Physical Therapy

Protocols

Pathology and Treatment:  Operative intervention is typically indicated in acute tears especially in younger and more active patients and in chronic tears that have failed nonoperative treatment. There are several repair techniques, but we usually repair these tears arthroscopically with a two row technique which has been shown to have improved biomechanical strength and surface area for healing.  It is cliché to say that every tear is a little different, but in many respects this is true.  The tendons can be torn from the bone (most common) and within its substance.  The tears can also have different shapes and tissue quality.

The rotator cuff tendons are repaired to the bone and to themselves.  The quality of the repair is determined by the quality of the bone and tendon tissue and dictates how and when therapy is performed.  Most of the time the patient will have a video of their own surgery which can be reviewed with them if desired.  

At the time of the rotator cuff repair other procedures might need to be performed.  These can include a subacromial decompression which typically involves removing any bone spurring and making ample space for the rotator cuff.  It can also include repairing the biceps tendon and cleaning up any other damaged tissue.

Goals & Guidelines: Obtain range of motion (ROM) first then proceed to strengthening. In general it takes about 6-8 weeks for the tendon tissue to heal enough to begin strengthening.  Therefore we have to be careful with the range of motion exercises in that first phase of therapy which is 6-8 weeks.  Remember that the goal of the first 6-8 weeks is to not re-tear the rotator cuff and get some ROM (a shoulder with an intact rotator cuff with some stiffness is easier to manage than a shoulder with re-torn rotator cuff with dysfunction). The patient is allowed to use the operative arm for waist level activities such as using a computer, countertop level activities, and personal hygiene care but is to do no lifting, pushing or pulling with the arm nor reaching behind one’s back.  Shoulder immobilizer/sling needs to be worn when sleeping or when outside the home for the first 6-8 weeks.  When the patient is at home, the sling should be worn when they are up and walking around but may be removed when they are seated.  Most patients are more comfortable sleeping in a recliner for the first few weeks, but may sleep in a bed when comfortable. While sleeping the patient is to place a pillow or a stack of blankets under the elbow and arm of the operative extremity in order to have the arm/shoulder in the plane of the body (extension of the shoulder is both painful and stresses the repair). 

A multimodal approach is used to manage the discomfort which typically includes NSAID’s like ibuprofen, ice or cryotherapy, and narcotics.  It is preferable to discontinue the use of narcotics as soon as possible and switch to Tylenol or other less addictive medications.

The second phase of therapy focuses on regaining the remaining range of motion deficits, including internal rotation, and the initiation of strengthening. At no point should the patient be asked to use a UBE machine or cycling with the arms because this is a repetitive activity that stresses the repair. Pain medication of some sort can be taken prior to therapy.  The patient should perform their stretching program 1 time per day for the first 6 weeks and then 2 times per day after the 6 week point until FROM is obtained. Their strengthening program should be performed every other day once it is started. Expect maximum medical improvement 5-6 months after surgery.  It is important to note that everyone is not the same, nor are all rotator cuff tears the same or repaired the same fashion. Everyone progresses at different rates depending on age, past medical history, current health status, smoking, etc…These are only guidelines and not set in stone. If the patient is not progressing as he/she should, please contact us.

The patient with concomitant frozen shoulder can be a very difficult situation. This is more common in diabetics and middle aged females but can occur in males as well.  Sometimes we have to treat these shoulders in a staged fashion by performing extensive releases first and obtaining FROM and then coming back at a later date and performing the repair. If the ROM loss is severe this is probably the best option but if the ROM loss is mild, we may elect to do the releases and the repair at the same time to try to save the patient from a second operation. The only caveat is that the therapy afterward might be difficult as the patient is more prone to getting stiff again secondary to the pre-existing frozen shoulder. If this is the case, we may ask that the passive ROM be near full immediately postop but this will be relayed to you.

0 – 2 Weeks

-Pendulum exercises only

2 -4 Weeks

Passive Supine Forward Elevation and Passive External Rotation exercises may be performed by a therapist or family member or using the opposite arm to raise the operative arm. It is imperative that the patient and family member understands the therapy protocol and is able to demonstrate that he/she can perform the exercises, as they are responsible for performing these at home. Ten reps of each exercise is done one time per day. Stress to the patient that there should be no active use of the operative shoulder with these exercises…it is being passively stretched only.

-Start working on scapular stabilization for protraction, retraction, elevation and

depression.

4-6 Weeks

-Start Supine Active Assisted Forward Elevation (SAAFE)

-Start table slides

6 – 8 Weeks

Start internal rotation stretching behind the back.  It is easy to teach the patient how to use a belt or towel in the nonoperative arm to pull the operative arm up their back.  Pulleys can also be used for this.

-Supine Active Forward Elevation (SAFE).

-Start using pulleys for forward elevation.

8 – 12 Weeks

-Start Active forward elevation using good mechanics.  Set the shoulder blades by retracting them first.  Make sure the patient is not using any trapezial substitution. These should be performed with the thumb up.

-Progress to Wall Slide into Scaption (using the wall as a support). 

-Progress to Active Range of Motion in abduction, and scaption with the elbow flexed to decrease the moment arm for the deltoid and RC. If minimal to no soreness and no substitution patterns are seen you may begin strengthening with theraband.

-If good form and mechanics are observed you may begin Standing Overhead Reach.

-Progress to light dumbbell strengthening

12 – 16 Weeks

-Continue more strengthening focusing on deltoid and RC and periscapular strengthening, resisted abduction in scapular plane, and neuromuscular control.

-Continue stretching which can be more aggressive at this point.

16-20 Weeks

-Strengthening can include light bench press (being careful not to extend the shoulder).  Dumbbell bench on the floor can minimize this extension.  Can start lat pulls and seated rows.

-Once good strength is obtained, sport specific exercise such as concentric and eccentric resisted throwing, rebounder throwing, swimming and ground strokes can be started.

-Golfers can start swinging a golf club and work on swing mechanics

-Emphasize proper mechanics for the patient’s desired activities (golf, overhead throwing, etc.)

20 Weeks

May return to sport and other activities.

Pathology and Treatment:  Massive tears are defined by the amount of tissue that is torn.  There are 4 rotator cuff tendons and massive tears involve at least 2 of the 4.  The repairs take more time to repair and heal.  Operative intervention is typically indicated in acute tears especially in younger and more active patients and in chronic tears that have failed nonoperative treatment. There are several repair techniques, but even in massive tears, we usually repair these tears arthroscopically with a two row technique which has been shown to have improved biomechanical strength and surface area for healing.  It is cliché to say that every tear is a little different, but it many respects this is true.  The tendons can be torn from the bone (most common) and within its substance.  The tears can also have different shapes and tissue quality.  Some patients are placed on the large/massive protocol not because of tear size but because of tissue quality.

The rotator cuff tendons are repaired to the bone and to themselves.  The quality of the repair is determined quality of the bone and tendon tissue and dictates how and when therapy is performed.  Most of the time the patient will have a video of their own surgery which can be reviewed with them if desired. 

At the time of the rotator cuff repair other procedures might need to be performed.  These can include a subacromial decompression which typically involves removing any bone spurring and making ample space for the rotator cuff.  It can also include repairing the biceps tendon and cleaning up any other damaged tissue.

Goals & Guidelines: Obtain range of motion (ROM) first then proceed to strengthening. In general it takes about 8-10 weeks for the tendon tissue to heal enough to begin strengthening.  Therefore we have to be careful with the range of motion exercises in that first phase of therapy which is 8-10 weeks.  Remember that the goal of the first 8-10 weeks is to not re-tear the rotator cuff and get some ROM (a shoulder with an intact rotator cuff with some stiffness is easier to manage than a shoulder with re-torn rotator cuff with dysfunction). The patient is allowed to use the operative arm for waist level activities such as using a computer, countertop level activities, and personal hygiene care but is to do no lifting, pushing or pulling with the arm nor reaching behind one’s back.  Shoulder immobilizer/sling needs to be worn when sleeping or when outside the home for the first 8-10 weeks.  When the patient is at home, the sling should be worn when they are up and walking around but may be removed when they are seated.  Most patients are more comfortable sleeping in a recliner for the first few weeks, but may sleep in a bed when comfortable. While sleeping the patient is to place a pillow or a stack of blankets under the elbow and arm of the operative extremity in order to have the arm/shoulder in the plane of the body (extension of the shoulder is both painful and stresses the repair). 

A multimodal approach is used to manage the discomfort which typically includes NSAID’s like ibuprofen, ice or cryotherapy, and narcotics.  It is preferable to discontinue the use of narcotics as soon as possible and switch to Tylenol or other less addictive medications.

The second phase of therapy focuses on regaining the remaining range of motion deficits, including internal rotation, and the initiation of strengthening. At no point should the patient be asked to use a UBE machine or cycling with the arms because this is a repetitive activity that stresses the repair. Pain medication of some sort can be taken prior to therapy.  The patient should perform their stretching program 1 time per day for the first 8 weeks and then 2 times per day after the 8 week point until FROM is obtained. Their strengthening program should be performed every other day once it is started. Expect maximum medical improvement 6-8 months after surgery.  It is important to note that everyone is not the same, nor are all rotator cuff tears the same or repaired the same fashion. Everyone progresses at different rates depending on age, past medical history, current health status, smoking, etc…These are only guidelines and not set in stone. If the patient is not progressing as he/she should, please contact us.

0-2 Weeks

-No formal therapy

2-4 Weeks

-Pendulum exercises

4-6 Weeks

– Passive Supine Forward Elevation and Passive External Rotation exercises may be performed by a therapist or family member or using the opposite arm to raise the operative arm. It is imperative that the patient and family member understands the therapy protocol and is able to demonstrate that he/she can perform the exercises, as they are responsible for performing these at home. Ten reps of each exercise is done one time per day. Stress to the patient that there should be no active use of the operative shoulder with these exercises…it is being passively stretched only.

-Start working on scapular stabilization for protraction, retraction, elevation and

depression.

6-8 Weeks

-Start Supine Active Assisted Forward Elevation (SAAFE)

-Start table slides

8-10 Weeks

Start internal rotation stretching behind the back.  It is easy to teach the patient how to use a belt or towel in the nonoperative arm to pull the operative arm up their back.  Pulleys can also be used for this.

-Supine Active Forward Elevation (SAFE).

-Start using pulleys for forward elevation.

10-14 Weeks

-Start Active forward elevation using good mechanics.  Set the shoulder blades by retracting them first.  Make sure the patient is not using any trapezial substitution. These should be performed with the thumb up.

-Progress to Wall Slide into Scaption (using the wall as a support). 

-Progress to Active Range of Motion in abduction, and scaption with the elbow flexed to decrease the moment arm for the deltoid and RC. If minimal to no soreness and no substitution patterns are seen you may begin strengthening with theraband.

-If good form and mechanics are observed you may begin Standing Overhead Reach.

-Progress to light dumbbell strengthening

14-18 Weeks

-Continue more strengthening focusing on deltoid and RC and periscapular strengthening, resisted abduction in scapular plane, and neuromuscular control.

-Continue stretching which can be more aggressive at this point.

18-22 Weeks

-Strengthening can include light bench press (being careful not to extend the shoulder).  Dumbbell bench on the floor can minimize this extension.  Can start lat pulls and seated rows.

-Once good strength is obtained, sport specific exercise such as concentric and eccentric resisted throwing, rebounder throwing, swimming and ground strokes can be started.

-Golfers can start swinging a golf club and work on swing mechanics

-Emphasize proper mechanics for the patient’s desired activities (golf, overhead throwing, etc.)

24 Weeks

May return to sport and other activities.

Pathology and Treatment: Arthritis of the shoulder is defined by the loss of cartilage on the humeral head (ball) and the glenoid (cup). It is also associated with stiffness with a capsular contracture. In a total shoulder arthroplasty (TSA) the humeral head and glenoid are resurfaced and the capsule is completely released. This allows full or nearly full range of motion (FROM) to be obtained on the operating table. A TSA requires a subscapularis tenotomy or a lesser tuberosity osteotomy and the respective repair needs to be protected post-operatively (no resisted IR for 6 weeks). The goal of this procedure is to reduce or eliminate pain by resurfacing the joint and to restore FROM (as much as possible) by completely releasing the capsule. Even though FROM is usually obtained on the operating room table, most patients are unable to maintain this ROM as most patients have had longstanding contractures of the shoulder. These contractures not only involve the capsule (which is released at the time of surgery) but also the muscle-tendon units that cross the shoulder. These muscle-tendon units have not seen FROM for years and thus it is uncomfortable to stretch them. However, it is necessary to work on nice long slow stretches to maintain the ROM obtained in the OR.

Goals Guidelines: Maximize ROM while protecting subscapularis repair. Once ROM is lost, it is very hard to get it back while strengthening can be done at any point. The first phase of therapy is 6 weeks and is focused on active assisted ROM exercises only. During this time the patient may work on scapular protraction and retraction for strengthening but no strengthening exercises for deltoid or rotator cuff (RC). The patient is allowed to use the operative arm for waist level and midline activities such as personal hygiene care but is to do no lifting, pushing or pulling with the arm. Shoulder immobilizer only needs to be worn when outside the home for the first six weeks. If the patient feels more comfortable with the sling, then he/she may wear it at home as well but it is not necessary. For the first couple weeks, most patients are more comfortable sleeping in their sling and a recliner but they may move to a bed when comfortable.   While sleeping in bed the patient is to place a pillow or a stack of blankets under the elbow and arm of the operative extremity in order to have the arm/shoulder in the plane of the body (extension of the shoulder is both painful and stresses the repair). Therapists should teach patient how to perform proper axillary hygiene by bending over at the waist (like doing pendulum exercises).  The second phase of therapy is about 2 months and focuses on continued stretching (which can be more aggressive) and strengthening.  The strengthening starts slowly and progresses to functional exercises.  Whether using bands or weights, the strengthening should not be painful and focus on a resistance with which the patient can perform 10-15 reps comfortably. Most patients are able to play a round of golf at 4 months postop and are released to more aggressive activities at that point but improvements in strength and function continue for up to 2 years.

0 – 6 Weeks

-Immediately start Pendulums, Supine Active Assisted Forward Elevation (SAAFE), and External Rotation With Stick. It is imperative that the patient understands the exercises and are able to demonstrate that they can perform the exercises, as they are responsible for performing these at home. Stretching exercises should be performed 2 times per day.

-Also start internal rotation in the supine position.  In the supine position, position the arm in about 300 of abduction.  External and internal rotation can be performed in this position.

-All ranges of motion should be taken to tolerance and focus on long slow stretches with appreciable gains being realized each week.

6 – 8 Weeks

Continue stretching but can be more aggressive.  Start External Rotation Stretching in Doorway, Pulley assisted ROM,

-Start IR, ER and abduction isometric strengthening exercises. Start very slowly on the IR isometrics.

-Start Supine Active Forward Elevation (SAFE) exercises.

-Start Functional Internal Rotation using a towel or belt to pull the operative arm up behind the back.

-DC sling at 6 weeks

8 – 12 Weeks

-Should strive for FROM at this point. If not continue more aggressive stretching, including Wall Slide into Scaption,

-Start Standing Overhead Reach and 4 Way Shoulder Rubber-Band strengthening and Active Range of Motion in upright position.  Make sure that the patient is not developing substitution patterns with active ROM. If the patient is developing these patterns then try Wedge Assisted Active Forward Elevation (WAFE). WAFE and stretching exercises should be performed on a daily basis and strengthening only every other day at most.

12 – 16 Weeks

-Teach continued home program for deltoid Active Range of Motion and RC strength maintenance

-Other strengthening exercises can be started such as bench press and lat pulls and military press with dumbbells or with machines as long as form is good.  There should be no pain with strengthening. When bench pressing do not let the elbows extend below the plain of the body.

-Work on neuromuscular control

-Teach specific exercises and proper mechanics for specific sport such as golf, racket sports, fishing or a vocation.  Throwing exercises such as concentric and eccentric resisted throwing with bands and throwers ten exercises can be started now.

16 Weeks

-Return to unrestricted activity. Impress upon the patient that heavy lifting and other weight bearing activities can lead to loosening and accelerated polyethylene/

glenoid wear and thus should be avoided. 

Pathology and Treatment: The reverse TSA is a relatively new prosthesis which is used in cases of rotator cuff tear arthropathy or in revision cases where the RC is deficient or non-functional. The use of this prosthesis in the USA started in 2004 and has dramatically expanded in its indication and scope.  Rotator cuff tear arthropathy is defined as an irreparable RCT associated with arthrosis of the glenohumeral joint. These patients will often present with a painful pseudoparalytic shoulder secondary to static or dynamic superior instability. The reverse TSA is also used in revision situations, when there are bone loss issues, and in some fractures.

It is called a reverse TSA because the “ball” is secured to the glenoid and the “cup” is on the stem. The biomechanics are completely different from an anatomic TSA. In an anatomic TSA the rotator cuff is intact and the mechanics/kinematics of the joint remain unchanged. The goal in an anatomic TSA is recreate the normal anatomy. However in a reverse TSA (a non-anatomic prosthesis), the loss of rotator cuff function is compensated for by the biomechanics of the prosthesis. The reverse TSA provides a stable center of rotation about the glenosphere and an increased ability of the deltoid to function.

Goals and Guidelines: Therapy for a reverse TSA is very similar to an anatomic TSA. The first phase of therapy is 6 weeks and is focused on active assisted ROM exercises only. During this time, the patient may work on scapular protraction and retraction for strengthening but no strengthening exercises for deltoid or remaining rotator cuff (RC).  The patient is allowed to use the operative arm for waist level and midline activities such as personal hygiene care but is to do no lifting, pushing or pulling with the arm. Shoulder immobilizer only needs to be worn when outside the home for the first six weeks. If the patient feels more comfortable with the sling, then he/she may wear it at home as well but it is not necessary. For the first couple weeks, most patients are more comfortable sleeping in their sling and a recliner but they may move to a bed when comfortable.   While sleeping in bed the patient is to place a pillow or a stack of blankets under the elbow and arm of the operative extremity in order to have the arm/shoulder in the plane of the body (extension of the shoulder is both painful and stresses the repair). Therapists should teach patient how to perform proper axillary hygiene by bending over at the waist (like doing pendulum exercises).  The second phase of therapy is about 2 months and focuses on continued stretching (unlike anatomic TSA’s, stretching should not be aggressive with a reverse TSA as the procedure is non-anatomic and reverse TSA patients tend to be more osteoporotic) and strengthening.  The strengthening starts slowly and progresses to functional exercises.  In many cases, the anterior cuff (subscapularis) and posterior cuff (teres minor) remain intact and can be strengthened to improve internal and external rotation function.  Whether using bands or weights, the strengthening should not be painful and focus on a resistance with which the patient can perform 10-15 reps comfortably. Most patients are able to play a round of golf at 4 months postop and are released to more aggressive activities at that point but improvements in strength and function continue for up to 2 years.

0-6 weeks

-Immediately start Pendulums, Supine Active Assisted Forward Elevation (SAAFE), and External Rotation With Stick. It is imperative that the patient understands the exercises and are able to demonstrate that they can perform the exercises, as they are responsible for performing these at home. Stretching exercises should be performed 2 times per day.

-Also start internal rotation in the supine position.  In the supine position, position the arm in about 30° of abduction.  External and internal rotation can be performed in this position.

-All ranges of motion should be taken to tolerance and focus on long slow stretches with appreciable gains being realized each week.

6-8 weeks

Continue stretching but can be more aggressive.  Start External Rotation Stretching in Doorway, Pulley assisted ROM,

-Start IR, ER and abduction isometric strengthening exercises. Start very slowly on the IR isometrics.

-Start Supine Active Forward Elevation (SAFE) exercises.

-Start Functional Internal Rotation using a towel or belt to pull the operative arm up behind the back.

-DC sling at 6 weeks

8-12 weeks

-Should strive to optimize the ROM.  Both the therapist and patient should understand that the reverse TSA is non-anatomic procedure and as such, the ROM can be more limited.  It is important to work on scapular motion so that the acromion can be moved out of the way to achieve greater degrees of ROM.

-Start Wall Slide into Scaption, Start Standing Overhead Reach and 4 Way Shoulder Rubber-Band strengthening and Active Range of Motion in upright position.  Make sure that the patient is not developing substitution patterns with active ROM. If the patient is developing these patterns then try Wedge Assisted Active Forward Elevation (WAFE). WAFE and stretching exercises should be performed on a daily basis and strengthening only every other day at most.

12-16 weeks

-Teach continued home program for deltoid Active Range of Motion and RC strength maintenance

-Other strengthening exercises can be started such as bench press and lat pulls and military press with dumbbells or with machines as long as form is good.  There should be no pain with strengthening. When bench pressing do not let the elbows extend below the plain of the body.

-Work on neuromuscular control

-Teach specific exercises and proper mechanics for specific sport such as golf, racket sports, fishing or a vocation.  Throwing exercises such as concentric and eccentric resisted throwing with bands and throwers ten exercises can be started now.

16 Weeks

-Return to unrestricted activity. Impress upon the patient that heavy lifting and

other weight bearing activities can lead to loosening and accelerated polyethylene/ glenoid wear and thus should be avoided. 

Pathology & Treatment: The shoulder consists of three gross anatomic structures that create stability within the joint: the rotator cuff muscles, ligaments and the cartilaginous labrum. The labrum is a rubbery cartilaginous ring that surrounds the shoulder socket (glenoid). It creates a greater surface area on the glenoid for the head of the humerus to sit comfortably. It is a very important stabilizing structure secondary to its ligamentous attachments and a superior attachment of the long head of the biceps. If there is a lesion of the labrum, the shoulder may become unstable and/or painful with chest level, rotational, or overhead activities such as throwing. If the tear occurs in the superior portion of the labrum it is deemed a SLAP (Superior Labral Anterior Posterior) tear. SLAP tears are further classified into types I-IV and surgical repair is usually performed for type II tears that destabilize the long head of the biceps anchor.

Goals and Guidelines: The goals of the labral repair are to regain full range of motion of the operative shoulder while emphasizing both static (ligamentous) and dynamic (muscular) stability for a pain-free return to activity or sport. If the patient is an overhead athlete, then focusing on lower extremity strength, flexibility, and core stabilization are vital components in ability to return to sport. Overhead activities such as the serve in tennis, throwing a baseball or football, or swinging a golf club involves the funneling of energy from the feet, through the legs, pelvis, trunk, into the shoulder, through the elbow out of the hand. The patient will usually begin therapy within 3-5 days after surgery.  Phase I is obtaining ROM and is about 6 weeks and the second phase is strengthening and transitioning to function training for sport.  The patient is allowed to use the operative arm for waist level and midline activities such as personal hygiene care but is to do no lifting, pushing or pulling with the arm. Shoulder immobilizer only needs to be worn when outside the home for the first six weeks. If the patient feels more comfortable with the sling, then he/she may wear it at home as well but it is not necessary. For the first couple weeks, most patients are more comfortable sleeping in their sling and a recliner but they may move to a bed when comfortable.   While sleeping in bed, the patient is to place a pillow or a stack of blankets under the elbow and arm of the operative extremity in order to have the arm/shoulder in the plane of the body (extension of the shoulder is both painful and stresses the repair). Therapists should teach patient how to perform proper axillary hygiene by bending over at the waist (like doing pendulum exercises).  

0-2 weeks

-Immediately start Pendulums when comfortable, start Supine Active Assisted Forward Elevation (SAAFE), and External Rotation With Stick. It is imperative that the patient understands the exercises and are able to demonstrate that they can perform the exercises properly, as they are responsible for performing these at home. Stretching exercises should be performed once a day.

-Also start internal rotation in the supine position.  In the supine position, position the arm in about 30° of abduction.  External and internal rotation can be performed in this position.

-All ranges of motion should be taken to tolerance and focus on long slow stretches with appreciable gains being realized each week.

2-4 weeks

Begin scapular depression, retraction, protraction and elevation.

-Start IR, ER and abduction isometrics

-Start Functional Internal Rotation using a towel or belt to pull the operative arm up behind the back.

4-6 weeks

Patient may begin sub-max 4 Way TheraBand Strengthening

6-8 week

May begin posterior capsule stretching at this point. Joint Mobilizations to stretch the posterior capsule may be appropriate to prevent or address glenohumeral Internal Rotation Deficit (GIRD) leading to SLAP tears.

Start Active Range of Motion in all planes (flexion, scaption, abduction) for deltoid strengthening.

May increase tension for 4 Way Shoulder Rubber-Band Strengthening (punches, extension, internal and external rotation).

8-12 weeks

Begin more aggressive peri-scapular strengthening exercises that focus on the inferior trap and serratus anterior strengthening. TVA’s exercises– named because of the position the arms are in when performing the exercises (T=prone horizontal Abduction, V=MMT position for inferior trap—focus on scapular depression and retraction during the movement, A= the patient is prone with arms straight and in 30º-45º of abduction, focus on scapular retraction and depression.

Standing Horizontal Abduction with TheraBand

Rhythmic Stabilization beginning with patient’s arm in 90° of flexion and manual resistance given by the therapist in different planes and with different resistances. The patient’s goal is to try and prevent the therapist from moving his/her arm. Progressions can include increase in tempo and resistance. Further progression would be into a PNF pattern. Progress to standing and move into flexion, scaption, abduction and PNF patterns.

Start more aggressive strengthening @ 10 wks. May begin lat. pulldowns, seated rows and pull throughs or lower rows. AVOID behind the neck lat pulldowns, military pressing, and bench pressing.

Push-up into wall with ball under uni-lateral hand focusing on scapular retraction. Progress to stability ball on a table while performing a push-up. Progress to stability ball on the floor. Do not forget to set shoulder blades into the correct position.

12-16 weeks

Start more sport specific or work hardening rehab

May begin light bench pressing but do not let bar down to chest to avoid elbows passing the plane of the body. Place a phonebook or block on chest to avoid contact of bar to the chest.

Work on neuromuscular control with body blade (sagittal plane, scapular plane, frontal plane, internal rotation, external rotation at waist level progressing to 90° of abduction, then to a PNF pattern)

Internal and external rotation plyometrics with trampoline/rebounder

May begin light interval throwing program outlined by therapist or athletic trainer if internal rotators and external rotators have an equal strength ratio. A normal ratio is when the external rotators are at 2/3 ratio of the internal rotators.

16-20 weeks

Gradual return to sport. If the sport requires overhead throwing then the patient should follow the throwing program.

Pathology and Treatment: There are three main stabilization mechanisms to be considered with rehabilitation of the unstable shoulder.

  1. Static stability- which is stability provided by the capsule, labrum and ligaments of the shoulder.
  2. Dynamic stability- which is provided by relationship between the rotator cuff and scapular positioning.
  3. Neurologic- which is provided by proprioceptive awareness and proper mechanics with movements.

The shoulder consists of three gross anatomic structures that create static stability within the joint: the cartilaginous labrum, ligaments and capsule. The labrum is a rubbery cartilaginous ring that surrounds the shoulder socket (glenoid). It creates a greater surface area on the glenoid for the head of the humerus to sit comfortably. It is a very important stabilizing structure secondary to its ligamentous attachments.

 

Anterior instability is the most common form of instability and is usually secondary to a tear in the anterior and inferior labrum called a Bankart lesion. This can be associated with a bony depression in the posterior aspect of the head called a Hill Sachs lesion. It is also usually associated with stretching of the anterior band of the inferior glenohumeral ligament and the axillary pouch. Surgical reconstruction is usually via repair of the Bankart lesion (either arthroscopic or open) with tightening of the ligaments. Sometimes the Hill Sachs lesion is so large that it has to be addressed as well, but this is less common. Also, the Bankart lesion can include some bone of the glenoid which might require screw fixation.  Instability can be complex as defects can occur in either the soft tissue or bone and can occur on either the glenoid (cup) side or humeral (ball) side or a combination of both.  Determining the most appropriate and predictable surgery requires assimilating of all the data including age of the patient, activity level, and structural defects. Surgeries can include everything from arthroscopic labral repairs and tendon transfers to open stabilization with bone grafts (like the Latarjet) to partial replacements.

 

Goals & Guidelines: With stabilization surgeries, we focus on isometric strengthening and progress to isokinetic and then functional strengthening.  The emphasis is not initially on ROM as much as it is with other surgeries given that the goal is to tighten up the shoulder.   Shoot for about 75% of normal ROM by about 3-4 months.  The protocol focuses on the operative arm but please also work on core strength and conditioning for total rehabilitation of the athlete.  Patients are in an immobilizer/sling for 6 weeks. While sleeping, the arm should be kept in the plane of the body with pillows or blankets under the operative elbow. The patient is allowed to use the operative arm for waist level and midline activities such as personal hygiene care but is to do no lifting, pushing or pulling with the arm. The degree of allowed ER for these waist level activities is dictated by postoperative time and is delineated below. No combined ER and abduction until 6 weeks. Teach patient how to perform proper axillary hygiene by bending over at the waist (like doing pendulum exercises).

 

 

 

0 – 2 Weeks

Start scapular depression, retraction, protraction and elevation.

-Start IR, ER and abduction isometrics

-ER limited to neutral

 

2 – 4 Weeks

Supine Active Assisted Forward Elevation (SAAFE) to 120° and External Rotation with stick limited to 30°.

 

4 – 6 Weeks

-Start sub-maximal 4 Way Theraband Strengthening exercises.

-Increase ER to 45°.

-Increase FE to 140°.

 

6 – 8 Weeks

-Start Active Range of Motion in all planes except for combined abduction and ER

Increase 4 Way Shoulder Theraband Strengthening

 

8 – 12 Weeks

-Patient may perform combined ER and abduction actively. Increase ER stretches of the abducted arm as tolerated.

-Begin more aggressive periscapular strengthening exercises that focus on the inferior trap and rhomboids by performing lower rows and seated rows

– Rhythmic Stabilization with Bodyblade beginning with patient’s arm at 90°.  Progressions can include increase in tempo and position. Further progression would be into a PNF pattern avoiding abduction and ER. Progress to standing and move into flexion, scaption, abduction and PNF patterns.

-At 10 weeks, full active motion is encouraged again not pushing the abduction ER

-Start more aggressive strengthening exercises at 10 weeks for deltoid and rotator cuff. Avoid behind the neck lat pull downs and military presses. No heavy lifting. Do not strengthen to the point of fatigue.  Once the muscles are fatigued, they can no longer provide dynamic stability and the patient thus relies more on the static restraints that were just repaired.

 

12 –16 Weeks

– Push-up into wall with ball under uni-lateral hand focusing on scapular retraction. Progress to stability ball on a table while performing a push-up then. Progress to stability ball on the floor. Do not forget to set shoulder blades into the correct position.

-May start light bench press, more aggressive deltoid strengthening and lat pulls in front of body

-Continue Bodyblade endurance and proprioceptive exercises

 

16 – 20 Weeks

-Continue to increase the intensity of the strengthening exercises

-May start throwing program for overhead athletes.

 

24 Weeks

-Return to unrestricted activity

Pathology and Treatment: There are three main stabilization mechanisms to be considered with rehabilitation of the unstable shoulder.

  1. Static stability- which is stability provided by the capsule, labrum and ligaments of the shoulder.
  2. Dynamic stability- which is provided by the relationship between both the rotator cuff and scapular positioning.
  3. Neurologic- which is provided by proprioceptive awareness and proper mechanics with movements.

The shoulder consists of three gross anatomic structures that create static stability within the joint: the cartilaginous labrum, ligaments and capsule. The labrum is a rubbery cartilaginous ring that surrounds the shoulder socket (glenoid). It creates a greater surface area on the glenoid for the head of the humerus to sit comfortably. It is a very important stabilizing structure secondary to its ligamentous attachments.

 

Traumatic posterior instability is usually associated with a posterior labral tear or posterior Bankart lesion. A posterior Bankart lesion is defined as a tear of the posterior or posterior/inferior labrum. It is analogous to an anterior Bankart lesion. Surgical reconstruction includes repair of the posterior labrum and tightening of the loose posterior capsule and posterior band of the inferior glenohumeral ligament.

 

Goals and Guidelines: With stabilization surgeries, we focus and isometric strengthening and progress to isokinetic and then functional strengthening.  The emphasis is not initially on ROM as much as it is with other surgeries as the goal is to tighten up the shoulder. Shoot for about 75% of normal ROM by about 3-4 months.  The protocol focuses on the operative arm but please also work on core strength and conditioning for total rehabilitation of the athlete.  Patients are in an immobilizer/sling for 6 weeks. While sleeping, the arm should be kept in the plane of the body with pillows or blankets under the operative elbow. The patient is allowed to use the operative arm for waist level and midline activities such as personal hygiene care but is to do no lifting, pushing or pulling with the arm. No active internal rotation behind the back for 6 weeks to avoid stretching the posterior capsule. Teach patient how to perform proper axillary hygiene by bending over at the waist (like doing pendulum exercises).

 

 

0-2 weeks

-No specific therapy

 

2-6 weeks

-Start scapular depression, retraction, protraction and elevation.

-Start IR, ER and abduction isometrics

-Start Supine Active Assisted Forward Elevation (SAAFE) with FE no greater than 140°.

-Start External Rotation with stick to 40°.

 

6-12 weeks

-Transition from SAAFE to SAFE during the first 2 weeks and then progress to active ROM in all planes. No specific posterior capsular stretching until 8 weeks post op.

-Start 4 Way Theraband Strengthening

-At 8 weeks, start deltoid strengthening performing lateral and front raises and Rhythmic Stabilization with Bodyblade beginning with patient’s arm at 90°.  Progressions can include increase in tempo and position. Further progression would be into a PNF pattern. Progress to standing and move into flexion, scaption, abduction and PNF patterns.

-At 10 weeks, start more aggressive strengthening exercises. Avoid behind the neck lat pull downs and military presses.  Start TVA’s and 6 Pack Back periscapular strengthening exercises. Do not strengthen to the point of fatigue.  Once the muscles are fatigued, they can no longer provide dynamic stability and the patient thus relies more on the static restraints that were just repaired.

 

12-16 weeks

– Push-up into wall with ball under uni-lateral hand focusing on scapular retraction. Progress to stability ball on a table while performing a push-up then. Progress to stability ball on the floor. Do not forget to set your shoulder blades into the correct position.

-May start light bench press, more aggressive deltoid strengthening and lat pulls in front of body

-Continue Bodyblade endurance and proprioceptive exercises

 

16-20 weeks

-Continue to increase the intensity of the strengthening exercises

-May start throwing program for overhead athletes.

 

24 weeks

-Return to sport

Pathology and Treatment:  The ulnar collateral ligament connects the inside of the humerus to the ulna.  It maintains the stability of the elbow when throwing.  It can be injured by repetitive throwing or at times from a single hard throw.  Partial injuries can be rehabilitated but complete tears usually require reconstruction if the player is to continue throwing at a competitive level.  The decision to perform a reconstruction should not be taken lightly as the rehabilitation to return to throwing takes an extended period of time and dedication on the part of the athlete.

 

When the decision is made to perform a reconstruction, a tendon graft is used to reconnect the medial aspect of the humerus to the ulna.  We currently use a docking technique utilizing either the palmaris longus tendon from the forearm or if absent a split flexor tendon (FCR).

 

Goals and Guidelines:  The goal is to allow the ligament to heal with subsequent mobilization and strengthening.  While the protocol focuses on the operative arm, the athlete and therapist should concomitantly work on lower extremity and core strengthening as well as conditioning. For the first 2 weeks, the arm is in a posterior splint.  Once the splint is removed, the patient will go into a hinged brace and work on regaining range of motion.  While in the brace, the patient is allowed to use the arm for activities of daily living.  At 6 weeks, strengthening is initiated and a throwing program is started at 4 months.

 

0-2 Weeks

-Remain in posterior splint

 

2-6 Weeks

-Hinged elbow brace is placed and the patient works on slowly improving flexion, extension, pronation and supination

 

6-8 Weeks

-Start elbow flexion/extension and pronation/supination strengthening

-Start wrist strengthening

 

8-10 Weeks (Alternate the muscle groups that are being strengthened)

-Start periscapular strengthening with seated rows and lower rows working on rhomboid and lower trapezius strengthening to position the shoulder blade

-Start 4 Way Theraband Strengthening for the rotator cuff

-Start deltoid strengthening with forward and lateral raises

 

10-12 Weeks

-Start light bench-press and lat pulls

-Start TVA’s and Six Pack Back

-Start Thrower’s 10 exercises

 

12-16 Weeks

-Continue to work on strengthening

-Start Concentric and Eccentric Resisted Throwing

-Start Rebounder Throwing

-Push-up into wall with ball under unilateral hand focusing on scapular retraction. Progress to stability ball on a table while performing a push-up, then progress to stability ball on the floor. Do not forget to set shoulder blades into the correct position.

 

16 Weeks

-Start Phase I Interval Throwing Program

Interval Throwing Program for Baseball Players

 

Phase I 

The Interval Throwing Program (ITP) is designed to gradually return motion, strength and confidence in the throwing arm after injury or surgery by slowly progressing through graduated throwing distances. The ITP is initiated upon clearance by the athlete’s physician to resume throwing, and performed under the supervision of the rehabilitation team, (physician, physical therapist and athletic trainer).

 

The program is set up to minimize the chance of re-injury and emphasize pre-throwing warm-up and stretching. In development of the interval throwing program, the following factors are considered most important.

 

  1. The act of throwing the baseball involves the transfer or energy from the feet through the legs, pelvis, trunk, and out the shoulder through the elbow and hand. Therefore, any return to throwing after injury must include attention to the entire body. 2. The chance for re-injury is lessened by a graduate progression of interval throwing. 3. Proper warm-up is essential. 4. Most injuries occur as the result of fatigue.  5. Proper throwing mechanics lessen the incidence of re-injury.  6. Baseline requirements for throwing include: Pain-free range of motion, adequate muscle power and adequate muscle resistance to fatigue

 

Because there is an individual variability in all throwing athletes, there is no set timetable for completion of the program. Most athletes, by nature, are highly competitive individuals and wish to return to competition at the earliest possible moment. While this is a necessary quality of all athletes, the proper channeling of the athlete’s energies into a rigidly controlled throwing program is essential to lessen the chance of re-injury during the rehabilitation period. The athlete may have the tendency to want to increase the intensity of the throwing program. This will increase the incidence of re-injury and may greatly retard the rehabilitation process. It is recommended to follow the program rigidly as this will be the safest route to return to competition.

 

During the recovery process the athlete will probably experience soreness and a dull, diffuse aching sensation in the muscles and tendons. If the athlete experiences sharp pain, particularly in the joint, stop all throwing activity until this pain ceases. If continued pain, contact your physician. 

 

Weight Training:  The athlete should supplement the ITP with a high repetition, low weight exercise program. Strengthening should address a good balance between anterior and posterior musculature so that the shoulder will not be predisposed to injury. Special emphasis must be given to posterior rotator cuff musculature for any strengthening program. Weight training will not increase throwing velocity, but will increase the resistance of the arm to fatigue and injury. Weight training should be done the same day as your throw: however, it should be after your throwing is completed, using the day in between for flexibility exercises and a recovery period. A weight training pattern or routine should be stressed at this point as a “maintenance program.” This pattern can and should accompany the athlete into and throughout the season as a deterrent to further injury. It must be stressed that weight training is of no benefit unless accompanied by a sound flexibility program.

 

Individual Variability: The ITP is designed so that each level is achieved without pain or complication before the next level is started. This sets up a progression such that a goal is achieved prior to advancement instead of advancing on a specific timeframe. Because of this design, the ITP may be used for different levels of skills and abilities from those in high school to professional levels. The reason for implementation of the ITP will vary from person to person. Example: One athlete may wish to use alternate days throwing with or without using weights in between; another athlete may have to throw every third or fourth day due to pain or swelling. Listen to your body – it will tell you when to slow down. Again, completion of the steps of the ITP will vary from person to person. There is no set timetable in terms of days to completion. 

 

Warm-up: Jogging increases blood flow to the muscles and joints thus increasing their flexibility and decreasing the chance of re-injury. Since the amount of warm-up will vary from person to person, the athlete should jog until developing a light sweat, then progress to the stretching phase. 

 

Stretching: Since throwing involves all muscles in the body, all muscle groups should be stretched prior to throwing. This should be done in a systematic fashion beginning with the legs and including the trunk, back, neck and arms. Continue with capsular stretches and L-bar range of motion exercises. 

 

Throwing Mechanics: A critical aspect of the ITP is maintenance of proper throwing mechanics throughout the advancement. The use of the Crow-Hop method simulates the throwing act, allowing emphasis of the proper body mechanics. This throwing method should be adopted from the start of the ITP. Throwing flat footed encourages improper body mechanics, placing increased stress on the throwing arm and, therefore, predisposing the arm to re-injury. The pitching coach and sports biomechanist (if available) may be valuable allies to the rehabilitation team with their knowledge of throwing mechanics. 

 

Components of the Crow-Hop method are first a hop, then a skip, followed by the throw. The velocity of the throw is determined by the distance, whereas the ball should have only enough momentum to travel each designed distance. 

 

Throwing: Using the Crow-Hip method, the athlete should begin warm-up throws at a comfortable distance (approximately 30-45 ft.) and then progress to the distance indicated for that phase (refer to the table below). The program consists of throwing at each step 2 to 3 times without pain or symptoms before progressing to the next step. The objective of each phase is for the athlete to be able to throw the ball without pain the specified number of feet (45 ft., 60 ft., 90 ft., 120 ft., 150 ft., 180 ft.), 75 times at each distance. After the athlete can throw at the prescribed distance without pain, they will be ready for throwing from flat ground 60ft/6 in. in the normal pitching mechanics or return to their respective position (step 14). At this point, full strength and confidence should be restored in the athlete’s arm. It is important to stress the Crow-Hop method and proper mechanics with each throw. Just as the advancement to this point has been gradual and progressive, the return to unrestricted throwing must follow the same principles. A pitcher should first throw only fast balls at 50%, progressing to 75% and 100%. At this time, he may start more stressful pitches such as breaking balls. The position player should simulate a game situation, again progressing at 50-75-100%. Once again, if an athlete has increased pain, particularly at the joint, the throwing program should be backed off and re-advanced as tolerated, under the direction of the rehabilitation team. 

 

Batting: Depending on the type of injury that the athlete has, the time of return to batting should be determined by the physician. It should be noted that stress placed upon the arm and shoulder in the batting motion are very different from the throwing motion. Return to unrestricted use of the bat should also follow the same progression guidelines as seen in the training program. Begin with dry swings progressing to hitting off the tee, then soft toss and finally live pitching. 

Summary: In using the interval Throwing Program (ITP) in conjunction with a structured rehabilitation program, the athlete should be able to return to full competition status, minimizing any chance of re-injury. The program and its progression should be modified to meet the specific needs of each individual athlete. A comprehensive program consisting of maintenance strength and flexibility program, appropriate warm-up and cool down procedures, proper pitching mechanics, and progressive throwing and batting will assist the baseball player in returning safely to competition.

 

45’ Phase

Step One:  Warm-up throwing  45’ – 25 throws

       Rest for 15 minutes

      Warm-up throwing  45’ – 25 throws

 

Step Two:  Warm-up throwing  45’ – 25 throws

       Rest for 10 minutes

       Warm-up throwing  45’ – 25 throws

       Rest for 10 minutes

       Warm-up throwing  45’ – 25 throws

60’ Phase

Step Three: Warm-up throwing  60’ – 25 throws

                   Rest for 15 minutes

       Warm-up throwing  60’ – 25 throws

 

Step Four: Warm-up throwing  60’ – 25 throws

      Rest for 10 minutes

      Warm-up throwing  60’ – 25 throws

      Rest for 10 minutes

      Warm-up throwing  60’ – 25 throws

 90’ Phase

 Step Five: Warm-up throwing  90’ – 25 throws

                   Rest for 15 minutes

      Warm-up throwing  90’ – 25 throws

 

Step Six:   Warm-up throwing  90’ – 25 throws

      Rest for 10 minutes

      Warm-up throwing  90’ – 25 throws

      Rest for 10 minutes

      Warm-up throwing  90’ – 25 throws

 

120’ Phase

Step Seven: Warm-up throwing  120’ – 25 throws

         Rest for 15 minutes

        Warm-up throwing  120’ – 25 throws

 

Step Eight:  Warm-up throwing  120’ – 25 throws

         Rest for 10 minutes

        Warm-up throwing  120’ – 25 throws

         Rest for 10 minutes

        Warm-up throwing  120’ – 25 throws

 

150’ Phase

Step Nine: Warm-up throwing  150’ – 25 throws

       Rest for 15 minutes

      Warm-up throwing  150’ – 25 throws

 

Step Ten:  Warm-up throwing  150’ – 25 throws

       Rest for 10 minutes

      Warm-up throwing  150’ – 25 throws

       Rest for 10 minutes

      Warm-up throwing  150’ – 25 throws

 

 

180’ Phase

 Step 11:   Warm-up throwing  180’ – 25 throws

      Rest for 15 minutes

     Warm-up throwing  180’ – 25 throws

 

Step 12:    Warm-up throwing  180’ – 25 throws

       Rest for 10 minutes

      Warm-up throwing  180’ – 25 throws

       Rest for 10 minutes

      Warm-up throwing  180’ – 25 throws

 

Phase II– Throwing Off the Mound

After the completion of Phase I of the Interval Throwing Program (ITP) and when the athlete can throw to the prescribed distance without pain, the athlete will be ready for throwing off the mound or return to their respective position. At this point, full strength and confidence should be restored in the athlete’s arm. Just as the advancement to this point has been gradual and progressive, the return to unrestricted throwing must follow the same principles. A pitcher should first throw only fast balls at 50%, progressing to 75% and 100%. At this time, the athlete may start more stressful pitches such as breaking balls. The position player should simulate a game situation, again progressing at 50-75-100%. Once again, if an athlete has increased pain, particularly at the joint, the throwing program should be back off and re-advanced as tolerated, under the direction of the rehabilitation team. 

 

Summary: In using the Interval Throwing Program (ITP) in conjunction with a structured rehabilitation program, the athlete should be able to return to full competition status, minimizing any chance of re-injury. The program and its progression should be modified to meet the specific needs of each individual athlete. A comprehensive program consisting of maintenance strength and flexibility program, appropriate warm-up and cool down procedures, proper pitching mechanic, and progressive throwing and batting will assist the baseball player in returning safely to competition.

 

STAGE ONE: FASTBALLS ONLY

All throwing off the mound should be done in the presence of your pitching coach to stress proper throwing mechanics.  

 

Step 1 Interval Throwing (Use Interval Throwing to 120’ Phase as warm-up): 15 Throws off mound @ 50% (Use speed gun to aid in effort control)

 

Step 2 Interval Throwing: 30 Throws off mound @ 50%

 

Step 3:  Interval Throwing: 45 Throws off mound @ 50%

 

Step 4:  Interval Throwing: 60 Throws off mound @ 50%

 

Step 5:  Interval Throwing: 70 Throws off mound @ 50%

 

Step 6:  45 Throws off mound @ 50% – 30 Throws off mound @ 75%

 

Step 7:  30 Throws off mound @ 50% – 45 Throws off mound @ 75%

 

Step 8:  65 throws off mound @ 75% – 10 Throws off mound @ 50%

 

 

STAGE TWO: FASTBALLS ONLY

 

Step 9:  60 throws off mound @ 75% – 15 Throws in Batting Practice

 

Step 10: 50-60 throws off mound @ 75% – 30 Throws in Batting Practice

 

Step 11: 45-50 throws off mound @ 75% – 45 Throws in Batting Practice

 

 

STAGE THREE:

 

Step 12: 30 Throws off mound @ 75% warm-up   15 Throws off mound @ 50% BREAKING BALLS

 

Step 13: 30 Throws off mound @ 75%   30 Breaking Balls @ 75%   30 Throws in Batting Practice

 

Step 14: 30 Throws off mound @ 75%  60-90 throws in Batting Practice (Gradually increase breaking balls)

 

Step 15: SIMULATED GAME: PROGRESSING BY 15 THROWS PER WORKOUT

Patient Exercise Guides

315,236  230,173 223,169 242,181

  • Start by tying the rubber band to a sturdy object. Begin the exercise by “setting your shoulder blades” or pinching them together.
  • Now put yourself into a position to pull the band toward your abdomen, paying attention that your elbow does not move away from your side and that your shoulder rotates forward rotates forward as seen in picture 1.
  • The next exercise is in the opposite direction, rotating the shoulder AWAY from your abdomen. Initiate this movement again by setting your shoulder blades and avoiding excessive movements from rotating your trunk or extending your wrists/elbows- the correct ending position is shown in picture 2.
    • A towel under the arm may be used to assist with keeping the elbow by the side.
  • For the third exercise, rotate your body so that the band is behind you and can provide resistance as you punch out, as shown in picture 3.
  • For the fourth exercise, rotate your body so the band is in front of you and can provide resistance as you pull your arm toward your body.
    • NEVER PULL THE BAND SO FAR THAT YOUR ELBOW GOES PAST YOUR BODY

This exercise is a great progression for the TVA exercise (shown under “TVA’s”). You can perform this exercise over the corner edge of a table or a stability ball. Begin by “setting your shoulder blades” in the proper position- pinched together.

1

1. Perform a rear deltoid row by pulling your arms even with your body and keeping your shoulder blades pinched together. 

2

2. Externally rotate both of your arms to a comfortable position while maintaining proper shoulder blade position. 

3

3. Pull your shoulder blades and your arms down and in. 

4

4. While maintaining scapular depression (shoulder blades pulled back and down), lift your arms above your head to a comfortable position. 

5

5. Lower your arms down again to shoulder level while initiating scapular depression. 

6

6. Lower your arms back down to the floor to the starting position and repeat the exercise as prescribed.

265,200

Begin this exercise by getting a stability ball and placing it on the wall at your release point for your overhead throw, as shown above. Set your scapulae by depressing and pinching them together. 

272,206

Next, have a partner grab just above your elbow and try to move your arm. Your job is to try and keep your arm in the same position as when you started. Your partner can make this more challenging by adding more aggressive, quicker or multi-directional perturbations.

 

This exercise is shown seated on a stability ball, but may be done seated and progressed to standing to include follow through from a single leg balance. This can then be progressed to a baseball mound. 

1 2 3 4

Have a partner toss a weighted ball over your shoulder. As you catch the ball, follow through as if you were throwing. Once you complete the follow through, immediately reverse the throwing motion and toss the ball back to your partner.

This exercise consists of all the phases of the throwing motion. Use a teammate or partner to hold some resistive tubing. Begin on one leg in the cocking phase and slowly progress through the overhead throwing motion.

7 6 5 4

Once you achieve your complete follow through and are balancing on the opposite lower extremity that you began the exercise on, slowly control the resistance from the band and return to the starting position.

3 2 1

A partner and resistive band are required for this exercise. Have your partner stand i front of you and put a moderate amount of tension on the band. Begin this exercise in the cocked position and balancing on one leg. Next, go through the rest of the overhead throwing motion, avoiding dropping your elbow below 90 degrees and focusing on the overhead throw. As you finish your follow through, pause at the end range and gold the balanced position to help work on hip stability. Obviously your head would remain up in the follow through so you can place and locate the ball. The head is down in this picture to help emphasize the single leg lean/balance portion of the exercise.

1 2 3 4

 

This is a progression from the neutral strengthening at waist level. You must first have adequate strength and stability before progressing to this exercise. Perform this exercise under proper supervision

External Rotation at 90/90

245,185

Begin this exercise by raising your arm parallel with the floor and setting your shoulder blades in the proper position by pinching them together. It is very important to NOT drop your elbow below parallel as this will lead to poor shoulder/throwing mechanics. Slowly allow the tension in the rubber band to release and rotate your arm forward. Next, rotate your arm back as if you were throwing a football or baseball slowly and with good control. Repeat this exercise 10 times. Perform 2-3 sets as tolerated every other day.

Internal Rotation at 90/90

203,152

Begin the next exercise again with your arm parallel to the floor, paying attention that your elbow does not drop below this position. Next, rotate your arm forward before returning to the starting position. Perform 10 reps with good, quality movements as tolerated. Perform 2-3 sets every other day.

This is an exercise for strengthening the external rotators in 90 degrees abduction for patients that do not initially have enough strength to actively maintain 90 degrees of abduction. A foam roll, pillow or rolled up towel may be placed under the arm to put the arm into 90 degrees of abduction. The patient then properly sets the shoulder blades by pinching them together and tries to externally rotate the shoulder. Hold the contraction for 2-3 seconds and slowly return back to the starting position. Perform 10 reps once per day. Strengthening exercises are recommended to be performed every other day to avoid excessive soreness.

253,189 252,189

Stand with your arm at a comfortable level, preferably chest level, and flush against the wall. Gradually lean forward and rotate away from the wall. Hold the stretch in a tolerable position for 30 seconds and repeat 5 times. Perform the exercise 2 times per day.

197,263 273,366

 

Imagine that your body is a clock. Your head is 12 o’clock, your feet are 6 o’clock and your waistline would be 3 o’clock and 9 o’clock.

P1010149-large

Have someone adjust your elbow approximately a fist distance from your side. Place a towel roll under the elbow of your involved arm. Take a stick approximately 30 inches long with both hands. On your INVOLVED shoulder, bend your elbow to 90 degrees. Letting the non-operative arm do all the work, relax your involved shoulder and, while maintaining the 90 degree angle, push your arm toward 2 o’clock for the left arm or 10 o’clock for the right arm.

P1010192-mediumP1010187-medium

Perform this exercise for 10 reps once per day unless otherwise directed by your physician. Hold for 10-20 seconds as tolerated.

Begin this exercise by pinching your shoulder blades together. Next, raise your arm straight in front of you to 90 degrees (parallel with the floor) without using any momentum from your body or shrugging your shoulders. The next variation is raising your arm straight out to the side as seen in the 2nd picture, again focusing on not using momentum or shrugging your shoulder. The final variation is at a 45 degree angle from your side, known as scaption.

364,273

465,349

434,326

0

Toss a towel or rope over your UNAFFECTED shoulder. Grasp the rope behind your back with the AFFECTED shoulder as shown in the picture. Use the rope or towel to pull your AFFECTED arm up the mid-line of your back to a tolerable position. Hold the stretch for 30 seconds and repeat 5 times once per day.

IF YOU ARE HAVING TROUBLE GETTING YOUR HAND BEHIND YOUR BACK

Use a strengthening band as shown in the picture below. Grab the rubber band with the involved arm and slowly create tension by moving away from the anchor point of the band, allowing the tension to pull your hand towards the midline of your back.

PIC_0025-large

Create a TOLERABLE stretch and hold it for 30 seconds. Perform 5 repetitions daily or as directed by your therapist or physician. Once this is achieved easily, you may transition to the rope/strap stretch as shown above.

Begin this exercise by setting your shoulder blades into the proper position by retracting and depressing them. Grasp a strengthening band in your hands about shoulder width apart. Pull the band apart while keeping your shoulder blades pulled back and down.

PIC_0044-large

PIC_0045-large

 

Start by tying the band that your healthcare provider supplied you with to a sturdy object. Begin the exercise by “setting your shoulder blades” or pinching them together. Now stand with the band beside you, on the side of your involved shoulder. Pull the rubber band toward your abdomen, making sure that your elbow does not move away from your side and you do not round your shoulder forward. The next exercise is in the opposite direction, away from your abdomen. Turn and face the other way so that the band is now on the side of your non-involved shoulder. Set your shoulder blades again, and rotate your arm outwards, avoiding excessive rotation and movement from your trunk, elbow and wrist as seen in the second picture. These exercises are used to strengthen the anterior and posterior portions of the rotator cuff.

338,252   232,1750

Adjust the patient’s elbow about a fist distance away from their side, paying particular attention that the patient DOES NOT actively try to assist you in moving the arm.

  • Place a towel roll under the patient’s involved arm for comfort
  • Place the elbow at a 90 degree angle. Use your hand to stabilize the elbow
  • Use your other arm to help rotate the involved shoulder away from the body
  • Hold the stretch gently for approximately 10-20 seconds and gradually increase the hold time as tolerated
  • Perform 10 reps once per day unless otherwise directed by your physician

623,468

403,301

Begin this exercise by using your un-involved arm to balance yourself on an object such as a table, chair or bed. Lean forward at the waist and relax your involved arm so that gravity pulls it down toward the floor. Gently swing your body and use the momentum of your body to get your arm to swing. Do not actively move your arm as this may cause pain or stress the repair in your shoulder. Again, use your body’s MOMENTUM to get your arm to move like an elephant’s trunk. Swing your arm forward/backward, side to side and clockwise/counterclockwise. Begin this exercise with small movements for 10 seconds and progress to 15-20 seconds as tolerated or prescribed by your healthcare provider.

pendulum

 

These exercises are designed to use larger muscular forces at high rates of speed in a sport-specific direction to develop power and strength as part of a return-to-play progression. An upper extremity plyometric program should be implemented only when a patient or athlete demonstrates full range of motion, good periscapular control, rotator cuff and deltoid strength. Two-handed plyometrics should be initiated first while uni-lateral plyometrics should begin once the patient/athlete demonstrates proficiency with bilateral drills. These exercises can also be progressed by using different balancing devices.

Two Hand Chest Pass

08 09

Two Hand Shoulder-to-Shoulder Pass

010 296,223 209,158

Two-Handed Overhead Soccer Throw

285,215 258,194

External Rotation @ Side Into Rebounder

215,162 184,138

Internal Rotation @ Side into Rebounder

222,166 224,167 222,166

Throwing in Door Frame @ 90

267,201 286,216

Throwing in Door Frame @ Release Point

011 202,152

Eccentric and Concentric PNF Toss

1 2 3 4

This exercise is shown on a ball secondary to space limitations indoors. The exercise may be progressed functionally to standing and then to a mount.

PNF D2 Flexion

Begin this exercise by pinching your shoulder blades together. Keep your arm straight and rotate it as if your thumb was in you front pocket. Keeping your arm straightm bring your arm across your body while rotating your thumb toward the ceiling. Slowly return your arm to the starting position while rotating your thumb back toward your front pocket.

271,204 265,199

PNF D2 Extension

Begin this exercise by pinching your shoulder blades together and grabbing a resistive band overhead. Next, pull the band across your body and rotate your arm as if you are putting your thumb into your pocket, keeping your arm straight the entire time. 

231,174 236,178

Get a round ball of some sort (medicine ball, soccer ball, basketball, softball, baseball, etc.) and place it under one hand. This is designed to increase the activity of the periscapular muscles. Perform a push-up to a comfortable range of motion. Repeat with the ball under the opposite.

06

To progress this exercise, take the stability ball and put it on the edge of a table. Place both hands on the stability, pinch your shoulder blades together and perform a push up on the ball to a comfortable range of motion.

The next progression would be to place the ball on the floor. Again, pinch your shoulder blades together and perform a push-up to a comfortable range of motion. 

 

This is an exercise to re-educate the proper scapular mechanics needed while elevating the shoulder. These exercises are important in order for the individual to understand the proper movement of the shoulder blades when raising the arm forward and out to the side.

Begin this exercise by imagining that your shoulder is a clock. Up us 12, down is 6, forward is 3 and backwards is 9. Take a ball in the arm that you are re-educating. Place your opposite arm behind your head as shown to promote proper positioning of the opposite shoulder blade. Elevate your shoulder blade toward the 12 o’clock position as seen in picture 1. Next, depress your scapula toward 6 o’clock as seen in picture 2. Move your shoulder forward to 3 o’clock. Finally, retract your shoulder blades backwards toward 9 o’clock by pinching both shoulder blades together as seen in picture 3.

PIC_0035-medium Scapular elevation (12 o’clock)

PIC_0034-medium Scapular depression (6 o’clock)

PIC_0033-medium Scapular retraction (9 o’clock)

Note that scapular elevation during overhead movements can impinge soft tissue in the narrow subacromial space. During these movements, encourage depression (6 o’clock) and retraction (9 o’clock) to inhibit the upper traps and protect these structures. Pay close attention to the movements and muscles that are being used when performing these movements. This will help to promote proper scapular mechanics when lifting your arm. 

Begin this exercise in 90 degrees of scaption, in the transverse plane, out at an angle. Keep your elbow extended and reach forward. Next, focus on extending your arm even further by protracting your scapula or pushing your shoulder blade forward and away from your spine. Avoid shrugging your shoulder or using your upper trap. Make note that by also concentrating on pulling the shoulder blades down, the upper trap will be inhibited.

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Side Lying

Lay down on your side in a bed, table or floor, placing your arm at a 90 degree angle as shown in the picture. Gently push your arm forward and down toward the surface until a stretch is felt. Hold for 30 seconds and repeat 5 times, twice per day.

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Standing

Lean against a wall and place your involved arm parallel to the floor. Bend your elbow at 90 degrees to the body as seen in the picture. Gently rotate your arm downward toward the wall. Hold for 30 seconds and repeat 5 times, twice per day. Make sure that your shoulder blade is held against the wall so it doesn’t move with the stretch.

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Begin this exercise by using your un-involved arm to lift your involved arm over your head. Release your involved arm and try to lower it back down easily. Once you can perform this 20 times easily and under good control, you may transition to raising the involved arm without assistance. As you get stronger and reach the point where 15 reps becomes easy, you may increase the resistance by adding 1 pound weights in the involved extremity. Make sure that you “set your shoulder blades” by pinching them together and holding them in place during the exercise.

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A variation of this exercise is to perform a wall slide (described under “Wall Slide”) and then step back away from the wall while actively lowering the arm from an elevated position. This accomplishes both stretching and eccentric strengthening.

  • Lay flat on your back on a bed, couch, floor or table without a pillow under your head
  • Use a pillow at the side of your body and under the arm so that the arm does not pass the plane of the body on return back to the starting position as this will stress the repair
  • Relax your involved arm onto your abdomen. Grasp the wrist of the involved shoulder
  • Gently and easily put traction on your arm as you lift it towards the ceiling using the uninvolved arm
  • Slowly take the involved arm over your head and down toward the table
  • Once you begin to feel a stretch, hold for 10-20 seconds before gently lowering your arm back down toward your abdomen. Repeat 10 times once per day unless otherwise instructed by your physician
  • MAKE SURE THAT THE UNINVOLVED ARM US DOING ALL OF THE WORK AND THAT THE INVOLVED SHOULDER IS TOTALLY RELAXED DURING THIS STRETCH

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Begin by lying on your back and reaching for the ceiling. Under your own control, take your arm as far back towards your head as tolerated without the assistance of the other arm. Bend your elbow to create a shorter lever arm and bring the arm back to the original position. You may keep the arm straight instead of bending the elbow as you begin to get stronger. Once you are able to perform 15 reps easily, you may increase the resistance by adding a 1# weight in your hand. Perform this exercise 2 times per day every other day. You may progress to Wedge Assisted Forward Elevation if directed by your physician/therapist.

  • Have the patient lay on the floor, couch bed or table.
  • Do not use a pillow under the head as this will limit range of motion. Make sure the patient is  as close to the edge of the surface as possible. This will assist the person stretching the patient in maintaining proper body mechanics.
  • A pillow should be placed beside the body and under the arm so that the arm does not go past the plane of the body as this will stress the repair.
  • Slightly bend the elbow of the involved shoulder over the patient’s abdomen. Gently grasp around the patient’s forearm and just above the elbow as shown in the picture.
  • IT IS VERY IMPORTANT THAT THE PATIENT IS RELAXING AND NOT GUARDING OR USING THE ARM TO ASSIST IN MOVEMENT DURING THIS EXERCISE

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1. Wrist Flexion/Extension and Supination/Pronation

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2. Elbow Extension/Flexion

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3. Serratus Punch in Scaption

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4. Middle Deltoid Raise to 90°

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5. Scaption to 90°

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6. Prone Horizontal Abduction

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7. Internal/External Rotation @ 0° and 90°

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8. Push-Up Progression

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Progress from the wall push-up to table with a stability ball and then to floor with a medicine ball

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9. Prone Rows

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10. PNF

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Thumb tacks are another scapular exercise that help an individual understand the proper mechanics of the shoulder blades during elevation of the arm.

Begin by placing your thumbs into the wall slightly lower than chest level and pinching your shoulder blades together as seen in the picture.

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Next, rotate your thumbs inward as if you were pushing a thumb-tack into the wall. Pay close attention that you are not elevating your scapula toward the 12 o’clock position, but depressing them toward the 6 o’clock position (for help, see “Scapular Clocks”).

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Next, rotate your thumbs back to the starting position and pinch your shoulder blades together again. This exercise is promoting proper scapular retraction (9 o’clock) and protraction (3 o’clock) while avoiding excessive scapular elevation (12 o’clock).

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This is a 3 part exercise working the small muscles in your upper back and shoulders to help stabilize your shoulder blades. Begin by lying on your stomach on a stability ball or over the edge of a table. Set your scapulae in the starting position by pinching your shoulder blades together and pulling them down. Next, move your arms out to the side as if you were making the letter “T” as shown in picture 1. Return to the starting position. The next exercise looks like the letter “V” as shown in picture 2. It is very important to depress and retract your shoulder blades during this exercise. The final exercise looks like the letter “A” as shown in picture 3. If you are unable to keep your shoulder blades in the proper position, stop and rest. Resume when comfortable.

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  • Find the corner of a wall in your house. Stand beside the wall with your hip and your involved shoulder facing the wall as shown in the picture.
  • Put a towel between your hand and the wall to decrease friction.
  • Slowly and gently slide your hand up the wall as high as you can tolerate using the momentum from your body to elevate your shoulder. Gently lean into the stretch.
  • Your goal is to get your armpit to touch the wall. Perform this exercise 5-10 times holding each stretch for 5-10 seconds as tolerated, unless otherwise instructed by physician.

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IF YOU ARE ALLOWED TO STRENGTHEN- A corollary to this stretch is to step away from the wall and try to lower the arm actively. Make sure that you “set your shoulder blades” when doing this strengthening exercise by pinching them together as you lower the arm.

Begin by lying on your back and reaching for the ceiling. Under your own control, take your arm as far back towards your head as tolerated without the assistance of the other arm. Bend your elbow to create a shorter lever arm and bring the arm back to the original position. You may keep the arm straight instead of bending the elbow as you begin to get stronger. Once you are able to perform 15 reps easily, you may increase the resistance by adding a 1# weight in your hand. Perform this exercise once per day, every other day.

The progression of this exercise is to add a small wedge underneath the upper body to introduce more gravitational pull on the arm. Once the patient can perform 15 reps on a small wedge, a bigger wedge may be placed underneath the body, again increasing the difficulty. The ultimate goal of the exercise is to transition from active forward elevation in the supine position to active forward elevation in an upright position by using wedges to gradually increase resistance.

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