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Table 7.
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Examples of Interventions for Patients with Subacromial Pain Syndrome, Matched by Irritability Level*
Impairments Associated with
Subacromial Pain Syndrome
Limited shoulder external
High Irritability
Interventions
Isometrics in neutral position Elastic band, isotonics
rotation strength
Limited passive glenohumeral
joint mobility including posterior
shoulder tightness and/or
glenohumeral internal rotation
deficit (GIRD)
Low grade manual therapy
to shoulder, manipulations
to spine, and physiological
mobility exercises in midranges
Pectoralis minor length Scapular retraction and
positioning exercise; soft
tissue and manual therapy
techniques
Scapular muscle weakness or
motor control deficit
*Modified from McClure and Michener.
Scapular clock or setting
exercises
130
education regarding sleeping positions, and isometric exercise.
It is expected that patients will transition from exercises with a
symptom modulation focus to interventions that target muscle
performance and other impairments related to the patient’s
movement dysfunction.
In addition to exercise, strong evidence supports including
manual therapy in the initial phase of treatment to enhance
short-term improvements in pain and function in patients with
subacromial pain syndrome.
225
Manual therapy techniques
are advocated for neurophysiological effects to modulate pain
and to complement exercise to improve mobility, muscle
activity, and strength.
280,281
Examples of techniques include
passive physiological GH joint ROM, manual terminalrange stretching,
and rotator cuff muscles,
282
soft tissue techniques to scapulothoracic
283
neurodynamic mobilizations,
and mobilization and thrust-manipulation techniques to the
shoulder girdle and spine.
225,284
Manual therapy techniques used
to specifically target posterior shoulder tightness and GIRD
include high-grade posterior/inferior GH joint mobilizations,
soft tissue techniques to the posterior shoulder region (rotator
283
cuff),
and terminal stretching in shoulder IR or modified
sleeper stretch,
194
flexion.
285
horizontal adduction,
286
and low shoulder
Operative management subacromial pain syndrome:
subacromial decompression
A meta-analysis of randomized trials (n=11) suggests
surgical treatment for persistent subacromial pain is no more
Moderate Irritability
Interventions
Low Irritability
Interventions
Resisted higher load
and eccentric exercises
below shoulder height
High-grade larger
amplitude mobilizations
to glenohumeral joint
Stretching supine over
foam roller with arms
below 90°
Low rows and resisted
scapular retraction
exercises in abducted
positions
Grade IV mobilizations
terminal range of motion
and sustained stretching
Terminal stretching in
doorway with arm abducted
at 90° and externally rotated
Prone horizontal scapular
plane resisted abduction
effective than physical therapy exercise in terms of improving
pain or function at short and long-term (10-year follow-up).
287
In patients for whom non-surgical interventions have been
exhausted without satisfactory improvements, arthroscopic
subacromial decompression with acromioplasty is preferred
over bursectomy to improve patient-reported outcomes.
288
Post-operative rehabilitation of patients following subacromial
decompression is similar to post-operative rehabilitation
following biceps tenotomy and capsular release, with no
structures that require specific protection. Rehabilitation is
guided based on tissue irritability and progression through
active assistive, active, and resistive phases occurs as quickly
as the patient tolerates. Full return to function ranges from 6
weeks to 3 months following the procedure.
Full-thickness rotator cuff tear
Rotator cuff tears are common in adults over the age of
142
e clinical presentation of patients with symptomatic
60.
full-thickness rotator cuff tears vary based on the location and
size of the tear which is typically measured by the greatest
diameter in centimeters (cm) (small <1 cm, medium 1-3 cm,
large >3-5 cm, and massive >5cm).
289
In the STAR–Shoulder,
130
full-thickness rotator cuff tears fall into the Shoulder Pain with
Muscle Performance Deficits classification and are not delineated
from subacromial pain syndrome. Clinical tests are not sensitive
to detect small full-thickness rotator cuff tears from subacromial
220
pain syndrome.
However, large and massive rotator cuff
tears are characterized by significant weakness and positive lag
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119
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signs.
e physical therapy management of patients with
full-thickness rotator cuff tears vary based on the mechanism
of onset (traumatic versus atraumatic) and size (small/medium
versus large/massive). Traumatic rotator cuff tears detected
or suspected with clinical examination is considered a red
flag which require a referral to a shoulder surgeon for further
128
imaging and evaluation.
is is not the case for patients with
suspected atraumatic degenerative rotator cuff tears that occurs
in older (>60) patients.
Physical therapy interventions for patients with small to
medium size rotator cuff tears who are treated non-operatively
should include exercise to strengthen the shoulder, with focus
on the balance of anterior and posterior force couples (ER to IR
strength ratios), initially with the arm at the side, and progressing
to elevation; stretching to improve mobility, particularly
posterior shoulder tightness; and mobilization of the shoulder
girdle. e rehabilitation approach focuses on identifying
impairments related to the movement dysfunction and may
not differ from one devised for a patient with subacromial pain
syndrome. Individualized impairments related to the movement
dysfunction identified in the examination should be prioritized
for the home program.
ere is growing evidence on the effectiveness of physical
therapy interventions for patients with small to medium size
rotator cuff tears. In randomized controlled trials with 2- to
5-year follow-up, no clinically significant differences in patientreported outcomes have been found between those treated
with surgical repair followed by physical therapy and those
treated with non-operative physical therapy interventions.
290,291
although longer term follow up at 10 years show clinically
significant differences in patient-rated outcomes (Constant
Score; Association of Shoulder and Elbow Surgeons [ASES];
88
pain) favoring the surgical repair.
Additionally, rotator cuff
tear size, muscle atrophy, and fat infiltration had progressed
84,290
in some patients in the physical therapy only group.
In
patients who elect non-operative physical therapy, it is unclear
what factors influence tear progression and if tear progression
advances enough to preclude future repair and subsequent
140
resolution of symptoms.
erefore, for patients with a rotator
cuff tear, who are not progressing with rehabilitation, surgical
consultation is usually recommended.
In patients with large and massive rotator cuff tears, nonoperative rehabilitation programs emphasize strengthening the
deltoid and remaining intact rotator cuff to gain functional
292,293
elevation motion.
Frequently, there is an inability to
normalize anterior-posterior force couples and restoring normal
217,219,294
ER:IR strength and endurance ratios.
Several published
case series have outlined physical therapy programs with
progressive assisted to resisted ROM exercise components.
292,293
ere is preliminary evidence that variations in the location of
the tear (subscapularis, teres minor) and remaining portion of
the rotator cuff are associated with distinct functional gains.
Tears involving the supraspinatus and infraspinatus have a
greater proportion of patients that are able to achieve greater
than 160° shoulder elevation, compared to massive tendon tears
295
in other locations.
Larger studies are needed to support this
preliminary finding.
In older patients with large and massive rotator cuff tears,
the etiology is frequently considered an acute on chronic injury
that occurs when a trauma extends an existing asymptomatic
chronic full-thickness rotator cuff tear. e chronicity is
determined by the presence of rotator cuff intramuscular fat
infiltration and atrophy on imaging. In patients with large
rotator cuff tear and substantial intramuscular degenerative
292
changes, a repair is not recommended.
For older patients
with lower activity demands, rehabilitation focusing on
assistive to progressive resisted motion exercises and deltoid
strengthening may allow the patient with an irreparable large/
massive rotator cuff tear to meet functional goals. In patients
who are younger or are unable to meet functional demands,
other procedures such as tendon transfers (latissimus), superior
capsular reconstruction, or reverse TSA are recommended. In
younger patients with a traumatic acute large/massive rotator
cuff tear, referral to an orthopaedic shoulder surgeon should be
128
expedited.
Operative management: rotator cu repair
With a traumatic mechanism of injury, surgical repair is
typically recommended as the primary treatment in younger
88
individuals and those participating in high demand activities.
ese recommendations have evolved due to the likelihood of
progression of tear size, muscle atrophy, and fat infiltration that
has been shown to occur in patients with acute on chronic rotator
84
cuff tear treated non-operatively.
Evidence is just emerging on
optimal management for patients with acute traumatic rotator
cuff tears. One year outcomes of a randomized trial comparing
physical therapy intervention to surgical repair have recently
suggested no significant difference in patient-reported pain
296
and quality of life,
and another that also includes a third
sham surgery group to control for placebo effects of surgery
144
is currently underway.
us, evolving recommendations on
optimal primary interventions in this specific patient population
will be of interest to physical therapists. Post-operative physical
therapy management for patients following a rotator cuff repair
are discussed later in this chapter. (See Summary of Post-operative
Progressions: Rotator Cu Repair Rehabilitation Pathway in Table
8).
Instability: motor coordination deficits
e patient with GH joint instability is typically younger
(<40) and presents with a history of dislocation or feeling that
their shoulder is unstable.
130
Symptoms are attributed to excessive
GH joint mobility. e associated ICF category is shoulder pain
and motor coordination deficits as the primary impairments.
Examination findings include a positive apprehension (anterior
40
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or posterior), relocation, and/or hyperabduction tests.
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130
In
patients with atraumatic etiology, generalized systemic laxity
can be present combined with a history of overhead activity.
Unlike secondary impingement attributed to laxity, patients
with anterior instability should report apprehension, not
pain. However, when clinicians encounter a patient with
pain during apprehension and a positive relocation test, and
positive impingement signs (Neer, Hawkins, and Jobe signs),
the clinical diagnosis used by practitioners varies with both
297
secondary impingement and instability being used.
With the
STAR-Shoulder classification, subacromial pain syndrome is
the best label. If pain is located in the posterior shoulder and
reproduced with anterior apprehension and is reduced with a
relocation test, posterior internal impingement is suspected.
Glenohumeral internal rotation deficit and posterior shoulder
tightness are common contributing impairments in patients
with unidirectional anterior instability or internal impingement.
Numerous classification systems exist to better define
subgroups of patients with GH joint instability, based on
etiology (traumatic/atraumatic), direction (anterior/posterior/
multidirectional), and frequency (primary/recurrent). is
includes the TUBS and AMBRI classifications previously
discussed. e FEDS (Frequency, Etiology, Direction, and
298
Severity) and Stanmore Classification
are other systems with
established reliability and are more inclusive of the variety of
37,38,299
patient presentations.
Evidence on the effectiveness
of interventions for patients with shoulder instability are
typically based on varying definitions of the population. ere
are 2 primary population subgroups in the literature: first
time primary or recurrent traumatic anterior dislocation; and
atraumatic instability that typically is described as MDI.
Regardless of the type of instability, pain, anxiety, fear, and
300
avoidance of movement are common
and can lead to altered
muscle recruitment and movement patterns and strength loss.
Early reassurance and education are essential. Identification
of the ROM in which the patient feels confident is helpful to
encourage movement and decrease fear. ese motions will
differ for anterior versus posterior instability. Graded motor
imagery has been shown to decrease kinesiophobia and fear in
269
an individual with frozen shoulder
and may be considered in
the management of patients with shoulder instability. Adjuncts,
such as mirrors and functional electrical stimulation may be
used to provide a feed-forward feedback to facilitate better
301,302
movement strategies.
e use of a cognitive behavioral
approach to increase the rate and level of return to sport that
303
has been used with knee injuries
is something to consider in
the management of individuals with shoulder instability.
Traumatic instability
Shoulder dislocations are typically anterior in direction
304
and are nearly 7 times more common in young males than
305
age-matched females.
While most traumatic shoulder
dislocations occur in individuals between the age of 15 and
29 years, a second peak in incidence, likely attributed to falls,
128
occurs in elderly females over the age of 70 years.
Almost
90% of recurrent anterior dislocations occur within 2 years of
306
the primary dislocation.
in younger aged individuals and male sex.
ere is increased risk for recurrence
307-309
Common complications associated with a dislocation in
adults over 40 years of age include glenoid or greater tuberosity
125,310,311
fractures and full-thickness rotator cuff tears.
ese
conditions, which warrant a referral, should be considered and
evaluated for in patients seen following a dislocation, particularly
when active ROM continues to be limited and painful beyond
10 to 14 days after the dislocation. Transient brachial plexus
injuries can occur in patients with GH joint dislocations and
are more common in athletes who have sustained high energy
injuries. Brachial plexus injuries have been reported to occur
in 18-71% of shoulder dislocations, primarily affecting the
axillary nerve, and most neuropraxia and axonotmesis resolve
312
spontaneously in the majority of patients.
In all patients,
an examination of upper extremity motor, sensory, and reflex
status is important given the incidence of nerve injury with even
313
low velocity trauma.
Patients with more severe nerve injuries
following a dislocation will not follow the same clinical care
pathway of those without. A referral to a specialist is warranted
in patients with significant motor loss or progressive weakness
for nerve conduction velocity testing and EMG evaluation and
monitoring. A more prolonged course of rehabilitation may be
needed to allow for motor function to return.
Optimal management of a patient following a first-time
traumatic anterior shoulder dislocation is debated. A systematic
review showed that nearly half (47%) of patients do not
experience a recurrence of shoulder instability with non-surgical
314
management following an anterior GH joint dislocation.
However, others support surgical stabilization as the first choice
treatment in younger male patients engaged in high-demand
315
activities.
Decision-making regarding the surgical or non-
surgical management of individuals with recurrent traumatic
316
anterior shoulder instability is complex and multi-factorial.
Individuals typically want to know when they can return to
activity and clinicians should set realistic expectations. Clinical
tools are available to calculate the risk of recurrence following a
317,318
primary dislocation.
Shared decision-making using the best
available evidence with the patient and taking into consideration
patient preferences, is advocated for individualized management
319
decisions.
Factors such as time of the sport’s season, muscle
strength, endurance, and power, as well as psychological factors
should be used in the decision-making process.
320
Posterior dislocations are rare, but common causes are
321
trauma (67%) or a seizure (31%).
Subluxation is much more
common than dislocation in patients with posterior shoulder
instability.
322
Patients with posterior instability have symptoms
in a position of shoulder flexion, adduction, and IR, as these
323-325
movements place tension on the posterior capsule.
ere
is a higher incidence of posterior instability in individuals who
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41
participate in sports, such as football linemen, than in the
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326,327
general population or other sport participants.
Success
rates with non-surgical management are higher in those with
posterior shoulder instability than anterior instability, with up
to 70% of patients being successfully managed non-surgically
328
at 1-year follow-up.
However, long-term outcomes are not
sustained, with a 52% decline in 10 years. ere is low-level
evidence that suggests better outcomes are achieved with nonsurgical management for non-traumatic posterior dislocations
than those whose history includes trauma.
329
Following any primary GH joint dislocation, patients will
present with a high to moderate irritability level. Immobilization
in a traditional sling (not in ER) should be limited to 1 week,
as a longer immobilization duration or ER position does not
330
reduce the risk of recurrence.
Patients should be encouraged
to wean from use of the sling as comfort permits. Limiting
immobilization to a week minimizes the negative consequences
of decreased strength and motor control due to disuse. Patients
should be encouraged to regain ROM as comfort permits.
Younger patients are rarely limited in regaining motion after a
primary dislocation, while those over the age of 30 years may
experience more persistent limitation in ROM (particularly in
331
ER and flexion).
Patients should initiate early activation of
rotator cuff and scapular musculature potentially with isometrics
in the first week and include activities to address proprioception,
332
motor control, and kinesiophobia.
In patients with high
psychological risk factors and high levels of pain, explanation
should be provided on how anxiety can negatively impact
outcomes and these patients may benefit from a referral to a
333
provider to improve their mental health.
Social support from
physical therapists has been identified as a key contributor to
patient satisfaction and decreased post-injury depression when
returning to sport after an episode of shoulder instability.
334,335
After the first 10 to 14 days, the initial trauma to the
joint tissues is typically subsided
336
and less pain is expected.
317
Matched interventions in the moderate irritability phase focuses
on effective strengthening, while building patient confidence
337
and motor control skills.
Controlled active ROM in safe
ranges progressing to positions with higher risk of recurrence
may be considered. Similarly, strengthening and motor control
exercises progressing from isometrics at the side to mid-ROM
and then into positions that are more provocative are used
initially with light resistance and a focus on good technique
and endurance. A randomized controlled trial evaluated
the effectiveness of a comprehensive neuromuscular control
program (SINEX) compared to standard care consisting of
elastic band resisted rotator cuff and scapular exercises described
332
by Rockwood.
Participants who engaged in the SINEX
program achieved better levels of shoulder function (Western
Ontario Shoulder Instability Index [WOSI]), pain levels, and
clinical signs of instability at 12 weeks when compared to those
332
in the standard care program.
e SINEX program was designed to target proprioceptive
deficits and movement quality through guided supervision
from physical therapists. e progressive program includes
components of strength, coordination, balance, proprioception,
and closed kinetic chain exercises. Within the program, there
are 7 separate exercise progressions targeting scapular setting
and control, GH joint setting and control during IR, GH
setting and control in ER, GH muscle co-contraction, dynamic
GH muscle stability, GH proprioception with an exercise ball,
332
and GH proprioception using a laser pointer.
Criteria for
progression within each of the 7 exercise series include achieving
specific load and repetitions, symptoms less than 5/10, good
movement quality throughout the exercise, and no need for
visual, verbal, or tactile feedback from the physical therapist
or other means (mirrors). A progressive neuromuscular motor
control program that integrates the kinetic chain, and that is
matched to the shoulder irritability level, is best evidence-based
management of traumatic shoulder instability.
For patients with shoulder instability and persistent pain
and disability, surgical capsulolabral stabilization procedures
including a Bankart repair can be successful to restore stability
338-341
and improve pain and function.
(See Summary of post-
operative Bankart Repair Rehabilitation Pathway in Table 9.)
Atraumatic instability
Atraumatic instability is less common, and prevalence is not
333
fully known with estimates ranging from 2-30%.
Instability
without a clear history/mechanism of trauma commonly occurs
as a result of repetitive overhead movements or congenital
abnormalities often believed to be related to hyperlaxity and
inadequate muscle control. Systematic reviews that have
investigated the effect of exercise for the treatment of MDI have
342,343
revealed a high-risk of bias and very low-level evidence.
Since these reviews, 1 randomized clinical trial has been
conducted comparing the Watson rehabilitation program with
the classic Rockwood program
329
in patients with atraumatic
instability. e Watson program includes an emphasis on
scapular neuromuscular control and upwardly rotated scapular
126
position with ROM and rotator cuff strengthening exercises.
e Rockwood program, as previously mentioned, consists of
elastic band resisted rotator cuff and scapular strengthening.
Similar to results of the SINEX trial for traumatic instability,
the Watson neuromuscular control program resulted in greater
improvements in pain and function at 2-year follow-up. Again,
emphasis on neuromuscular control appears to be superior to
strengthening alone in patients with GH joint instability.
Another approach is the Derby rehabilitation program,
designed with a strategy to improve exercise adherence by
limiting the number of exercises in the home program of
patients with either recurrent anterior or posterior atraumatic
344
instability.
e program consists of only 2 exercises performed
daily to fatigue, one from a progression designed to target speed
of muscle activation and the other from a progression of exercises
42
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targeting proprioception and trunk stability. A prospective
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cohort study evaluated the effectiveness of this program
demonstrating short-term (average 30 weeks) improvements in
stability, pain, and function with only 7 sessions of supervised
344
physical therapy.
Interestingly, the program did not differ
in design for patients with posterior versus anterior instability
suggesting less specificity based on direction of instability is
effective.
e focus of rehabilitation advocated in patients with
posterior shoulder instability has traditionally differed from
anterior instability in positions that are avoided in early stages
of rehabilitation progression. For patients with posterior
instability, emphasis on scapular protraction in theory can
enhance GH joint stability, changing posteriorly directed stress
on the soft tissues to the bony glenoid with functional activities
requiring flexion or horizontal adduction. Decreased muscle
activity of the posterior rotator cuff and increased activity of the
latissimus dorsi has been reported in individuals with recurrent
345
posterior instability.
us, integrating functional electrical
stimulation to the infraspinatus during ROM and functional
progressive positions may be effective to improve patientreported outcomes in individuals with posterior instability.
346
Superior labrum, anterior to posterior injuries
Patients presenting with a SLAP lesion will often report
219
a history of repetitive overhead activity or a trauma.
e
patient commonly complains of some of the following signs
and symptoms including deep shoulder pain, popping with
rotation movements, feeling of posterior shoulder tightness,
and feeling of fatigue with overhead activities commonly called
219,347-351
a “dead arm.”
e STAR-Shoulder classifies patients
with suspected SLAP and labral tears into the Shoulder Pain
and Muscle Performance Deficit: Subacromial Pain Syndrome
diagnosis. Despite challenges associated with the validity of
119
the clinical diagnosis of SLAP lesions,
combinations of
examination findings that also include tests used to rule in
219
instability are advocated.
Non-operative pathways for SLAP
lesions fall under the subacromial pain syndrome diagnosis
in the STAR-Shoulder rehabilitation classification, however
post-operative management is typically based on capsulolabral
pathologies associated with instability.
e physical therapy patient care plan is formulated from
a comprehensive evaluation to establish impairments related to
the patient’s current level of function and prioritize the type of
treatment best suited for an individual patient presenting with
SLAP pathology. e majority of patients receive a trial of non-
219,352,353
operative care prior to progressing to surgery.
Physical
therapy intervention plan is often multi-modal with medication
and interventions focused on resolving tightness of the posterior
shoulder, reduced muscle performance of the GH and scapular
219
force couples, and integration of kinetic chain function.
Specific treatments include stretching and mobilizations
to the GH joint structures including muscle tendon units
(not limited to posterior rotator cuff, latissimus dorsi, and
pectoralis musculature). Muscle performance is treated by
normalizing ER:IR strength and endurance ratios.
217,219,294
Deficits in scapular, core, and lower extremity kinetic chain
function should all be addressed to minimize the stress on the
upper extremity and maximize the contribution of the trunk
219
and lower extremities during overhead activities.
Surgery is
considered a last resort in the majority of patients. (See Post-
operative Rehabilitation Guidelines: Capsulolabral Rehabilitation
354 355
pathway in Table 9.
)
Other Diagnoses
Proximal humeral fracture
Patient’s sustaining proximal humeral fractures are more
356
often older individuals who have experienced a fall.
356
incidence is typically higher in females.
Humeral fractures
e
are considered fragility fractures and thus may be associated
with other medical comorbidities. e patient presenting with
a proximal humeral fracture should be screened for medical and
health conditions that would impact the outcome of treatment.
356
Treatment of proximal humeral fractures in patients depends on
the type and grade of fracture (1-4 part), and other individual
357
and objective factors.
Non-operative treatment including
physical therapy is advocated in approximately 75% of the
patients sustaining this injury.
357
Determining the appropriate focus and intensity of
treatment should be based on the patient’s overall health,
functional status, goals, and condition of the shoulder complex
130
based on a physical therapy evaluation.
e patient’s fracture
stability, neurological deficits, and the condition of the rotator
cuff must be established with the physician. Operative treatment
may include direct fracture fixation or joint replacement.
e post-operative rehabilitation process is often specific to
the fracture and surgical procedure as communicated by the
surgeon.
Acromioclavicular joint injury
e mechanism for AC joint pain can be either traumatic
(sprains) or atraumatic (OA or arthropathy). Acromioclavicular
joint injuries with a traumatic onset range from subtle instability
with pain alone (Type I) to complete separation involving AC
and CC ligaments disruption (Type III). Common causes are a
blow to the top of the shoulder, onto the AC joint, with the arm
at the side in an adducted position or a fall on an outstretched
hand where the humeral head is driven superiorly into the
acromion.
Management of traumatic AC joint injuries is based on
the Rockwood classification. Expert consensus recommends
non-surgical management for the most common Type I and
358
II injuries.
Patients sustaining these injuries often return to
sport at 3-6 weeks post injury. However studies have reported
approximately 50% of those sustaining a Type I or II injury,
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have persistent pain and disability at 10 years.
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359
Outcomes are
comparable for Type III injuries managed surgically and nonsurgically. Delays in surgical stabilization in Type III injuries
do not appear to have a negative impact on outcomes.
360
Given this, shared decision-making should incorporate clinical
presentation, patient factors, pain, and functional deficits in
361
informing management.
ere is no harm with rehabilitation
as the first choice of intervention for AC joint injuries.
Rehabilitation of patients with an acute traumatic injury
to the AC joint involves a short period of sling immobilization
(1-3 weeks) and pain management. is should be followed by
passive and active ROM with progression as symptoms allow.
362
Other types of immobilization devices have not been shown
to be more effective than a traditional sling and adherence can
248
be a challenge.
Because the scapulothoracic muscles are the
primary movers and stabilizers of the AC joint, it is not surprising
that scapula dyskinesis has been associated with persistent pain
248
and reduced function in AC joint Type II sprains.
A 6-week
program targeting the scapular muscles has been shown to be
effective in reducing pain and increasing function in 80% of
363
patients with Type III injuries.
e importance of supported
postures that relieve tension on the AC joint and trapezius
are also an important component of education. Patients with
persistent AC joint instability (Type III) are at increased risk of
364
developing cervical symptoms.
In traumatic AC joint injuries where the clavicle is
prominent (Type II or III), it is important to note that this
prominence represents depression of the scapula and not true
elevation of the clavicle. In patients with clear deformity, deltoid
and trapezius muscle strengthening in mid-ranges may enhance
AC joint stability. Surgical repair is indicated in patients who
do not want the cosmetic deformity or have persistent pain.
e post-operative rehabilitation process is often specific to the
surgical procedure as communicated by the surgeon.
Interventions for AC joint OA or arthropathy, should
focus on addressing impairments in AC joint accessory
mobility (mobilize if hypomobile; stabilize if hypermobile) and
normalizing scapulothoracic motion and shoulder strength.
Rehabilitation targeting the rotator cuff and scapular muscles
should be the primary choice of intervention.
Glenohumeral joint osteoarthritis
Approximately 5% of patients complaining of shoulder
dysfunction present with symptomatic GH joint OA.
365
Individuals with OA report pain and stiffness, progressive mild
to moderate ROM loss, with decreasing function and quality
366
of life.
Non-operative treatment for OA has been thought
to be palliative, however, because of the higher prevalence
of radiographic OA (20%) compared to symptomatic OA
365
(5%),
musculoskeletal pathology prior to beginning treatment.
the patient must be assessed for other medical and
130
e hallmark findings of GH joint OA are increasing stiffness,
loss of ROM, pain with compression to the joint, and specific
functional limitations. Glenohumeral joint OA should be
suspected in adults over the age of 60 diagnosed with primary
adhesive capsulitis, with radiographic results providing clarity.
e treatment strategy is based on the progression of the disease,
the amount of chondral surface damage, and the level of night
and activity related pain and dysfunction experienced by the
patient.
367
Traditional treatment of symptomatic GH joint OA
has been surgically based with humeral head replacement or
TSA. Outcomes of TSA have been good especially in older,
368,369
low demand patients.
to mild GH joint OA may choose non-operative treatment.
However, patients with moderate
e patient’s condition should be evaluated in accordance
with knowledge of the current disease process and stages of
130,132
irritability.
Given the underlying pathoanatomic and
progressive nature of OA the patient should be treated with a
multi-modal rehabilitation program to improve function and
comfort. e combination of education for joint protection
techniques and activity modification, oral or injectable antiinflammatory or other medications, and gentle ROM and joint
367,370
stretching is often prescribed.
Careful monitoring of the
patient’s progress over 1-2 months should be reviewed with the
patient and care team to update the care plan.
130
Arguably the most important non-operative technique
to manage mild to moderate GH joint OA may be education.
e Centers for Disease Control and Arthritis Foundation
recommend self-management education as the first step in the
371
National Health Agenda for Osteoarthritis published in 2010.
Information provided to the patient can help them identify
372,373
strategies for joint preservation, activity modification,
373
and symptom control.
Physical therapy alone or combined
with a period of relative rest and medication has been offered
as an additional non-operative intervention to address specific
372-376
impairments identified.
Patients with minor deficits in
mobility and strength may be the best candidates for physical
375
therapy treatment.
It has been suggested that rehabilitation for patients with
primary GH joint OA can cause an increase in pain and decline
in patient function, which may occur when physical therapy
interventions are not appropriately matched to the patient
pain severity and irritability levels. In a case series, 129 patients
with GH joint OA showed improved pain and function up to
36 months when treated non-operatively with multi-modal
interventions including formal physical therapy, non-steroidal
anti-inflammatory medication, and corticosteroid injection.
377
Patient interview and patient-reported outcome scales
can clarify the patient’s current impairments, help set realistic
goals, and help identify and monitor the functional progress.
Communication with the physician is imperative to establish
the overall health of the joint (geometry and presence of
osteophytes). Individuals reporting rapid increase in symptoms
or complaining of persistent symptoms may be referred to
their physician for an updated treatment plan and surgical
44
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intervention.
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373,375
(See Summary of post-operative procedures:
Total Shoulder Arthroplasty Rehabilitation Pathway in Table 10.)
Post-operative Rehabilitation Principles
Considerations for the design of rehabilitation programs
for patients after shoulder surgery must involve knowledge
of the initial pathology and surgical procedure. After surgery,
safeguarding disrupted or healing tissues is paramount. In the
shoulder, it is critical to prioritize protection of the muscle
tendinous structures (for example rotator cuff) over the healing
of bone or other soft tissue. Other considerations, regardless of
the specific surgical procedure, includes the patient’s age, habits,
tissue irritability, laxity, activity requirements (household, sport,
or work), goals, and psychosocial status. Past medical and
musculoskeletal history may influence the functional prognosis,
pace, and focus of rehabilitation. e patient’s demographics
and psychosocial factors (resiliency and fear) are critical
planning considerations for the rehabilitation priorities.
e post-operative program is typically divided into 4
phases and guided by tissue healing timeframes and activity
demands. Few exceptions exist, with arthroscopic capsular
release (secondary to adhesive capsulitis or scarring related to
previous pathology or surgery), subacromial decompression,
and biceps tenotomy as examples of procedures requiring
mobilization rather than protection post-surgery to ensure the
best outcome. Recovery of normal motion is emphasized after
these procedures which involve a shorter formal rehabilitation
program.
e shoulder requires a safe environment after surgery
based on the healing timeframes after reconstructive or repair
procedures. ese timelines are used to guide the progression
to normal mobility and dynamic stability. e goals of postoperative rehabilitation focus on reduction of pain severity and
irritability of the condition followed by the development of
normal upper extremity mobility, motor control, and function.
Phase I of the program usually emphasizes tissue protection.
Most procedures including rotator cuff repair, joint arthroplasty,
or shoulder stabilization require a period of immobilization
or protection. Proper positioning and controlled activation
of the upper quarter musculature is critical to support the
shoulder and shield healing tissues from stress during normal
daily activities. e first decision in this phase, timeframe
and duration of an immobilization strategy, is often made
pre-operatively or immediately post-surgery prior to hospital
discharge. Options may include full-time (24-hour per day)
immobilization in a sling; or relative immobilization with sling
off only for showering and rehabilitation). A gentle progression
of ROM and mobility is begun during Phase I with emphasis
on the distal upper extremity and progressing to the shoulder
region. Regardless of surgery type, the majority of rehabilitation
protocols focus on the maintenance of distal upper extremity
joint (elbow, wrist, and hand) motion and function as soon as
possible after surgery. e amount and direction of shoulder
ROM allowed is based on the specific procedure and tissue
quality and response to immobility and re-mobilization.
e second phase of the rehabilitation program usually
begins between 4 and 6 weeks post-surgery with controlled
restoration of shoulder mobility primarily performed with
passive and active-assisted ROM exercises. e third phase of
the rehabilitation program is focused on progressive muscle
strengthening based on loading to the repaired tissues. e
subsequent fourth phase of rehabilitation emphasizes restoration
of performance and high-demand physical activity that may
be individualized based on the patient’s goals. e pathology
specific post-operative recommendations are highlighted in
Tables 8-10.
Rotator cuff repair post-operative rehabilitation
After rotator cuff repair, a complete immobilization strategy
is often recommended ranging from 4-8 weeks depending on
the size of the tear and tissue quality. In contrast, randomized
trials show earlier gains in mobility and function with limited/
no use of a sling in Phase I and no detriment to healing rates
378-380
of small to medium size repairs.
While physical therapists
may have a differing opinion from surgeons in how long the
patient should be immobilized following a rotator cuff repair,
381
the surgeon has the responsibility to weigh all the various
biological and surgical factors that affect healing of the repair to
determine the immobilization duration. While initially debated,
recent high-quality evidence suggests patients who experience a
re-tear have improved but compromised functional outcomes
compared to patients with healed repairs.
88,290
For many
surgeons, the risk of a re-tear may not be worth the short-term
benefit in mobility achieved with early motion or eliminating
use of a sling, that is inconsequential long-term on pain and
function. Both an early and delayed post-operative rotator cuff
repair phased progression intended to address these healing
decisions are typically used in physical therapy for patients with
rotator cuff repair. e decision of which approach to use is
based on the size of the rotator cuff tear, patient factors like age
and tissue quality of the remaining tendon, surgical technique,
and surgeon preference. Table 8 provides a summary of post-
operative rotator cuff rehabilitation pathways.
382-385
To guide the phased rehabilitation program of patients
following a rotator cuff repair, the EMG signal intensity of the
rotator cuff muscles during exercises and activities has been used
as surrogate approximation of tendon loading in a systematic
386
review
rehabilitation guidelines.
and development of post-operative consensus
382
A comprehensive understanding
of the “location” of shoulder exercises along the continuum of
rotator cuff EMG signal intensity
386,387
can be used to help with
exercise prescription through the phases of rehabilitation postsurgery. Exercises to restore mobility that produce less than 15%
of maximum voluntary contraction (MVC) of the supraspinatus
have been advocated in early Phase I.
382
Interestingly, exercises
historically not typically performed in Phase I of many postoperative protocols (for example, active supine punches)
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45
Table 8.
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Summary of Post-operative Rotator Cuff Repair Rehabilitation Pathway
382-385
Phase
Timeline
Phase I
Gradual restoration of ROM using assisted ROM exercises with EMG signal <15% of MVC
Rotator Cuff Repair
(Small-Medium)* Priorities
Rotator Cuff Repair
(Large-Massive) Priorities
(passive/assisted)
0-2 weeks Distal elbow and wrist ROM Distal elbow and wrist ROM
2-4 weeks Begin shoulder ROM for assisted FE and ER Distal elbow and wrist ROM
4-8 weeks Assisted FE progressed per tolerance 0-90° and ER
per tolerance 0-30°
Begin shoulder ROM week 5-8; assisted FE and
ER; progress per tolerance FE 0-90° and ER 0-30°
Phase II (active) Progression to functional ROM - late in Phase II muscle activation with ROM against gravity with
exercises with EMG signal up to 30% of MVC
7-12 weeks
Phase III
(endurance)
Gradual progression of AA ➙ active FE and ER to
full ROM
Gradual progression of AA ➙ active FE and ER to
full ROM beginning week 8
Progress to muscle performance activities, based on EMG signal intensity, that initially (weeks 12-16) do
not exceed 30% of MVC to those not exceeding 49% of MVC (16-20 weeks). Exercises should be pain
free, focus on good motor control, and limit fatigue.
12-20 weeks Suggested progression for muscle performance exercises during Phase III include AA to active exercises
against gravity, manual to elastic band resistance activities below 90° with progression to full controlled
active ROM
Phase IV
(strengthening)
Progression to Phase IV guided by patient and health care team input and need. Patients involved in
overhead work and sporting activities are those most often progressing to this level. Exercises progress to
those that involve ≥50% MVC based on EMG signal intensity
>20 weeks Loading progressed cautiously using control repetitions, ROM, and weight. Monitor pain, motor
control, and limit fatigue.
*Small to medium tears in younger or more active populations may have protocols with a faster timeline per surgeon recommendations.
†Treating physician specific recommendations, protocols, or prescription supersedes these summarized guidelines.
Abbreviations: AA, active-assisted; ER, external rotation; FE, forward elevation; ROM, range of motion
generate less EMG signal intensity than a pendulum exercise
and pulley assisted elevation (which has historically been used).
Also of note, exercises that produce more than 50% MVC, such
as the side lying resisted ER, prone horizontal abduction, and
dynamic hug, are often used earlier in the rehabilitation than
382
what is advocated (Phase IV) in consensus guidelines
based on
objective muscle activation data. Examples of exercises, based on
EMG signal intensity as a percentage of MVC, for each phase
387
of rehabilitation post-surgical rotator cuff repair
are shown in
the Appendix. Physical therapists are encouraged to revisit the
typical exercise progressions they may be using in post-operative
protocols and collaborate with surgeons to reprioritize the order
and use of exercises based on this information.
treatment.
asymptomatic middle aged individuals,
for a SLAP repair should be narrow. Operative treatment
options range from debridement of the labral tear, biceps
tenotomy or tenodesis, to SLAP repair with or without
capsular plication.
based on the type and extent of the SLAP lesion along with
concomitant pathology. Of great interest, a single randomized
trial comparing surgical biceps tenodesis, labral repair, or sham
surgery followed by rehabilitation for SLAP lesions shows
improvements but no significant difference in pain, function,
satisfaction
procedure compared to sham.
219
With a high prevalence of SLAP lesions in
219,389
e operative decision making is
247
and quality of life outcomes at 2 years for either
active treatment component of the sham group, rehabilitation
SLAP, capsulolabral, and Bankart repair
post-operative rehabilitation
Surgical management of SLAP lesions is generally
recommended for those who do not respond to non-operative
and non-operative management has been advocated as the first
line of intervention for patients with SLAP lesions.
In select patients who undergo surgery for a SLAP lesion,
the post-operative rehabilitation program must consider the
388
the indications
390
Because rehabilitation was the
46
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pathoanatomy and specific procedure. e program will consist
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of a sling use for comfort followed by restoration of ROM,
muscle performance, and functional return to sport activities
for those treated with biceps tenotomy and debridement
procedures. In contrast, the rehabilitation program will be
more involved and similar to other capsulolabral repairs if
more extensive surgical procedures like SLAP repair are used.
e post-operative speed of rehabilitation after Bankart repair
has slowed down as the procedure advanced from an open to
an arthroscopic surgical procedure to ensure tissue healing
354,391,392
in the young active patient.
Progression is guided by
tissue healing and a controlled loading program to improve the
opportunity for patients to return to high levels of activity. Many
individuals sustain their shoulder injury while participating in
rigorous contact sports and require the ability to participate in
training including weight lifting, cardiovascular activities, and
391
contact drills prior to full release to activity.
Table 9 provides
a summary of the post-operative rehabilitation process for
capsulolabral Bankart rehabilitation.
354,355
Latarjet post-operative rehabilitation
Patients presenting with an instability event that combines
soft tissue pathology with significant bone loss (>15% of the
glenoid) or off track lesions may require a Latarjet procedure
to correct the amount of shoulder instability associated with
393
their injury.
Other cited rationale for use of the Latarjet
procedure include failed previous stabilization and contact
394
sports participation.
e Latarjet surgery is a non-anatomic
procedure that involves transferring the bone off the distal end
of the coracoid to the anterior aspect of the glenoid to augment
the bone loss and also provide stability.
394
e rehabilitation and
return to sport timeline is variable in the reported literature based
on type and level of sport, healing of bone block, and overall
function of the patient. Rehabilitation guidelines for patients
340,341,395
recovering from the Latarjet procedure are variable.
General recommendations include immobilization for a period
of 1 to 4 weeks. Typically, ROM activities are started within the
first week and remain a focus of post-operative rehabilitation
for the first 6 weeks to allow for bone healing of the graft.
Patients are encouraged to progress overhead elevation and IR
but delay restoring ER at 0° of abduction with ER restricted
395
to neutral until 6 weeks.
Strength activities are initiated at 6
to 8 weeks and progressed to 12 weeks. Published timeframes
for return to sport are quite variable ranging from 3 weeks to 6
340,341,395
months.
Total shoulder arthroplasty (anatomical and reverse)
post-operative rehabilitation
Proposed surgical procedures to treat the symptoms and
impairments associated with GH joint OA that have been
advocated as joint preserving operations, typically indicated in
younger patients, include arthroscopic debridement, capsular
release, joint surface microfracture, autologous chondrocyte
implantation, osteochondral drilling, and interpositional
or osteoarticular grafts.
372-375,396,397
Specifics about these
interventions and post-surgical rehabilitation procedures are
beyond the scope of this work and readers are referred to cited
literature for more details.
e most common surgical intervention for older patients
with primary GH joint OA is an anatomic TSA which typically
Table 9.
Summary of Post-operative Bankart Surgery Rehabilitation Pathway
354,355
Phase Timeline Arthroscopic Shoulder Stabilization Procedures Rehabilitation Pathway: Phase Priorities
Phase I
0-6 weeks
AA to active ROM beginning between week 0-3 and progressing until week 6.
FE: 0-135°
ER @ the side: 0-30°. At week 6 begin ER @ 90° maximum ROM to 45°
Phase II
6-12 weeks
Active shoulder ROM progressed to functional as tolerated and based on need. Begin open and closed
chain scapular and rotator cuff exercises. Loading is progressed while controlling repetitions, rest cycles,
ROM, and weight. Emphasize uniplanar motion, endurance, and stability. Monitor pain, motor control,
and limit fatigue.
Phase III
12-24 weeks
Phased IV
>24 weeks
No limit to comfortable ROM. Advance to multiplanar motion. Transition from elastic resistance bands
to combination of bands, body weight, and light weight. Combine concentric and eccentric load.
Loading progressed to sport and work specific needs. Monitor repetitions, ROM, and weight. Monitor
pain, motor control, and limit muscular fatigue during functional progression. Slow progression of load
through manipulation of frequency, intensity, and duration to build endurance while protecting healing
tissue.
Abbreviations: AA, active-assisted; ER, external rotation; FE, forward elevation; ROM, range of motion
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requires an intact rotator cuff. For patients with rotator cuff tear
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arthropathy, GH joint OA with an irreparable rotator cuff tear,
some fractures, or tumors, a reverse TSA is a viable treatment
option. After anatomic TSA, recent literature has recommended
relative immobilization
398
for 2-8 weeks.
399
Patients recovering
from reverse TSA are often prescribed use of an abduction
sling followed by a transition to a regular sling after 2 weeks
with a total of 4 week of protection.
400
is decision between
relative immobilization or protection, sling type, and time
frame is often related to the initial pathology (such as revision
of TSA or fracture stabilization).
400
A 2-4 week protection
strategy requiring sling use for comfort during activities outside
the house, during rest, and sleep activities for safeguarding
the repair is indicated based on surgeon recommendation. A
gradual progressive active to light resistance ROM and exercise
program typically follows until patients are able to achieve
functional goals that are typically to return to lower-level
demand activities. Information on the rehabilitation pathway
following total or reverse TSA can be found in Table 10.
398,399
PATIENT TREATMENT OUTCOMES
Patient-reported outcome measures (PROMs) serve many
functions in the management of patients with musculoskeletal
complaints. ey not only provide a snapshot of general physical
and mental well-being, disability, functional status, pain, and/
or satisfaction regarding a condition or body region; they also
gauge progress, assess the clinical quality of providers, and
facilitate communication across healthcare disciplines and with
401
payers.
When deciding between publicly available PROMs,
important considerations include outcome utility, validity,
reliability, responsiveness to change, and scale attenuation
effects.
Patient-Reported Outcome Measures
Of primary importance is understanding the utility or
purpose of a PROM. A summary of PROMs that may be used
in patients with shoulder dysfunction is shown in Table 11. e
Short-Form 36-Item Health Survey (SF-36) and the Veteran’s
RAND 12-Item General Health Survey (VR-12) are commonly
used Health-Related Quality of Life (HRQoL) measures that
are normalized to the general population.
402-404
ey offer a
snapshot of the physical and mental health of a patient relative
to a nationally representative sample of respondents.
Regional Specic Outcome Tools
General upper extremity surveys including the Disabilities
of the Arm, Shoulder, and Hand (DASH) and its ‘quick’ version
(qDASH) describe general upper extremity disability related to
common functional demands or activities.
405,406
e DASH and
qDASH are 30 and 11 multiple choice questions, respectively,
that establish pain and disability associated with certain
activities and symptoms related to the entire upper extremity.
e scores on the 2 questionnaires are strongly correlated,
with the qDASH reducing the time required to complete the
Table 10.
Phase
Timeline
Phase I
0-6 weeks
Phase II
6-12 weeks
Phase III
12-16 weeks
Summary of Post-operative Joint Replacement Surgery Rehabilitation Pathway
Anatomic Total Shoulder
Rehabilitation Priorities
Passive and AA ROM
Limit FE: 0-90°
Limit ER: 0-20° based on physician
recommendation to protect subscapularis
Assisted FE progressed per tolerance to
120-130° and ER per tolerance to 0-30°.
IR, hand to hip.
No limit to comfortable ROM. Low
Passive and AA ROM
FE: 0-90° (0-2 weeks) progressed to 120°+ (by 4-6 weeks)
ER: 0-20° (0-2 weeks) progressed to a maximum of 45°
(by 4-6 weeks)
Begin active shoulder ROM week 4. Progress as tolerated
to functional ROM for FE and active ROM. Begin deltoid
isometrics.
Gradual progression of light deltoid exercises.
Reverse Total Shoulder
Rehabilitation Priorities
loading exercises. Focus on muscle
398,399
performance exercises below 90°.
Phase IV
16-20 weeks
(if needed)
*e pace of rehabilitation progression may vary based on surgical management of the subscapularis.
†Treating physician specific recommendations, protocols, or prescription supersedes these summarized guidelines.
Abbreviations: AA, active-assisted; ER, external rotation; FE, forward elevation; IR, internal rotation; ROM, range of motion
Loading progressed cautiously. Control repetitions, ROM, and weight. Monitor pain, motor control, and
technique during functional progression. Slow progression of load through manipulation of frequency,
intensity, and duration to build endurance while protecting healing tissue.
48
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