C

Neuromuscular Testing and Rehabilitation of the Shoulder Complex

George I. Davies, M Ed, PT, SCS, ATC' Steven Dickoff-Hoffman, MS, PT, SCS, ATC2

George j. Davies

Steven Dickoit-Hoitman

The shoulder complex plays an integral role in performing an athletic skill involving the upper extremity. The intricacy of the neuromotor components controlling shoulder motion and athletic skill is an issue that the sports physical therapist deals with on a daily basis when rehabilitating athletic patients. The purpose of this article is to review neuromotor control of the shoulder complex and describe an exercise routine developed to enhance proprioception, kinesthesia, and neuromuscular control. Clinical research studies examining the strength of the rotator cuff and scapular stabilizers, in addition to joint position sense, are reviewed. The results of these studies are discussed as they apply to the exercises described in the article designed to improve dynamic stability. The results of these studies and implementation of these exercises will help the sports physical therapy clinician assist the athletic patient and improve dynamic and neuromotor control of the shoulder.

Key Words: proprioception, neurornuscular conditioning, kinesthesia

he shoulder joint complex has been described as comprising four distinct anatomical articulations (glenohumeral, sternoclavicular, acromioclavicular, and scapulothoracic) and two physiological joints (scapulothoracic and suprahumeral o r subacromial) (1 O,45). These joints are finely controlled by muscular attachments and proprioceptors found within the joint capsule and musculotendinous unit. Coordinated function of these joints is essential for athletic function. Without appropriate neuromuscular control, the shoulder can become dysfunctional. T h e end result will be poor athletic performance and ultimate clinical svmptomatology. Shutte and Happel (68) have stated that alterations in joint innervation caused by athletic trauma can occur and markedly affect joint function. Shoulder joint kinesthesia can be adversely affected as a result of athletic trauma and lead to a variety of clinical entities that are commonly
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' Professor, University of Wisconsin-La Crosse, 243 Cowley Hall, La Crosse, WI 54601; Director, Clinical and Research Services, Western Wisconsin Sports Medicine; President, Sports Physical Therapy Section, American Physical Therapy Association Director of Sports Medkine and Rehabilitation, HealthSouthlNorthHills Sports Medicine Center, Pittsburgh, PA; Rehabilitation Consultant, Pittsbunh Pirates Baseball Club

'

treated in the sports physical therapy setting. It is the purpose of this article to review the neurophvsiological basis of neuromuscular control of the shoulder and discuss the functional implications of proprioceptive testing and exercise on athletic performance.

NEUROPHYSIOLOGICAL BASIS OF CONTROL

From an anatomical standpoint, the shoulder is intrinsically unstable. It relies on the integrity of noncontractile structures to provide static stability. These structures are the glenoid labrum, capsule, capsular ligaments, and bony articulation. T h e humeral head is approximately three times the radius of the glenoid fossa, and this anatomical relationship lends t o the intrinsic instability of

glenohumeral joint. Dynamically, the glenoid must follow the movement of the humeral head to maintain its instant center of rotation and glenohumeral congruency. Without adequate neuromuscular control of the scapulothoracic articulation, the glenohumeral joint will not function around a stable base of support (9,24,70). Therefore, coordinated activity of the glenohumeral and scapulothoracic joints is essential in providing dynamic stability of the shoulder complex. Efficiency of muscle activity is dependent upon the optimal alignment of the scapula on the chest wall and the length-tension relationship of the scapular stabilizers and rotator cuff. For optimal dynamic control during athletic activity, the scapula stabilizers must fire in a consistent and a coordinated fashion. Altera-

tiori of neuroniuscular control can lead to a n asynchronous firing pattern, leading to a maltracking glenohumeral joint which often leads t o dysfunction. Static and dynamic control of the glenohumeral joint require a stable base of support. T h e humeral depressors and rotator cuff stabilize and control movements of the glenohumeral joint around a stable scapulothoracic articulation. T h e capsular ligaments are under less tension when the glenohumeral articulation is stable, and articulation/compression of the glenohumeral joint is dependent upon arm position. Rowe (65) has shown that a favorable balance between compression and shear forces makes the shoulder elevation position of 90" the optimal position of joint stability and congruity. At this position, compression and shear forces are minimal, creating a stable humeral head in the glenoid. When the anchoring stability of the scapula is lost, the deltoid becomes less efficient, rotator cuff stabilizing strength is decreased, the humerus elevates superiorly, and the athlete develops functional subluxation leading t o suprahumeral impingement (28,47). Numerous authors (28,29,68,70,80) have researched the effect of joint injury and alteration of proprioceptive input. Distraction forces on the glenohumeral joint are tremendous during athletic activity, increasing tensile stress of the capsular ligaments and static restraints. Glenohumeral distraction leads to glenohumeral instability, proprioceptive deficits, and mechanoreceptor damage (70). When the mechanoreceptors are damaged, kinesthetic awareness of the shoulder is inhibited and the shoulder becomes dysfunctional.

Tyler and Hutton (76) have shown that coactivation firing mily protect joints from compressive and distractive forces. Hasan and Stuart (33) have stated that centrally mediated stabilization based on afferent feedback has the advantage that it can be turned off temporarily in the interest of maneuverability. This statement is important with regard to the shoulder because the shoulder joint not only requires extreme neuromuscular control, but it must also maintain excessive amounts of motion to be dynamically effective. Joint/muscle afferents detect position of the shoulder due to mechanical deformation of the capsule and proprioceptors. Intuitively, it makes sense that muscle conditioning enhances joint position, and central/peripheral control can be associated with coactivation exercises. This article discusses methods for testing shoulder kinesthesia and treatment intervention techniques employed t o improve joint position sense and kinesthesia.

FIGURE 1. Modriled lateral scapular shde testI loo.

NEUROMUSCULAR TESTING
This article presents neuromuscular testing performed by the authors that complements the physical examination techniques previously discussed. Previous publications discuss comprehensive functional examination of the shoulder complex ( 1 7).

Modified Lateral Scapular Slide Test

Since the scapulothoracic joint is a physiological joint and forms the foundation for glenohumeral joint function, it is important t o evaluate and objectively document the status of scapulothoracic joint position, arthrokinematics, and muscular power. Kibler (47) has described the lateral scapular slide test, which is an objective method to quantify the bilateral comparison of the scapula in three different positions. Kibler states that less than 1 cm of asymmetry in a bilateral comparison is within normal

limits. More than 1 cm of asymmetry is correlated t o impingement syndromes in the shoulder. However, there are no descriptive norms provided in Kibler's article. Davies et al (23) have developed a modified lateral scapular slide test (MLSST) that uses the three positions described by Kibler as well as two additional positions (Figure 1). T h e two additional positions were added because, often, patients only have complaints of pain in the overhead (above the shoulder's transverse plane level) position. T h e five test positions are described in Table 1. T h e specific procedure used in the modified lateral scapular slide test is t o measure from the T 7 posterior spinous process to the inferior angle of the scapula in all five positions. Furthermore, Davies et al (23) evaluated differences in changes from one position to the next position to determine if there were significant changes in the arm position angle. T h e results demonstrated there was not a statistically significant change from one arm position to the next.

Scapulothoracic lsokinetic Testing

Frequently, patients present with scapular winging, a dysfunction in the normal Codman's scapulohumeral rhythm, weaknesses of the scapulothoracic muscles, o r postural faults and asymmetrical scapular positions. However, other than manual
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IS KINESTHESIA TRAINABLE?
T h e early work of Sherrington (69) has shown that muscle facilitation and inhibition can enhance static and dynamic control of a joint.

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--

Position

L Shoulder

X (cm)

SD (cm)

X (cm)

R Shoulder

Data Analysis
T h e seven measurements are averaged for a mean score for the difference in degrees. T h e positive and negative signs have been deleted from the present data analysis. This is another area that lends itself t o further research regarding the specific planes of motion, shoulder angles, and correlation t o specific deficits and particular pathologies. Table 3 contains descriptive data for 100 males. Davies et al (1 9) have evaluated and reported on kinesthetic deficits that result secondary t o Bankart shoulder reconstructions. Therefore, from a clinical perspective, if a patient's scores are higher than the means, then the patient begins using many of the kinesthetic rehabilitation techniques that are described later in this article.

muscle testing, there have been few descriptions of objective testing of the scapulothoracic joint (16,46). This is the first published information of scapulothoracic Cybex (Cvbex, Ronkonkoma, NY) testing and descriptive data. T h e first author (GJD) has performed scapulothoracic isokinetic testing for patients with shoulder conditions because of the importance of a strong scapulothoracic foundation for normal shoulder function (23). Scapulothoracic protraction-retraction is tested using the positioning and stabilization illustrated in Figure 2. Table 2 contains descriptive relative data that have been normalized to body weight. Correlation to the Modtfied Lateral Scapular Slide Test As previously indicated, if a patient has an asymmetry on the modified lateral scapular slide test, it correlates with an impingement syndrome. However, the question still remains as to what caused the asymmetry. O n e plausible explanation would be muscle weakness; however, this needs to be objectively quantified. Consequently, Davies et al (23) have evaluated scapulothoracic isokinetic testing and its correlation to the modified lateral scapular slide test.

FIGURE 2. Scapulothoracrc lsoklnetic testing o i prolnction.

Effects of Fatigue on Kinesthesia

As one fatigues, the mechanics of performing an activity often change, which may lead to injury. Since there are no studies on the effects of fatigue on shoulder kinesthesia, Davies et al (22) performed a study on 75 subjects (1 50 shoulders). Several motions, including internal rotation, external rotation less than 4Fi0, and abduction greater than 9 0 , demonstrated statistically significant changes in the kinesthetic tests.

Shoulder Kinesthetic Testing

T h e importance of kinesthesia/ proprioception in the joints of the body to provide position sense, allow normal function, and prevent injury has been emphasized. When rehabiliJOSPT Yolume 18 Sumber 2*Augusr 1993

tation is performed for lower extremity problems, kinesthetic testing and rehabilitation are a very intimate part of the total rehabilitation program. However, limited studies on shoulder kinesthesia (1 3- 15,3 1,32, 35,36,43) exist, and few provide clinically useful and easily applicable testing and interpretation (50,70). Kinesthetic testing usually involves the following techniques: threshold t o sensation of movement, end range-of-motion reproduction, and angular joint replication. T h e first author has been regularly performing kinesthetic testing using angular joint replication with an electronic digital inclinometer (Cybex, Ronkonkoma, NY) on shoulder patients since the late 1980s. Table 3 lists the shoulder kinesthetic testing positions developed by Davies. Figure 3 demonstrates shoulder kinesthetic angular replication testing in abduction below 90" in the range of motion.

Functional Throwing Performance Index

There are numerous functional tests for the lower extremities. However, the literature has limited information on functional tests of the u p per extremities. Various tests described for the upper extremities include: 1) hand grip dynamometer tests; 2) isotonic strength tests (1 RM/10 RM); 3) isotonic muscular endurance tests (such as pull-ups (chin-ups), flexed arm hangs, and push-ups); 4 ) power tests (vertical rope climb); 5) sports skills tests

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Peak TorqueIBody Weight (%)(Normalized Data)

speed

Protraction

Retraction

Retraction/Protraction Ratio

N = 125 subjects (250 shoulders).

TABLE 2. Scapulothoracic protractionlretraction isokinetic testing (normalizeddata).

PreIPost Angular JointReplications Mean Average o f Absolute Difference in Degrees

Flexion < 90' Flexion > 90' Abduction < 90" Abduction > 90' External rotation < 45" External rotation > 45' Internal rotation Average Standard deviation Range
N = 100 males.

2.6
2.7 2.3 5.0

2.7 2.4 2.9 3.0 2.6 2.7

FTPI is a very practical, low-cost, easily administered, space-efficient test. It is reliable and provides a general indication of one's functional performance capabilities following an injury o r surgery. Table 4 provides descriptive data on 100 males. T h e means, standard deviations, and ranges are described for the FTPI. Reliability Study Quincy et al (6 1) performed an FTPI reliability study which demonstrated that the test-retest reliability of 2 5 male subjects performing the FTPI was .9 1.

N = 100 males

TABLE 4. Functional Throwing Performance Index

(FTPI) descriptive data-males.

ing a balance between the scapular stabilizers, rotator cuff, and noncontractile tissues is imperative. Specific techniques for meeting the above goals are discussed.

Total Arm Strength (TAS)

In both the examination and the rehabilitation process, it is important to integrate the concept of the total arm strength. Several recent articles have addressed this issue (26,67,72).

TABLE 3. Shoulder kinesthetic descriptive datamales.

NEUROMUSCULAR REHABILITATION
When developing the goals for neuromuscular conditioning of the unstable shoulder, the following principles should be employed: 1 ) Proximal stability (54); 2) glenohumeral control at the desired angle (30,49,63,7 1); 3 ) eccentric rotator cuff strength (2,7,2 1,25,48, 53,73); 4 ) flexibilitv of the internal and external rotators (5.28.58); 5) compressive stability and force couple enhancement; and 6 ) rapid accelerat ion/deceleration. i'arious books and articles have addressed rehabilitation programs. Readers are referred to the following references for additional information (3.6.8. 34,37,39,41,42.51,56,60,61,64,74, 79.8 1). U'hen developing a rehabilitation program for the shoulder, the therapist must work toward retraining muscles to balance stability and mobility, which will diminish the possibilitv of functional subluxation and eventual suprahumer;~limpingement. T h e importance of establish-

Specific Principles of Neuromuscular Rehabilitation

When dealing with some of the common shoulder problems seen in a sports medicine clinic, such as impingement syndromes (hypomobile and hypermobile) and anterior instabilities (microsubluxators, subluxators, and dislocators), we try to emphasize three points: I ) increase dynamic caudal glide provided bv the rotator cuff muscles, 2) increase range of motion of the posterior capsule and flexibility of the posterior rotator cuff niuscles (infraspinatus and teres minor), and 3) create a posterior "biased" dominant shoulder. Dpamic Caudal Glide As Inman et al (38) described, restoration of dynamic caudal glide is critical for normal arthrokinematics of the shoulder. Furthermore, superior miVolume 18 Number 2 August 1993

FIGURE 3. Shoulder hecthetrc anjqhr replrcatron tectrng (abduction 90".

(sports-specific skill tests); and 6 ) softball distance throw (nlaximunl distance). However, most of these tests are not appropriate for patients. nor d o thev lend thenlselves to be performed in most phvsical therapy clinics. Davies (20) developed a clinically-oriented Functional Throwing Performance Index (FTPI). T h e

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gration of the head of the humerus in the glenoid fossa during overhead activities can be prevented. Increase Range of Motion and Flexibility of the Posterior Shoulder Many patients have a hypomobile posterior capsule and/or decreased flexibility of the posterior rotator cuff muscles (infraspinatus, teres minor). A hypomobile/tight posterior shoulder causes anterior migration of the humeral head, placing additional stress on the anterior capsule/ synovium (9). Posterior "Biased" Dominant Shoulder In analogy t o what has been learned from patients who had anterior cruciate ligament (ACL) deficiency reconstruction, we questioned how t o bias o r focus o u r rehabilitation program. Years ago, when we rehabilitated ACL patients, emphasis was placed on the quadriceps muscles (not understanding back then that potentially harmful anterior translation could occur). With the realization that the hamstrings are synergistic with the ACL, rehabilitation programs that emphasized selective strengthening of the hamstrings to produce a "hamstring dominant knee" were developed. Rehabilitation programs for anterior shoulder instabilitv have met with limited success. Most rehabilitation programs emphasize the only anterior dynamic stabilizer (subscapularis), which may paradoxically lead to increased anterior translation (9). T o draw a parallel to the knee, it is hypothesized that the posterior cuff mav be svnergistic in preventing anterior translation of the humeral head. Limited research (9,59,66) has addressed this concept. Using the knee as a model once again, most knee pathologies cause deficits more frequently in muscle power of the quadriceps than the hamstrings. Likewise, most pathologies of the shoulder create a preferential muscle power deficit of the external rotators rather than the internal rotators. Consequently, in many shoulder conditions, we try to create a posterior
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"biased" dominant shoulder to negate anterior translation of the humeral head. This is performed by focusing on and emphasizing many of the exercises through positioning, gravity, etc., to stimulate the infraspinatus, teres minor, and posterior deltoid. T h e posterior "biased" dominant shoulder involves specific unilateral muscle group ratios with the goal of a 10% increase in the unilateral ratio. This changes the ratio to increase the proportional muscle power of the external rotators.

The objective of a kinesthetic rehabilitation program is to facilitate the shoulder's performance of a complicated skill without conscious

Impulse Inertial Exercise

Impulse Inertial Exercise (Impulse Inertial System, Engineering Manufacturing Associates, Newman, GA) has been available for approximately 15 years. However, few studies (1,2,52) have evaluated the efficacy of this mode of exercise. Several empirical guidelines have been proposed by various authors (l,2), but no prospective controlled randomized experimental o r outcome studies are available. Recently, Johnston and Davies (44) began a training study of impulse inertial exercise of shoulder rotator cuff muscles on the effects of muscle power, kinesthesia, and an FTPI test.

Kinesthetic Rehabilitation
Kinesthesia, as defined by Newton (55). is the ability to discriminate joint position, relative weight of body parts, and joint movement, including direction, amplitude, and speed. T h e objective of a kinesthetic rehabilitation program is to facilitate the shoulder's performance of a complicated skill without conscious guidance. This sequence involves both open and closed kinematic chain conditioning t o facilitate joint proprioceptors t o enhance stability and dvnamic control (Table 5). Sequence When we perform kinesthetic rehabilitation techniques for the shoulder, we usually begin

Scaption Rowing Lower trapezius Sitting push-ups Push-ups with a 'plus" Internal rotationlexternal rotation endurance velocity spectrum-concentric/eccentric 0 2 isokinetic velocity spectrum-concentric1 eccentric Plyometric wall push-ups Sitting table slide Propr~oceptive neuromuscular facilitation rhythmic stabilization techniques Internal rotationlexternal rotation tubing plyometrics D2 flexionlextension plyometrics Ball toss into Plyoback-chest, soccer, 90190 Profitter-side-to-side Quadrupedltripod balancing Step walking on plyoboxes-'wheel barrel" Push-ups on uneven objects, Physioball Mimic functional skill in front of mirror
TABLE 5. Kinesthetic rehabilitation techniques.

with closed kinetic chain exercises. Although there is limited research, the closed kinetic chain exercises cause axial loading and compression in the joint, therefore, increasing noncontractile stability. This causes cocontraction of agonist/antagonist muscle groups, thereby creating increased dvnamic joint stability. Progression Various parameters can be considered in the progression of the patient, such as: 1 ) submaximal to maximal effort, 2) slow to faster speeds in execution of

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the activity patterns. 3 ) known to unknown patterns. 4 ) different positions of the shoulder and arm, and 5) stable to increasingly unstable surface areas.

Open Chain Exercises

T h e goal of open chain strengthening is to provide proximal control of the scapulothoracic joint to facilitate a stable base of support for glenohumeral mobility. T h e scaption exercise has been shown t o optimally align the rotator cuff and scapular stabilizers in a favorable length-tension relationship (2). These exercises are performed with elevation of the arm in the scapular plane with humeral external rotation o r internal rotation. A variety of different forms of resistance can be employed, including surgical tubing, manual resistance, isotonics, and isokinetic resistance. Jobe (4 1) has identified four "core" exercises that are important for facilitating glenohumeral and scapulothoracic control. These include scaption, rowing, lower trapezius strengthening, push-ups with a "plus," and sitting push-ups. T h e rowing exercise is important because it strengthens the scapular adductors in a both concentric and eccentric fashion. T h e lower trapezius exercise facilitates scapular depression and rotation. Push-ups with a "plus" are effective in improving strength of the scapular retractors and stabilizers, including the serratus anterior. T h e sitting push-up is important in stabilizing the scapular depressors and glenohumeral stabilizers. Other open chain exercises include scapular protractionlretraction, which can be employed manually. These exercises decrease the tensile overload of contractile and noncontractile tissue and create a proprioceptive awareness of scapular control. T h e D2 diagonal pattern exercise can be employed t o mimic functional directionality and faciliate triplanar conditioning (57). Concentric, eccentric, and ply-

ometric muscle activity can be employed, mimicking functional strength. T h e internal/external rotators can be exercised in a modified neutral position (1 8,20) at the early phase of conditioning, leading up to the 90190 position, which is the optimal position for glenohumeral congruity and stability. These exercises should be performed at a functional speed consistent with athletic activity. Manual resistance o r surgical tubing can be applied to resist against the athlete's effort to accelerate the arm at a speed that is considered "functional." It should also be performed to fatigue, o r when the athlete loses the ability t o maintain the shoulder in a 90" abducted position. T h e 90190 position can also be utilized isokinetically, whereby a robotic dynamometer can provide concentric and eccentric resistance through a velocity spectrum. T h e D2 flexion/extension pattern (Figure 4) can also be replicated isokineticallv.

FIGURE 4. ItoAtnettc recrctance o i the shoulder in the DL pattern.

Closed Chain Exercises

T o balance compression and shear forces of the glenohumeral joint, strengthening of the shoulder joint in a closed pack position will result in less tensile stress of the capsular ligaments and facilitate cocontraction of dynamic stabilizing structures. Rowe (65) has shown that t o balance compression and shear forces, shoulder elevation at 90" is the optimal position for joint stability. In this position, the head of the humerus is stabilized centrally in the glenoid fossa, and distraction forces with mechanical deformation of the mechanoreceptors are minimal. Enhancement of static stability in a closed kinetic chain helps to "educate" the proprioceptors t o balance the shoulder girdle musculature when functioning dynamically. T h e following exercises describe methods by which closed kinetic chain conditioning of the shoulder girdle complex can be implemented.

T h e push-up with a "plus" can be performed on the floor, wall, table, o r any other unyielding surface. T h e "plus" phase of this exercise helps t o facilitate scapular protraction and serratus anterior strengthening while maintaining the shoulder joint in a 90" elevated position. T h e sitting push-up is advocated by Jobe et al (40,4 1). It facilitates strengthening of the scapular depressors. Quadruped and tripod balancing (Figure 5) in an all-fours position helps to facilitate cocontraction of antagonists and scapular strengthening. T h e therapist can manually challenge the patient in this position t o further enhance dynamic control. T h e Pro Fitter (Fitter International, Alberta, Canada) (Figure 6), Stairmaster (Stairmaster Sports Medical Products, Kirkland, U'A), o r Kinetron (Cpbex, Ronkonkoma, NY) can be used to facilitate both dynamic and static control of the glenohumeral joint and scapular stabilizers. Varying the speed and applying plyometric resistance are methods by which advanced training of the scapular stabilizer muscles can
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Tightness of the external rotators has been shown to result in anterior translation and superior migration of the humerus.
FIGURE 5. Therapist challenge to tr~pod balance.

subluxation force on the arm (58). Passive flexibility in the 90/90 position is important t o facilitate normal throwing mechanics and minimize suprahumeral migration.

Plyometrics
Plyometric exercises are characterized by powerful muscle contractions in response to rapid dynamic loading o r stretching of the involved muscles (1 1,12,27,62). They are of short amplitude followed by a maximal contraction. Plyometric activity consists of an eccentric phase, which is the sliding of actin and myosin filaments with stretch of the series elastic components. An amortization phase, which is the time between the eccentric prestretch and the resultant concentric phase, follows. After the eccentric phase, an instantaneous reflex response results from stretching the series elastic components and the muscle spindle. Release of potential energy is triggered by the myotatic stretch reflex, resulting in a rapid and ballistic concentric muscle contraction, which is the power o r performance phase. From a physiological standpoint, the rate of stretch is more important than the magnitude of stretch (4,11,62). T h e muscle spindle is responsible for monitoring the rate and magnitude of change in length of muscle. Following the eccentric phase of plyometric activity, the muscle spindles facilitate a myotatic stretch re-

FIGURE 6. Exercises on the ProfitteP

be employed. Push-ups on uneven objects, such as a physioball, box steps, o r balance board, can also be implemented to further stress the scapular stabilizers.

flex, resulting in an excitatory contraction of the agonist. T h e golgi tendon organ, which is sensitive to tension and inhibitory to the agonist, monitors the muscular response. T h e favorable balance between the muscle spindle and golgi tendon organ coordinate the ballistic concentric muscle activity that is stored in the series elastic component and results in the generation of a dynamic response. From a functional standpoint, many athletic activities employ plyometric muscle function. T h e late cocking phase of throwing is one example where an eccentric contraction of the internal rotators followed by an amortization period and then a quick ballistic response of the internal rotators results in rapid propulsion of a ball o r other implement (78). Racquet sports and swinging a golf club o r baseball bat also employ this type of muscle action (1 1). From a neuromotor standpoint, plyometric activity is one of the most functional exercises an athlete can perform to replicate the muscle activity that will be called upon during ath!etic activity. Plyotech System (Plyopack) T h e Plyotech System'" (Functionally Integrated Technologies, Watsonville, CA) (Figure 7) has been developed

Flexibility Exercises
T h e importance of passive flexibility, particularly in internal and external rotation, has been previously emphasized (5,28,58). Tightness of the internal and external rotators can result in abnormal shoulder mechanics, particularly when throwing an object. Tightness of the external rotators has been shown t o result in anterior translation and superior migration of the humerus (9). Tightness of the internal rotators has been shown t o result in an athlete "opening up early," leading with their shoulder and creating an anterior
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FIGURE 7. 90/90toss into Plyoback".

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to allow patients to perform plyometric rehabilitation exercises using a medicine ball on their own. T h e device is versatile, providing a variable angle on the Plvopack, and there are five different medicine ball sizes t o allow for progression and overload. Several authors (1 2,27,62, 77,78) have recommended various plyometric/medicine ball exercises; however, there are n o controlled research studies demonstrating their efficacy. Exercises and Progression In order to implement a plyometric program, the therapist should carefully analyze the specific skills of the sport and attempt to replicate these skills and/or the muscle demands in the plyometric exercise. An upper extremity plyometric program must be preceded by appropriate stretching and warm-up, followed by cool-down and relaxation. Since this is an advanced program, the athlete should have been on an isotonic and isokinetic progressive exercise program prior t o implementing the plyometric training program. A progression of plvometric exercise for the upper extremities includes a chest pass with a medicine ball, a soccer-stvle pass, self-tossing in a supine position, soccer-and-chest

passing into a Plyoback, passing into a wall, and a unilateral ball toss. T h e one-handed baseball throw in a 901 9 0 position is useful for throwers. Surgical tubing can be used to apply plyometric resistance in a modified neutral position, scapular plane, D2 diagonal pattern (Figure 8), and 901 9 0 position. Plyometric push-ups can also be performed into a wall, table, o r physioball (Figure 9). Following plyometric exercise, the athlete embarks on a functional progression program, performing specific skills that they will be asked t o d o when competitive. T h e Profitter'" (Fitter International, Alberta, Canada) can be used to enhance dynamic control of the shoulder by performing plyometric exercise in a lateral side-to-side directi~ and back, unilaterally anc

the Davies' Shoulder Functional Shoulder Rating Scale (20). Results using this scale applied to 3 6 patients with a functional dynamic subluxation are described in Table 6.

SUMMARY
O n e of the purposes of this article was to present testing techniques of the shoulder complex, such as modified lateral scapular slide test and descriptive data, scapulothoracic isokinetic testing and descriptive data, shoulder kinesthetic angular replication testing and descriptive data, and a functional throwing performance index and descriptive data.

ASSESSMENT OF OUTC( STUDIES

This article has descr ious testing and treatmen for neuromuscular consid the shoulder. When asses: cacy of treatment, it is im establish comprehensive a gent criteria. As an exam1 al (75) indicate that the R der rating score is not ser enough in determining fu stability. Therefore, t o ml prehensivelv assess the efi our treatment interventio

FIGURE 8. Plvometric D2 with tubing. 456

FIGURE 9. Plvometrrc puch-upc rnto a Phvooball".

TABLE 6. Uutcorne studv ot rehabrlrtatron ot rotator curl rmprngernent svndrorne secondaw to dvnarnrc iunctronal subluxatron.

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Furthermore, several rehabilitation techniques f o r the shoulder have been described, including isokinetic exercise, Impulse Inertial exercise, plyometrics, and clinical kinesthetic rehabilitation. These techniques are clinically applicable and will aid i n the treatment o f athletes requiring neuromuscular retraining o f the shoulder and complaining o f impingement and functional JOSPT subluxation.

ACKNOWLEDGMENTS
T h e authors acknowledge and express thanks t o professional colleagues w h o assisted w i t h data collection: Richard Quincy, MS, P T , A T C ; Kris Lawson, M A ; and Brian Heiderscheit f o r their assistance i n testing and research. T h e authors acknowledge Brian Jones f o r his assistance i n manuscript preparation and statistical analysis. W e also thank Sue Haugstad f o r her typing and manuscript preparation and T o d d Davidson and Dan Williams, P T , f o r their contributions t o this manuscript.

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Volume 18 Number 2 August 1993 *JOSPT