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Manual Therapy (2003) 8(4), 195206

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1356-689X/03/$ - see front matter
doi:10.1016/S1356-689X(03)00094-8

Masterclass

Dynamic evaluation and early management of altered motor control around the
shoulder complex

M.E. Magarey, M.A. Jones

Discipline of Physiotherapy, School of Health Sciences, University of South Australia, Adelaide, Australia

SUMMARY. Altered dynamic control appears to be a signicant contributing factor to shoulder dysfunction.
The shoulder relies primarily on the rotator cuff for dynamic stability through mid-range. Hence, any impairment
in the dynamic stabilizing system is likely to have profound effects on the shoulder complex. The rotator cuff
appears to function as a deep stabilizer, similar to the transversus abdominus and vastus medialis obliquus, with
some evidence of disruption to its stabilizing function in the presence of pain. Similarly, serratus anterior appears to
function as a dynamic stabilizer, also demonstrating altered function in painful shoulders. Examination of dynamic
control begins with a detailed examination of posture, evaluation of natural movement patterns and functional
movements and assessment of the specic force couples relevant to shoulder function. One useful strategy in
management of altered motor control related to these force couples is that of training isolated contraction of the
rotator cuff prior to introduction of loaded activity, together with facilitation and training of appropriate scapular
muscle force couples serratus anterior and trapezius, in relation to arm elevation.
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INTRODUCTION effective in other areas of the body (Richardson &

The focus of this paper is assessment and manage-
ment of dynamic control of the shoulder complex.
The shoulder is a mobile joint that relies heavily for
mid-range stability on muscle control (Schenkman &
Rugo de Cartaya 1987, 1994; Lippitt & Matsen 1993;
Lippitt et al. 1993; Souza 2000; Ciullo 1996; Kibler
1998a; David et al. 2000). Therefore, evaluation of
such control and treatment directed at its improve-
ment should form an integral part of management of
all shoulder disorders. The programmes suggested are
yet to be subjected to the rigours of scientic
evaluation but follow principles demonstrated to be
Received: 1 November 2001
Revised: 7 March 2003
Accepted: 4 July 2003
Mary E Magarey Dip Physio, Grad Dip Advanced Manip Therapy,
PhD, Mark A Jones, BS(Psychology), RPT, Grad Dip Advanced
Manip Therapy, MAppSc (Manipulative Physiotherapy), Discipline
of Physiotherapy, School of Health Sciences, University of South
Australia, North Terrace, Adelaide, South Australia 5153,
Australia.
Correspondence to: Tel.: +61-8-8302-2768; Fax: +61-8-8302-
2766.
Jull 1995; OSullivan et al. 1997a, b, 2000; Richard-
son et al. 1999). They are based on research on
muscle function and control (Hodges & Richardson
1996; OSullivan et al. 1997a, b, 2000; Richardson
et al. 1999; Cowan et al. 2000, 2001; Shumway-Cook
& Woollacott 2001), reports from other experienced
clinicians (for example, Wilk & Arrigo 1992; Kibler &
Chandler 1994; Wilk 1994; Kibler 1998a, b; Chmie-
lewski & Snyder-Mackler 2001; McConnell 2001)
coupled with extensive clinical experience within a
framework of sound reective reasoning (Jones et al.
2000) and knowledge of patterns of presentation of
shoulder disorders (Magarey 1999).
Panjabis (1992) now familiar concept of a neutral
zone for the lumbar spine as a zone in which
translatory movements are available can equally be
applied to the glenohumeral joint (Hess 2000). The
capsulolabral structures (passive restraints) are re-
sponsible for setting the limits of passive movement
(Jobe 1990; OBrien et al. 1990; ODriscoll 1993;
Pagnani & Warren 1994) with the muscles, inuenced
in their activity by their neural control, responsible
for maintaining the humeral head centred in the

195
 ARTICLE IN PRESS
196 Manual Therapy
glenoid fossa during mid-range movements, thus
stiffening the joint (Schenkman & Rugo de Cartaya
1987, 1994; Lippitt & Matsen 1993; Lippitt et al.
1993; Wilk 1994; Burkhart 1996; Ciullo 1996; David
et al. 1997, 2000; Kibler 1998a). Any disruption to
those mechanisms can lead to abnormal translation
of the humeral head during active movement. In
relation to the scapula, muscle and neural inuences
are very important to its stability as its ligamentous
attachments are limited to those of the acromiocla-
vicular joint (Kibler 1998b).
The balance of muscle activity within force couples
is often more important to normal function than
isolated strength of individual muscles (Kibler 1998a,
b; Kibler & Chandler 1994). Such balance is
determined by the length of muscle and associated
fascial tissue and the pattern of recruitment. When
tested in isolation in a classic isometric manual
muscle test, a muscle may test strongly, but perform
poorly during functional activity.
Kibler (1998a) used the term, the length-depen-
dent pattern of muscle activity to describe co-
contraction force couples which operate locally
around a joint, controlled by feedback from muscle
spindle receptors and responding to perturbations of
joint position. The primary function of such force
couples is maintenance of joint stability.
One key force couple relevant to stability of the
glenohumeral joint is that between the lower elements
of the rotator cuff subscapularis anteriorly and
infraspinatus/teres minor posteriorly (Saha 1971;
Poppen & Walker 1978; Kapandji 1982; Soderberg
1986; Schenkman & Rugo de Cartaya 1987, 1994;
Norkin & Levangie 1988; Burkhart 1994, 1996; Wilk
1994) (Fig. 1). These muscles are ideally placed to
draw the humeral head into the glenoid and maintain
its axis of rotation, so that they can perform their role
of concavity compression (Saha 1971; Lippitt &
Matsen 1993; Lippitt et al. 1993; Sharkey & Marder
1995; Wuelker et al. 1995, 1998). Failure of function
of these muscles in their stabilizing role will lead to
creation of an abnormal axis of rotation (Poppen &
Fig. 1Pictorial representation of the transverse and coronal plane
force couples of the rotator cuff, demonstrating the role of the
infraspinatus posteriorly and subscapularis anteriorly to draw the
humeral head into the glenoid fossa. Reproduced with kind
permission of Williams & Wilkins, Baltimore, from Burkhart
(1996).
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Walker 1978; Howell & Galinat 1987; Schenkman &
Rugo de Cartaya 1987, 1994; Howell et al. 1988;
Souza 2000) and abnormal translation of the head of
humerus (Burkhart 1994, 1996).
In the scapulothoracic area, the force couples
associated with movement overhead alter through
range, as the axis of rotation changes with increasing
elevation and plane of movement (Inman et al. 1944;
Poppen & Walker 1978; Dvir & Berme 1978;
Schenkman & Rugo de Cartaya 1987, 1994; Bagg &
Forrest 1988; Culham & Laprade 2000; Abelew
2001), but the primary contributors are serratus
anterior and trapezius (Inman et al. 1944; Basmajian
1963; Kapandji 1982; Bagg & Forrest 1986, 1988;
Schenkman & Rugo de Cartaya 1987, 1994; Norkin
& Levangie 1988; Souza 2000). In the early part of
range, when the axis of rotation is at the root of the
scapular spine, the principal rotators are the upper
bres of both serratus anterior and trapezius (Bas-
majian 1963), whereas when the axis of rotation
moves towards the acromioclavicular joint, the
relative contribution of upper trapezius lessens while
that of lower trapezius increases, together with the
lower bres of serratus anterior (Basmajian 1963;
Schenkman & Rugo de Cartaya 1987, 1994) (Fig. 2A,
B). Serratus anterior is, therefore, a signicant
component of the force couple throughout range
(Bagg & Forrest 1986).
David et al. (2000) demonstrated consistent activa-
tion of the rotator cuff prior to the more supercial
delto-pectoral muscles during isokinetic rotation in
normal shoulders, conrming their role as dynamic
stabilizers for the glenohumeral joint. Similarly,
analysis of activation during rotation in the normal
shoulder revealed that at least one component of the
antagonist rotator cuff was always active (David et al.
2000), providing evidence of their stabilizing role.
Strong evidence is available that pain alters the
timing of contraction in stabilizing muscles
transversus abdominis and multidus in relation to
the lumbar spine (Hides et al. 1994, 1996; Richardson
& Jull 1994, 1995; Hodges & Richardson 1996, 1998;
Hodges et al. 1996; OSullivan et al. 1997a, b, 2000),
vastus medialis obliquus in relation to the knee
(Cowan et al. 2001). Preliminary continuation of our
shoulder stabilization research (David et al. 2000)
with unstable shoulders has shown widely differing
patterns of onset of muscle activity, with failure of
the rotator cuff and biceps to be activated prior to the
delto-pectoral group and, in some instances, failure
to re until after the onset of movement thus
demonstrating a similar disruption to stabilizing
function as found in the knee and lumbar spine.
Kibler (1998b) considered that serratus anterior
and lower trapezius are susceptible to inhibition in
painful shoulders. This inhibition is seen early as a
non-specic response to any painful condition in the
shoulder, presenting as a disorganization of the
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Altered motor control around the shoulder complex 197

Fig. 2Force couples around the scapula relevant in arm elevation (Adapted from Bagg and Forrest 1986; Kapandji 1982). Depicted is the
most common pattern of muscle recruitment reported by Bagg and Forrest (1986). (A) In the rst 601, the axis of rotation of the scapula is
situated at the root of the spine of the scapula. Primary muscles involved in upward rotation of the scapula are lower bres of serratus
anterior and upper trapezius, working via the clavicle, with lower and middle trapezius functioning eccentrically to control the movement. In
this range, muscle function is highly variable. (B) In the next 601, the axis of rotation begins to move along the spine of the scapula towards
the acromioclavicular joint. This means that the emphasis of contribution of the muscles changes, with the bres of lower trapezius now
becoming more actively involved in upward rotation, along with those of lower serratus anterior and upper trapezius. (C) By the time the
arm reaches 1201 of elevation, the axis of rotation is at the acromioclavicular joint. Upper trapezius is no longer positioned to be able to
function to upwardly rotate the scapula, whereas lower trapezius is now ideally situated to perform this function, in conjunction with lower
serratus anterior. (D) In the nal stages of elevation, lower trapezius and lower serratus anterior are the primary rotators of the scapula, with
upper trapezius functioning to rotate the clavicle and middle trapezius working eccentrically to control the degree of upward rotation.

normal ring pattern and a decreased ability to Alteration in activity of serratus anterior in the
produce torque and to stabilize the scapula, a painful shoulders of swimmers and throwers has been
phenomenon Kibler (1998b) described as scapular found when compared to that of non-painful athletes
dyskinesis. (Glousman et al. 1988; Scovazzo et al. 1991; Pink

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 ARTICLE IN PRESS
198 Manual Therapy
et al. 1993). Wadsworth and Bullock-Saxton (1997)
found signicant delay in activation of serratus
anterior in the painful shoulders of swimmers
compared with non-painful shoulders, with little
change in timing of activation of trapezius. All these
studies highlight serratus anterior as the primary
stabilizer of the scapulothoracic region, functioning
in a manner similar to other deep stabilizers.
The movement of elevation has been used as an
example of the need to consider force couples.
Clearly, different considerations must be made if
the disorder involves other movements and loads.
Adduction against resistance needs to be considered
in conjunction with elevation in the throwing or
swimming athlete, for example. This function is well
described in Schenkman and Rugo de Cartaya (1994)
and Souza (2000).
PRINCIPLES OF A DYNAMIC ASSESSMENT
Patients move in a variety of ways, with a wide range
of what can be called normal (Shumway-Cook &
Woollacott 2001). Inuences on movement patterns
include avoidance of pain, general health and mood,
relative length of tissues, strength and level of activity
of muscles and timing of contraction of those
muscles. Functional demands and habitual activities
also contribute to development of particular move-
ment patterns (Shumway-Cook & Woollacott 2001).
All these factors must be considered during examina-
tion of muscle function around the shoulder.
Antalgic movement patterns are familiar features
of physical examination a classic example is the arm
that drifts towards the plane of the scapula during
frontal plane abduction, with prevention of this
movement causing pain. A patient who is unwell or
depressed often demonstrates a hunched posture with
slow, heavy movements. Such a posture, if habitual,
could lead to learned poor scapular rotation during
arm elevation, with the potential for development of
a subacromial impingement.
The concept of relative exibility or relative
stiffness should be familiar to physiotherapists
(Sahrmann 2001). Movement occurs in the path
offering the least resistance, such that compensation
for a tightened tissue or restricted joint occurs with
movement in a different plane or of a different body
part. A weakened muscle will also disrupt a normal
movement pattern as its weakness must be compen-
sated for by an altered pattern of activity in a
substitute muscle capable of achieving similar action.
Altered timing of contraction, as discussed above,
inuences movement patterns, such that either the
torque producing muscles tend to be activated
without pre-setting by the stabilizers (Hodges &
Richardson 1996, 1998; David et al. 1997; Cowan
et al. 2001) or the nature of activity of the stabilizers
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is converted from one which is direction-independent
to one which becomes direction-specic (Hodges &
Richardson 1997).
To achieve a successful outcome from any dynamic
stabilization programme, rehabilitation must be
centred on the patients abilities rather than impair-
ments. The starting point for progression must be
correct movement patterns and muscle recruitment.
Training in an incorrect pattern will only reinforce
the pattern. Therefore, the assessment of muscle
function must reveal the patients abilities in addition
to impairments. As a simple example, if lower
trapezius is tested in a standard manual muscle test
position (Kendall et al. 1993) and found to be weak,
the position in which the muscle is tested, or the load
placed on the muscle during testing, must be
incrementally reduced to a stage where the contrac-
tion can be initiated and maintained successfully. The
point from which to start re-training of lower
trapezius, if appropriate, is that where the contrac-
tion can be successfully achieved. Each of the tests
described below is based on this principle.
Gentile (1992) advocated that goal-directed func-
tional behaviour should be analysed at three different
levels: the action itself, the movements that are
incorporated in that action and the neuromotor
processes that drive the movements for example,
the integrity of the motor and sensory systems.
DYNAMIC EXAMINATION
Knowledge of, and the indications for, inclusion of
specic muscle length (Evjenth & Hamberg 1980) and
isolated strength tests (Kendall et al. 1993) is assumed
by the reader. In this paper, those components and
techniques that we have found particularly useful
during dynamic examination will be discussed.
Observation of posture
Altered joint position such that some muscles appear
tight or overactive and others lengthened or under-
active provides early hypotheses in relation to muscle
function. Observation of the posture of the whole
body is an integral component of postural assessment
of the upper quarter. This should occur in the context
of the patients functional demands, so that it
includes evaluation of routine postures used by the
patient. Lower quarter muscle development and
spinal posture can indicate whether whole body
integrated movement patterns are adequate for
normal upper quarter muscle function.
Cervicothoracic posture has considerable inuence
on scapular position and mobility and therefore, also
glenohumeral mobility (Crawford & Jull 1991;
Culham & Peat 1993; Solem-Bertoff et al. 1993).
Specic analysis of scapular and arm position will
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then provide initial clues to the comparative load
carried by the glenohumeral and scapulothoracic
joints. Finally, specic analysis of contour and tone
of all relevant muscle groups should be made.
Analysis of movement patterns
Particular emphasis is placed on detailed visual
analysis of spontaneous movement patterns. Specic
attention is given to recruitment of particular muscle
groups related to each movement, visual assessment
of the timing of that recruitment and the relative
contribution of all body parts to the movement.
An important part of normal function is the ability
to dissociate different body parts during movement.
Our clinical experience has shown us that the inability
to dissociate trunk from scapular movement, for
example, is often a signicant contributor to shoulder
dysfunction. In the same way, poor trunk and pelvic
stability place considerable stress on the upper
quarter during loaded or rapid functional activities
(Kibler 1998a,b).
Control of the movement, both concentric and
eccentric, is also evaluated, at speeds relevant to the
patients presentation. Similarly, if symptoms are
only provoked after repetition or under load, these
components are included. Repetition of arm elevation
while holding a small weight may demonstrate altered
movement patterns not detected with a single
unloaded movement.
Careful attention is placed on detection of sub-
stitution strategies and provocation of symptoms.
Any asymmetries found are corrected actively, if
possible, and passively to evaluate their effect on
symptom production and performance of the move-
ment. Active correction provides some insight to
the patients awareness of postural or movement
impairment and the appropriate motor strategy to
correct it. Postural correction or facilitation of a
more normal muscle activation that alters pain on
movement provides a positive indication of a
relationship between pain and movement and of the
potential benet of a dynamic rehabilitation pro-
gramme.
Specic evaluation of relevant force couples
In an initial examination, more importance is placed
by the authors on evaluating the force couples
relevant to stabilization of the shoulder complex
than on isolated manual muscle testing as knowledge
of the more subtle stabilizing capability of the
shoulder complex allows better interpretation of
the results of the more supercial muscle strength
assessments. Testing of more global muscle
function termed the forcedependent patterns by contraction, the ability to maintain it during arm
Kibler (1998a) tends to be addressed at later
sessions.
Manual Therapy (2003) 8(4), 195206
Altered motor control around the shoulder complex 199
Rotator cuff
The two tests that we have developed and used over a
number of years to determine dynamic control of the
head of humerus in the glenoid are the dynamic
rotary stability test and the dynamic relocation test.
1. The Dynamic Rotary Stability Test (DRST).
The DRST is used to evaluate the ability of the
rotator cuff to maintain the normal centring of the
humeral head in the glenoid when loaded through
rotation (Howell & Galinat 1987; Howell et al. 1988).
In a frankly unstable shoulder or one in which
rotator cuff dynamic control is lacking, the humeral
head can be felt to translate when the rotator cuff is
loaded. In more subtle situations, or where the
instability is more functional than structural, provo-
cation of symptoms, alteration in the quality of
contraction, clicking/clunking and compensation by
other muscle groups are often noted, without the
sensation of humeral head translation.
The DRST is undertaken in different parts of the
range of glenohumeral exion and abduction from
neutral towards the functional position(s) in which
the patient has symptoms, whether pain, weakness,
apprehension or instability (Fig. 3). The aim is to nd
the position(s) in range where the patient has control
of the head of humerus as close as possible to the
position in which control is lost. The test is performed
isometrically, isotonically, concentrically and eccen-
trically at different speeds and under different loads.
The amount of resistance added is usually light to
moderate, as the assessment is one of the ability to
stabilize, rather than one of strength of rotation.
2. The Dynamic Relocation Test (DRT). The DRT
is a test of the ability of the transverse force couple of
the rotator cuff to stabilize the head of humerus in
the glenoid against a de-stabilizing load. It is
predicated on the knowledge that, in normal situa-
tions, the rotator cuff functions in some degree of co-
contraction to stabilize the glenohumeral joint during
dynamic function and this activation precedes that of
the more supercial torque producing muscles (David
et al. 1997, 2000). Co-contraction stiffens a joint and
is an important feature of early stages of skill
acquisition (Shumway-Cook & Woollacott 2001). In
patients with shoulder pain, the co-contraction and
pre-setting appears to be lost. Once the ability to
isolate the co-contraction has been determined in the
optimal position (Fig. 4), maintenance of this isolated
contraction can be evaluated in different positions
and during different tasks.
Patients with a dysfunctional shoulder may nd
isolation of this contraction to the rotator cuff
difcult without considerable facilitation and prac-
tice. Once the patient can master the relocation
movement is evaluated, using any relevant functional
movement, with progressively increasing difculty. If
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200 Manual Therapy
Fig. 3(A, B) Dynamic rotary stability test, demonstrating two different positions in which humeral head control can be evaluated. The
operators left hand is placed over the humeral head so that he is able to detect any translation that occurs during contraction of the
rotators. In the example shown, he is resisting isometric lateral rotation in mid-range and near end-range, in a position functionally relevant
for a thrower.
Fig. 4Dynamic relocation test. The patient is positioned such
that his upper arm is in approximately 60801 of abduction in the
scapular plane, as this position optimizes the line of pull of
the lower elements of the rotator cuff. The middle nger of the
operators left hand is placed over the belly of subscapularis, so
that he is able to detect activity in this muscle during the test. He is
also able to feel activation of the more supercial muscles at the
same time. Alternatively, the operator may palpate subscapularis
from a posterior approach particularly useful if the patient has a
tendency to over-activate the pectorals. With his right hand, the
operator applies a very gentle longitudinal distraction force to the
arm and asks the patient to draw his arm into the socket, while he
feels for activation of subscapularis, remembering that this occurs
in conjunction with activation of infraspinatus/teres minor.
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abnormality were detected in the DRST, the test
position in which loss of control was found can be re-
evaluated with facilitation of dynamic relocation. If
control is improved, dynamic rehabilitation has a
good chance of success. The specic techniques for
these tests are outlined elsewhere (Magarey & Jones,
2003). To date, research on the reliability and validity
and on establishing normative values for these tests is
incomplete.
Scapular stabilization and movement
Scapular stabilizing and movement function is
evaluated with two methods, using weightbearing
assessment of scapular control and with modied
PNF diagonal patterns in isolation from and in
conjunction with arm movements.
1. Weightbearing assessment of scapular control.
Weightbearing assessment allows evaluation of a
number of factors. In particular, it is a useful position
for testing dissociation of spinal movement from
scapular movement and lumbar from thoracic move-
ment, in addition to scapular control. Although
dissociation can be evaluated in many different
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Fig. 5Assessment of scapular function in four point kneeling.
(A) The standard starting position, emphasizing spinal neutral
position. (B) A more challenging position for the subjects
right scapular region, in one arm weightbearing.
positions, the steps to evaluate this ability are integral
to the scapular assessment and are therefore included.
The standard starting position for weightbearing
assessment is four point kneeling, although assess-
ment should be undertaken in multiple different
positions, as a wide variation appears to exist in
peoples ability to function in weightbearing. The
positions used include leaning against a wall or table,
four point kneeling, prone on elbows and weightbear-
ing in the frontal and scapular plane. In the frontal
plane, the contribution of the trapezius components
of the force couple may be stressed more than
serratus anterior as a result of the lesser protraction
component (Inman et al. 1944; Schenkman & Rugo
de Cartaya 1994).
In four point kneeling, the patients ability to
dissociate pelvic from lumbar, lumbar from thoracic
movement and thoracic from cervical movement is
evaluated rst. Spinal dissociation and awareness of
natural posture will facilitate success in scapular
control re-training. The next step is to determine
whether the patient can protract and retract
the scapulae without concurrent spinal movement
(Fig. 5). If this can be achieved, the scapulas holding
ability in neutral (mid-range) protraction is then
assessed through different stages and types of
Manual Therapy (2003) 8(4), 195206
Altered motor control around the shoulder complex 201
loading. If loading in this position fails to demon-
strate any impairment, the assessment can be
progressed to more challenging positions or de-
mands. Equally, if scapular control is not adequate,
positions which require less weightbearing or cogni-
tive load should be evaluated.
2. Scapular diagonal patterns. One method in
which to assess functional muscle performance is
through the use of the PNF patterns from
glenohumeral extension/abduction/medial rotation to
elevation/adduction/lateral rotation (D1) and from
extension/adduction/medial rotation to elevation/
abduction/lateral rotation (D2) (Voss et al. 1953;
Knott & Voss 1968; Engle 1994). During these
movements, the scapula moves from retraction/
depression/downward rotation to protraction/eleva-
tion/upward rotation and from protraction/depres-
sion/downward rotation to retraction/elevation/
upward rotation, respectively. Having rst deter-
mined that the relevant range is available passively,
an initial assessment of the patients ability to
perform these scapular patterns independent of arm
movement is undertaken. Without inclusion of the
arm, the rotation component of the scapular move-
ment is minimal, but the resultant diagonal move-
ments are regularly dysfunctional with a painful
shoulder. This may simply relate to lack of familiarity
with the movement, so inclusion of stimulation with
passive, active assisted and resisted movement
through the patterns is used to determine whether
this is the case (Fig. 6A,B). If so, repeat assessment of
unassisted active scapular diagonal movement is
signicantly improved, whereas in the impaired
shoulder, such improvement is not immediately
evident (Fig. 7).
Often, patients and non-symptomatic individuals
will be biased in their un-loaded scapular diagonal
patterns, possibly reecting learned movements. For
example, physiotherapists and keyboard operators
frequently present with an exaggerated protraction
component at the expense of shoulder elevation in the
D1 pattern.
Finally, the scapulas ability to rotate upwardly
during arm elevation is evaluated, using similar
principles to those described for the scapular
patterns. With this assessment, the emphasis is on
the retraction/downward rotation to protraction/
upward rotation component with less emphasis on
depression/elevation (Fig. 8).
In most instances, the authors have found that, at
initial dynamic assessment, these tests, coupled with
appropriate muscle length assessment, are all that
need to be included for the upper quarter. Specic
evaluation of isolated muscle strength may be
appropriate, particularly for the athletic population,
but frequently, because of impairment in the stabiliz-
ing force couples, such evaluation is withheld until
stabilization is improved. However, evaluation of
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 ARTICLE IN PRESS
202 Manual Therapy

Fig. 6(A) D1 scapular PNF pattern depression/retraction Fig. 7(A) D2 scapular PNF pattern depression/protraction
component. (B) D1 scapular PNF pattern elevation/protraction component. (B) D2 scapular PNF pattern elevation/retraction
component. component.

trunk control, either the ability to isolate the deep

stabilizers, as described by Richardson et al. (1999)
and control of pelvic and hip muscle function, or
through control of neutral and later out-of-neutral
postures and movements should be included, as
upper quarter stability requires a strong stable base
on which to work (Fleisig et al. 1994; Kibler 1998a,b).

MANAGEMENT OF MUSCLE CONTROL

DYSFUNCTION OF THE SHOULDER
COMPLEX

From the examination ndings, a management plan

can be made, addressing those aspects of each part of
the examination found to be impaired and ensuring
maintenance of an appropriate balance between
function of the scapulothoracic and scapulohumeral
muscles. Training for control of one region must not
occur at the expense of the other. Similarly, training
for either the glenohumeral joint or scapulothoracic
region must be implemented in positions of total
body control and stability. In this paper, the
dominant features associated with the early stages
of rehabilitation are addressed.
Our approach to management of muscle control
impairment of the shoulder complex follows similar
Fig. 8Facilitation of scapular upward rotation. Resistance is
provided to protraction through the patients hand between the
therapists upper arm and trunk and to upward rotation through
the lateral aspect of the scapula and through resisted extension of
the arm. The technique may be performed with the resistance to
scapular movement only if resisted arm movement provokes pain.
principles to those outlined in other dynamic
stabilization programmes (for example, OSullivan
et al. 1997a, b, 2000; Richardson et al. 1999;
Comerford & Mottram 2001; Sahrmann 2001).
Progression through the programmes is considered

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 ARTICLE IN PRESS
in terms of attainment of specic skills and control
a criteria-based protocol (Chmielewski & Snyder-
Mackler 2001) rather than length of time, as in
many shoulder rehabilitation programmes (for ex-
ample, Kunkel & Hawkins 1994; Loeb et al. 1994;
Souza 2000; OBrien et al. 1994; Scarpinato &
Andrews 1994; Timmerman et al. 1994; Ciullo
1996). Our approach also works on the principle of
specicity of muscle function and the importance of
functional relevance for transfer of training (Kibler &
Chandler 1994; Kibler 1998a; Shumway-Cook &
Woollacott 2001) so that, as soon as possible, any
re-training occurs in positions relevant to the
patients habitual activities.
The authors use the concept of re-training by
breaking function into interim steps (Schmidt 1991;
Winstein 1991). One goal of any motor control
rehabilitation is to gain awareness of, and the ability
to, activate the deep stabilizers of the region prior to
activation of the, usually, more supercial torque
producing muscles and to maintain that activation
during activity. Another is retraining of optimal
movement patterns. Both involve motor programme
retraining and therefore, rened, controlled activa-
tion of the deep stabilizing force couples, using either
strategies of isolation or controlled posture or move-
ment facilitated by imagery. Activation of isolated
muscles is often difcult to conceptualize. Therefore,
patient explanation of the reasons for the programme
and the processes required become important aspects
of the management. Similarly, imagery can facilitate
understanding of the action required. Without the
patients understanding and collaboration in the
process, it is doomed to failure, as perseverance, even
when there is little obvious initial change, is essential
to success.
Pain inhibition appears to have a powerful
inuence on the motor system (Richardson 1987;
Hodges & Richardson 1996, 1998; Cowan et al 2001),
so palliative treatment may be necessary to decrease
pain in the early stages. However, there is no need to
wait for pain to settle before starting a motor control
programme within a pain-free range at a load that
does not provoke symptoms, as often, restoration of
control acts as a potent pain inhibitor.
Retraining motor programming, or the neural
control in Panjabis (1992) model, is dependent
on motor learning. Motor learning involves
learning new strategies for sensing as well as
moving, arising from a complex of perception
cognitionaction processes (Shumway-Cook &
Woollacott 2001). Motor learning can be enhanced
by the use of mental imagery, tactile, verbal, visual,
taping, weightbearing and movement oriented
cues different cues are effective with different
people. Initially, facilitation is undertaken in an
optimal position for the relevant muscles, usually
mid-range.
Manual Therapy (2003) 8(4), 195206
Altered motor control around the shoulder complex 203
Frequent stimulation and repetition improve
awareness and the ability to activate far more than
an isolated exercise session once a day (Catalano &
Kleiner 1984; Shumway-Cook & Woollacott 2001).
Therefore, while learning the activation technique, we
encourage patients to practise it for a few minutes
several times a day. Initially, each region is trained in
isolation that is, the rotator cuff is worked with the
scapula in an unchallenged position and vice versa.
The muscles are worked in co-contraction in their
relevant force couples, with the contractions initially
isometric and isotonic with low load, with a gradual
build up and release.
Once dynamic stability is established, the positions
in which control is emphasized are determined by the
examination ndings and functional needs of the
patient. During the DRST, for example, the patient
may have demonstrated good control up to 601 of
abduction in isotonic external rotation, while iso-
metric control may have been satisfactory to 1201. If
these positions are re-tested with pre-setting of the
rotator cuff via the DST manoeuvre, better control
may be found. Training should then be started in
those positions in which the patient has control, but
as close to the position where that control is lost as
possible. Isometric and isotonic training can be
undertaken concurrently, as long as the patient is
aware of the different sensations associated with
control and lack of control. Teaching this difference
in feel may be time consuming initially, but is
essential to success of the programme, as training in
a position in which control is lacking may reinforce
poor movement patterns.
As control is mastered, the load can be increased
cognitively by asking the patient to maintain control
in one area and work on the other. Once activation
can be achieved in an isometric, stable situation, we
encourage the patient to incorporate the activation
into simple tasks of daily living. Deliberate activation
of the rotator cuff in the DRT manoeuvre while
waiting at trafc lights in a car, or prior to reaching
to answer the telephone; setting of the scapulae in an
optimal position while at a computer or before
reaching into a cupboard are examples of cognitive
challenge. When such tasks are mastered, physical
load, speed and more complicated, integrated tasks
can be progressively added. Progression is made with
any particular exercise only when the step before is
mastered. The more times the technique is repeated
and the more different situations in which it is
repeated, the quicker the patient is likely to master it.
While this intensive training is underway for the
upper quarter, any more general impairment in
motor control should also be addressed. Issues such
as poor dissociation may need to be improved before
scapular work can be initiated and transversus
abdominis and gluteal control can be incorporated
and progressed from the rst day of treatment. If
r 2003 Elsevier Ltd. All rights reserved.
 ARTICLE IN PRESS
204 Manual Therapy
control is good, but general strengthening is indi-
cated, this can be undertaken in conjunction with the
upper quarter control programme. Progression in
each region may be at different rates, depending on
the degree of impairment, so each component must
be regularly checked and progressed individually.
Once this level is mastered, function is re-evaluated
to determine the need for further progression. For
many non-athletic patients, we have found that
addressing the motor control issues and teaching
the patient appropriate strategies to continue mon-
itoring and stimulating the control are sufcient for a
return to normal function. However, in the manual
labourer or overhead athlete, further progression is
needed. Whether rehabilitation is ceased at this point
or continued, the authors have found that the patient
who has had pain in the shoulder needs to continually
monitor their dynamic control and practise it
regularly, or the control tends to be lost. A brief
self-directed activation session once or twice a week
or deliberate pre-activation during normal function is
sufcient to maintain the control once mastered to
this level.
CONCLUSION
In this paper, we have presented an approach to
dynamic evaluation and management of the shoulder
complex that we use in conjunction with detailed
passive examination and management as indicated
for each patient. The ideas presented here represent
one set of strategies that we have found to improve
shoulder function. A deliberate setting in neutral
rather than specic pre-activation can also be
effective with different patients. Interestingly, a
number of researchers have demonstrated that stable
movement patterns become more unstable just prior
to a transition to a new movement pattern in both
adults and children (Kelso & Tuller 1984; Gordon
1987; Woollacott & Shumway-Cook 1990). Thera-
pists should be aware of this possibility when
reassessing patients undergoing a dynamic rehabilita-
tion programme such as the one suggested. It is
important that patients be made aware of this
possibility so that they do not become discouraged
through this phase of their training.
While the dynamic component of our management
approach has not been challenged through clinical
trial, it is based on similar principles to those
demonstrated as effective in the cervical and lumbar
spine regions (OSullivan et al. 1997a,b, 2000; Jull
2000; Jull et al. 2002). If the whole process is linked
by sound reective clinical reasoning (Jones et al.
2000), the optimal balance of passive and dynamic
management will be included.
r 2003 Elsevier Ltd. All rights reserved.
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