Rehabilitation Principles for Shoulder Dysfunction

Rehabilitation protocols and progressions can vary from patient to patient and from surgeon to surgeon. In your text, you will find some guidelines for PT interventions based on the tissue healing phase. Note: most of the progressions are based on patient pain response, quality of shoulder motions (degree or absence of compensation), and surgical approach. All interventions consider pain levels and interventions to decrease pain and inflammation associated with exercises and functional use. Techniques to mobilize soft tissue (cross friction massage, joint mobilization) are introduced incrementally and respect pain limits and capsular barriers. Active exercises are generally progressed when there is no pain; resistive exercises are progressed (weights/bands) later in the rehabilitation stage when normal shoulder mechanics are restored. Proprioceptive activities in closed chain are only initiated when there is evidence of both increased strength and endurance in the rotator cuff (RTC) muscles without pain. Posture is ALWAYS included to prevent or minimize recurrence.

When referencing your text, formulate patterns for intervention based on the protection phase of the condition. For example, how does ROM exercise classification change as you progress the patient from maximal to moderate to minimal protection phases?

Posture

• Forward head, kyphotic posture markedly increases risk of shoulder dysfunction due to altered mechanics and static compressive stresses
• Faulty posture decreases the subacromial space, which can lead to impingement syndromes and progressive tearing of the RTC
• External rotation motion is insufficient to allow adequate clearing of greater tubercle around the coracoacromial arch
• performing AROM in scaption (scapular plane) does not require internal or external rotation motion to clear the greater tubercle
• Postural re-education for correction of faulty mechanics can inhibit protective muscle spasm, increase circulation to subacromial space and increase length in scapular muscles
• Specific components of kyphotic posture and postural muscle contributors include:

 Manual stretches for increasing flexibility are illustrated on pages 504-505 in your course text.

Joint Protection

• Slings post-operatively to prevent active use and force of gravity on repaired or injured structures
• Slings with neuromuscular conditions resulting in RTC insufficiency
• Taping
• PROM in allowable range for joint rehydration
• Activity modification
• Interventions are ALWAYS selected based on joint protection principles for the condition (maximum, moderate, minimal/return to function)
• Adequate warm up; reinforcement of short, but frequent bouts of exercise in allowable range for progressive increased endurance without joint overuse

Early on in RTC repair rehabilitation, care must be taken to minimize anterior translation of the humeral head to avoid compression forces to the repaired structures. Techniques during PT include:

• support the humerus on a folded towel when supine
• for assisted shoulder extension rotation ROM, position the patient prone with arm hanging over bed/mat and work from 90 to 0 extension
• for passive external rotation ROM, position the humerus in slight flexion and 45 degrees abduction

Scaption

Exercises in the scapular plane are preferred for rehabilitation and home exercise programs for rotator cuff dysfunction. In addition to greater tubercle clearance, scaption allows muscles to strengthen in the most functional position and produces less tension on the joint capsule compared to straight plane motions (e.g., flexion and abduction

Pain management

• ice
• rest (immobilization with progressive increased activity and regular rest intervals)
• modalities (iontophoresis, ultrasound, TENS)
• clinical tip: to maximize access to the supraspinatus tendon, position the patient with their arm behind their back. This will move the supraspinatus tendon anterior to the acromion
• decompression (Pendulum exercises)
• activity modification
• patient instruction in self-massage
• joint mobilization (primarily Grades I-II)

Restoring Combined Motion - Scapular Control

When progressing PROM to AAROM, continuously monitor for normal scapulohumeral rhythm; compensatory motions are an indicator of RTC insufficiency and care should be taken to instruct the patient in risks for reinjury/recurrence associated with abnormal mechanics

Scapular "setting" exercises are essential to restoring shoulder function. Consider these the "core strengthening" of the shoulder complex. Supine positioning can be used to assist with scapular setting during early ROM activities

During closed chain activities, monitor your patient for signs and symptoms of scapular muscle insufficiency. Scapular winging during wall push-ups or quadruped activities indicate poor stability of the scapula

Consider Entire Extremity

During the acute healing phase, ROM exercise for the forearm, wrist and hand can maintain mobility, provide pain relief and indirectly and gently mobilize recently injured and repaired structures.