig. 17.22 in the section on exercise).

Develop Support in Related Regions

• Postural awareness and correction techniques are used. (See related information on 'Interventions for Impaired Posture' in Chapter 14.)

• Supportive techniques, such as shoulder strapping or scapular taping, tactile cues, and mirrors, can be used for reinforcement. Repetitive reminders and practice of correct posture are necessary throughout the day.

Management: Controlled Motion Phase

After the acute symptoms are under control, the main emphasis becomes the use of the involved region with progressive, nondestructive movement and proper mechanics while the tissues heal. The components of the desired functions are analyzed and initiated in a controlled exercise program.^{48,49,194,223,224,229} If there is functional laxity in the joint, the intervention is directed toward learning neuromuscular control of and developing strength in the stabilizing muscles of both the scapula and glenohumeral joint.^{30,101,105,183,205} If there is restricted mobility that prevents normal mechanics or interferes with function, mobilization of the restricted tissue is performed. Exercise techniques and progressions are described later in the chapter.

Patient Education

Patient adherence to the program and avoidance of irritating the healing tissues are necessary. The home exercise program is progressed as the patient learns safe and effective execution of each exercise. Continue to reinforce proper postural habits.

Develop Strong, Mobile Tissues

• Manual therapy techniques, such as cross-fiber or friction massage, are used. The extremity is positioned so the tissue is on a stretch if it is a tendon or in the shortened position if it is in the muscle belly. The technique is applied to the tolerance of the patient.

• Following massage, the patient is instructed to perform an isometric contraction of the muscle in several positions of the range. The intensity of contraction should not cause pain.

• The patient should be taught how to self-administer the massage and isometric techniques.

Modify Joint Tracking and Mobility

Mobilization with movement (MWM) may be useful for modifying joint tracking and reinforcing full movement when there is painful restriction of shoulder elevation because of a painful arc or impingement¹³⁷ (see Chapter 5 for a description of principles).

• Posterolateral glide with active elevation (Fig. 17.17 A)

  • Patient position: Sitting with the arm by the side and head in neutral retraction.

  • Therapist position and procedure: Stand on the side opposite the affected arm and reach across the patient's torso to stabilize the scapula with the palm of one hand. The other hand is placed over the anteromedial aspect of the head of the humerus. Apply a graded posterolateral glide of the humeral head on the glenoid. Request that the patient perform the previously painful elevation. Maintain the posterolateral glide mobilization throughout both elevation and return to neutral. Ensure that no pain is experienced during the procedure. Adjust the grade and direction of the glide as needed to achieve pain-free function. Add resistance in the form of elastic resistance or a cuff weight to load the muscle.

• Self-Treatment. A mobilization belt provides the posterolateral glide while the patient actively elevates the affected limb against progressive resistance to end-range (Fig. 17.17 B).

Develop Balance in Length and Strength of Shoulder Girdle Muscles

It is important to design a program that specifically addresses the patient's impairments. Typical interventions in the shoulder girdle include but are not limited to:

• Stretch shortened muscles. Shortened muscles typically include the pectoralis major, pectoralis minor, latissimus dorsi and teres major, subscapularis, and levator scapulae.

• Strengthen and train the scapular stabilizers. Scapular stabilizers typically include the serratus anterior and lower trapezius for posterior tipping and upward rotation and the middle trapezius and rhomboids for scapular retraction. It is important that the patient learns to avoid scapular elevation when raising the arm. Therefore, practice scapular depression when abducting and flexing the humerus.

• Strengthen and train the rotator cuff muscles. Place emphasis on the shoulder external rotators.

Develop Muscular Stabilization and Endurance

• Alternating isometric resistance is applied to the scapular muscles in open-chain positions (side-lying, sitting, supine), including protraction/retraction, elevation/depression, and upward/downward rotation, so the patient learns to stabilize the scapula against the outside forces (see Fig. 17.37 in the exercise section).

• Scapular and glenohumeral patterns are combined using flexion, abduction, and rotation. Alternating isometric resistance is applied to the humerus while the patient holds against the changing directions of the resistance force (see Figs. 17.38, 17.39, and 17.42 in the exercise section).

• Closed-chain stabilization is performed with the patient's hands fixated against a wall, a table, or the floor (quadruped position) while the therapist provides a graded, alternating isometric resistance or rhythmic stabilization. Observe for abnormal scapular winging. If abnormal scapular winging occurs, the scapular stabilizers are not strong enough for the demand, so the position should be changed to reduce the amount of body weight (see Fig. 17.43 in the exercise section).

• Muscular endurance is progressed by increasing the amount of time the individual holds the pattern against the alternating resistance. The limit is reached when any one of the muscles in the pattern can no longer maintain the desired hold. The goal at this phase should be stabilization for approximately 3 minutes.

Progress Shoulder Function

As the patient develops strength in the weakened muscles, it becomes important to develop a balance in strength of all shoulder and scapular muscles within the range and tolerance of each muscle. To increase coordination between scapular and arm motions, dynamically load the upper extremity within tolerance of the synergy with submaximal resistance. To improve muscular endurance, have the patient increase control from 1 minute to 3 minutes.

Management: Return to Function Phase

Specificity of training toward the desired functional outcome begins as soon as the patient has developed control of posture and the basic components of the desired activities without exacerbating the symptoms. While working with the patient, continue to teach him or her how to progress the program when discharged and how to prevent recurrences. Suggestions are summarized in Box 17.9.

Increase Muscular Endurance

To increase muscular endurance, repetitive loading of the defined patterns is increased from 3 minutes to 5 minutes.

Develop Quick Motor Responses to Imposed Stresses

• The stabilization exercises are applied with increased speed.

• Plyometric training in both open-chain and closed-chain patterns is initiated if power is a desired outcome. (Refer to Chapter 23.)

Progress Functional Training

Specificity of training progresses to an emphasis on timing and sequencing of events.

• Eccentric training is progressed to maximum load.

• Desired functional activities are simulated—first under controlled conditions, then under progressively challenging conditions using acceleration/deceleration drills.

• The patient is involved in assessing performance in terms of safety, symptom provocation, postural control, and ease of execution and then practices adaptations to correct any problems.

Painful Shoulder Syndromes: Surgery and Postoperative Management

Surgical intervention is an option for painful shoulder syndromes when conservative management does not resolve symptoms and improve function. For an individual with primary impingement as a result of structural variations in the acromion (see descriptions and Fig. 17.16 in the previous section), subacromial decompression may be performed. An individual with a partial- or full-thickness rotator cuff tear may require surgical repair.

Subacromial Decompression and Postoperative Management

When pain and loss of functional mobility associated with primary impingement do not resolve sufficiently with nonoperative management, subacromial decompression, designed to increase the volume of the subacromial space and provide adequate gliding room for tendons, is often warranted. Subacromial decompression also is referred to as anterior acromioplasty or decompression acromioplasty. However, acromioplasty, which alters the shape of the acromion, is typically, but not always, one of the components of subacromial decompression.¹²⁸

Indications for Surgery

The following are generally accepted indications for surgical management of impingement syndromes.^*

• Pain during overhead activities and loss of functional mobility of the shoulder as the result of primary impingement that persists (typically for 3 to 6 months or longer) despite a trial of nonoperative interventions.

• Stage II (Neer classification; see Box 17.7) impingement with nonreversible fibrosis or boney alterations of the subacromial compartment, calcific deposits in the cuff tendons, and symptomatic subacromial crepitus.

• Intact or minor tear of the rotator cuff.

NOTE: Patients who present with secondary impingement (GH joint hypermobility or instability associated with a partial-or full-thickness tear of the rotator cuff) are not candidates for surgical subacromial decompression alone. For these patients, subacromial decompression is combined with concomitant repair of the cuff tear; otherwise, the procedures inherent in subacromial decompression can worsen GH instability.^79,128,215

Procedures

Surgical approach. Subacromial decompression is performed using an arthroscopic or open approach. Although an open approach has been used successfully for many years,^{84,139,142,170} the preferred procedure today in most cases is an arthroscopic approach.^59,215 Unlike a traditional open approach, in which the proximal attachment of the deltoid must be detached and then repaired prior to closure,¹⁴² with an arthroscopic approach, the deltoid remains intact, enabling the patient to regain functional use of the upper extremity more rapidly after surgery. For the most part, the traditional open approach for subacromial decompression is now reserved for some patients with a massive rotator cuff tear who also are undergoing an open repair. Another option preferred by some surgeons is a "mini-open" approach, which involves splitting the deltoid insertion vertically rather than detaching it.¹²⁸

Component procedures. There are several surgical procedures that can be performed for subacromial decompression, depending on the pathology observed during examination of the shoulder prior to or during surgery.^{1,59,75,79,128,154,176,215}

• Removal of the subacromial bursa (bursectomy), which is typically thickened (enlarged) by chronic inflammation

• Release of the coracoacromial ligament, which is usually hypertrophied and may also be frayed, followed by complete or partial resection or recession

• Resection of the anterior acromial protuberance and contouring the undersurface of the remaining portion of the acromion (acromioplasty) to enlarge the subacromial space (Fig. 17.18)

• Removal of any osteophytes at the AC joint and in some cases resection of the distal portion of the clavicle for advanced arthritis of the AC joint

Postoperative Management

The type of surgical approach used and the status of the rotator cuff significantly affect rehabilitation decisions after subacromial decompression. If the rotator cuff is intact preoperatively, rehabilitation after arthroscopic decompression progresses quite rapidly because the shoulder musculature is left intact during the procedure. In contrast, if a repair of the rotator cuff is required in addition to decompression, or a mini-open or open approach is used, rehabilitation progresses at a slower rate to allow the repaired shoulder musculature adequate time to heal.

NOTE: The guidelines outlined in this section are for postoperative rehabilitation after arthroscopic subacromial decompression for a patient with primary shoulder impingement who has an intact rotator cuff. If subacromial decompression is combined with repair of the rotator cuff, the guidelines presented in a later section of this chapter on rehabilitation after rotator cuff repair are appropriate.

Immobilization

The shoulder is immobilized and supported in a sling with the arm positioned at the patient's side or in slight abduction; the shoulder is internally rotated; and the elbow is flexed to 90°. The sling is worn for comfort for 1 to 2 weeks but is removed for exercise the day after surgery.^128,215,225

Exercise Progression

Exercise interventions after subacromial decompression targets many of the impairments noted for rotator cuff impingement discussed previously in this chapter. This information merits review to understand why specific exercises are included in the postoperative rehabilitation program.

Because arthroscopic decompression is often performed on an outpatient basis, a patient initially may need to carry out the prescribed exercises at home with little supervision and then follow up with a series of outpatient therapy visits at a later time. Therefore, patient education is of the utmost importance for each phase of rehabilitation.

Exercise: Maximum Protection Phase

The first phase of rehabilitation after arthroscopic decompression begins on the day after surgery and extends for 3 to 4 weeks. Emphasis is placed on pain control and immediate but comfortable assisted movement of the shoulder to prevent adhesions of the cuff tendons in the subacromial space. Attaining full or nearly full passive ROM of the operated shoulder (compared to the noninvolved shoulder) is a reasonable goal by 4 to 6 weeks postoperatively.⁷⁹

Patient education begins immediately and is directed toward helping the patient recognize and avoid postures that contribute to symptoms during exercise and ADL. Active (unassisted) shoulder ROM is permissible as soon as motions are pain-free and proper scapulothoracic and glenohumeral control can be maintained. This may be possible as early as 2 weeks postsurgery.

Goals and interventions. The following goals and exercises are indicated for the early stage of tissue healing.^{1,3,39,79,128,225}

• Control pain and inflammation.

  • Use of a sling when the arm is dependent.

  • Use of cryotherapy and prescribed anti-inflammatory medication.

  • Shoulder relaxation exercises.

• Prevent loss of mobility of adjacent regions.

  • Active ROM of the cervical spine, elbow, wrist, and hand.

• Develop postural awareness and control.

  • Active movement of the scapula with emphasis on retraction.

  • Posture training, emphasizing cervical retraction, thoracic extension, scapula retraction and a neutral lumbo-pelvic complex.

• Restore pain-free shoulder mobility.

  • Assisted shoulder ROM as tolerated by pain, initially guiding with the sound upper extremity and later a wand. Start in the supine position to provide additional stability to the scapula against the thorax and with the upper arm on a folded towel in slight abduction and flexion. Shoulder motions include elevating the arm in the plane of the scapula, forward flexion, abduction, rotation, and horizontal abduction and adduction. Progress to performing exercises in a semi-reclining position and then in a seated or standing position while maintaining thoracic extension.

  • Assisted shoulder extension in a standing position with a wand held behind the back.

  • Stretching the posterior shoulder structures in pain-free range using a cross-chest stretch into horizontal adduction. Postpone until next phase if painful.

  • Active ROM (unassisted) of the shoulder and scapula within pain-free ranges, maintaining proper scapulothoracic and glenohumeral control; begin supine and progress to sitting. Active shoulder motions may be possible by 2 weeks postoperatively.

• Prevent reflex inhibition and atrophy of shoulder girdle musculature.

  • Pain-free, low-intensity, multiple-angle isometrics of GH musculature with the arm supported and emphasis on the rotator cuff against minimal resistance. Begin submaximal isometrics a week or so postoperatively. Lightly resist with the uninvolved upper extremity. Focus on increasing repetitions more than resistance.^118,184

  • Submaximal alternating isometric and rhythmic stabilization exercises for scapulothoracic muscles with the involved arm supported by the therapist. Target the scapular retractors and upward rotators.

Criteria to progress. Criteria to advance to the second phase include^{39,79,102,128,225}:

• Minimal discomfort when the shoulder is unsupported; arm swing is comparable to opposite arm during ambulation.

• Almost full, pain-free, passive ROM of the shoulder (full mobility of the scapula; at least 150° of arm elevation; full internal/external rotation).

• In the supine position, pain-free active elevation of the arm well above the level of the shoulder.

• Pain-free, active external rotation of the shoulder to about 45°.

• At least fair (3/5) and preferably good (4/5) muscle testing grade of shoulder musculature.

Exercise: Moderate Protection Phase

Exercises during the second phase of rehabilitation are directed toward attaining full, pain-free shoulder ROM and improving neuromuscular control and muscle performance (strength, muscular endurance) of the rotator cuff, scapular stabilizers, and prime movers. The patient may be ready to begin this phase of rehabilitation as early as 3 to 4 weeks postoperatively but more often by 4 to 6 weeks. This phase extends over a 4- to 6-week period or until the patient meets the criteria to progress to the next phase.

Goals and interventions. The goals, exercises, and activities during the second phase of rehabilitation are^{39,79,102,225}:

• Restore and maintain full, pain-free passive mobility of the shoulder girdle and upper trunk.

  • Joint mobilization emphasizing posterior and caudal glides of the humerus and scapulothoracic mobility.

  • Low-intensity self-stretching of muscles that could restrict sufficient upward rotation of the scapula and rotation of the humerus, specifically the levator scapulae, rhomboids, middle trapezius, subscapularis, latissimus dorsi, and pectoralis major and minor. Recall that tightness of these muscles may contribute to subacromial impingement during overhead movements of the arm.

  • Self-stretching of the posterior shoulder muscles and posterior capsule of the GH joint, as these structures may be tight in the presence of shoulder impingement.

  • Self-stretch of the upper trunk by lying supine on a rolled towel placed vertically between the scapulae.

  • Performance of exercises and functional movement patterns during ADL into the increased ROM.

• Reinforce posture awareness and control.

  • Continue to emphasize cervical, thoracic, and lumbopelvic alignment during exercises and function.

• Develop dynamic stability, strength, endurance, and control of scapulothoracic and GH muscles.

  • Stabilization exercises against increasing resistance and in weight-bearing positions. Emphasize isolated strengthening of the serratus anterior and trapezius muscles.

  • Upper extremity ergometry for muscular endurance. To avoid an impingement arc, initiate in a standing position rather than while seated.

  • Dynamic strengthening exercises of isolated shoulder muscles against low-loads (1- to 5-lb weight or light-grade elastic tubing), gradually increasing repetitions. Begin resisted elevation of the arm in the supine position to stabilize the scapula against the thorax; progress to sitting or standing.

  • Use the involved arm for functional activities that involve light resistance.

PRECAUTION: Be certain the patient can perform active shoulder flexion and abduction against gravity without elevating the scapula before progressing to resisted exercises above shoulder level.

Criteria to progress. The criteria to progress to the final phase of rehabilitation are^39,102,225:

• Negative impingement tests.

• Full, pain-free, active ROM of the shoulder without evidence of substitute motions.

• At least 75% strength of the shoulder musculature compared with the sound shoulder.²²⁵

Exercise: Minimum Protection/Return to Function Phase

The final phase of rehabilitation usually begins 8 weeks postoperatively, at which time soft tissues are reasonably well healed and require little to no protection. Exercises continue until about 12 to 16 weeks postoperatively or until the patient has returned to full activity. Exercises are directed toward continuing to improve strength and endurance of the shoulder girdle muscles using isolated movements and those that simulate functional activities. Patients often see continued improvement in functional use of the operated upper extremity for 6 months postoperatively.³

The time necessary for full recovery and unrestricted activities depends largely on the level of demand of the anticipated activities. A patient wishing to return to competitive sports requires a more demanding progression of advanced exercises (e.g., plyometric training and sport-specific drills) than a sedentary individual.^39,225,228

Goals and interventions. The goals, exercises, and activities during the final phase of rehabilitation after subacromial decompression are similar to the final phase of nonoperative management of primary impingement syndrome. Refer to the information presented in the previous section of this chapter as well as other resources.^{39,49,223,225,228}

Rotator Cuff Repair and Postoperative Management

There are two broad categories of rotator cuff tears, defined by the depth of the tendon tear: partial-thickness and full-thickness tears. Either type may require surgical management. A partial-thickness tear extends inferiorly or superiorly through only a portion of the tendon from either the acromial (bursal) or humeral (articular) surface of the tendon. A full-thickness tear is a complete tear, which extends the entire depth of the tendon.^79,87,128

Indications for Surgery

The primary indications for surgical management of a rotator cuff tear confirmed by imaging are pain and impaired function as the result of the following.^*

• Partial-thickness or full-thickness tears of the rotator cuff tendons with irreversible, degenerative changes in soft tissues. Some patients with Neer stage II lesions and most with Neer stage III lesions who continue to be symptomatic and have functional limitations after a trial of nonoperative treatment are candidates for surgery.

• Acute, traumatic rupture of the rotator cuff tendons often combined with avulsion of the greater tuberosity, labral damage, or acute dislocation of the GH joint in individuals with no known history of prior cuff injury. Full-thickness, traumatic tears occur most often in young, active adults.

NOTE: Surgical repair is not indicated in patients who are asymptomatic despite the presence of a cuff tear confirmed by imaging.

Procedures

There are several operative options for repairing a torn rotator cuff, including arthroscopic, open, and mini-open repairs.^{68,79,81,128,215} The decision about which option to choose depends on the severity and location of the tear, the number of tendons involved, the extent of associated lesions, the type of onset (repetitive microtrauma or traumatic injury), the quality and mobility of the torn tissues, bone quality, patient-related considerations (age, health, activity level), and the surgeon's preference and experience.

Type of Repair

The type of cuff repair is typically classified by the surgical approach and techniques used. There are three categories of repair.^†

• Arthroscopic approach. The entire procedure is performed arthroscopically and requires only a few small incisions for port sites.

• Mini-open (arthroscopically assisted) approach. There are two variations of this type of procedure, both of which involve arthroscopic subacromial decompression and a deltoid-splitting approach. In one variation, only the subacromial decompression is performed arthroscopically, whereas in the other variation a portion of the cuff repair itself is also performed arthroscopically.²³⁶ In both cases, an anterolateral incision is made at the acromion and is extended distally (either 1.5 or 3.5 cm but no more than 4 cm to avoid the axillary nerve) along the fibers of the deltoid insertion. The deltoid is split longitudinally between its anterior and middle portions to allow visualization of the cuff tear without detaching the deltoid from its proximal insertion.^{62,68,128,160,204}

• Traditional open approach. An anterolateral incision is made that extends obliquely from the middle one-third of the inferior aspect of the clavicle, across the coracoid process, and to the anterior aspect of the proximal humerus. The proximal insertion of the deltoid must be detached and reflected for exposure of the operative field during an open subacromial decompression and cuff repair. After the cuff repair is complete, the deltoid is reattached to the acromion.^* As arthroscopic and arthroscopically assisted repairs of the rototor cuff have advanced, the use of the traditional open approach has decreased.

Components of a Rotator Cuff Repair

Regardless of the approach, subacromial decompression is performed (particularly for cuff tears associated with chronic impingement) before repair of the cuff is undertaken. After the tear is visualized, the margins of the torn tendon are débrided and released from any adherent soft tissues. Then the cuff tendon is mobilized for advancement and apposition to bone that has been prepared for sutures and is attached by tendon-to-bone fixation. Depending on whether an arthroscopic or mini-open approach is used, fixation is accomplished by sutures and suture anchors, tacks, or staples.^{62,66,79,128,203,215}

In addition to subacromial decompression, other concomitant procedures may be required. For example, capsular tightening or labral reconstruction may be performed if unidirectional or multidirectional instability of the GH joint is present. Because degenerative changes in the tendon of the long head of the biceps brachii are often associated with chronic rotator cuff disease, a repair of this tendon also may be necessary.

Selection of Surgical Procedures

The surgeon weighs many factors when determining which type of cuff repair is most appropriate for each patient. One such consideration is the severity of the tear, including thickness (partial or full), size, and number of tendons torn. Although there is some variability in the literature, there are four generally accepted categories that describe the longitudinal size of rotator cuff tears: small (1 cm or less), medium (1 to 3 cm), large (3 to 5 cm), and massive (more than 5 cm or a full-thickness tear of more than one tendon).^8,62,79,217

A small, partial-thickness cuff tear is usually managed surgically with a fully arthroscopic approach to débride the frayed margins of the torn tendon and includes a subacromial decompression. The torn portion of the tendon may or may not be repaired.^{8,79,128,195,203,215}

Two decades ago, primarily small and medium full-thickness cuff tears were managed with a fully arthroscopic approach.^67,79,128 With the evolution of arthroscopic techniques, an increasing number of large, full-thickness tears and some massive tears are managed with a fully arthroscopic approach.^215,236 However, variations of the mini-open (deltoid splitting) approach are frequently the surgeon's choice for repair of medium and large tears.^62,128,204 Even some massive tears are managed with a deltoid-splitting approach.^128,217 The traditional open approach, requiring detachment and repair of the deltoid, is now primarily reserved for repairs of multiple tendon tears associated with extensive injury to the shoulder.^62,128

The location of the cuff tear, amount of retraction and mobility of a full-thickness tear, and the quality of the remaining tendon and underlying bone also influence the surgeon's selection of the type of cuff repair expected to be most effective.^{79,128,203,215} Whereas small, medium, and large tears of the supraspinatus or infraspinatus are routinely managed with arthroscopic or mini-open approaches, tears of the subscapularis are often managed with a traditional open approach.⁶² If there is significant retraction and poor mobility of the torn tendon or poor tissue quality, many surgeons believe that a stronger repair can be achieved with an open procedure than an arthroscopic repair.⁷⁹

Postoperative Management

After surgical repair of a torn rotator cuff tendon, there are many factors that influence decisions about the position and duration of immobilization, the selection and application of exercises, and the rate of progression of each patient's postoperative rehabilitation program. These factors and their potential impact are summarized in Table 17.4. These factors also will affect postoperative prognosis and outcomes.

There is little consensus in the literature or in clinical practice as to how and to what extent each of these factors, singularly or collectively, has an impact on the decisions made by the surgeon and the therapist about a patient's postoperative rehabilitation program. Hence, predetermined guidelines and protocols for postoperative management after rotator cuff repair are diverse and sometimes contradictory.^* For example, some authors have pointed out that if deltoid detachment and repair are components of the surgery, as is necessary for a traditional open repair, deltoid strengthening exercises should be postponed for approximately 6 to 8 weeks postoperatively until the repaired deltoid has healed.^39,58,128 Yet another author suggested that rehabilitation should proceed similarly regardless of whether deltoid detachment was required so long as secure fixation of the deltoid was achieved.⁷⁷

Given the diverse characteristics of patients undergoing rotator cuff repair and the variety of surgical options available, it is not surprising that no single postoperative program can be used for all patients or has been shown to yield better outcomes than another. Therefore, to meet each patient's needs and goals, a therapist can use published protocols or those developed at individual clinical facilities as general guidelines for postoperative management. Modifications to protocols and guidelines should be made based on ongoing examination of the patient's response to interventions and through close communication with the surgeon.

Despite variations among postoperative programs, they share three common elements: (1) immediate or early postoperative motion of the GH joint; (2) control of the rotator cuff for dynamic stability; and (3) gradual restoration of strength and muscular endurance. This section will present general exercise guidelines that incorporate these elements into the phases of rehabilitation after arthroscopic or mini-open repair of a full-thickness cuff tear. Potential modifications and precautions due to a traditional open procedure or on factors such as size, location of the tear, and the quality of the repair will be noted.

NOTE: The goals, exercise interventions, and progression of rehabilitation after débridement rather than repair of a partial-thickness tear are comparable to postoperative management after subacromial decompression for cuff impingement presented in the previous section of this chapter.

Immobilization

The position and duration of immobilization of the operated shoulder after rotator cuff repair depends on many factors, including the size, severity, and location of the tear and the type and quality of the repair. The size of the cuff tear partially determines whether the patient's operated arm is supported in a sling (shoulder adducted, internally rotated, and elbow flexed to 90°) or in an abduction orthosis or pillow (shoulder elevated in the plane of the scapula approximately 45°, shoulder internally rotated, and elbow flexed). Patients supported in an abduction splint may require assistance from a family member to support the operated arm in the 45° shoulder position when the splint is removed for exercise, dressing, or bathing.

Table 17.5 summarizes the immobilization recommendations for fully arthroscopic and mini-open/deltoid-splitting approaches. Immobilization after a traditional open procedure that involves deltoid detachment and repair is not included in Table 17.5 because of the variations in guidelines reported in the literature.^{39,79,128,217}

The rationale for initially immobilizing the shoulder in abduction is based on two principles. (1) In the abducted position, the repaired shoulder is held in a more relaxed, neutral position, reducing the possibility of reflexive muscle contractions that could disrupt the repairs. (2) Supporting the arm in abduction, rather than adduction, reduces tension on the tendons and, therefore, may improve blood flow to the repaired tendon(s).

Exercise Progression

Regardless of whether a patient undergoes a rotator cuff repair on an inpatient or outpatient basis, contact with a therapist for exercise instruction after surgery is usually limited to a few visits unless the patient does not progress satisfactorily. Therefore, the emphasis of a therapist's interaction with a patient must be placed on patient education for an effective and safe home-based exercise program.

Goals and interventions for each phase of rehabilitation after arthroscopic or mini-open cuff repair follow. General guidelines for exercise and precautions after rotator cuff repair are summarized in Box 17.10. Precautions specific to a particular type of cuff tear or surgical procedure are also noted. The suggested timelines for each phase are general and must be adjusted based on factors already noted (see Table 17.4).

Exercise: Maximum Protection Phase

The priorities during the initial phase of rehabilitation are to protect the repaired tendon, which is at its weakest approximately 3 weeks after repair,²⁰³ and to prevent the potential adverse effects of immobilization. For almost all patients, the immobilization (sling or splint) is removed for brief sessions of passive or assisted ROM within limited (protected) and comfortable ranges during the first few days after surgery (see Table 17.5).

The maximum protection phase extends for as little as 3 to 4 weeks after a fully arthroscopic or mini-open repair of small or medium tears or as long as 6 to 8 weeks after repair of large or massive tears. After a fully arthroscopic repair of a small or medium cuff tear, every effort is made to attain nearly full passive shoulder ROM, particularly elevation and external rotation, by 6 to 8 weeks postoperatively.^62,128,215

Goals and interventions. The following goals and selected interventions combined with the appropriate use of pain medication are initiated during the maximum protection phase.^*

• Control pain and inflammation.

  • Periodic use of ice.

  • Arm support for comfort.

  • Shoulder relaxation exercises.

  • Grade I oscillations of the GH joint.

• Prevent loss of mobility of adjacent regions.

  • Assisted ROM of the elbow.

  • Active ROM of the cervical spine, wrist, and hand.

• Prevent shoulder stiffness/restore shoulder mobility.

  • Pendulum exercises typically the first postoperative day or when the immobilizer may be removed for exercise.

  • Passive ROM of the shoulder within safe and pain-free ranges. Initially perform exercises in the supine position; begin both arm elevation and external rotation in the plane of the scapula.

  • Self-assisted ROM using the opposite hand or a wand for control by 1 to 2 weeks for patients with repairs of small to medium tears and about 2 weeks later for patients with repairs of large tears.

  • Active control of the shoulder with assistance as needed from the therapist or family members. With the patient lying supine, place the arm in 90° of shoulder flexion if pain-free. In this position, the effect of gravity on the shoulder musculature is minimal. This position has been called the "balance point position" of the shoulder.⁵⁶ Help the patient control the shoulder while moving to and from the balance point position, making small arcs and circles with the arm.

  • Active shoulder ROM by the latter part of this phase for small tears and as symptoms permit, initially supine with the elbow flexed, progressing to a semi-reclining position with the elbow less flexed.

PRECAUTION: Use only passive, nonassisted ROM for 6 to 8 weeks for a repair of a massive cuff tear or after a traditional open repair with deltoid detachment.^39,217

• Prevent or correct postural deviations.

  • Posture training and exercises to facilitate proper spinal alignment and shoulder retraction. (See Chapters 14 and 16.)

• Develop control of scapulothoracic stabilizers.

  • Active movements of the scapula.

  • Submaximal isometrics to isolated scapular muscles.¹¹⁸ To avoid excessive tension in repaired GH musculature, see that the operated arm is supported but not bearing weight.

  • Side-lying scapular protraction/retraction to emphasize control of the serratus anterior.

• Prevent inhibition and atrophy of GH musculature.

  • Low-intensity, muscle-setting exercises (against minimal resistance). Setting exercises should not provoke pain in a healing cuff tendon. Begin as early as 1 to 3 weeks post-operatively depending on the size of the tear and quality of the repair.^39,56,58

PRECAUTION: Recommendations for the safest position of the shoulder in which to begin isometric training of the GH musculature after cuff repair are inconsistent. Perhaps the safest suggestion is to start in a position that creates minimal tension on the repaired cuff tendons (shoulder internally rotated and flexed and abducted to about 45° and elbow flexed).⁵⁸ As the strength of the cuff muscles improves during the later phases of rehabilitation, exercises and activities can be performed with the arm positioned in more challenging and functional positions.

Criteria to progress. Criteria to advance to the second phase include:

• A well healed incision.

• Minimal pain with assisted shoulder motions.

• Progressive improvement in ROM.

Exercise: Moderate Protection Phase

The focus of the second phase of rehabilitation is to begin to develop neuromuscular control, strength, and endurance of the shoulder while continuing to attain full or nearly full, pain-free shoulder motion. Emphasis is placed on developing control of the scapular stabilizers and rotator cuff muscles.

For a patient with a repair of a small or medium tear, this phase begins around 4 to 6 weeks postoperatively and extends an additional 6 weeks. For most patients, strengthening exercises typically begin around 8 weeks postoperatively. This phase may begin as late as 12 weeks for a patient with a repair of a large or massive tear.

Goals and interventions. The following goals and interventions are appropriate during this phase of rehabilitation.^{8,25,39,56,58,62,128}

• Restore nearly complete or full, pain-free, passive mobility of the shoulder.

  • Self-assisted ROM with an end-range hold by means of wand or pulley exercises, in single planes and combined (diagonal) patterns. Add shoulder internal rotation, extension beyond neutral, and horizontal adduction.

  • Mobilization of the incision site if well healed to prevent adherence of the scar.

PRECAUTION: The use of passive stretching and grade III joint mobilizations, if initiated during this phase of rehabilitation, must be done very cautiously. Vigorous stretching is not considered safe for 3 to 4 months, the time needed for the repaired tendons to have healed and become reasonably strong.¹²⁸

• Increase strength and endurance and re-establish dynamic stability of the shoulder musculature.

  • Active ROM of the shoulder through gradually increasing the pain-free ranges. Continue to have the patient perform active elevation of the arm in the supine position until the motion can be initiated without first elevating the scapula. When transitioning to upright positions (sitting or standing), reinforce the importance of maintaining an erect trunk during exercises.

  • Isometric and dynamic strengthening to scapulothoracic stabilizers. First, use alternating isometrics in nonweight-bearing positions; then progress to rhythmic stabilization during light upper extremity weight-bearing activities.

  • Submaximal multiple-angle isometrics of the rotator cuff and other GH musculature against gradually increasing resistance.

  • Dynamic strengthening and endurance training of the GH musculature within pain-free ranges against light resistance, such as light-grade elastic tubing or a 1- to 2-lb weight. Perform exercises below the level of the shoulder if pain is provoked with active movements above the shoulder.

  • Upper extremity ergometry at or just below shoulder level against light resistance to increase muscular endurance.

  • Use of the involved upper extremity for light (no-load or low-load) functional activities.

Criteria to progress. Criteria to transition to the final phase of rehabilitation and gradually return to unrestricted activities include:

• Full, pain-free passive ROM.

• Progressive improvement of shoulder strength and muscular endurance.

• A stable GH joint.

Exercise: Minimum Protection/Return to Function Phase

This final phase usually begins no earlier than 12 to 16 weeks postoperatively for patients with strong repairs or at 16 weeks or later for a tenuous repair. This phase may continue 6 months or more depending on the patient's expected functions during activities.

Goals and interventions. The goals and interventions during this final phase of rehabilitation are consistent with those previously discussed for late-stage nonoperative management of cuff disorders and for the final phase of rehabilitation after subacromial decompression. However, the progression of activities after a cuff repair is more gradual, and the time frame for adhering to precautions is more extended.

If full ROM still has not been restored by the beginning of this phase, include passive stretching of the GH musculature and joint mobilization. Incorporate activities that move the arm into the increased ranges of motion, such as gently swinging a golf club or tennis racket if the motions are pain-free. Advanced, task-specific strengthening activities dominate this phase of rehabilitation.

Patients generally are not allowed to return to high-demand activities for 6 months to 1 year postoperatively, depending on the patient's level of comfort, strength, and flexibility as well as the demands of the desired activities.

Shoulder Instabilities: Nonoperative Management

Related Pathologies and Mechanisms of Injury

Glenohumeral joint hypermobility can be atraumatic or traumatic. Atraumatic hypermobility, often referred to as instability, can be due to generalized connective tissue laxity or from microtrauma related to repetitive activities. Traumatic instability is caused by a single or sequence of high force events that compromise the integrity of the stabilizing structures, often dislocating the GH joint. With traumatic dislocation, there is complete separation of the articular surfaces of the GH joint from direct or indirect forces applied to the shoulder.¹⁵⁶ Atraumatic instability may be a predisposing factor to traumatic dislocation, especially with repetitive stressful overhead activities.⁸⁹ GH joint hypermobility, regardless of whether atraumatic or traumatic, is often categorized as unidirectional or multidirectional. A secondary effect of hypermobility is an impingement syndrome (described in an earlier section).

Atraumatic Hypermobility

Unidirectional instability. Unidirectional instability can be anterior, posterior, or inferior and is named for the direction that the joint is compromised. It may be the result of physiological laxity of the connective tissues or repetitive nonuniform loading of the joint. With the compromise of stabilizing structures, the humeral head may continue to dislocate or sublux in the direction of the instability. This can lead to progressive degeneration of tissues and eventually tears in the supporting structures.

• Anterior instability usually occurs with forces against the arm when it is in an abducted and externally rotated position, resulting in anterior humeral head translations. If these forces occur with enough frequency and force to compromise anterior GH joint structures, instability results. Often these forces are self-generated, as in throwing athletes who repetitively position the arm such that the anterior capsule is overloaded. Positive signs include apprehension, load and shift, and anterior drawer tests.^123,226

• Posterior instability is much less common but can occur from repetitive forces against a forward-flexed humerus, translating the humeral head posteriorly. There is a positive posterior drawer sign.^123,226

• Inferior instability is typically the result of rotator cuff weakness/paralysis and is frequently seen in patients with hemiplegia.⁷² It is also prevalent in patients who repetitively reach overhead (workers or swimmers, for example) and those with multidirectional instability. This is detected with a positive sulcus sign.^123,226

Multidirectional instability. The GH joint is considered to have multidirectional instability when stability is compromised in more than one direction. Some individuals have physiologically increased extensibility of connective tissue, causing excessive joint mobility. In the GH joint, this increased extensibility allows larger than normal humeral head translations in all directions.^156,181 Many individuals, particularly those involved in overhead activities, develop laxity of the capsule from continually subjecting the joint to stretch forces.^65,98 Multidirectional instability is confirmed by a combination of the positive tests noted previously for unidirectional instability.

Common Structural and Functional Impairments

With atraumatic instability, symptoms are often chronic, intermittent, and activity dependent. Acute symptoms are infrequent but may occur if there is a significantly increased demand placed on the joint. Decreased endurance of the rotator cuff muscles may be a precipitating factor of repetitive trauma of the joint.

Common Activity Limitations and Participation Restrictions (Functional Limitations/Disabilities)

• Possibility of recurrence when replicating the dislocating position or with forces applied to the arm in the dislocating position

• With anterior instability, restricted ability in sports activities, such as pitching, swimming, serving (tennis, volleyball), spiking (volleyball)

• With posterior dislocation, restricted ability in sports activities, such as follow-through in pitching and golf; restricted ability in pushing activities, such as pushing open a heavy door or pushing one's self up out of a chair or out of a swimming pool

• Discomfort or pain when sleeping on the involved side

• Inability to maintain arm positions or complete tasks requiring prolonged effort, especially overhead tasks

Traumatic Hypermobility

Traumatic anterior shoulder dislocation. Anterior dislocation most frequently occurs when there is a posteriorly directed force to the arm while the humerus is in a position of elevation, external rotation, and horizontal abduction. In that position, stability is provided by the subscapularis, GH ligaments (particularly the anterior band of the inferior ligament), and long head of the biceps.^109,172,208 A significant force to the arm may damage these structures, along with the attachment of the anterior capsule and glenoid labrum (Bankart lesion depicted in Fig. 17.19).

Traumatic anterior dislocation is usually associated with complete rupture of the rotator cuff. There may also be a compression fracture at the posterolateral margin of the humeral head (Hill-Sachs lesion also depicted in Fig. 17.19). Neurological or vascular injuries may also occur during dislocations.⁷⁶ The axillary nerve is most commonly injured, but the brachial plexus or one of the peripheral nerves could be stretched or compressed.

Traumatic posterior shoulder dislocation. Traumatic posterior shoulder dislocation is less common. The mechanism of injury is usually a force applied to the arm when the humerus is positioned in flexion, adduction, and internal rotation, such as falling on an outstretched arm.¹⁶⁴ The person complains of symptoms when doing activities such as push-ups, a bench press, or follow-through on a golf swing.⁷⁶

Recurrent Dislocations

With significant ligamentous and capsular laxity, unidirectional or multidirectional recurrent subluxations or dislocations may occur with any movement that reproduces the humerus positions and forces that caused the original instability, causing significant pain and functional limitation. Some individuals can voluntarily dislocate the shoulder anteriorly or posteriorly without apprehension and with minimal discomfort.^156,185 The rate of recurrence after the first traumatic dislocation is highest in the younger population (< 30 years). Because they are more active and place greater demands on the shoulder, longer immobilization (> 3 weeks) is advocated after dislocation than in the less than 30-year-old patient. Shorter immobilization (1 to 2 weeks) is advocated for older patients.^127,130

Common Structural and Functional Impairments

• After an acute traumatic injury, symptoms resulting from tissue damage include pain and muscle guarding due to bleeding and inflammation.

• When a dislocation is associated with a complete rotator cuff tear, there is an inability to abduct the humerus against gravity, except the range provided by the scapulothoracic muscles.

• Asymmetrical joint restriction/hypermobility. With anterior instability, the posterior capsule may become tight; with posterior instability, the anterior capsule may become tight. After healing from a traumatic event, there may be capsular adhesions.

• With recurrent dislocations, the individual can dislocate the shoulder at will, or the shoulder may dislocate during specific activities.

Common Activity Limitations and Participation Restrictions (Functional Limitations/Disabilities)

• With rotator cuff rupture, inability to reach or lift objects to the level of horizontal, thus interfering with all activities using humeral elevation

• Possibility of recurrence when replicating the dislocating position or with forces applied to the arm in the dislocating position

• With anterior dislocation, restricted ability in sports activities, such as pitching, swimming, serving (tennis, volleyball), spiking (volleyball)

• Restricted ability, particularly when overhead or horizontal abduction movements are required while dressing, such as putting on a shirt or jacket, and with self-grooming, such as combing the back of the hair

• Discomfort or pain when sleeping on the involved side in some cases

• With posterior dislocation, restricted ability in sports activities, such as follow-through in pitching and golf; restricted ability in pushing activities, such as pushing open a heavy door or pushing one's self up from a chair or out of a swimming pool

Closed Reduction of Anterior Dislocation

NOTE: Reduction manipulations should be undertaken only by someone specially trained in the maneuver because of the vulnerability of the brachial plexus and axillary blood vessels.

Management: Protection Phase

Protect the Healing Tissue

• Activity restriction is recommended for 6 to 8 weeks in a young patient. If a sling is used, the arm is removed from the sling only for controlled exercise. During the first week, the patient's arm may be continuously immobilized because of pain and muscle guarding.

• An older, less active patient (> 40 years of age) may require immobilization for only 2 weeks.

• The position of dislocation must be avoided when exercising, dressing, or doing other daily activities.

Promote Tissue Health

Protected ROM, intermittent muscle setting of the rotator cuff, deltoid, and biceps brachii muscles, and grade II joint mobilization techniques (with the humerus at the side or in the resting position) are initiated as soon as the patient tolerates them.

PRECAUTIONS: In order not to disrupt healing of the capsule and other damaged tissues after anterior dislocation, ROM into external rotation is performed with the elbow at the patient's side, with the shoulder flexed in the sagittal plane, and with the shoulder in the resting position (in the plane of the scapula, abducted 55° and 30° to 45° anterior to the frontal plane) but not in the 90° abducted position. The forearm is moved from in front of the trunk (maximal internal rotation) to 0° or possibly 10° to 15° external rotation.

CONTRAINDICATION: Extension beyond 0° is contraindicated.

Management: Controlled Motion Phase

Provide Protection

The patient continues to protect the joint and delay full return to unrestricted activity. If a sling is being used, the patient increases the time the sling is off. The sling is used when the shoulder is tired or if protection is needed.

Increase Shoulder Mobility

• Mobilization techniques are initiated using all appropriate glides except the anterior glide. The anterior glide is contraindicated even though external rotation is necessary for functional elevation of the humerus. For a safe stretch to increase external rotation, place the shoulder in the resting position (abducted 55° and horizontally adducted 30°); then externally rotate the humerus to the limit of its range, and apply a grade III distraction force perpendicular to the treatment plane in the glenoid fossa (Fig. 17.20).

• The posterior joint structures are passively stretched with horizontal adduction self-stretching techniques.

Increase Stability and Strength of Rotator Cuff and Scapular Muscles

Both the internal and external rotators need to be strengthened as healing occurs.²⁶ The internal rotators and adductors must be strong to support the anterior capsule. The external rotators must be strong to stabilize the humeral head against anterior translating forces and to participate in the deltoid-rotator cuff force couple when abducting and laterally rotating the humerus. Scapular stability is important for normal shoulder function and to maintain the scapula in normal alignment. The following exercises are initiated.

• Isometric resistance exercises with the joint positioned at the side and progressed to various pain-free positions within the available ranges.

• Partial weight-bearing and stabilization exercises.

• Dynamic resistance, limiting external rotation to 50° and avoiding the position of dislocation.

• At 3 weeks, supervised isokinetic resistance for internal rotation and adduction at speeds of 180° per second or higher may be used.⁷ Position the patient standing with the arm at the side or in slight flexion and elbow flexed 90°. The patient performs internal rotation beginning at the zero position with the hand pointing anteriorly and moving across the front of the body.

• Progress to positioning the shoulder at 90° flexion. Have the patient perform the exercise from zero to full internal rotation. Do not position in 90° abduction.

• By 5 weeks, all shoulder motions are incorporated into exercises on isokinetic or other mechanical equipment except in the position of 90° abduction with external rotation.

Management: Return to Function Phase

Restore Functional Control

The following are emphasized.

• A balance in strength of all shoulder and scapular muscles

• Coordinated scapulothoracic and arm motions

• Endurance for each previously described shoulder instability exercise

As stability improves, progress to:

• Eccentric training to maximum load.

• Increasing speed and control of combined motions.

• Simulating desired functional patterns for activity.

Return to Full Activity

• The patient can return to normal activities when there is no muscle strength imbalance, good coordination is present during skilled movements, and the apprehension test is negative. Full rehabilitation takes 2.5 to 4 months.⁷

• It is important that the patient learns to recognize signs of fatigue and impingement and is educated about how to reduce the exercise load when these signs are noticed.

Closed Reduction of Posterior Dislocation

The management approach is the same as for anterior dislocation with the exception of avoiding the position of humeral flexion with adduction and internal rotation during the acute and healing phases.

When mobilization is allowed, begin joint mobilization techniques using all appropriate glides except the posterior glide. Posterior glide is contraindicated. If adhesions develop that limit internal rotation, mobility can be regained safely by placing the shoulder in the resting position (abducted 55° and horizontally adducted 30°), internally rotating it to the limit of its range, and applying a grade III distraction force perpendicular to the treatment plane in the glenoid fossa (same as in Fig. 17.20 but with the arm internally rotated).

Shoulder Instabilities: Surgery and Postoperative Management

Surgical stabilization procedures are often necessary to repair chronic, recurrent instabilities and acute traumatic lesions in the glenohumeral, acromioclavicular, and sternoclavicular joints to restore function. Background information on GH joint instabilities and injuries that frequently occur with dislocations to this joint was described in the previous sections on nonoperative management.

Glenohumeral Joint Stabilization Procedures and Postoperative Management

If a reasonable trial of nonoperative management has not been successful in preventing recurrence of GH joint instability, surgical stabilization may be considered. Recurrent instability after a traumatic event responds more favorably to surgical management than atraumatic instabilities.^14,127 Young, active patients who have sustained an acute, traumatic, anterior dislocation for the first time may elect to undergo surgery without a prior course of rehabilitation, because there is a particularly high rate of recurrence of dislocation in this group after nonoperative management.^127,130

In another randomized study¹⁰⁷ of young patients (mean age 22 years) who sustained traumatic anterior dislocations, patients either participated in a trial of nonoperative management or underwent immediate arthroscopic stabilization. Over a 2-year period, 47% of the patients in the nonoperative group—but only 15% of the surgical group—experienced recurrence of the dislocation. The results of these studies demonstrate that in young patients, early surgical stabilization followed by postoperative rehabilitation significantly reduces the incidence of recurrent instability compared to nonoperative management.

Indications for Surgery

The following are common indications for surgical stabilization of the GH joint.^{127,130,199,215,219}

• Recurrent episodes of GH joint dislocation or subluxation that impair functional activities

• Unidirectional or multidirectional instability during active shoulder movements that causes apprehension about placing the arm in positions of potential dislocation, leading to compromised use of the arm for functional activities

• Instability-related impingement (secondary impingement syndrome) of the shoulder

• Significant inherent joint laxity resulting in recurrent involuntary dislocation

• High probability of subsequent episodes of recurrence of dislocation after an acute traumatic dislocation in young patients involved in high-risk (overhead), work-related, or sport activities

• Dislocations associated with significant cuff tears or displaced tuberosity or glenoid rim fractures

• Irreducible (chronic, fixed) dislocation

• Failure to resolve the instability and restore function with nonoperative management.

Procedures

Procedures designed to improve stability and prevent recurrent instability of the GH joint must balance stabilization of the joint with retention of near-normal, functional mobility. Stabilization procedures, which may involve the anterior, posterior, or inferior portions of the capsule, are performed today using either an arthroscopic or open approach depending on the type of lesion(s) present and type of procedure selected by the surgeon.^{127,130,164,194,215} Open stabilization procedures are highly successful (low recurrence of dislocation) and have been considered the standard for years. However, with advances in arthroscopic techniques and methods of tissue fixation, the use and success of arthroscopic stabilization procedures has steadily increased.²¹⁵

Recurrent anterior (unidirectional) dislocation is by far the most common form of GH instability managed with surgical stabilization.¹³⁰ In contrast, posterior or posteroinferior instabilities are less fequently managed with surgical stabilization.¹⁶⁴ The surgical procedures can be organized into several categories.

Bankart repair. A Bankart repair involves an open or arthroscopic repair of a Bankart lesion (detachment of the capsulolabral complex from the anterior rim of the glenoid) (see Fig. 17.19), which commonly accompanies a traumatic anterior dislocation. During the repair an anterior capsulolabral reconstruction is performed to reattach the labrum to the surface of the glenoid lip.^*

With an open repair, the humeral insertion of the subscapularis is detached (a takedown) or split longitudinally for access to the lesion and capsule.^{71,127,175,179} Occasionally, access is achieved through the rotator cuff interval, which allows the subscapularis to remain intact.¹²⁷ If the subscapularis is detached, it is repaired after the labrum has been reattached. With an arthroscopic approach, multiple portal sites are used, and the subscapularis is not disturbed.^5,215 Repair of a Bankart lesion is combined with an anterior capsular shift if capsular redundancy is present.

With an open procedure, the labrum is reattached with direct transglenoid sutures or suture anchors, whereas with an arthroscopic approach transglenoid sutures, suture anchors, or tacks are used.^89,215 Generally, more secure fixation is achieved with an open repair than with an arthroscopic repair, although in recent years advances in arthroscopic tissue fixation have improved.²¹⁵

Capsulorrhaphy (capsular shift). Capsulorrhaphy, which can be performed using either an open or arthroscopic approach, involves tightening the capsule to reduce capsular redundancy and overall capsule volume by incising, overlapping in a pants-and-vest manner (imbrication), and then securing the lax or overstretched portion of the capsule (plication) with direct sutures, suture anchors, tacks, or staples.^†

A capsular shift procedure is tailored to the direction(s) of instability: anterior, inferior, posterior, or multidirectional (anteroinferior or posteroinferior). For example, if a patient has recurrent anteroinferior (multidirectional) instability, an anterior or inferior capsular shift is performed in which the anterior or inferior portion of the capsule is incised, tightened by imbrication (plication), and resutured. Most capsular shift procedures are performed because of anterior instability.^{13,127,130,233}

Electrothermally assisted capsulorrhaphy. Electrothermally assisted capsulorrhaphy (ETAC) involves an arthroscopic approach that uses thermal energy (radiofrequency thermal delivery or nonablative laser) to shrink and tighten loose capsuloligamentous structures. The procedure—also referred to as a thermal-assisted capsular shift (TACS) or thermocapsular shrinkage—can be used alone but more often is used in conjunction with other arthroscopic procedures, such as repair of a glenoid tear, a capsular shift, débridement of a partial rotator cuff tear, or subacromial decompression.^‡

It has been shown in animal and human cadaveric studies that thermal energy initially makes collagen fibrils more extensible; but as the collagen tissue of the capsuloligamentous structures heals, it shortens or "shrinks," causing a decrease in capsular laxity.^88,186 If one or more of the glenohumeral ligaments is detached or if rotator cuff lesions that could be contributing to the instability are detected, they are repaired arthroscopically prior to ETAC.

Posterior capsulorrhaphy (posterior or posteroinferior capsular shift). Recurrent, involuntary posterior or posteroinferior instability (far less common than anterior instability), if treated surgically, can be managed with either an open or arthroscopic capsular shift to remove posterior and inferior redundancy of the capsule.^* Additional soft tissue procedures, such as repair of a posterior labral tear (reverse Bankart lesion) or in rare instances plication and advancement of the infraspinatus to reinforce the posterior capsule, may be necessary. Shoulders without an effective posterior glenoid can be surgically managed with capsulolabral augmentation²¹⁵ or occasionally with a glenoid osteotomy.^127,164

Employing arthroscopic posterior stabilization, a capsular shift and repair of the posterior labrum can be accomplished with the shoulder musculature remaining intact.¹⁶³ For an open stabilization, a posterolateral incision is made; the deltoid is split; and the infraspinatus, teres minor, and posterior capsule are incised.^164,200 In some instances of traumatic multidirectional instability, anterior capsulorrhaphy is used to tighten the posterior capsule indirectly.^127,164,215

Repair of a SLAP lesion. A tear of the superior labrum is classified as a SLAP lesion (superior labrum extending anterior to posterior).^{50,199,215,231} Some SLAP lesions are associated with a tear of the proximal attachment of the long head of the biceps tendon and recurrent anterior instability of the GH joint. An arthroscopic repair involves débridement of the torn portion of the superior labrum, abrasion of the boney surface of the superior glenoid, and reattachment of the labrum and biceps tendon with tacks or suture anchors. Concomitant anterior stabilization is also performed if instability is present.

Postoperative Management

General Considerations

As with rehabilitation after repair of rotator cuff tears, guidelines for postoperative management after surgical stabilization of the GH joint are based on many factors. These factors, all of which can influence the composition and progression of a postoperative program, are summarized in Table 17.6. Additional factors, such as the philosophy and training of the surgeon and a number of patient-related variables (general health, medications, preinjury functional status and postoperative goals, education, compliance) that affect rehabilitation after GH stabilization and rotator cuff repair already have been addressed (see Table 17.4).

The content in this section identifies general principles of management across three broad phases of postoperative rehabilitation after a variety of surgical stabilization and reconstruction procedures for recurrent unidirectional or multidirectional instabilities of the GH joint. These general guidelines cannot begin to address the many variations of rehabilitation programs recommended for specific stabilization procedures. However, many detailed protocols or case-based descriptions of rehabilitation programs for use after specific procedures and for specific types of shoulder instabilities and associated labral or rotator cuff lesions in various patient populations are available in the literature.^*

Regardless of the type of instability, associated pathology, or type of surgical stabilization procedure, a postoperative rehabilitation program must be based on the findings of a comprehensive examination and individualized to meet the unique needs of each patient. The focus of postoperative rehabilitation is to restore pain-free shoulder mobility and muscular strength and endurance, particularly the dynamic joint stabilizers, to meet the patient's functional needs while preventing recurrence of shoulder instability.

Immobilization

Position. The position in which the patient's shoulder is immobilized after surgery is determined by the direction(s) of instability prior to surgery. After surgical reconstruction for recurrent anterior or anteroinferior instability, the shoulder is immobilized in a sling or splint in adduction (arm at the side) or varying degrees of abduction and in internal rotation (forearm across the abdomen) with the arm slightly anterior to the frontal plane of the body.^96,127 After surgery for posterior or posteroinferior instability, the upper extremity is supported in an orthosis, and the shoulder is immobilized in the "handshake" position (neutral rotation to 10° to 20° of external rotation, 20° to 30° of abduction, elbow flexed, and arm at the side or sometimes with the shoulder in slight extension).^60,127,164

Duration. The duration of immobilization—that is, the period of time before use of the immobilizer is completely discontinued—is determined by many factors, including the type of instability, the procedure(s) performed, and the surgeon's intraoperative assessment. This period can range from 1 to 3 weeks to as long as 6 to 8 weeks. However, the period of continuous immobilization of the operated shoulder (before shoulder motion can be initiated) is kept as short as possible but varies with the type of procedure. For example, after an anterior stabilization procedure, the immobilizer may need to be worn continuously for only a day to a few days but in some cases up to 1 to 2 weeks.¹³⁰ In contrast, repairs of posterior or multidirectional instabilities, which are associated with a higher recurrence of dislocation, usually require a longer period of immobilization.^127,164,200 After a posterior stabilization procedure, the shoulder may be continuously immobilized and ROM delayed for up to 6 weeks postoperatively.^102,164

Time frames for immobilization also vary based on the factors that influence all aspects of postoperative rehabilitation (see Table 17.5). For example, the duration of immobilization is usually shorter for an elderly patient than for a young patient, because the elderly patient is more likely to develop postoperative shoulder stiffness than the young patient. In contrast, a patient with generalized hyperelasticity or a younger patient involved in high-demand activities, who is likely to place excessive stresses on healing tissues, requires a longer period of immobilization to reduce the risk of redislocation.¹²⁷

Exercise Progression

As with the position and duration of immobilization, the decisions of when the arm may be temporarily removed from the immobilizer to begin shoulder exercises and to what extent specific shoulder motions are either permissible or must be limited are also based on many of the factors previously summarized (see Table 17.6).

Rehabilitation after anterior stabilization (anterior capsular shift or Bankart repair) is similar after open and arthroscopic procedures. In both instances, there are precautions that must be heeded, particularly during the first 6 weeks after surgery while soft tissues are healing. During this time period after an open procedure, the anterior capsule and the detached and repaired subscapularis must be protected from excessive stresses. With an arthroscopic anterior stabilization, although the subscapularis remains intact, it is also necessary to protect the anterior capsule fixation during the initial phase of rehabilitation, because soft tissue fixation may not be as secure as the fixation used in an open procedure.

Precautions after arthroscopic or open anterior stabilization or reconstruction procedures are summarized in Box 17.11.^{39,71,89,102,127,130,151,215} Precautions for thermally assisted capsular tightening,^{57,61,167,209,230} posterior stabilization procedures,^{60,102,163,164} and repair of a SLAP lesion^39,50,231 are noted in Box 17.12.

Exercise: Maximum Protection Phase

The initial phase of rehabilitation extends for about 6 weeks after surgery during which time protection of the tightened capsule or repaired or reconstructed structures, such as the labrum or the subscapularis, is necessary while minimizing the negative consequences of immobilization. Exercises may be initiated the day after surgery for select patients who have had an anterior stabilization procedure,³⁹ but more often are begun 1 to 2 weeks postoperatively.^102,151 ROM is delayed for a longer period of time after a thermally assisted stabilization,^{57,61,167,209,230} a posterior stabilization procedure,^{60,102,163,164} or repair of a SLAP lesion and torn biceps tendon^39,50,231 (see Box 17.12).

Goals and interventions. The goals and exercises for the maximum protection phase are summarized in this section.^{39,57,60,89,151,228,237}

• Control pain and inflammation.

  • A sling for comfort when the arm is dependent or for protection when in public areas. While seated, remove the sling (if permissible) and rest the forearm on a table or wide armrest with the shoulder positioned in abduction and neutral rotation to provide support but prevent potential contracture of the subscapularis and other internal rotators of the shoulder.

  • Cryotherapy and prescribed anti-inflammatory medication

  • Shoulder relaxation exercises

• Prevent or correct posture impairments.

  • Emphasis on spinal extension and scapular retraction; avoid excessive thoracic kyphosis

• Maintain mobility and control of adjacent regions.

  • Active ROM of the cervical region, elbow, forearm, wrist, and fingers the day after surgery

  • Active scapulothoracic movements

PRECAUTION: Initially, strengthen the scapular stabilizing muscles in open-chain positions to avoid the need for weight bearing on the operated upper extremity. When weight-bearing activities are initiated, be cautious about the position of the operated shoulder to avoid undue stress to the vulnerable portion of the capsule for about 6 weeks postoperatively.

• Restore shoulder mobility while protecting tightened or repaired tissues.

  • Pendulum exercises for the first 2 weeks postoperatively.

  • Self-assisted ROM and wand exercises for the GH joint within protected ranges as early as 2 weeks or as late as 6 weeks postoperatively. Begin shoulder elevation in the supine position; begin humeral rotation with the arm supported and the shoulder in a slightly abducted and flexed position.

  • With an anterior stabilization, gradually progress to near-complete ROM by 6 to 8 weeks except for external rotation, extension, and horizontal abduction beyond neutral.

  • With a posterior stabilization, progress cautiously into flexion, horizontal adduction, and internal rotation.

  • Progress to active shoulder ROM when motion can be performed without pain, apprehension, or use of substitute motions, such as elevating the scapula to initiate arm elevation.

  • Use the operated arm for nonweight-bearing, waist-level functional activities with no external resistance by 2 to 4 weeks postoperatively.

• Prevent reflex inhibition and atrophy of GH musculature.

  • Multiple-angle, low-intensity isometric exercises of GH musculature as early as the first week or by 3 to 4 weeks postoperatively. Use caution with resisted internal rotation after subscapularis repairs.

  • Possible initiation of dynamic exercises against light resistance in protected ranges of motion at 4 to 6 weeks emphasizing the GH stabilizers.

  • Be particularly cautious when applying any type of resistance to musculature that has been torn or surgically detached, incised, or advanced and then repaired. Note that following a SLAP repair, resisted elbow flexion and resisted shoulder elevation will result in increased tensile loading of the long head of the biceps tendon.

NOTE: In some cases, dynamic exercises against light resistance are delayed until the intermediate phase of rehabilitation (about 6 to 8 weeks postoperatively), when only moderate protection is necessary.

Criteria to progress. Criteria to advance to the second phases of rehabilitation are:^39,57,89,102

• A well healed incision.

• Reasonable improvement in ROM.

• Minimal pain.

• No sense of apprehension about instability with active motions.

Exercise: Moderate Protection Phase

The moderate protection phase of rehabilitation begins around 6 weeks postoperatively and continues until approximately 12 to 16 weeks. The focus is on maintaining joint stability while achieving nearly full active (unassisted) ROM of the shoulder; developing neuromuscular control, strength, and endurance of scapulothoracic and GH musculature; and using the upper extremity through greater ranges for functional activities.

Goals and interventions. The goals and interventions for the intermediate phase of rehabilitation are as follows.^{39,57,89,102,228,237}

• Regain nearly full, pain-free, active ROM of the shoulder.

  • Continue active ROM with the goal of achieving nearly full ROM by 12 weeks.

  • Incorporate ROM gains into functional activities.

  • Stretching and grade III mobilization in positions that do not provoke instability. After an anterior stabilization procedure, pay particular attention to increasing horizontal adduction, as the posterior structures are often tight preoperatively and continue to be tight postoperatively.

• Continue to increase strength and endurance of shoulder musculature.

  • Alternating isometrics against increasing resistance with emphasis on the scapula and rotator cuff musculature.

  • Dynamic resistance exercises initiated or progressed using weights and elastic resistance with emphasis on scapulothoracic and glenohumeral stabilizers. Begin in mid-range positions, progressing to end-range positions. Emphasize both the concentric and eccentric phases of muscle activation.

  • Dynamic strengthening in diagonal and simulated functional movement patterns.

  • Upper extremity ergometry with a portable reciprocal exerciser on a table for muscular endurance. Include forward and backward motions.

  • Progressive upper extremity weight bearing during strengthening and stabilization exercises.

PRECAUTIONS: After anterior stabilization, do not initiate dynamic strengthening of the internal rotators from full external rotation, particularly in the 90° abducted position. When strengthening the shoulder extensors, do not extend posterior to the frontal plane. Similarly, when strengthening the horizontal abductors, do not horizontally abduct posterior to the coronal plane. In addition, maintain the shoulder in neutral rotation during horizontal abduction and adduction. After posterior stabilization, do not initially begin dynamic strengthening of the external rotators from a position of full internal rotation

Criteria to progress. Criteria to progress to the final phase of rehabilitation and the focus of exercises are similar to the criteria already identified for the final phase of rehabilitation after rotator cuff repair.

Exercise: Minimum Protection/Return to Function Phase

This phase usually begins around 12 weeks postoperatively or as late as 16 weeks, depending on individual characteristics of the patient and the surgical stabilization procedure. Stretching should continue until ROM consistent with functional needs has been attained. Gains in ROM are possible for up to 12 months as collagen tissue continues to remodel. Resistance exercises to improve strength and endurance are progressed to replicate movements involved in functional activities, including positions of provocation of instability. Plyometric training (discussed in Chapter 23) is introduced and gradually progressed, particularly in patients intending to return to high-demand sports or work-related activities. Participation in desired work-related and sports activities often takes up to 6 months postoperatively.

PRECAUTIONS: Some patients may have permanent restrictions placed on functional activities that involve high-risk movements and that could potentially cause recurrence of the instability. After some anterior stabilization procedures, full external rotation (ER) in 90° of abduction may not be advisable or possible.¹⁰²

Acromioclavicular and Sternoclavicular Joint Stabilization Procedures and Postoperative Management

Acromioclavicular Joint Stabilization

A grade III separation, in which the acromioclavicular (AC) and coracoclavicular ligaments are completely ruptured may be surgically reduced and stabilized with a variety of techniques.^147,169 Techniques for management of acute dislocations include primary stabilization of the AC joint with Kirschner wires, Steinman pins, screws, or most recently bioabsorbable tacks, sutures, or fiber wires. Other procedures include a muscle-tendon transfer that moves the tip of the coracoid process with the attached tendons of the coracobrachialis and short head of the biceps to the undersurface of the clavicle¹⁵⁴ or the Weaver-Dunn procedure, which resects the distal clavicle and transfers the CA ligament from the acromion to the shaft of the distal clavicle.¹⁴⁷ Based on a small body of evidence in the literature, it appears the best results are achieved with primary AC and coracoclavicular stabilization procedures. Chronic AC dislocations, which are usually associated with degenerative changes of the AC joint, are most often managed with distal clavicle resection coupled with coracoclavicular stabilization.^154,169

Sternoclavicular Joint Stabilization

Although most sternoclavicular (SC) dislocations are managed nonoperatively, an acute posterior dislocation of the SC joint that cannot be successfully reduced with a closed maneuver or an SC joint that dislocates recurrently are managed surgically. Surgical reduction of a traumatic anterior dislocation is not recommended.^168,234 Surgical options for posterior SC dislocations include open reduction with repair of the stabilizing ligaments or resection of a portion of the medial clavicle and fixation of the remaining clavicle to the first rib or sternum with a soft tissue graft.^168,234

Postoperative Management

After surgical stabilization of either the AC or SC joint, the shoulder is immobilized for up to 6 weeks.⁴⁴ Exercise interventions are directed toward functional recovery as healing allows. No muscles provide dynamic stabilization of the AC and SC joints, so scapular and glenohumeral strength must be developed to provide indirect stability.

During the first few weeks of immobilization, the patient is encouraged to perform active ROM of the wrist and hand. If the elbow is supported on a table, the patient is permitted to perform active ROM of the elbow and forearm. The operated extremity, if supported, may be used for light functional activities, such as holding a utensil or typing, but weight bearing and shoulder ROM are completely prohibited during the first 6 weeks.⁴⁴

When the immobilization can be removed, restoration of shoulder and elbow mobility and neuromuscular control of the shoulder girdle are the focus of the exercise program. Shoulder ROM (passive, progressing to assisted ROM), active scapular motions, and light isometrics of the shoulder musculature are initiated. Stabilization exercises, dynamic strengthening of the shoulder and scapula musculature, and stretching to restore full ROM are gradually introduced and progressed, as graduated functional activities are integrated into the rehabilitation program.