Rehabilitation of shoulder
injuries
Muscle Origin Insertion Innervation Action
Supraspinatus Medial 2/3 of the greater tuberosity of the Suprascapular nerve (C5, -Stability of shoulder joint;
supraspinous fossa of the humerus C6) -Initiation of abduction of
scapula
arm to 15o at shoulder
joint
Infraspinatus Medial 2/3 of the infra- greater tuberosity of the Suprascapular nerve (C5, -Stability of shoulder joint
spinous fossa of the scapula humerus C6) - Lateral rotation of arm .
Teres minor Upper 2/3 of the lateral greater tuberosity of the Axillary nerve (C5, 6) -Stability of shoulder joint
border of the scapula humerus. -Adduction and lateral
rotation of arm
Subscapularis Medial 2/3 of subscapular Lesser tuberosity of Upper and lower -Stability of shoulder joint
fossa . humerus subscapular nerves (C5, -Adduction;& medial
C6) rotation of the arm .
Shoulder impingement
Definition:
Normally shoulder movement relies on muscles to both move the arm and stabilize the humeral
head within the center of the joint.
• Primary impingement occurs through repetitive overhead activity which narrows the
subacromial space and can result in tendon injury.
• Secondary impingement occurs when there is too much mobility within the shoulder joint
from excessive motion and weak support muscles, which if it happens excessively can also cause
impingement.
Examination
1) History:
a) Most commonly patient does not come in acute stage but after shoulder symptom fail to resolve by rest.
b) Onset:
• sudden --------traumatic &
• Gradual --------------degenerative
c) Pain (with overhead activities-----sleeping on the involved side referred to lateral aspect of upper arm----
may lead at end to functional loss).
d) Loss of motion: Prolonged shoulder pain causes the patient to restrict instinctively the range
of use and often results in an initial adhesive capsulitis.
e) weakness and inability to raise the arm may indicate that the rotator cuff tendons are actually torn.
Common Functional
Limitations/Disabilities:
1-When acute, pain may interfere with sleep, particularly when rolling onto the involved
shoulder.
2-Pain with overhead reaching, pushing, or pulling.
3-Difficulty lifting loads.
4-Inability to sustain repetitive shoulder activities (such as reaching, lifting, throwing, pushing,
pulling, or swinging the arm).
5-Difficulty with dressing, particularly putting a shirt over the head.
Examination
1)inspection:
a) Rounded shoulder with internal rotation of
glenohumeral joint.
b) Forward head posture.
c) Winging of the scapula (weakness of
serratus anterior) or Sprengel’s deformity).
2) Palpation:
a) Tenderness at rotator cuff tendons.
b) Spasm of surrounding ms (upper trapezius,
deltoid, levator scapula).
Examination
3) ROM:
• There is painful arc of abduction between 60 to 120 degrees due to pinching of inflamed tender structure
under acromion process and coracoacromial ligament.
• Pain in the last 10 degrees of abduction is due to pathology at acromioclavicular joint.
• May led to frozen shoulder (adhesive capsulitis). (Figure 11.12)
Examination
4) Muscle test:
Manual motor testing for the rotator cuff muscles:
A. Geber's lift-off test for subscapularis
In this position, the patient attempts to move the hand away from the lower back by extending and
further internally rotating the arm. The examiner can also provide resistance to this movement if the
patient is able to complete the movement Fig (11.13.A).
B. External rotation with adducted and elbow flexed 90 degrees for test of the infraspinatus and teres
minor. Fig (11.13B)
C. Arm abduction 90 degrees in the scapular plane (30 degrees) anterior to the coronal plane of the body
and internal rotation for test of the supraspinatus. Fig (11.13C)
D. Serratus anterior---forward flex arm till 90 apply backward force to the arm ----medial border of the scapula wing.
Manual motor testing for the rotator cuff
muscles
Shoulder Special Tests
Neer’s
Hawkins Kennedy
Empty Can Test
Neer’s Test
Posture: Patient seated with examiner standing
Fixation: Ipsilateral scapula to prevent protraction
Test: Passive forward elevation of the arm with internal
rotation
Positive: Pain in the shoulder
Hawkins Kennedy
Posture: Patient seated with arm in 90° forward elevation
Test: Passive forced internal rotation at different degrees of
ab/adduction
Positive: Pain in the shoulder
Empty Can Test
Posture: Patient seated with arm in 90° abduction, 30°
horizontal adduction and full internal rotation Test: Resist
abduction/flexion
Positive: Pain in the shoulder; muscle weakness
Modification: Repeat with full external rotation to reduce
pain
Rotator Cuff Tests
External Rotation Lag Sign
For: Posterior Cuff Integrity
Posture: Patient seated with the back towards the examiner.
The shoulder in 20º abduction, the elbow in 90º flexion and
maximal external rotation minus 5º to avoid elastic recoil in
the shoulder.
Test: Maintain this position
Positive: Unable to maintain position
Rotator Cuff
Tests
Belly Press Test
For: Subscapularis Integrity
Posture: Patient seated with arm 45° and full
internal rotation
Test: Resist further internal rotation
Positive: Weakness present
SLAP Tests
SLAP Tears "superior labrum from anterior to posterior.":
A SLAP tear is an injury to part of the labrum of the shoulder. The labrum is the ring of cartilage
that surrounds the socket of the shoulder joint.
Anterior Slide Test
Biceps Load II Test
Anterior Slide
Test
For: SLAP
Posture: standing or sitting, hands on the hips with the
thumbs pointing posteriorly.
Fixation: the examiner places one hand on top of the
shoulder from posterior, with the index finger over the
anterior aspect of the acromion. The other hand is
placed behind the elbow.
Test: A forward and slightly superior directed force is
supplied to the elbow and upper arm. The patient is
asked to push against this force
Positive: pain or a click in the front of the shoulder
under the examiner’s hand.
Biceps Load II
For: SLAP
Posture: Supine with arm abducted to 120° and
maximally externally rotated, elbow at 90° and
forearm supinated.
Test: Resist elbow flexion
Positive: Pain
Instability Tests
Apprehension Test
For: Anterior Instability
Posture: Patient supine, 90° abduction and
maximal external rotation
Test: Anterior force through posterior aspect of
humeral head
Positive: Apprehension or pain
Instability Tests
Relocation Test
For: Anterior Instability
Posture: Patient supine, 90° abduction and
maximal external rotation
Test: Posterior force through anterior aspect of
humeral head
Positive: Relief of pain
Acromioclavicular
Tests
O’Brien Test
For: AC Joint Dysfunction or SLAP
Posture: Patient standing in front of examiner.
Arm 90° forward flexion, 10-15 ° adduction and
full internal rotation
Test: Resist Flexion. Repeat with supinated wrist
Positive: Pain over ACJ when in internal rotation
OR Pain in shoulder
Acromioclavicular
Tests
AC Joint Tenderness Test
For: AC Joint Dysfunction
Posture: Patient sitting
Test: Palpation ACJ
Positive: Pain over ACJ
Horizontal Adduction
For: AC Joint Dysfunction
Posture: Patient sitting
Test: Passive Horizontal Adduction
Positive: Pain over ACJ
Shoulder Impingement
Rehabilitation
Phase 1: Maximal protection – Acute phase
Goals
• Relieve pain and swelling
• Decrease inflammation
• Retard muscle atrophy
• Maintain/increase flexibility
Active rest
• Eliminate any activity that causes an increase in symptoms
Shoulder Impingement
Rehabilitation
Range of motion
• Pendulum exercises
• Active-assisted ROM – limited symptom-free available range
o Rope/pulley: flexion
o L-bar: flexion with neutral external rotation
Joint mobilizations
• Grades 1 and 2
• Inferior and posterior glides in scapular plane
Shoulder Impingement
Rehabilitation
Modalities
• Cryotherapy
• Transcutaneous electrical stimulation (TENS), high-voltage galvanic stimulation (HVGS)
Strengthening
• Isometrics – submaximal
o External rotation
o Internal rotation
o Biceps
o Deltoid (anterior, middle, posterior)
Shoulder Impingement
Rehabilitation
Criteria for Progression to Phase 2
• Decreased pain and/or symptoms
• Increased ROM
• Painful arc in abduction only
• Improved muscular function
Phase 2: Motion phase – subacute phase Goals
• Reestablish nonpainful ROM
• Normalize arthrokinetics of shoulder complex
• Retard muscular atrophy without exacerbation of pain
Shoulder Impingement
Rehabilitation
Range of motion
• Rope/pulley: flexion, abduction
• L-bar
o Flexion
o Abduction (symptom-free motion)
o External rotation in 45o abduction, progress to 90o abduction
o Internal rotation in 45o abduction, progress to 90o abduction
o Initiate anterior and posterior capsular stretching
Shoulder Impingement
Rehabilitation
Joint mobilization
• Grades 2,3,4
• Inferior, anterior, and posterior glides
• Combined glides as required
Modalities
• Cryotherapy
• Ultrasound/phonophoresis
Strengthening exercises
• Continue isometric exercises
• Initiate scapulothoracic strengthening exercises (see scapular exercise program)
• Initiate neuromuscular control exercises
Shoulder Impingement
Rehabilitation
Criteria for Progression to Phase 3
• Painless active ROM.
• No shoulder pain or tenderness.
• Satisfactory clinical examination.
Phase 3: Intermediate strengthening phase
Goals
• Normalize ROM
• Symptom-free normal activities
• Improve muscular performance
Range of motion
• Aggressive L-bar active-assisted ROM in all planes
• Continue self-capsular stretching (anterior-posterior)
Shoulder Impingement
Rehabilitation
Strengthening exercises
• Initiate isotonic dumbbell program
o Side-lying neutral : Internal rotation , External rotation
o Prone : Extension Horizontal abduction
o Standing : Flexion to 90o , Supraspinatus
o Initiate serratus exercises
o Wall pushups
o Initiate arm ergometer for endurance
Shoulder Impingement
Rehabilitation
Maintenance Exercise Program:
Flexibility Exercises
• L-Bar: • Flexion • External rotation and internal rotation at 90o abduction
• Self-capsular stretches
Isotonic Exercises
• Fundamental shoulder exercises
• Perform 3 times a week
Shoulder Impingement
Rehabilitation
Criteria for progression to phase 4
• Full, nonpainful ROM
• No pain or tenderness
• 70% of contralateral strength
Phase 4: Dynamic advanced strengthening phase
Goals
• Increase strength and endurance
• Increase power
• Increase neuromuscular control
Isokinetic testing : • Internal and external rotation modified neutral • Abduction-adduction
Thank you
