Shoulder Rotator Cuff Disease

Thomas F. Murray, Jr., MD

Anatomy

The term Rotator Cuff is used to describe the group of muscles and their
tendons in the shoulder that helps control shoulder joint motion. The
supraspinatus is at the top (superior) of the shoulder, the subscapularis is
anterior (front), and the infraspinatus and teres minor are posterior (behind).
These muscles insert or attach to the humeral head by way of their tendons. The
tendons fuse together giving rise to the term cuff. Although each muscle acting
alone may produce an isolated rotational movement of the shoulder, the role they
play together is to help keep the humeral head (ball) centered within the glenoid
(socket) as the powerful deltoid and other larger shoulder muscles act to lift the
arm overhead.

Above the rotator cuff is a

bony projection from the
scapula (shoulder blade)
called the acromion. The
acromion forms the
ceiling of the shoulder,
serves as the point of
origin for the deltoid
muscle, and joins the
clavicle (collarbone) to
form the acromioclavicular
(a/c) joint. Between the
rotator cuff tendons and
the acromion is a
protective fluid-filled sack
called a bursa". With
normal humeral elevation
there is some contact
between the rotator cuff,
the bursa, and the
acromion.
 A healthy and strong rotator cuff holds
the humeral head down in the socket
and minimizes the upward pressure
on the acromion.

Pathology

Rotator cuff pathology can be caused by extrinsic (outside) or intrinsic (from

within) causes. Extrinsic examples include a traumatic tear in the tendon(s) from
a fall or accident. Overuse injuries from repetitive lifting, pushing, pulling, or
throwing are also extrinsic in nature. Intrinsic factors include poor blood supply,
normal attrition or degeneration with aging, and calcific invasion of the tendon(s).

Rotator cuff tendonitis is the

term used to describe irritation of
the tendon(s) either from
excessive pressure on the
acromion or less commonly from
intrinsic tendon pathology.
Irritation of the adjacent bursa is
known as subdeltoid or
subacromial bursitis. Repetitive
overhead activities resulting in
irritation of the tendon(s) and
bursa from repeated contact with
the undersurface of the acromion
is called Impingement
Syndrome.
Rotator cuff dysfunction is typically a
continuum of pathology ranging from
tendonitis and bursitis to partial tearing, to
a complete tear in one or more of the
tendons. Although the earlier stages may
resolve with conservative care, actual
tearing of the tendon can be more
problematic. These tears most commonly
occur at the tenoperiosteal (tendon to
bone) junction. Because this area has a
relatively poor blood supply, injury to the
tendon here is very unlikely to actually
heal. Additionally, the constant resting
tension in the muscle-tendon unit, or
muscle tone, pulls any detached fibers
away from the bone, preventing their
reattachment. Finally, joint fluid from within
the shoulder may seep into the tear gap
preventing the normal healing processes
from occurring.

Diagnosis

Patients with rotator cuff pathology commonly present with an activity related dull
ache in their upper lateral (outer) arm and shoulder. Above shoulder level activity
is usually most difficult. Many people have little to no discomfort with below
shoulder level activities such as golf, bowling, gardening, writing or typing, etc.
Conversely, tennis, baseball/softball, basketball, swimming, painting, etc. will be
more problematic.

Pain in the shoulder may extend down as far as the elbow, but not usually
beyond. Neck pain on the same side may develop later as a result of using the
scapular elevators excessively to compensate for abnormal glenohumeral
motion. These scapular elevators, such as the trapezius originate from the
cervical spine and can cause pain in the posterior neck and well as occipital (low)
headaches. Patients may also experience snapping or cracking within the
shoulder, pain at night, difficulty lying on the shoulder, and difficulty getting
dressed. Late findings include weakness and loss of shoulder motion.
X-rays will not show the rotator cuff, but
they will reveal any evidence of arthritis,
spurs within the shoulder, loose bodies,
fractures from a related fall, abnormal
displacement of the humerus out of the
glenoid, and congenital (birth) related
problems. Therefore, good quality x-rays
are a must in the proper evaluation of the
shoulder.
In this patient's shoulder xray, the
humeral head no longer matches up
with the glenoid because the rotator
cuff is torn, and the strong deltoid
muscle is pulling the head superiorly
toward the acromion

Magnetic Resonance Imaging or

MRI has allowed visualization of
the soft tissues of the body,
including the rotator cuff. An MRI
can depict tendonitis, partial
tearing, and complete tears of
the rotator cuff. While an MRI is
usually not required to diagnose
a torn rotator cuff, it can be very
helpful to determine which
tendons are torn, how large the
tear is, the degree of tendon
retraction, the extent of muscle
belly atrophy (shrinkage), and
any coexisting problems.

Conservative Treatment
 Many rotator cuff tears do not require surgery.
Conservative treatment of rotator cuff disease
classically includes rest, activity modification,
nonsteroidal anti-inflammatory medications, and
physical therapy. Therapy may include heat,
cold, ultrasound, electrical stimulation, massage
and other modalities, but the hallmark of an
effective rotator cuff rehabilitation program is
therapeutic exercise. Stretching of particularly
the posterior joint capsule can help the
tendency of the humeral head to migrate
superiorly toward the acromion with forward
elevation. Strengthening of the remaining
rotator cuff through resistance exercises can
again help contain the humeral head within the
glenoid and avoid undue pressure up on the
acromion. Finally, muscle re-education to
normalize the mechanics of shoulder motion
can help return the patient to his or her full
function.

In patients who fail to improve with initial conservative therapy, there may be a
role for judicious use of corticosteroid (cortisone) injection therapy in the bursa
above the tendon. The mechanism of how this technique may be helpful is not
completely clear, but it may reduce bursal and tendon irritation and swelling. The
cortisone does not just mask the problem, but helps break the cycle of pain,
swelling, weakness, and continued impingement. Injection therapy may then
help reduce pain and impingement and allow the individual to continue to work
on rotator cuff strengthening. Current recommendations are that a maximum of 3
cortisone injections should be used per shoulder. There is some evidence in
laboratory research that more than 3 cortisone injections around an otherwise
healthy tendon may result in considerable weakening of the tendon and even
rupture.

Surgical Treatment

Patients with more advanced rotator cuff disease or a more significant injury may
fail efforts at conservative therapy. If the patient feels that his or her quality of life
is being significantly impacted by the shoulder dysfunction, then consideration of
surgical intervention is certainly reasonable. In some cases simple debridement
of a frayed or partially torn cuff tendon along with smoothing of the undersurface
of the acromion (acromioplasty) above the tendon may be all that is needed.
More significant partial tearing (more than 50% of the tendon thickness) and
complete tears require reattachment of the tendon ends back to the humeral
head.

Rotator cuff repair is most commonly done by an open surgical procedure, which
typically requires a 2 to 4 inch incision at the top of the shoulder. The deltoid
muscle is split and the undersurface of the acromion is smoothed. Strong stitches
are placed in the torn ends of the rotator cuff tendons, and they are attached
back the bone of the humerus through specially created tunnels or commercially
available suture anchors. Because the entire shoulder cannot be visualized
through the open approach, many surgeon will perform an initial diagnostic
arthroscopy of the shoulder at the time of the repair to be sure there are no other
coexisting problems within the shoulder which could be addressed at that time.
This technique may be done on an inpatient basis, or as an outpatient surgery, if
the patient is comfortable enough to go home that same day.

Arthroscopic techniques for rotator cuff repair were developed over 10 years ago
and have been continually refined. This is an extremely difficult approach for the
surgeon to initially learn, but once mastered, can be quite rewarding for both
doctor and patient. Unlike the open technique, the incisions used for an
arthroscopic repair only the size of a shirt buttonhole. There may be 3 to 4 of
these very small incisions, and early indications are, as might be expected, that
patients have much less postoperative pain and require less prescription pain
medication as a result. As a result, this is usually done as an outpatient
procedure. Several studies have shown that the long-term results are as good as
the gold standard open approach.

Post Operative Rehabilitation

Whether done open or arthroscopically, rotator cuff repair is a major operation

that requires considerable rehabilitation. Several rehabilitation protocols for
rotator cuff repair are available and are based on the size of the tear and repair.
The shoulder is typically protected in a sling for 4 weeks, although some gentle
passive motion is typically begun almost immediately.

It takes 12 weeks for the tendon to begin to heal down to the bone, and that the
attachment continues to mature and strengthen for 2 years. Despite the
prolonged healing course, patients can very often begin light computer work or
writing in 1 to 2 weeks, lift the arm overhead 2 months after surgery, participate in
golf, fishing, and other less strenuous activities at 4 months, and return to full
sports and work participation at 5 to 6 months.

Long term studies have revealed 80 to 95 percent good to excellent results for
rotator cuff repair done open or arthroscopically. Patient satisfaction rates are just
as high. In the majority of these studies, over 90% of patients agreed that in
respect they would have the surgery again if needed. Unfortunately patients with
workers compensation cases or other litigation related to the shoulder injury
have not enjoyed the same success rates. Good to excellent results in these
patients may be as low as 65 to 75 percent, yet they are just as likely to indicate
that they would have the surgery again if necessary. A well-motivated patient
combined with a well-done repair and a comprehensive rehabilitation program,
typically results in a satisfied patient who is able to return to his or her normal
activities of daily living with little to no compromise.

Shoulder Rehabilitation After

Capsular Shift with
Subscapularis Spitting Approach
INTRODUCTION:

This summary of the evaluation and rehabilitation

of a patient who is being treated with a shoulder
stabilization procedure is designed to guide the
therapist and patient. It consists of three parts:
pre-operative evaluation, post-surgical
rehabilitation, and data collection for study
purposes. All are designed to help obtain the best
possible result and provide data for the
improvement of technique.

There are basically three phases of a rehabilitation

program based upon the phases of wound healing.
Shoulder reconstructions are basically a balance
of healing of the capsule and structures of the
glenoid versus the need to obtain range of motion.
The goal is to obtain maximum obtainable range
of motion without compromise of the surgical
repair. Most individuals after this operation
should lose no more than five degrees of external
rotation after surgery. However each patient
should be individualized and there can be no
cookbook approach to these patients. Most
activities are recommended for a majority of
patients but it is not necessary that all patients do
all exercises (e.g. medicine balls). The ACUTE
PHASE (inflammatory phase) consists of POD 1-
21, the INTERMEDIATE PHASE (Reparative
Phase) consists of post - op weeks 3 - 6, and the
ADVANCED PHASE (Remodeling) consists of
weeks 13-14.

PREOPERATIVE PHYSICAL THERAPY:

The goals of the preoperative evaluation are

threefold:

1. To educate the patient about the surgery

 and rehabilitation process.
2. To instruct the patient on pre-operative
strengthening.
3. To collect data necessary to compare pre-
operative and post-operative motion and
function.
o Documentation - The Physical
Therapist records MMT, AROM,
PROM
o Education
1. Review program which is
attached
2. Review expectations for
recovery of motion and
function
3. Answer questions
o Preoperative Home Program
1. ROM
2. Strengtheningwith tubing
or weights:
a. Jobe exercises
b. Scapular stabilizers
c. Isometrics
3. Aerobic fitness

INPATIENT PHYSICAL THERAPY:

MD: MD changes bandage

P.T.:
POD #1: Begin finger, wrist and elbow
AROM
POD #2: Begin Codman's pendulum
exercises
(Note: in some revision cases these may
not be initiated right away.)
Home Program (instruct prior to
D/C)
1. AROM fingers, wrist,
elbow
2. PROM in forward shoulder
flexion to full range,
opposite arm cradle
3. Codman's
4. PROM for abduction in
scapula plan
5. PROM ER in this position
to operative limit
6. Shower POD #5
7. Arrange office visit and
P.T. visit with staff on that
 day
8. Ice therapy

OUTPATIENT THERAPY

Days 8 - 14

1. Sutures removed by MD
2. Wear immobilizer to sleep for
approximately 2 weeks (may be
exceptions)and for most of the day
3. Begin P.T.
a. 2 - 3 x per week (usually 2 x)
b. Wand extension-flexion supine
c. Prone Codman's
d. AAROM for ER in adduction to
operative limit as determined by
MD
e. PROM in abduction in scapular
plane, PROM ER in this position
to operative limit
f. Begin shoulder pinches (scapular
retraction) and depression
(discourage shrug or "wound wing
sign")
g. AROM in flexion and anterior to
plane of scapula as pains allows, to
maximum of 1500
4. Standing active forward flexion internal
and external rotation with no weights,
proper mechanics up to, but not over
shoulder height
5. Home Program
a. 3 - 5 x per day
b. Continue PROM in ER to
operative limit with arm at side
using cane or assisted by family
member

Days 15 - 21

1. Continue immobilizer to sleep (determined

by MD); Can go without the immobilizer
during the day.
2. ROM as above
3. Isometric flexion below shoulder level,
submaximal isometric external rotation
Weeks 3 - 6
Avoid tendonitis and impingement

1. Begin Jobe's program--begin with lightest

tubing, progress as tolerated (or may use
weight of arm, but then increase with
dumbbells in one pound increments)
2. Progress to light resistance (2-3 lbs.)
3. If mechanics are normal and painless, add
manual resistance to serratus anterior
(caution, see #8 below)
4. Add IR/ER week 5 - 6 (1 - 2 lbs.)
sidelying or tubing
5. Full ROM forward flexion
6. Full ROM abduction; verbal and visual
feedback to correct any scapular
compensation
7. Progress ER as tolerated (PROM): Focus
at this stage is mostly for increasing ER.
8. Avoid and aggressively treat any biceps
tendinitis

Weeks 7 - 8
Avoid tendonitis and impingement

1. Normal ER at side by week 8 (actively), at

least within 10 degrees of normal
2. Jobe's 5 lbs.
3. IR/ER 5 lbs. sidelying
4. Medicine ball chest passes (2-6 lbs.),
progress to overhead throwing then to side
passing
5. Continue above exercises, avoiding
compensatory shoulder shrugs.

Weeks 9 - 12

1. Full AROM
2. Biceps curl, light empty can (less than 60
degrees ABD in scapular plane)
3. Isokinetic IR/ER, FF, ABD test week 12 as
needed

Weeks 13 - 14
 1. Begin formal weight training except half-
bench only (No behind the frontal plane,
i.e. keep elbows in front of body for all
weight work)
2. Begin throwing program if ER within 5
degrees, all else normal

SPECIAL CONSIDERATIONS

1. Revisions cases will vary according to the

amount of scar and the perceived chance
of recurrence. Some will need to be held
back and some will need to be pushed
depending upon the findings at surgery.
2. All IR, ER, and ABD to be done in
scapular plane.
3. Avoid any impingement signs at all stages;
note all symptoms per protocol for further
study.

4. Any questions contact the surgeon.

Dislocated shoulder rehabilitation

Alternative exercises
How long will the effects of the injury last?
When can I return to my sport or activity?
Read more about dislocated shoulders

As an athlete, your number one concern is getting back to full strength as soon as possible so that you
can return to training and competition. That is why appropriate rehabilitation is extremely important.
Rehabilitation for a dislocated shoulder often includes the following:

reduce activity during the acute phase

ice injury multiple times per day
compression of the injured shoulder with a secure wrap or ACE bandage
elevation of the injured shoulder above heart level
use anti-inflammatory medications such as ibuprofen to reduce inflammation and speed up
recovery

The major objectives of rehabilitation from a dislocated shoulder are to increase flexibility, establish
pain-free range of motion, and strengthen the muscles of the upper back, front chest, and upper arm.
In severe cases, you should avoid activity that causes shoulder pain altogether. In these cases, you
can still maintain cardiovascular fitness by cycling, unless otherwise prescribed by your doctor.

Rehabilitative exercises should be performed on both sides of the body to maintain symmetry in the
strength and range of motion of the back, chest, and upper arms. In many individuals, the tendency to
experience shoulder dislocation is present on both sides, so doing these exercises to increase the
pain-free range of motion and improve strength of both shoulders may help preventive injury to either
shoulder.

Rehabilitation exercises often prescribed by your doctor may include:

 Shrugs
Stand with hands at sides with no weight in either hand. Raise shoulders to the point of pain
and hold for five seconds. Relax for five seconds. Perform this sequence 10 times, 3 times
daily. As pain permits, hold dumbbells of equal weight in each hand while performing this
exercise. Add weight by using hand-held dumbbells as pain permits.

Bicep curls
Stand with arms fully extended at sides while grasping 2- to 5-pound weights in each hand,
held palm forward. Flex the arms at the elbow to approximately 100 degrees, or to the point of
pain, whichever comes first. Hold this position for 5 to 10 seconds. Return to the start position.
Rest for 5 seconds. Repeat this exercise 10 times. You can increase the weight as pain allows
and strength develops.
Triceps curls
Stand with elbows directed upward over the shoulders and with arms relaxed. Extend arms at
the elbow so that the hands proceed upward to the point of pain. Hold this position for five
seconds. Return to the starting position and relax for five seconds. Perform this sequence 10
times, 3 times daily. As pain permits, add weight by using hand-held dumbbells.
Chest raises
Lie on belly with hands extended along sides of the body. Raise the upper chest from the floor
to the point of pain and hold this position for 5 seconds. Return to the start position and relax
for 10 seconds. Repeat this sequence 10 times, 3 times daily.
Saws
Reach out and place the unaffected side hand on a corner of a table. Bend at the waist. Flex
the injured side arm at the elbow and pull the injured side arm backward and upward as if
sawing wood. Slowly bring the shoulder blades as close together as pain will permit. Slowly
bring the injured side arm down to its beginning position. Repeat this sequence 10 times, at
least three times daily.
Pendulum swings
Stand with the hand of the unaffected arm resting on the corner of a table and supporting
some of the body weight. Slightly bend the knee on the unaffected side and extend the other
leg sideways. Allow the injured arm to hang loosely over the unaffected side foot. By shifting
the body weight, cause the relaxed injured arm to swing in circles to the fullest extent possible
as limited by pain. Perform 25 swings in a clockwise direction. Pause. Perform 25 swings of
the injured arm in a counterclockwise direction. Repeat this sequence at least three times
daily.
Shoulder rotation
Stand in a doorway with affected side arm bent at the elbow and the palm of the hand against
the doorframe. Turn the body away from the injured side hand until a stretching sensation is
experience in the injured shoulder. Hold this position for 10 seconds. Return to the starting
position. Relax for 10 seconds. Repeat this sequence 10 times at least three times a day.
Shoulder Flexion
Stand erect close to a wall. With the palm of the injured side arm turned so as to face you,
slowly slide the forearm and then the upper arm up the wall by moving closer to the wall. Slide
the arm upward to the point of initial significant pain. Hold this position for 10 seconds. Return
to the starting position and relax for 10 seconds. Repeat this sequence 10 times, at least three
times daily.
Towel stretch
Roll a towel lengthwise. While standing erect, dangle the rolled towel down the back, holding it
with the unaffected side hand. Reach behind the back with the hand of the injured side and
grasp the rolled towel. Gently pull upward on the towel, raising the injured side arm until first
significant pain in the injured shoulder appears. Hold this position for 10 seconds. Relax the
arms while maintaining the grasp on the rolled towel for ten seconds. Repeat this sequence 10
times at least three times daily.
Flexed elbow pull
Bend and raise the injured side elbow to shoulder height. Grasp the injured side elbow with
the uninjured side hand. Gently pull the injured side elbow toward the opposite shoulder until
limited by first significant pain. Hold this position for 10 seconds. Relax for 10 seconds. Repeat
this sequence 10 times at least three times daily.
Several other exercises might aid in rehabilitation of shoulder dislocation, and your doctor may
prescribe them in addition to or instead of those above. Substitution or replacement of the above
exercises are dictated by the exact nature of the shoulder dislocation, whether it is a forward (anterior),
rearward (posterior) dislocation, or a downward (inferior) dislocation whether it is a first time incident,
and upon how the injury is responding to treatment.

Depending on the severity of the injury, some of the above exercises, and perhaps others of similar
nature intended to increase the range of motion of the injured shoulder, may be prescribed to be done
in water or a warm whirlpool apparatus. Water relieves the arm of some of its weight, thus allowing a
greater pain-free range of motion, while warm water and a water massaging effect may also be
effective.

Alternative exercises
During the period when normal training should be avoided, alternative exercises may be used. These
activities should not require any actions that create or intensify pain at the site of injury. They include:

stationary bicycle (add resistance gradually from one session to the next, as pain allows)
walking
jogging/running
swimming (if pain permits)

How long will the effects of the injury last?

Ligaments and tendons are the structures likely to be injured in most shoulder dislocations, and often
these tissues may take longer to completely heal.

You can probably expect to experience pain upon certain movements of the arm, swelling, and
discoloration for six weeks. But, it's not unusual for symptoms of the dislocation, particularly pain upon
forceful movements of the arm, to last as long as 12 weeks. To some extent, the time to fully recover is
influenced by your dedication to your rehabilitation program.

When can I return to my sport or activity?

Return to full participation should be avoided until you are symptom free and can perform all skills and
other requirements of your sport without pain. To return earlier is to invite further injury to the shoulder,
making subsequent dislocations more likely. This is especially true when the sport involves heavy
contact, such as in football or rugby.

Generally, the athlete who wishes to return to a contact sport should expect to be out of action for 6 to
12 weeks. Again, the time to return to full activity depends on the dedication toward your rehabilitation
program.

Remember: the goal of rehabilitation is to return you to your sport or activity as soon as is safely
possible. If you return too soon you may worsen your injury, which could lead to permanent damage.
Everyone recovers from injury at a different rate. Return to your activity is determined by how soon
your dislocated shoulder recovers, not by how many days or weeks it has been since your injury
occurred.
Frozen Shoulder Rehabilitation

Frozen shoulder rehabilitation

Rehabilitation exercises
Alternative exercises
Rehabilitation after surgery
When can I return to my sport or activity?
Read more about frozen shoulder

Rehabilitation
As an athlete, your number one concern is getting back to full strength as soon as possible so that you can re
to training and competition. That is why appropriate rehabilitation is extremely important. Rehabilitation for fro
shoulder focuses on relieving pain and restoring function and range of motion to the shoulder.

Non-surgical rehabilitation includes:

Pain relievers - ibuprofen and aspirin, to help reduce inflammation and relieve pain
Muscle relaxants - to help relax arm and shoulder muscles
Physical therapy - working with a physical therapist to stretch muscles and restore motion and functio
the shoulder
Heat and ice therapies - to help relieve pain and reduce swelling
Corticosteroid injections - as prescribed and given by your doctor

The major objectives of rehabilitation from frozen shoulder are to increase flexibility, obtain pain-free range of
motion, and strengthen the muscles of the shoulders, upper back, front chest, and upper arms. In severe case
you should avoid activity that causes shoulder pain altogether. In these cases, you can still maintain
cardiovascular fitness by cycling, unless otherwise prescribed by your doctor.

Surgery may be needed if there is no improvement after several months. These procedures can successfully
release and repair the shoulder, but it must be followed by an exercise program to maintain motion and restor
function.

Surgeries include:

Closed manipulation
Forceful movement of the arm at the shoulder joint to loosen the stiffness

Arthroscopic surgery
Surgery to improve movement at the shoulder joint

In these cases, your doctor may prescribe special physical therapy and recovery time will vary.

Rehabilitation exercises
If you have a stiff shoulder, see your physician to make sure you do not have any internal injury before startin
any exercise program. It is important that you follow your physician's instructions carefully, especially regardin
an exercise program. With your doctor's approval, you can do these simple exercises to help stretch and keep
your shoulder mobile:

Overhead stretch
Lie on your back with your arms at your sides. Lift one arm straight up and over your head. Grab your
elbow with your other arm and exert gentle pressure to stretch the arm as far as you can.

Cross-body reach
Stand and lift one arm straight out to the side. Keeping the arm at the same height, bring it to the fron
and across your body. As it passes the front of your body, grab the elbow with your other arm and exe
gentle pressure to stretch the shoulder.
Towel stretch
Drape a towel over the opposite shoulder, and grab it with your hand behind your back. Gently pull th
towel upward with your other hand. You should feel the stretch in your shoulder and upper arm.

Alternative exercises
During the period when normal training should be avoided, alternative exercises may be used. These activitie
should not require any actions that create or intensify pain at the site of injury. They include:

water running
stationary bicycle (add resistance gradually from one session to the next, as pain allows)

Rehabilitation after surgery

Surgery may be needed if there is no improvement after several months. These procedures can successfully
release and repair the shoulder, but it must be followed by an exercise program to maintain motion and restor
function. Surgeries include:

Closed manipulation
Forceful movement of the arm at the shoulder joint to loosen the stiffness

Arthroscopic surgery
Surgery to improve movement at the shoulder joint

When your doctor decides you are ready, you may start range-of-motion and strengthening exercises. You ma
be referred to a physical therapist to assist you with these exercises, and under no circumstance should you
return to sports activity until your shoulder is fully healed.

A physical therapy program usually begins with range-of-motion and resistive exercises, then incorporates po
aerobic and muscular endurance, flexibility, and coordination drills.

When can I return to my sport or activity?

Return to full participation should be avoided until your frozen shoulder has healed, full range of motion has
returned, and you can perform all skills and other requirements of your sport without pain.

Remember: the goal of rehabilitation is to return you to your sport or activity as soon as is safely possible. If y
return too soon you may worsen your injury, which could lead to permanent damage. Everyone recovers from
 injury at a different rate. Return to your activity is determined by how soon your frozen shoulder recovers, not
how many days or weeks it has been since your injury occurred.

Shoulder Rehabilitation -- Part I

Rehabilitation according to Dorland's Medical Dictionary is defined as the restoration of

normal form and function after injury or illness.1 This succinct definition leaves much to be
desired. Rehabilitation really begins from the initial contact of the practitioner with the patient
to the day of dismissal. A case history and functional examination leading to a specific
anatomic diagnosis is necessary to determine what has to be rehabilitated. In many practices a
sheet of exercises given to the patient at the end of treatment constitutes the "rehabilitation
phase."

The end-result of shoulder rehabilitation should be the establishment of

normal joint mobility and normal balance between the force couples of the
shoulder. A force couple represents two equal but oppositely directed
forces not acting along the same line. Arm elevation requires a balance
between the scapulothoracic force couples (upper trapezius, lower
trapezius, levator scapulae, and serratus anterior) which rotates and
elevates the scapula upward and the force couple between the deltoid and
rotator cuff muscles. Weakness or contracture of any of the above upsets
the normal balance of arm function and leaves the door open for
microstress and inflammation. Balance is also important between the
shoulder flexors and extensors, and especially the internal and external
rotators. "Swimmers often overdevelop their pectoral and anterior cervical
muscles, resulting in slumping posture and weak scapular retractors and
adductors (rhomboids, middle trapezius, and upper fibers of latissimus
dorsi) and lateral rotators."2 Weak scapular muscles may prevent the
humeral head from clearing the acromion completely, resulting in
subacromial impingement. Especially in the swimmer, the
overdevelopment of internal shoulder rotators compared to external
rotators is a possible cause of tendinitis (swimmer's shoulder).2
The strategy of rehabilitation depends upon the diagnosis. Adhesive
capsulitis (hypomobility), instability (hypermobility), torn tendons and
tendinitis all require a separate approach.

Some pertinent generalities regarding shoulder rehabilitation are:

1. In the early stages of injury or inflammation, in order to allow scar formation to occur
in the normal lines of stress, only painless active and passive ranges of motion should
be allowed.
2. In the early stages only pendulum, painless isometric and active assisted exercises are
recommended.
3. Advanced strengthening exercises should not be used until a full painless range of
motion and accessory joint play motion is attained.
4. Eccentric muscular contraction provides more force than concentric muscular
contraction within an equal amount of resistance, and more problems of the shoulder
occur with eccentric activities. Therefore early stretching, especially if painful, may
aggravate the problem since stretching involves eccentric muscle activity.
5. After passive treatment involving friction massage, stretching or contract/relax
procedures, the patient should attempt as much painless active motion in all directions
as possible.
6. Athletes who participate in sports that require flexibility should do stress-endurance
types of exercises such as low load and high repetitions, rather than weight lifting
which emphasizes bulk. Loss of flexibility predisposes an athlete to microtearing and
inflammation.
7. In rebuilding the cuff muscles, since the cuff is considered an endurance muscle, if
weights over five pounds are used, larger muscle groups will substitute for the rotator
cuff muscles which will interfere with cuff strengthening.3 Begin cuff exercises with
one pound and painlessly progress to five pounds.
8. The speed of exercise may be more important than the amount of work. Low speed,
high load exercise produces greater increases in muscular force only at slow speeds,
while high speed, low load exercise produces increases in muscular force at all speeds
of contraction, at and below the training speed.4

Shoulder Rehabilitation Part II will appear next month and emphasize rehabilitation of
specific conditions.

References
1. Friel, J.P. Dorland's Medical Dictionary, 26th ed., Philadelphia 1981; W.B. Saunders
Co.
2. Hammer, W.I. Functional Soft Tissue Examination and Treatment By Manual
Methods: The Extremities. Gaithersburg, Maryland 1990; Aspen publishers, p 29.
3. Carson, W.G. "Rehabilitation of the Throwing Shoulder." Clin in Sports Med. 1989;
8:657-689.
4. Moffroid, M.T.; Whipple, R.H. Specificity of Speed of Exercise. J. of Orth and Sports
Phys Ther. 1990; 12: pp72-078.

Warren I. Hammer, M.S., D.C., D.A.B.C.O.

Norwalk, Connecticut
Editor's Note:

Dr. Hammer will conduct his next soft tissue seminar on November 10-11,
1990 in San Francisco, California. You may call 1-800-327-2289 to register.

Dr. Hammer's new book, Functional Soft Tissue Examination and Treatment
by Manual Methods: The Extremities, will soon be available. Please see the
Preferred Reading and Viewing list on page xx to order your copy in
advance.

Shoulder Injuries
Shoulder injuries often occur when you have fallen directly on the shoulder, an outstretched arm or just
from overuse. Sprains of ligaments that hold the bones together or strains of muscles are the most
common of shoulder injuries. A good stretching and strengthening program often reduces the chances
of acquiring a shoulder injury.

SYMPTOMS
Symptoms may include pain, swelling, loss of normal shoulder movement, deformity, or
burning/numbness down the arm and hand. If you have burning, numbness or deformity for any
reason, seek medical assistance immediately.

TREATMENT
The treatment for shoulder injuries varies from injury to injury and patient to patient. With all injuries,
place an ice bag on the affected part and remain in a comfortable position for 20 minutes between 4 to
6 times a day. Give yourself about 2 hours between treatments. Take acetominophen (Tylenol, Datril,
Panadol) as prescribed on product label for the first 48 hours or when necessary for pain afterward.
Avoid taking aspirin for the first 48 hours. Aspirin can increase swelling in the area of the injury.

Consult a physician for rehabilitative exercises specific to your injury. Do not attempt any activity or
exercise which is painful. If there are specific exercises on this handout your provider wants you to
perform, note check marks in the boxes [ ] next to each exercise.

SHOULDER REHABILITATION

CODMAN SERIES OF EXERCISE

These exercises are to be painfree. They should be done with fluid movement without jerking. Each
exercise is done 50 times three times a day. A 1-2 minute break is allowed between exercises.

Exercises 1-4 done in same position (Fig. 1).

[ ] 1. Clockwise Pendulum Swings
Hang arm perpendicular to floor. Form slow
deliberate circles with arm swinging
clockwise. Start small and move into 2-3
foot diameter.

[ ] 2. Counter-Clockwise Pendulum Swings

Same as #1 but done counter-clockwise.

[ ] 3. Sawing Motion
Bend elbow slightly and swing back and
forth as if sawing. Start slow and progress
to full swing.

[ ] 4. Cross-Body
Arm is held straight and swings across side to side. Start
slow and progress until arm is nearly parallel to floor.

[ ] 5. Shoulder Shrugs
Shoulders are raised upward.
Complete slowly with arms at side.
(Fig 2.)

Once this can be done three times a day with

50 repititions you may use 1-3 lbs. of weight
in hand. Remember that no pain or soreness
should be present with these exercises.
ISOMETRIC EXERCISES
Hold each exercise for 5 seconds and slowly relax. Each is to be done ten times three times a day. No
pain should be present. Remember the goal is no shoulder or arm movement.

For these exercises, Press into wall hand and keep upper body still. (Fig.3)

[ ] 1. Shoulder abduction [ ] 2. Shoulder flexion [ ] 3. External rotation

For these exercises, resistance of well arm meets resistance of affected arm. (Fig. 4)

[ ] 4. Shoulder flexion [ ] 5. External rotation [ ] 6. Shoulder abduction

 SHOULDER STRETCHING
Try to perform stretches before and after exercise. Hold for ten to fifteen seconds each for two to three
sets. The stretches should not cause pain or discomfort. A gentle stretch should be felt. Complete
exercises on both arms.

[ ] 1. Tricep Stretch
With arm in front of chest,
pull arm across with opposite
hand at elbow. (Fig. 5)

[ ] 2. Overhead Tricep Stretch

Same as cross-chest stretch except
pressure is to the rear. (Fig. 6)

[ ] 3. Over and Under Stretch

Drop a towel behind your head.
With your upper arm bent, reach
up with your arm to hold on to
the end of the towel. Gradually
move your hand up on the towel,
pulling your upper arm down, until
your hands are touching. (Fig. 7)
 [ ] 4. Pectoral/Deltoid Stretch
Lift your arms up behind you until
you feel a stretch in the arms,
shoulders or chest. Hold an easy
stretch for 5-15 seconds. Keep
chest out and chin in. (Fig. 8)

REFERENCES
Anderson, Bob, Stretching, Shelter Publications, Bolinas, California, 1980.
Arnheim, Daniel D., Modern Priciples in Athletic Training, Times Mirror/Mosby College Publishing, St. Louis, 1989.
Kistner, Carolyn and Cosby, Lynn Allen, Therapeutic Exercise Foundations and Techniques, F. A. Davis Company, Philadelphia, 1985.
Roy, Steven and Irvin, Richard, Sports Medicine Prevention, Evaluation, Management, and Rehabilitation, Prentice-Hall, Inc., Englewood
Cliffs, NJ, 1983.