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INVITED CLINICAL COMMENTARY

NON-OPERATIVE REHABILITATION FOR


TRAUMATIC AND ATRAUMATIC
GLENOHUMERAL INSTABILITY
Kevin E. Wilk PT, DPTa
Leonard C. Macrina MSPTa
Michael M. Reinold PT, DPT, ATCa

ABSTRACT INTRODUCTION
Shoulder instability is a common pathology often
Glenohumeral joint instability is a common
seen in the orthopaedic and sports medicine set-
pathology encountered in the orthopaedic and
ting. The glenohumeral joint allows tremendous
sports medicine setting. A wide range of sympto-
amounts of joint mobility to function, thus, making
matic shoulder instabilities exist ranging from
the joint inherently unstable and the most fre-
subtle subluxations due to contributing congenital
quently dislocated joint in
factors to dislocations as a
the body.1 Due to the joints
result of a traumatic
poor osseous congruency
episode. Non-operative
and capsular laxity, it great-
rehabilitation is utilized in
ly relies on the dynamic
patients diagnosed with
stabilizers and neuromuscu-
shoulder instability to
lar system to provide
regain their previous func-
functional stability. 2
tional activities through
Therefore, differentiation
specific strengthening exer-
between normal translation
cises, dynamic stabilization
and pathological instability
drills, neuromuscular train-
is often difficult to deter-
ing, proprioception drills,
mine. A wide range of
scapular muscle strengthening program and a
TABLE 4. Lower Extremity Function Scale shoulder instabilities
(LEFS) before surgery andexist
at the from subtle
completion subluxations
of physical therapy
gradual return to their desired activities. The spe-
to grossExtreme
instability. Often the success of the reha-
cific rehabilitation program should be varied based Difficulty or
bilitation
Unableprogram
to Quiteis basedModerate
a Bit on the recognition
A Little Bit and
on the type and degree of shoulder instability pres- Perform of Difficulty Difficulty of Difficulty No Difficulty
treatment program designed to treat the specific
ent and desired level of function. The purpose Activities of 1 Point 2 Points 3 Points 4 Points
type of0 instability
Points
present.
this paper is to outline the specific principles asso- Pre Post Pre Post Pre Post Pre Post Pre Post

ciated with non-operative rehabilitation for each


Usual work, housework of activitiesNon-operative rehabilitation is often implemented
or school
Usual hobbies, recreational, sporting activities
the various types of shoulder instability and to dis-
in patients diagnosed with a variety of shoulder

instabilities. These instability patterns can range


Getting into or out of bath
cuss the specific rehabilitation program for each
Walking between rooms
pathology type. Putting on shoes or socks
from congenital multidirectional instabilities
to
Squatting traumatic unidirectional dislocations. We have
Keywords: Dynamic stabilization, neuromuscular
Lifting objects from the floor classified glenohumeral joint instabilities into two
control, shoulder joint Light activities around the house broad categories: traumatic and atraumatic. Based
Heavy activities around the house
on the classification system of glenohumeral insta-
Getting in or out of the car
Walking two blocks
bility, as well as several other
factors, a non-opera-

Walking a mile tive rehabilitation
program may be developed. The
Ascending/descending a flight of stairs purpose of this paper is to
discuss and overview
Standing for an hour these factors along with the non-operative rehabil-
Sitting for an hour itation programs for the various types ofshoulder
Running on even ground
instability in order
to return the patient to their
Running on uneven ground
a Making sharp turns while running fast
previous level of

function.
Champion Sports Medicine
Hopping
American Sports Medicine Institute
Rolling over in bed
Birmingham, AL
Score prior to surgery
16 N O R T H A M E R I C A N J O U R N A L O F S P O R T S P
H YScore
S I CatAphysical
L T H Etherapy
R A P Ydischarge
| FEBRUARY 2006 | VOLUME 1, NUMBER 1
REHABILITATION FACTORS dislocation to occur, a Bankart lesion and soft tissue trau-
Seven key factors should be considered when designing a ma must be present on both sides of the glenohumeral
rehabilitation program for a patient with an unstable joint capsule. Thus, in the situation of an acute traumat-
shoulder (Table). These factors and their significance to ic dislocation, the anterior capsule may be avulsed off the
the rehabilitation program will be presented. glenoid (Bankart lesion) and the posterior capsule may be
stretched, allowing the humeral head to dislocate. Warren
Onset of Pathology et al4 refer to this damage to both the anterior and poste-
The first factor to consider in the rehabilitation of a rior capsule as the circle stability concept.
patient with shoulder instability is the onset of the pathol-
The rate of progression of the rehabilitation program will
ogy. Pathological shoulder instability may result from an
vary based upon the degree of instability and persistence
acute, traumatic event or chronic, recurrent instability.
of symptoms. For example, a patient with mild subluxa-
The goal of the rehabilitation program may vary greatly
tions and muscle guarding may initially tolerate
based on the onset and mechanism of injury. Following
strengthening exercises and neuromuscular control drills
a traumatic subluxation or dislocation, the patient typi-
more than a patient with a significant amount of muscu-
cally presents with significant tissue trauma, pain, and
lar guarding.
apprehension. The patient who has sustained a disloca-
tion often exhibits more pain due to muscle spasm than a
Frequency of Dislocation
patient who has only subluxed their shoulder.
The next factor to influence the rehabilitation program is
Furthermore, a first-time episode of dislocation is gener-
the frequency of dislocation or subluxation. The primary
ally more painful than the repeat event. Rehabilitation
traumatic dislocation is most often treated conservatively
for the patient with a first-time traumatic episode will be
with immobilization in a sling and early controlled pas-
progressed based on the patients symptoms with empha-
sive range of motion (ROM) exercises, especially with first
sis on early controlled range of motion, reduction of mus-
time dislocations. The incidence of recurrent dislocation
cle spasms and guarding, and relief of pain.
ranges from 17-96% with a mean of 67% in patient popu-
Conversely, a patient presenting with atraumatic lations between the ages of 21-30 years old.1,5-15 Therefore,
instability often presents with a history of repetitive the rehabilitation program should progress cautiously in
injuries and symptomatic complaints. Often the patient young athletic individuals. It should be noted that
does not complain of a single instability episode but, Hovelius et al8,16,17 has demonstrated that the rate of
rather, a feeling of shoulder laxity or an inability to per- recurrent dislocations is based on the patients age and
form specific tasks. Rehabilitation for this patient should not affected by the length of post-injury immobilization.
focus on early proprioception training, dynamic stabiliza- Individuals between the ages of 19 and 29 years are the
tion drills, neuromuscular control, scapular muscle most likely to experience multiple episodes of instability.
exercises, and muscle strengthening exercises to enhance Hovelius et al8,16,17 noted patients in their 20s exhibited a
dynamic stability due to the unique characteristic of recurrence rate of 60%, whereas, patients in their 30s to
excessive capsular laxity and capsular redundancy in this 40s had less than a 20% recurrence rate. In adolescents,
type of patient. the recurrence rate is as high as 92%18 and 100% with an
open physes.19
Degree of Instability
Chronic subluxations, as seen in the atraumatic, unstable
The second factor is the degree of instability present in
shoulder may be treated more aggressively due to the
the patient and the effect on their function. Varying
lack of acute tissue damage and less muscular guarding
degrees of shoulder instability exist such as a subtle sub-
and inflammation. Rotator cuff and periscapular strength-
luxation or gross instability. The term subluxation refers
ening activities should be initiated while ROM exercises
to the complete separation of the articular surfaces with
are progressed. Caution is placed on avoiding excessive
spontaneous reduction. Conversely, a dislocation is a
stretching of the joint capsule through aggressive ROM
complete separation of the articular surfaces and requires
activities. The goal is to enhance strength, propriocep-
a specific movement or manual reduction to relocate the
tion, dynamic stability and neuromuscular control,
joint, resulting in underlying capsular tissue trauma. The
especially in the specific points of motion or direction
degree of trauma to the soft tissue of the glenohumeral
which results in instability complaints.
joint with a shoulder subluxation is can be quite exten-
Direction of Instability
sive. Speer et al3 has reported that in order for a shoulder

NORTH AMERICAN JOURNAL OF SPORTS PHYSICAL THERAPY | FEBRUARY 2006 | VOLUME 1, NUMBER 1 17
Figure 1 these patients are more likely to repeatedly sublux the
Bankart lesion commonly observed with a traumatic
joint without complete separation of the humerus from
dislocation.
the glenoid rim. Capsular avulsions can occur on the gle-
1a. noid side (Bankart lesion) or on the humeral head side
Drawing referred to as a HAGL lesion (humeral avulsion of the
illustrating a
Bankart lesion. inferior glenohumeral ligament).21-23
The arrow denotes
the avulsed capsule Posterior instability occurs less frequently, only
from the glenoid. accounting for less than 5% of traumatic shoulder dislo-
cations.24,25 This type of instability is often seen following
a traumatic event such as falling onto an outstretched
hand or from a pushing mechanism. However, patients
1b. with significant atraumatic laxity may complain of poste-
CT arthrogram of rior instability especially with shoulder elevation,
a bony Bankart horizontal adduction and excessive internal rotation due
lesion. The large
arrow shows the to the strain placed on the posterior capsule in these posi-
dye that has tions. In professional or collegiate football, the incidence
leaked out of the of posterior shoulder instability appears higher than the
capsule. The small general population. This is especially true in linemen.
arrow shows the
bony lesion which Mair et al26 reported on nine athletes with posterior insta-
has pulled away bility in which eight of nine were linemen and seven
from the glenoid were offensive linemen. Often, these patients require
rim.
surgery as Mair et al26 also reported 75% required surgical
1c. stabilization. Kaplan et al27 reported in a study of
An arthroscopic collegiate football players that 78% required surgical sta-
view of a Bankart bilization.
lesion.
Multidirectional instability (MDI) can be identified as
shoulder instability in more than one plane of motion.
Patients with MDI have a congenital predisposition and
exhibit ligamentous laxity due to excessive collagen elas-
ticity of the capsule. Furthermore, Rodeo et al28 reported
that this type of patient turns over collagen at a faster rate.
The authors consider an inferior displacement of greater
than 8-10mm during
The fourth factor is the direction of instability present. the sulcus maneuver
The three most common forms include anterior, posteri- (Figure 2) with the arm
or, and multidirectional. Anterior instability is the most adducted to the side as
common traumatic type of instability seen in the general significant hypermobili-
orthopaedic population, representing approximately 95% ty, thus suggesting sig-
of all traumatic shoulder instabilities12. Following a trau- nificant congenital laxi-
matic event in which the humeral head is forced into ty.2
extremes of abduction and external rotation, or horizontal
abduction, the glenolabral complex and capsule may Due to the atraumatic
become detached from the glenoid rim resulting in ante- mechanism and lack of
rior instability. This type of detachment is referred to a acute tissue damage,
Bankart lesion.(Figure 1) Baker et al20 have identified four ROM is often normal to
types of Bankart lesions based on the size and the degree excessive. Patients with
of tissue involvement. Conversely, rarely will a patient recurrent shoulder
with atraumatic instability due to capsular redundancy instability due to MDI Figure 2
dislocate their shoulder. It is the authors opinion that generally have weakness Sulcus maneuver to assess
in the rotator cuff, deltoid inferior capsular laxity

18 NORTH AMERICAN JOURNAL OF SPORTS PHYSICAL THERAPY | FEBRUARY 2006 | VOLUME 1, NUMBER 1
muscle, and scapular stabilizers with poor dynamic stabi- they blend with the joint capsule to assist in stabilization
lization and inadequate static stabilizers. Initially, the of the humeral head. Injury with resultant insufficient
focus of the rehabilitation program is on maximizing neuromuscular control could result in deleterious effects
dynamic stability, scapula positioning, proprioception, to the patient. As a result, the humeral head may not cen-
and improving neuromuscular control in mid ROM. Also, ter itself within the glenoid, thereby, compromising the
rehabilitation should focus on improving the efficiency surrounding static stabilizers. The patient with poor neu-
and effectiveness of glenohumeral joint force couples romuscular control may exhibit excessive humeral head
through co-contraction exercises, rhythmic stabilization, migration with the potential for injury, an inflammatory
and neuromuscular control drills. Isotonic strengthening response, and reflexive inhibition of the dynamic
exercises for the rotator cuff, deltoid muscle, and scapular stabilizers.
muscles are also emphasized to enhance dynamic stabili-
ty. Morris et al29 reported the EMG activity of the rotator Several authors have reported that neuromuscular
cuff and deltoid muscle in MDI and asymptomatic sub- control of the glenohumeral joint may be negatively
jects. The authors noted the most significant difference affected by joint instability. Lephart et al10 compared the
was in the deltoid muscles compared to the rotator cuff ability to detect passive motion and the ability to repro-
muscles in their groups. duce joint positions in patients with normal, unstable,
and surgically repaired shoulders. The authors reported
Concomitant Pathologies a significant decrease in proprioception and kinesthesia
The fifth factor involves considering other tissues that in the shoulders with instability when compared to both
may have been affected and the premorbid status of the normal shoulders and shoulders undergoing surgical sta-
tissue. Disruption of the anterior capsulolabral complex bilization procedures. Smith and Brunoli36 reported a sig-
from the glenoid commonly occurs during a traumatic nificant decrease in proprioception following a shoulder
injury resulting in an anterior Bankart lesion. Often dislocation. Blasier et al37 reported that individuals with
osseous lesions may be present such as a concomitant significant capsular laxity exhibited a decrease in proprio-
Hill Sachs lesion caused by an impaction of the postero- ception compared to patients with normal laxity.
lateral aspect of the humeral head as it compresses Zuckerman et al38 noted that proprioception is affected by
against the anterior glenoid rim during relocation. This the patients age with older subjects exhibiting diminished
Hill Sachs lesion has been reported in up to 80% of dislo- proprioception than a comparably younger population.
cations.30-32 Conversely, a reverse Hill Sachs lesion may Thus, the patient presenting with traumatic or acquired
be present on the anterior aspect of the humeral head due instability may present with poor neuromuscular control.
to a posterior dislocation.33 Occasionally, a bone bruise
may be present in individuals who have sustained a Activity Level
shoulder dislocation as well as pathology to the rotator The final factor to consider in the non-operative reha-
cuff. In rare cases of extreme trauma, the brachial plexus bilitation of the unstable shoulder is the arm dominance
may become involved as well.34 Other common injuries and the desired activity level of the patient. If the patient
in the unstable shoulder may involve the superior labrum frequently performs an overhead motion or sporting
(SLAP lesion) such as a type V SLAP lesion characterized activities such as a tennis, volleyball, or a throwing sport,
by a Bankart lesion of the anterior capsule extending into then the rehabilitation program should include sport spe-
the anterior superior labrum.35 These concomitant cific dynamic stabilization exercises, neuromuscular con-
lesions may significantly slow down the rehabilitation trol drills, and plyometric exercises in the overhead
program in order to protect the healing tissue. position once full, pain free ROM and adequate strength
has been achieved. Patients whose functional demands
Neuromuscular Control involve below shoulder level activities will follow a pro-
The sixth factor to consider is the patients level of gressive exercise program to return full ROM and
neuromuscular control, particularly at end range. strength. The success rates of patients returning to over-
Neuromuscular control may be defined as the efferent, or head sports after a traumatic dislocation of their domi-
motor, output in reaction to an afferent, or sensory nant arm are extremely low.39 Arm dominance can also
input.2,10 The afferent input is the ability to detect the significantly influence the successful outcome. The
glenohumeral joint position and motion in space with recurrence rates of instabilities vary based on age, activi-
resultant efferent response by the dynamic stabilizers as ty level, and arm dominance. In athletes involved in
collision sports, the recurrence rates have been reported

NORTH AMERICAN JOURNAL OF SPORTS PHYSICAL THERAPY | FEBRUARY 2006 | VOLUME 1, NUMBER 1 19
collision sports, the recurrence rates have been reported the rates of recurrent dislocations. The authors conclud-
between 86-94%.6,40-42 ed that immobilization in external rotation significantly
reduced the recurrence rate of instability in chronic and
REHABILITATION GUIDELINES first-time dislocators. Itoi et al45 has recommended immo-
Patients may be classified into two common forms of bilization with the arm in 30 degrees of abduction and
shoulder instability traumatic and atraumatic. Specific external rotation, compared to a group of patients immo-
guidelines to consider in the rehabilitation of each patient bilized in internal rotation. The results indicated a 0%
population will be outlined. A four-phase rehabilitation recurrence rate in external rotation and 30% incidence of
program will be discussed for traumatic shoulder instabil- instability in the group immobilized in internal rotation.
ity, followed by an overview of variations and key reha- The authors stated that the resultant Bankart lesion had
bilitation principles for atraumatic shoulder instabil- improved coaptation to the glenoid rim with immobiliza-
ity (congenital and acquired laxity). tion in external rotation versus conventional
immobilization in a sling.
Traumatic Shoulder Instability
Passive ROM is initiated in a restricted and protected
Phase I-Acute Phase range based on the patients symptoms. The early motion
Following a first time traumatic shoulder dislocation or is intended to promote healing, enhance collagen organi-
subluxation, the patient often presents in considerable zation, stimulate joint mechanoreceptors, and aid in
pain, muscle spasm, and an acute inflammatory decreasing the patients pain through neuromuscular
response. The patient usually self-limits their motion by modulation.14,46-48 Painfree active-assisted ROM exercises
guarding the injured extremity in an internally rotated such as pendulums and external/internal rotation at 45
and adducted position against the side of their body to degrees of abduction using an L-bar (Breg Corp. Vista, CA)
protect the injured shoulder. The goals of the acute phase may also be initiated. Passive ROM exercises are also per-
are to 1) diminish pain, inflammation, and muscle guard- formed in a painfree arc of motion. Modalities such as
ing 2) promote and protect healing soft tissues, 3) prevent ice, transcutaneous electrical nerve stimulation (TENS),
the negative effects of immobilization, 4) re-establish and high voltage stimulation may also be beneficial to
baseline dynamic joint stability, and 5) prevent further decrease pain, inflammation, and muscle guarding.
damage to glenohumeral joint capsule. (Appendix 1)
Strengthening exercises are initially performed through
Immediate limited and controlled motion is allowed submaximal, painfree isometric contractions to initiate
following a traumatic dislocation in patients between the muscle recruitment and retard muscle atrophy.
ages of 18-28 years but immobilize patients between the Electrical stimulation of the posterior cuff musculature
ages of 29-54 years old. However, motion is restricted so may also be incorporated to enhance the muscle fiber
as to not to cause further tissue attenuation. A short peri- recruitment process early on in the rehabilitation process
od of immobilization in a sling to control pain and to allow and also in the next phase when the patient initiates iso-
scar tissue to form for enhanced stability may be neces- tonic strengthening activities.(Figure 3) Reinold et al49
sary for 7-14 days although no long-term benefits regard- believe that the use of electrical stimulation may improve
ing recurrence rates and immobilization have been made force production of the rotator cuff particularly the exter-
in younger patients between the ages of 18-28 years nal rotators immediately after an acute injury.
old.8,43 Individuals above the age of 28 are usually immo-
bilized for 2-4 weeks to allow scarring of the injured Dynamic stabilization exercises are also performed to
capsule. Potential complications with immobilization re-establish dynamic joint stability. The patient main-
may include a decrease in joint proprioception, muscle tains a static position as the rehabilitation specialist
disuse and atrophy, and a loss of ROM in specific age performs manual rhythmic stabilization drills to facilitate
groups. Therefore, prolonged use of immobilization fol- muscular co-contractions. These manual rhythmic stabi-
lowing a traumatic dislocation may not be recommended lization drills are performed for the shoulder internal and
in all patients. external rotators in the scapular plane at 30 degrees of
abduction and are performed at painfree angles which do
The ideal position to immobilize the glenohumeral has not compromise the healing capsule. Rhythmic stabiliza-
traditionally been in internal rotation with the arm close tion for flexion and extension may also be performed with
to the body. Recent studies by Itoi et al44,45 examined the shoulder at 100 degrees of flexion and 10 degrees of
positional differences of immobilization and compared horizontal abduction. Strengthening exercises are also

20 NORTH AMERICAN JOURNAL OF SPORTS PHYSICAL THERAPY | FEBRUARY 2006 | VOLUME 1, NUMBER 1
performed for the scapular retractors and depressors to external and internal rotation with exercise tubing at 0
reposition the scapula in its proper position. Scapula degrees of abduction along with sidelying external rota-
strengthening is critical for successful rehabilitation. tion and prone rowing. During the latter part of this
Closed kinetic chain exercises such as weight shifting on phase, isotonic exercises are progressed to emphasize
a ball are performed to pro- rotator cuff and scapulotho-
duce a co-contraction of the racic muscle strength.
surrounding glenohumeral Manual resistive exercises
musculature and to facilitate such as sidelying external
joint mechanoreceptors to rotation and prone rowing
enhance proprioception. may also prove beneficial by
Weight shifts are usually able having the clinician vary the
to be performed immediately resistance throughout the
following the injury unless ROM. Incorporating manual
posterior instability is present. concentric and eccentric
manual exercises and rhyth-
Phase II-Intermediate phase mic stabilization drills at end
During the intermediate range to enhance neuromus-
phase, the program empha- cular control and dynamic
sizes regaining full ROM along stability is also recommend-
with progressing strengthen- Figure 3 ed.(Figure 4)
ing exercises of the rotator Electrical stimulation to the posterior rotator cuff
Closed kinetic chain exercises
cuff, and re-establishing during exercise activity to improve muscle fiber
are progressed to include a
muscular balance of the recruitment and contraction
hand on the wall stabilization
glenohumeral joint, scapular
drills in the plane of the
stabilizers, and surrounding shoulder muscles. Before the
scapular at shoulder height as the patient tolerates. (Figure
patient enters Phase II, certain criteria must be met
5) Push-ups are performed first with hands on a table
which include diminished pain and inflammation, satis-
then progressed to a push-up on a ball or unstable surface
factory static stability, and adequate neuromuscular
while the rehabilitation specialist performs rhythmic
control.
stabilization to the involved and uninvolved upper
To achieve the desired goals of this phase, passive ROM is extremity along with the trunk to integrate dynamic sta-
performed to the patients tolerance with the goal of bility and core strengthening (tilt board, ball, etc.).(Figure
attaining nearly full ROM. Active-assisted ROM exercises 6) Caution should be placed while performing closed
using a rope and pulley along with flexion and exter- kinetic chain exercises in patients with posterior instabil-
nal/internal rotation exercises at 90 degrees of abduction ity for 6-8 weeks at allow for adequate healing and
using an L-bar may be progressed to tolerance without strength gains. Furthermore, patients with significant
stressing the involved tissues. External rotation at 90 scapular winging should perform push-ups until adequate
degrees of abduction is generally limited to 65-70 degrees scapular strength is accomplished. Core stabilization
to avoid overstressing the healing anterior capsuloliga- drills should also be performed to enhance scapular con-
mentous structures for approximately 4-8 weeks but trol. Additionally, strengthening exercises may be
eventually increasing ROM to full motion as the patient advanced in regards to resistance, repetitions, and sets as
tolerates. the patient improves. End range rhythmic stabilization
drills with the arm at 0 degrees of adduction or at 45
Isotonic strengthening exercises are also initiated during degrees of abduction are also performed. Exercises such
this phase. Emphasis is placed on increasing the strength as tubing with manual resistance and end range rhythmic
of the internal and external rotators and scapular muscles stabilization drills are also performed.(Figure 7) The goal
to maximize dynamic stability. The ultimate goal of the of these exercise drills is to improve proprioception and
strengthening phase is to re-establish muscular balance neuromuscular control at end range.
following the injury. Kibler1 noted that scapular position
and strength deficits have been shown to contribute to Phase III- Advanced Strengthening
glenohumeral joint instability. Exercises initially include In the advanced strengthening phase, the focus is on

NORTH AMERICAN JOURNAL OF SPORTS PHYSICAL THERAPY | FEBRUARY 2006 | VOLUME 1, NUMBER 1 21
improving strength, dynamic stability, and neuromuscu- motion during this phase. During bench press and seat-
lar control near end range through a series of progressive ed rows, the patient is instructed to not extend the upper
strengthening exercises for a gradual return to the extremities beyond the plane of the body to minimize
patients activity. Criteria to enter this phase include: 1) stress on the shoulder capsule. Latissimus pulldowns are
minimal pain and tenderness, 2) full range of motion, 3) performed in front of the head and the patient is instruct-
symmetrical capsular mobility, 4) good (at least 4/5 man- ed to avoid full extension of the arms to minimize the
ual muscle test) strength, amount of traction force
endurance and dynamic sta- applied to the shoulder joint.
bility of the scapulothoracic Also during this phase, the
and upper extremity muscu- patient continues to perform
lature. rhythmic stabilization drills
with the rehabilitation special-
Muscle fatigue has also been
ist and gradually progresses to
associated with a decrease in
a position of apprehension uti-
neuromuscular control.
lizing tubing at 90 degrees of
Carpenter et al observed
50
abduction with end range
the ability to detect passive
rhythmic stabilization drills to
motion of shoulders
enhance dynamic stability.
positioned at 90 degrees of
abduction and 90 degrees of A patient wishing to return to
external rotation. The inves- athletic participation may be
tigators reported a decrease instructed to perform plyomet-
Figure 4
in both the detection of exter- ric exercises for the upper
Sidelying manual external rotation while the clinician
nal and internal rotation extremity. These activities are
imparts rhythmic stabilization drills at end range
movement following an isoki- incorporated to regain any
netic fatigue protocol. remaining functional ROM as
Therefore, exercises designed well as improving neuromus-
to enhance endurance in the cular control and to train the
upper extremity such as extremity to produce and dissi-
using low resistance and high pate forces. Initially, 2-handed
repetitions (20-30 repetitions drills close to the body such as
per set) are incorporated dur- chest pass, side-to-side and
ing this phase. Also, exercise overhead soccer throws (Figure
sets utilizing time may be 8) using a 3-5 pound medicine
incorporated, such as 30 sec- ball may be performed to
ond or 60 second exercise enhance dynamic stabilization
bouts. These exercises may of the glenohumeral joint.
include tubing external and Figure 5 Exercises are initiated with 2-
internal rotation, plyoball Wall stabilization drills in the plane of the scapula hand drills close to the center
wall dribbling, and submaxi- of gravity and gradually pro-
mal manual resistance drills. gressed to longer lever arms away from the patients
body. Drills are progressed to challenge the dynamic sta-
Aggressive upper body strengthening through the con-
bilizers of the shoulder.
tinuation of a progressive isotonic resistance program is
recommended. A gradual increase in resistance as well as After approximately two weeks of pain free 2-handed
a progression to a more functional position by performing drills, the athlete progresses to 1-handed plyometric drills
tubing exercises at 90 degrees of abduction to strengthen using a small medicine ball (1-2 lbs) and throwing into a
the external and internal rotators is also recommended. plyoback. Plyoball wall dribbles in the 90/90 position
Additionally, more aggressive isotonic strengthening exer- (Figure 9) to improve overhead muscle endurance may
cises such as bench press, seated row, and latissimus pull- also be incorporated.
downs may be incorporated in a protected range of

22 NORTH AMERICAN JOURNAL OF SPORTS PHYSICAL THERAPY | FEBRUARY 2006 | VOLUME 1, NUMBER 1
Phase IV- Return to Activity Phase ed sports activities after completion of an appropriately
In the return to activity phase, the goal is to increase, designed rehabilitation program and a successful clinical
gradually and progressively, the functional demands on exam including full ROM, strength along with adequate
the shoulder in order for the dynamic stability and neuro-
patient to return to unre- muscular control.
stricted, sport or daily
We routinely perform a
activities. Other goals of this
combination of isokinetic test-
phase are to maintain the
ing for our overhead athletes,
patients muscular strength
which we refer to as the
and endurance, dynamic sta-
Throwers Series.54,55 Criteria
bility and functional range of
to begin an interval sport pro-
motion. The criteria to
gram includes an external
progress into this phase
rotation/internal rotation
include: 1) full functional
strength ratio of 66-76% or
ROM, 2) adequate static sta-
higher at 180/second, an
bility, 3) satisfactory muscu-
external rotation to abduction
lar strength and endurance,
ratio of 67-75% or higher at
4) adequate dynamic stabili-
180/second.54,55 Patients
ty, and 5) a satisfactory
returning to contact sports
clinical exam.
such as hockey, football,
The general orthopaedic rugby, etc may be required to
patient continues to perform wear a shoulder stability brace
a maintenance program to Figure 6 (Don-Joy) for the initiation of
improve strength, dynamic Rhythmic stabilization drills on an unstable surface to the sport return.(Figure 10)
stability, and neuromuscular further challenge the patients neuromuscular control.
control as well as maintain- Rehabilitation for
ing full, functional and Atraumatic Shoulder
painfree ROM. The athlete Instability
continues to perform aggres- Rehabilitation of the patient
sive strengthening exercises with congenital shoulder
such as plyometrics, proprio- instability poses a significant
ceptive neuromuscular challenge for the rehabilita-
facilitation drills, and isotonic tion specialist. The patient
strengthening. In addition, typically presents with sever-
the athlete may begin func- al episodes of instability
tional sport activities through which limits them from per-
an interval return to sport forming certain tasks which
program. These activities Figure 7 may include daily work tasks
are designed to gradually External rotation with tubing while the therapist as well as recreational or
return motion, function, and applies an external force throughout the ROM sports activities. This type of
confidence in the upper instability may arise from sev-
extremity by progressing through graduated sport-specif- eral factors including excessive redundancy and capsular
ic activities.51-53 These interval sport programs are set up laxity, poor osseous configuration such as a flattened gle-
to minimize the chance of re-injury while training the noid fossa, or weakness in the glenohumeral and scapu-
patient for the demands of each individual sport. Each lar musculature resulting in poor neuromuscular control.
program should be individualized based on the patients Any of these factors, individually or in combination, may
injury, skill level, and goals. The duration of each pro- contribute to pathological glenohumeral instability.
gram is based on several factors including the extent of
The focus of the rehabilitation program for the patient
the injury, the sport and level of play, along with the time
with atraumatic instability is similar to the traumatically
of season. The athlete is allowed to return to unrestrict-

NORTH AMERICAN JOURNAL OF SPORTS PHYSICAL THERAPY | FEBRUARY 2006 | VOLUME 1, NUMBER 1 23
unstable shoulder, however, this tion of shoulder pain may also be
program involves a slower progression accomplished through gentle motion
with careful consideration to avoid activities to neuromodulate pain,
excessive stretching to the capsular tis- NSAIDs prescribed by the physician
sue. Furthermore, early goals include and abstaining from painful arcs of
improving proprioception, dynamic active and passive ROM.
stability, neuromuscular control, and
The focus of the early phase of the
scapular muscle strengthening to grad-
rehabilitation program is to minimize
ually return the patient to functional
any further muscle atrophy and reflex-
activities without limitations. As pre-
ive inhibition resulting from disuse,
viously mentioned, the early phase of
repeated subluxation episodes, and
rehabilitation involves reducing shoul-
pain. Isometric contraction exercises
der pain and muscular inhibition
may be performed for the gleno-
while abstaining from activities that
humeral muscles particularly the
cause apprehension.
rotator cuff. Rhythmic stabilization
Shoulder muscle activation has been Figure 8 drills may also be performed to facili-
shown to differ in patients with con- 2- handed plyometric throw into a tate a muscular co-contraction/co-acti-
trampoline
genital laxity versus in a normal, sta- vation to improve neuromuscular con-
ble shoulder.29,56-59 Normal trol and enhance the sensitivi-
force coupling that exists to ty of the afferent mechanore-
dynamically stabilize the gleno- ceptors.10(Figure 11) The goal
humeral joint is altered result- is to create a more efficient
ing in excessive humeral head agonist/antagonist co-contrac-
migration and a feeling of sub- tion to improve force coupling
luxation by the patient. and joint stability during
Rockwood and Burkhead39 active movements.
found that an exercise program
The authors of this paper
was effective in the manage-
believe that exercises such as
ment of 80% of atraumatic
rhythmic stabilization drills
instability. A recent study by Figure 9
and closed kinetic chain
Misamore et al60 found Wall dribbles in the 90/90 position
exercises to promote a co-con-
improved results in 49% (28 of
traction and an improvement
59) of patients in a long term
in proprioception are beneficial for
follow up study of atraumatic, ath-
this patient population. Axial com-
letic patients.
pression exercises are progressed
The rehabilitation program (Appendix from standing weight shifts on a table
2) for the patient with atraumatic top to then include the quadruped
instability involves regaining full and tripod positions (Note - this posi-
ROM without excessive stress to the tion should be avoided if posterior
involved tissues. The patient often instability is present). Rhythmic sta-
presents with excessive ROM, there- bilization of the involved extremity as
fore, passive ROM activities are not well as at the core and trunk may be
the focus of the rehabilitation pro- applied during these closed kinetic
gram. Special attention is placed to chain drills to further challenge the
avoid excessive stretches to the Figure 10 patients dynamic stability and neu-
involved tissues. Modalities such as Don Joy brace used during sports activi- romuscular control. Unstable sur-
cryotherapy, phonophoresis, high ties to prevent excessive shoulder ROM faces such as tilt boards, foam, large
voltage stimulation, and TENS may exercise balls, and the Biodex
be used to minimize pain and inflammation. The reduc- stability system (Biodex Corp., Shirley, NY) may be incor-

24 NORTH AMERICAN JOURNAL OF SPORTS PHYSICAL THERAPY | FEBRUARY 2006 | VOLUME 1, NUMBER 1
porated to further challenge the patients dynamic and plyometric exercises may be beneficial as well to
stability while in the closed chain position to further pro- evoke a neuromuscular response.
mote a co-activation or cocontraction of the surrounding
Once sufficient strength of the scapular stabilizers and
musculature.(Figure 12)
posterior cuff has been achieved, the patient is encour-
Patients with congenital laxity often aged to use the shoulder only in the
present with significant rotator cuff and most stable positions; those in the plane
scapular strength deficits, particularly of the scapular during humeral eleva-
the external rotators, scapular retrac- tion. Activities that promote a feeling of
tors, and scapular depressors. A joint instability with or without subluxa-
progressive isotonic strengthening pro- tion or dislocation should be avoided.
gram may be initiated to improve Only when coordination and confidence
rotator cuff and scapular musculature are achieved through progressive
strength, endurance, and dynamic sta- strengthening should the patient
bility. Proper scapula stability and attempt activities in an intrinsically
movement is vital for asymptomatic unstable position. Bracing of the gleno-
function. Scapula strengthening will humeral joint for return to sporting
improve proximal stability and there- activities may also be necessary to pro-
fore enable distal segment mobility for vide immobilization or controlled ROM
during the patients functional tasks. to protect against further injury.
These exercises may include external Figure 11
The primary focus of the rehabilitation
rotation at 0 degrees of abduction, side- Manual rhythmic stabilization
program for the congenitally unstable
lying external rotation, standing exter- drills to promote a co-contraction
shoulder patient is to enhance strength
nal rotation at 90 degrees of abduction, and improve dynamic stability
and balance in the rotator cuff, improve
prone external rotation, prone
scapular position and core stability,
rowing, prone extension and prone
along with improved proprioception
horizontal abduction at 100 degrees
and neuromuscular control. Once
with external rotation. Other scapu-
symptoms have subsided and suffi-
lar training exercises commonly
cient strength has been achieved, the
incorporated include supine serratus
patient may resume normal shoulder
punches and a dynamic hug for
function, which may include sport
serratus anterior strengthening.
activities.
Bilateral external rotation with scapu-
lar retraction and table lifts may also
CONCLUSION
be performed to strengthen the lower
The glenohumeral joint is an
trapezius. Neuromuscular control
inherently unstable joint that relies on
drills are performed for the scapular
the interaction of the dynamic and
musculature by having the rehabilita-
static stabilizers to maintain stability.
tion specialist manually resist scapu-
Disruption of this interplay or poor
la movements. The goal of these
development of any of these factors
drills is to enhance strength,
Figure 12 may result in instability, pain, and a
endurance, and scapula proprioception. Axial compression drill on an unstable
loss of function. Rehabilitation will
surface while the rehabilitation
The function of neuromuscular performs rhythmic stabilizations to the vary based on the type of instability
control system must not be over- patients involved shoulder and trunk. present and the key principles
looked in this patient population. described. A comprehensive program
Functional exercise drills that include designed to establish full range of
positions of instability to induce a reflexive muscular motion, balance capsular mobility, along with maximiz-
response may protect against future injury or recurring ing muscular strength, endurance, proprioception,
episodes of instability. 2,61,62 Active joint repositioning dynamic stability and neuromuscular control is essential.
tasks, proprioceptive neuromuscular facilitation (PNF) A functional approach to rehabilitation using movement

NORTH AMERICAN JOURNAL OF SPORTS PHYSICAL THERAPY | FEBRUARY 2006 | VOLUME 1, NUMBER 1 25
patterns and sport specific positions along with an inter- 17. Hovelius L, Eriksson K, Fredin H, et al. Recurrences after
val sport program will allow a gradual return to athletics. initial dislocation of the shoulder. Results of a prospective
The focus of the program should minimize the risk of re- study of treatment. J Bone Joint Surg. 1983;65:343-349.
injury and ensure that the patient can safely produce and 18. Postacchini F, Gumini S, Cinotti G. Anterior shoulder
dissipate forces at the glenohumeral joint. dislocation in adolescents. J Shoulder Elbow Surg.
2000;9:470-474.
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recurrence of first time anterior dislocations with 23. Wolf EM, Cheng JC, Dickson K. Humeral avulsion of
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1987;69A:393-399. References continued on page 30

26 NORTH AMERICAN JOURNAL OF SPORTS PHYSICAL THERAPY | FEBRUARY 2006 | VOLUME 1, NUMBER 1
Appendix 1. Traumatic dislocation protocol

NON-OPERATIVE REHABILITATION - Extension


TRAUMATIC DISLOCATION OF THE SHOULDER - Biceps
- Internal Rotation (multi-angles)
The program will vary in length for each individual depending on - External Rotation (multi-angles)
several factors: - Electrical muscle stimulation may be used to ER during
Severity and onset of symptoms isometrics
Degree of instability symptoms - Scapular retract/protract elevate/depress (seated manual resist.)
Direction of instability
Concomitant pathologies Rhythmic Stabilization
Age and activity level of patient ER/IR in scapular plane (pain-free multi-angles)
Arm dominance Flex/Ext in scapular plane(pain-free angles, multi-angles)
Desired goals and activities Weight Shifts standing hands on table (CKC Exercises)
(ant. instability only)
I. PHASE I - ACUTE MOTION PHASE Proprioception training drills - Active joint reproduction
proprioceptive drills (ER,IR,Flex)
Goals:
Protect healing capsular structures II. Phase II - Intermediate Phase
Re-establish non-painful range of motion
Decrease pain, inflammation, and muscular spasms Goals:
Retard muscular atrophy / Establish voluntary muscle activity Regain and improve muscular strength
Re-establish dynamic stability Normalize arthrokinematics
Improve proprioception Enhance proprioception and kinesthesia
Enhance dynamic stabilization
Note: During the early rehabilitation program, caution must be Improve neuromuscular control of shoulder complex
applied in placing the capsule under stress until dynamic joint Criteria to Progress to Phase II:
stability is restored. It is important to refrain from activities in Nearly full to full passive ROM (ER may be still limited)
extreme ranges of motion early in the rehabilitation process. Minimal pain or tenderness
Decrease Pain/Inflammation: Good MMT of IR, ER, flexion, and abduction
Sling or ER brace for comfort and depending on age of patient Baseline proprioception and dynamic stability
(MD preference) Progress range of motion activities at 90 degrees abduction to
Therapeutic modalities (ice, TENS, etc.) tolerance (painfree)
NSAIDs
Gentle joint mobilizations (grade I-II) for pain neuromodulation Initiate isotonic strengthening
* Do not stretch injured capsule
Emphasis on external rotation and scapular strengthening
Range of Motion Exercises: - ER/IR Tubing
Gentle ROM only, no stretching - Scaption raises (full can)
Pendulums - Abduction to 90 degrees
Rope & Pulley - Sidelying external rotation to 45 degrees
- Elevation in scapular plane to tolerance - Standing ER with tubing with manual resistance
Active-assisted ROM L-Bar to tolerance - Hand on ball against wall resistance stabilization
- Flexion - Prone extension to neutral
- Internal Rotation with arm in scapular plane at 30 degrees - Prone horizontal adduction
abduction - Prone rowing
- External Rotation with arm in scapular plane at 30 degrees - Lower and middle trapezius
abduction - Sidelying neuromuscular exercise drills
- Motion is performed in Non-Painful arc of motion only * - Push-ups onto table
- Seated manual scapular resistance
H DO NOT PUSH INTO ER OR HORIZONTAL ABDUCTION with - Biceps curls
anterior instability - Triceps pushdowns
H Avoid excessive IR or horizontal adduction with posterior - Electrical muscle stimulation may be used to ER during exercises
instability
Improve Neuromuscular control of Shoulder Complex
Strengthening/Proprioception Exercises: - Initiation of proprioceptive neuromuscular facilitation
Isometrics (performed with arm at side) - Rhythmic stabilization drills
- Flexion - ER/IR at 90 degrees abduction (limit degree of ER)
- Abduction

NORTH AMERICAN JOURNAL OF SPORTS PHYSICAL THERAPY | FEBRUARY 2006 | VOLUME 1, NUMBER 1 27
Appendix 1 (contd). Traumatic dislocation protocol

- Flexion/Extension/Horizontal at 100 degrees flexion, 10 degrees - Push-ups on ball/rocker board with rhythmic stabilizations
horizontal abduction - Manual scapular neuromuscular control drills
- Progress to mid and end range of motion - Initiate perturbation activities (ER with exercise tubing with end
- Progress OKC program range rhythmic stab)
- PNF
- Manual resistance ER (supine sidelying eccentrics), prone Endurance training
row - Timed bouts of exercises 30-60 seconds
- ER/IR tubing with stabilization - Increase number of repetitions (sets of 15/20 reps)
- Progress CKC exercises with rhythmic stabilizations - Multiple bouts throughout day (3x)
- Wall stabilization on ball Initiate plyometric training
- Hand on wall wall circles for rotator cuff endurance - 2-hand drills:
- Hand on wall side to side motion for scapular muscles and - Chest pass throw
deltoid - Side to side throw
- Static holds in push-up position on ball - Overhead soccer throw
- Push-ups on tilt board - Progress to 1-hand drills:
- Core - 90/90 baseball throws
- Abdominal strengthening - Wall dribbles
- Trunk strengthening / Low back - 90/90 baseball throws against wall
H Continue to avoid excessive stress on joint capsule
- Gluteal strengthening
Continue Use of Modalities (as needed)
- Ice, electrotherapy modalities IV. Phase IV - RETURN TO ACTIVITY PHASE

III. Phase III - ADVANCED Strengthening Phase Goals:


Maintain optimal level of strength/power/endurance
Goals: Progressively increase activity level to prepare patient/athlete for
Improve strength/power/endurance full functional return to activity/sport
Improve neuromuscular control
Enhance dynamic stabilizations Criteria to Progress to Phase IV:
Prepare patient/athlete for activity Full ROM
No pain or palpable tenderness
Criteria to Progress to Phase III: Satisfactory isokinetic test
Full non-painful range of motion Satisfactory clinical exam
No palpable tenderness
Continued progression of resistive exercises Continue all exercises as in Phase III
Good normal muscle strength, dynamic stability, Progress isotonic strengthening exercises
neuromuscular control Resume normal lifting program (Physician will determine)
Continue use of modalities (as needed) Initiate interval sport program (as appropriate)
Continue isotonic strengthening (progress resistance) Continue modalities- ice, e-stim, etc. (as needed)
- Continue Throwers Ten Consider GH joint stabilizing brace for contact sports
- Progress to end range stabilization drills
- Progress to full ROM strengthening FOLLOW-UP
- Progress to bench press in restricted ROM (restrict horizontal Isokinetic test (ER/IR & Abd/Add)
abduction ROM) Progress interval program
- Progress to flat & incline chest press (weighted) restrict Maintenance of exercise program
motion
- Program to seated rowing and lat pull down (in front) in
restricted ROM
Emphasize PNF
Manual D2 with RS at 45, 90, & 145 degrees
Advanced neuromuscular control drills (for athletes)
- Ball flips on table
- ER tubing at 90 deg abduction with manual resistance & RS at
end range

28 NORTH AMERICAN JOURNAL OF SPORTS PHYSICAL THERAPY | FEBRUARY 2006 | VOLUME 1, NUMBER 1
Appendix 2. Atraumatic Instability protocol

Non-operative Rehabilitation for Atraumatic Instability Proprioception/Kinesthesia


This multi-phased program is designed to allow the patient/athlete to Active joint reposition drills for ER/IR
return to their previous functional level as quickly and safely as possi-
ble. Each phase will vary in length for each individual depending upon PHASE II INTERMEDIATE PHASE
the severity of injury, ROM/strength deficits, and the required activity
demands of the patient. Goals:
Normalize arthrokinematics of shoulder complex
PHASE I ACUTE PHASE Regain and improve muscular strength of glenohumeral and scapular
Goals: muscle
Decrease pain/inflammation Improve neuromuscular control of shoulder complex
Re-establish functional range of motion Enhance proprioception and kinesthesia
Establish voluntary muscular activation
Criteria to Progress to Phase II:
Re-establish muscular balance
Full functional ROM
Improve proprioception
Minimal pain or tenderness
Decrease Pain/Inflammation
Good MMT
- Therapeutic modalities (ice, electrotherapy, etc.)
- NSAIDs Initiate Isotonic Strengthening
- Gentle joint mobilizations (Grade 1 and II) for neuromodulation of Internal rotation (sidelying dumbbell)
pain External rotation (sidelying dumbbell)
Scaption to 90 degrees
Range of Motion Exercises
Abduction to 90 degrees
Gentle ROM exercises no stretching
Prone horizontal abduction
Pendulum exercises
Prone rows
Rope and pulley
Prone extensions
Elevation to 90 degrees, progressing to 145/150 degrees flexion
Biceps
L-Bar
Lower trapezius strengthening
Flexion to 90 degrees, progressing to full ROM
Internal rotation with arm in scapular plane at 45 degrees abduction Initiate Eccentric (surgical tubing) Exercises at Zero Degrees
External rotation with arm in scapular plane at 45 degrees abduction Abduction
Progressing arm to 90 degrees abduction Internal rotation
External rotation
Strengthening Exercises
Isometrics (performed with arm at side) Improve Neuromuscular Control of Shoulder Complex
Flexion Rhythmic stabilization drills at inner, mid, and outer ranges of motion
Abduction (ER/IR, and Flex/Ext)
Extension Initiate proprioceptive neuromuscular facilitation
External rotation at 0 degrees abduction Scapulothoracic musculature
Internal rotation at 0 degrees abduction Glenohumeral musculature
Scapular isometrics Open kinetic chain at beginning and mid ranges of motion
Biceps PNF
Retraction/protraction Manual resistance
Elevation/depression External rotation
Weight shifts with arm in scapular plane (closed chain exercises) Begin in supine position progress to sidelying
Rhythmic stabilizations (supine position) Prone rows
External/internal rotation at 30 degrees abduction ER/IR tubing with rhythmic stabilization
Flexion/extension at 45 and 90 degrees flexion Closed kinetic chain

H Note: It is important to refrain from activities and motion in extreme


Wall stabilization drills
- Initiated in scapular plane
ranges of motion early in the rehabilitation process in order to minimize
- Progress to stabilization onto ball
stress on joint capsule.
Weight shifts had on ball

NORTH AMERICAN JOURNAL OF SPORTS PHYSICAL THERAPY | FEBRUARY 2006 | VOLUME 1, NUMBER 1 29
Appendix 2.(contd) Atraumatic Instability protocol

Initiate core stabilization drills Medicine ball


- Abdominal Rocker board
- Erect spine Push-ups with stabilization onto ball
Gluteal strengthening Wall stabilization drills onto ball
Continue Use of Modalities (as needed) Program Scapular Neuromuscular Control Training
Ice, electrotherapy Sidelying manual drills
Progress to rhythmic stabilization and movements (quadrant)
PHASE III ADVANCED STRENGTHENING PHASE
Emphasize Endurance Training
Goals: Time bouts of exercise 30-60 sec
Enhance dynamic stabilization Increase number of reps
Improve strength/endurance Multiple boots bouts during day
Improve neuromuscular control
Prepare patient for activity PHASE IV RETURN TO ACTIVITY PHASE
Criteria to Progress to Phase III: Goals:
Full non-painful ROM Maintain level of strength/power/endurance
No pain or tenderness Progress activity level to prepare patient/athlete for full functional
Continued progression of resistive exercises return to
Good to normal muscle strength activity/sport
Continue Use of Modalities (as needed) Criteria to Progress to Phase IV:
Full non-painful ROM
Continue Isotonic Strengthening (PREs)
No pain or tenderness
Fundamental shoulder exercises II
Satisfactory isokinetic test
Continue Eccentric Strengthening Satisfactory clinical exam

Emphasize PNF Exercises (D2 pattern) With Rhythmic Stabilization Continue all exercises as in Phase III
Hold
Initiate Interval Sport Program (if appropriate)
Continue to Progress Neuromuscular Control Drills
Patient Education
Open kinetic chain
PNF and manual resistance exercises at outer ranges of motion
Closed kinetic chain
Push-ups with rhythmic stabilization
Progress to unsteady surface

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Clinical Director
49. Reinold MM, Wilk KE, Macrina LC, et al. The effect of Champion Sports Medicine
electrical stimulation of the infraspinatus on shoulder external 806 St. Vincents Drive, Suite 620
rotation force production following rotator cuff repair surgery. Birmingham, AL 35205
Presented at American Physical Therapy Association Phone: 205-939-1557
Combined Sections Meeting, February, 2005. Fax: 205-939-1536
50. Carpenter JE, Blaiser RB, Pellizon GG. The effects of email: kevin.wilk@championsportsmedicine.com
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